SPECIAL TOPIC

A Simplified Approach to Nasal Tip Shaping:

The Five-Suture Technique
C. Spencer Cochran, M.D.
Paul N. Afrooz, M.D.
Dallas, Texas; and Miami, Fla.
Summary: Techniques for nasal tip shaping have evolved from destructive to non-
destructive techniques. These techniques have proven to be effective, yet they are
often applied incrementally and require repeated intraoperative evaluation and
manipulation to assess their efficacy. We describe a simple, effective, and reliable
five-suture technique to achieve consistent results in tip shaping based on previous-
ly described ideals for nasal tip aesthetics  (Plast. Reconstr. Surg. 145: 938, 2020.)

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everal techniques for nasal tip shaping have
been described, the evolution of which has
moved from destructive to nondestruc-
tive suture techniques.1–6 These techniques have
proven to be effective, yet they are often applied
incrementally and require repeated intraopera-
tive evaluation and manipulation to assess their
efficacy. In this article, we describe a simple, effec-
tive, and reliable five-suture technique to achieve
consistent results in tip shaping based on previ-
ously described ideals for nasal tip aesthetics.
IDEAL NASAL TIP
The ideal nasal tip has been previously
described and consists of four distinct surface
landmarks, including the tip-defining points
bilaterally, the supratip breakpoint, and the colu-
mellar-lobular breakpoint7 (Fig. 1). The supratip
breakpoint and the tip-defining points form an
equilateral triangle. In a mirroring fashion, the
tip-defining points and the columellar-lobular
breakpoint form an equilateral triangle. These
adjacent equilateral triangles form a diamond-
shaped tip complex on frontal view. Furthermore,
the aesthetically pleasing tip is one in which a
smooth transition exists from tip lobule to alar
lobule without a line of demarcation.8
OPERATIVE TECHNIQUE
By way of the open rhinoplasty technique, we
advocate addressing the nasal tip as one of the
final steps in the rhinoplasty procedure. After
establishing the appropriate dorsal height and
From the Dallas Rhinoplasty Center and private practice.
Received for publication March 10, 2019; accepted August
29, 2019.
Copyright © 2020 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000006709
width, any additional manipulation of the bony
dorsum, septum, and cartilaginous midvault is
performed before addressing the nasal tip.
Before manipulating the lower lateral carti-
lages for tip shaping, the vestibular lining is dis-
sected from the posterior surface of the domes.
This is done so that the tip-shaping sutures can
be passed without violating the vestibular lining.
Following dissection of the vestibular lining from
the posterior surface of the domes, a columellar
strut is carved from the longest and sturdiest por-
tion of autologous cartilage, measuring approxi-
mately 4 to 5 mm wide. A pocket is created within
the soft tissue between the medial crura. [See
Video 1 (online), which demonstrates columel-
lar strut placement. A pocket is dissected between
the medial crura, leaving a small amount of tissue
between the posterior portion of the strut and the
anterior nasal spine. This provides a small amount
of recoil. The first suture in the five-suture tech-
nique secures the strut in place with a 5-0 poly­
diaxanone horizontal mattress suture. The knot is
buried between the medial crura.] The pocket is
not extended all the way to the nasal spine, thereby
maintaining a healthy pad of soft tissue between
the posterior end of the strut and the nasal spine
to prevent the strut from directly contacting the
nasal spine. Contact between the columellar
strut and the nasal spine is frequently reported
to cause a “clicking” sensation. Furthermore, the
soft-tissue pad between the posterior end of the
strut and the nasal spine provides a small amount
Disclosure: The authors have no financial interest
to declare in relation to the content of this article. No
funding was received for this article.
Related digital media are available in the full-text
version of the article on www.PRSJournal.com.

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Volume 145, Number 4 • Simplified Approach to Nasal Tip Shaping

of recoil and aids in establishing tip projection.
Because the strut is not contacting the unyielding
nasal spine, the tip complex has a more natural
dynamic with facial animation.
The first suture in the five-suture sequence
involves fixating the strut to the medial crura at
the base of the columella with a 5-0 polydiaxa-
none horizontal mattress suture. This horizontal
mattress suture is initiated between the medial
crura on one side of the strut to bury the knot
between the medial crura. The suture is passed
through the strut and the medial crus on one
side from medial to lateral, and then passed back
through the same medial crus in a horizontal mat-
tress fashion from lateral to medial. The suture is
then passed back through the strut and the con-
tralateral medial crus. In a mirroring horizontal
mattress fashion, the suture is passed through the
contralateral medial crus, and then tied between
the medial crura on one side of the strut.
The nasal skin flap is redraped over the nasal
tip complex to assess nasal tip projection. The
length of the strut is trimmed incrementally until
the desired nasal tip projection is achieved, bear-
ing in mind that, with this technique, the projec-
tion of the strut will determine the projection of
the domes and definitive tip projection. Specifi-
cally, the anterior-most aspect of the domes and
the strut will ultimately lie flush with one another.
[See Video 2 (online), which demonstrates how
the skin is redraped to assess tip projection.
The strut is trimmed to the desired level of tip
projection with a no. 15 blade. The anterior aspect
of the strut is then carved in a triangular fashion
such that the caudal portion is slightly wider than
the cephalic portion.]
The anterior portion of the strut is precisely
tailored to the desired projection with a no. 15
blade. To facilitate the desired diamond configu-
ration, the caudal interdomal distance should be
wider than the cephalic interdomal distance. To
emphasize this configuration, the cephalic por-
tion of the strut is narrowed in a triangular fash-
ion such that the caudal portion is wider than the
cephalic portion (Fig.  2). This further facilitates
the differential between cephalic and caudal inter-
domal distance and accentuates the desired dia-
mond-shaped configuration of the tip complex.
The second and third sutures of the five-suture
sequence involve securing each dome to the colu-
mellar strut separately rather than unifying the
tip with a single interdomal suture. At the caudal
portion of the most anterior portion of the strut,
a 5-0 polydiaxanone suture is passed through the
strut angled cephalically at 45 degrees, exiting the
strut on the contralateral side at the cephalic por-
tion of its height. The suture is then passed in the
same direction through the cephalic portion of
the medial and lateral genu of the dome, and tied
over the dome as a simple stitch. This is repeated
in a contralateral fashion to create the diamond-
shaped morphology of the nasal tip (Fig. 3). [See
Video 3 (online), which demonstrates placement
of the second and third sutures of the five-suture

Fig. 1. The four distinct surface landmarks of the nasal tip include the supratip breakpoint, the tip-defining points, and the
columellar-lobular breakpoint. The supratip breakpoint and tip-defining points form an equilateral triangle. In a mirroring
fashion, the tip-defining points and the columellar-lobular breakpoint form an equilateral triangle. These adjacent equi-
lateral triangles form a diamond-shaped tip complex on frontal view. (Reproduced with permission from ©TouchMD.)

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 Plastic and Reconstructive Surgery • April 2020

Fig. 3. Suture schematic for sutures 1 through 5 of the five-

suture technique. 1, Horizontal mattress suture to stabilize the
columellar strut to the medial crura; 2, simple suture from cau-
Fig. 2. To emphasize the diamond-shaped configuration of the
dal to cephalad through the columellar strut and the cephalic
tip complex, the cephalic portion of the strut is narrowed in a
aspect of the dome on one side; 3, simple suture from caudal to
triangular fashion such that the caudal portion is slightly wider
cephalad through the columellar strut and the cephalic aspect
than the cephalic portion.
of the dome on the contralateral side; 4, simple suture through
the cephalic aspect of the domes and columellar strut; 5, hori-
technique. A suture is passed through the anterior zontal mattress suture placed at the desired columellar-lobular
portion of the strut angled cephalically approxi- breakpoint. (Reproduced with permission from ©TouchMD.)
mately 45  degrees. The suture is then passed
through the cephalic portion of the dome and The fifth and final suture of the sequence
tied as a simple stitch. This is repeated on the con- involves approximation of the middle crura. This
tralateral side.] The angled placement of these suture is initiated between the middle crura and
sutures creates a differential cephalocaudal inter- placed in a horizontal mattress fashion incor-
domal distance. This also creates a differential in porating the columellar strut. Placement of this
the cephalocaudal width of each individual dome, suture influences the columellar-lobular break-
with the cephalic aspect narrower than the cau- point and the length of the infratip lobule (Fig. 3).
dal aspect. Furthermore, as the suture is tied, the
cephalic aspect of the domes is slightly recessed
relative to the caudal aspect of the domes. It is the
caudal aspect of the domes that serves as the tip-
defining points. Therefore, the caudal aspects of
the domes should ideally be slightly more project-
ing than the cephalic aspects (Fig. 4).
The fourth suture of the sequence is then
passed through the entire cephalic aspect of the
tip complex beginning on one side. The suture
is passed directly across the cephalic aspect of
the composite of the lateral and medial genu
of the dome on one side, columellar strut, and
then medial and lateral genu of the dome on
the contralateral side, and then tied in a simple
fashion (Fig.  3). [See Video 4 (online), which
demonstrates that the fourth suture is passed
through the cephalic portion of the composite Fig. 4. The caudal aspect of the domes serves as the tip-defining
of the domes and columellar strut and tied as a points and should be slightly more projecting than the cephalic
simple stitch.] aspects.

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Volume 145, Number 4 • Simplified Approach to Nasal Tip Shaping
[See Video 5 (online), which demonstrates the
fifth suture of the five-suture technique. A hori-
zontal mattress suture is placed incorporating the
medial crura at the desired level of the columel-
lar-lobular breakpoint. This suture influences the
length of the infratip lobule and the position of
the columellar-lobular breakpoint].
The skin is then redraped to assess tip shape,
and any further refinement is performed as
necessary. This technique is typically followed
by placement of alar contour grafts, closure
of the infracartilaginous and columellar inci-
sions, and assessment of the alar bases. To bol-
ster the vestibular lining to the undersurface of
the domes, absorbable gelatin surgical sponge
is used. The sponge is cut into several small
pieces and coated with mupirocin ointment.
The nostril apices are then packed with mul-
tiple small pledgets of absorbable gelatin sur-
gical sponge coated with mupirocin ointment.
These sponges coagulate and provide splinting
of the nostril apices and facilitate readherence
of the vestibular lining to the undersurface of
the domes.
DISCUSSION
The ideal nasal tip aesthetic has been previ-
ously described.7 The goal of the five-suture tech-
nique is to reliably recreate the diamond-shaped
morphology of the ideal nasal tip. In doing so, the
cephalic interdomal distance is narrow analogous
to the apex of the diamond, whereas the caudal
interdomal distance is wider, serving as the lateral
points of the diamond. Ideally, the caudal aspect
of the domes creates the tip-defining points. As
such, the caudal aspect should project slightly fur-
ther than the cephalic aspect, thereby accentuat-
ing the tip-defining points, whereas the recessed
cephalic aspect facilitates the creation of a supra-
tip break. This three-dimensional differential in
width and projection of the cephalic and caudal
aspects of the domes is facilitated by the tech-
nique described herein.
The concept of manipulating the morphol-
ogy of the domes with suture techniques has been
well established.1–6 However, not all transdomal
sutures are created equal, and their position has
considerable effects on the orientation of the lat-
eral crura. Guyuron and Behmand2 discussed the
significance of transdomal suture placement, and
its effect on the orientation of the lateral crura.
Dosanjh, Hsu, and Gruber9 described the hemi-
transdomal suture, emphasizing placement of the
transdomal suture in the cephalic portion of the
domes, warning that caudal placement may cause
a pinched appearance of the nasal tip. Toriumi8
further emphasized the importance of maintain-
ing a smooth transition from the tip lobule to
alar lobule without a line of demarcation. All the
aforementioned authors recognized and reported
on the significance of positioning the transdomal
suture, along with the desired eversion of the
caudal margin of the lateral crus relative to the
cephalic margin. This strengthens the alae and
facilitates a smooth transition from the tip lobule
to the alar lobule.
In our experience, the five-suture technique
achieves this favorable orientation of the lateral
crura. Furthermore, we frequently support the
caudal edge of the lateral crus with an extended
alar contour graft,10 which provides additional con-
trol and stabilization of the diamond-shaped tip
configuration, while also mitigating the tendency
for alar rim collapse. Therefore, this technique
serves to achieve several goals. The fashioning
of the columellar strut and five-suture technique
creates the diamond configuration of the tip com-
plex, and the desired three-dimensional width
and projection differential between the cephalic
and caudal aspects of the domes. Medialization of
the cephalic margin of the lateral crura and ever-
sion of the caudal margin are achieved, thereby
reducing tip bulbosity and strengthening the
alar margin. This promotes a smooth transition
from the tip to the alar lobule without a visible
demarcation.
This technique is effective and reproducible in
shaping the nasal tip. As with other techniques, it
may be titrated according to the desired aesthetic
goals, and other traditional tip-shaping or dome-
defining sutures may be added to this technique
as necessary. When determining the aesthetic
goals, several additional factors must be consid-
ered, including ethnicity and skin thickness. The
technique is individualized and may be adjusted
in accordance with these factors and the desired
aesthetic.
CONCLUSIONS
The nasal tip consists of four cardinal points
including the tip-defining points, the supratip
breakpoint, and the columellar-lobular break-
point. The diamond-shaped, three-dimensional
configuration formed by the supratip breakpoint,
tip-defining points, and the columellar-lobular
breakpoint is a desirable aesthetic that can be cre-
ated by the precise design of a columellar strut
and the five-suture nasal tip complex suturing
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 Plastic and Reconstructive Surgery • April 2020

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