1. EXTRUSION OF NASAL TIP SUTURES:TWO CASE REPORTS. EXTRUSION OF NASAL TIP SUTURES:TWO CASE REPORTS. Ahmed Al-Arfaj, Sami Alharethy, Zkhalid Alzahrani Ahmed Al-Arfaj, Sami Alharethy, Zkhalid Alzahrani Accepted in JPRAS February 2008 Accepted in JPRAS February 2008

2. INTRODUCTION: INTRODUCTION: Since 1931 when Joseph described the Suture in Rhinoplasty, the use of sutures in nasal tip surgery has evolved to include many techniques of suture placement. Since 1931 when Joseph described the Suture in Rhinoplasty, the use of sutures in nasal tip surgery has evolved to include many techniques of suture placement. Nasal tip sutures part I: the Evolution. Palst.Reconstr. surg. 112: 1125, 2003 Nasal tip sutures part I: the Evolution. Palst.Reconstr. surg. 112: 1125, 2003

3. Exposure of deep sutures lying along the suture line of rhinoplasty procedure is uncommon but have been reported. However exposure of nasal tip sutures (not lying along the suture lines) have not been reported in the literature. Nasal tip sutures part I: the Evolution. Palst.Reconstr. surg. 112: 1125, 2003

4. Case report Case report 21 year old male, smoker for the last 5 years, presented to our clinic with a deviated nasal dorsum and septum, nasal hump, drooping tip and complaining of right sided nasal obstruction. The patient had a moderately thick skin and gave a history of nasal trauma at the age of 5 years.. 21 year old male, smoker for the last 5 years, presented to our clinic with a deviated nasal dorsum and septum, nasal hump, drooping tip and complaining of right sided nasal obstruction. The patient had a moderately thick skin and gave a history of nasal trauma at the age of 5 years..

5. The patient under went open septorhinoplasty. The tipplasty included resection of the cephalic margin of the lower lateral cartilage and 5-0 nylon intra- and inter-domal sutures with buried knots. Defatting was not performed.

6. The immediate post-operative period was uneventful and the patient received post-operative antibiotic prophylaxis. He presented eight months postoperatively with an extruded stitch over the left side of the nasal tip. There was no history of trauma or infection.

7. The immediate post-operative period was uneventful and the patient received post-operative antibiotic prophylaxis. He presented eight months postoperatively with an extruded stitch over the left side of the nasal tip. There was no history of trauma or infection.

9. Case 2: A 19 year old male, a smoker for 7 years, presented with a broad nasal dorsum, dorsal hump, bulbous tip, and Left sided nasal obstruction. The patient had a thick sebaceous skin and gave no history of trauma. A 19 year old male, a smoker for 7 years, presented with a broad nasal dorsum, dorsal hump, bulbous tip, and Left sided nasal obstruction. The patient had a thick sebaceous skin and gave no history of trauma.

10. The patient underwent open rhinoplasty for correction of the above mentioned deformities, and 6-0 polypropylene intra- and inter-domal sutures with buried knots were used for tip refinement. The patient underwent open rhinoplasty for correction of the above mentioned deformities, and 6-0 polypropylene intra- and inter-domal sutures with buried knots were used for tip refinement. Defatting was not performed. Defatting was not performed. The immediate post-operative period was uneventful and the patient received postoperative antibiotic prophylaxis. The immediate post-operative period was uneventful and the patient received postoperative antibiotic prophylaxis.

11. Two and half years later the patient presented with an extruded stitch at the tip. There was no history of trauma. Two and half years later the patient presented with an extruded stitch at the tip. There was no history of trauma.

12. The two patients had revision open rhinoplasty, daily topical antibiotic ointment was given and the wound eventually healed with an acceptable scar. The two patients had revision open rhinoplasty, daily topical antibiotic ointment was given and the wound eventually healed with an acceptable scar.

13. Discussion: The main author performed more than three hundred rhinoplasty procedures in the period between 2002 till 2006, of which 242 required nasal tip sutures. The main author performed more than three hundred rhinoplasty procedures in the period between 2002 till 2006, of which 242 required nasal tip sutures. The author has been consistently using either 6-0 – 5-0 monofilament non absorbable sutures for nasal tip refinement. The author has been consistently using either 6-0 – 5-0 monofilament non absorbable sutures for nasal tip refinement.

14. While extrusion of sutures is a known complication of any surgical procedure, to our knowledge it has not been reported after nasal tip surgery. While extrusion of sutures is a known complication of any surgical procedure, to our knowledge it has not been reported after nasal tip surgery.

15. The following factors might have contributed to this complication: patient factors (smoking, thin nasal tip skin). patient factors (smoking, thin nasal tip skin). suture factors (type and size of the suture) suture factors (type and size of the suture) technical factors ( knot placement, defatting of the nasal tip skin). technical factors ( knot placement, defatting of the nasal tip skin).

16. It is interesting to note that both of our patients were smokers. Smoking adversely affects blood supply of the skin, and specially following skin undermining. It is interesting to note that both of our patients were smokers. Smoking adversely affects blood supply of the skin, and specially following skin undermining. Management of medical morbidities and risk factors before surging smoking, Diabetes, and other complicating factors.Women A. Semin plost. Sung 2006: 20: 205 – 213 Management of medical morbidities and risk factors before surging smoking, Diabetes, and other complicating factors.Women A. Semin plost. Sung 2006: 20: 205 – 213

17. Non-absorbable sutures are more likely to extrude long term while absorbable sutures are more prone for infection and extrusion short term. salthouse TN: tissue response to sutures in Rubin LR, ed: Biomaterials in Reconstructive surgery. St. Louis, mosby, 1983: 131.

18. larger sutures make bulky knots which increases the risk of extrusion. Nylon produces very minimal tissue reaction while polypropylene is almost inert. salthouse TN: tissue response to sutures in Rubin LR, ed: Biomaterials in Reconstructive surgery. St. Louis, mosby, 1983: 131.

19. Failure to burry the knots and defatting the nasal tip skin are other potential risk factors interestingly the author did burry the knots and did not perform defatting in both patients. Failure to burry the knots and defatting the nasal tip skin are other potential risk factors interestingly the author did burry the knots and did not perform defatting in both patients.

20. Although the etiology in our two cases remains unclear, we have stopped using non-absorbable sutures in nasal tip surgery and we are currently using 4-0 and 5-0 polydiaxanone sutures.

22. Thank you