A functional classification of internal suspension sutures in rhinoplasty and the adjunctive use of pulley sutures

Abstract

Purpose

Internal suspension sutures (ISS) were previously described as an adjunctive maneuver to support nasal tip position in rhinoplasty. With continued use, additional variants and indications have emerged. This communication proposes a functional classification of ISS according to the structure through which traction is applied, and describes the adjunctive use of pulley sutures to refine suture trajectory and vector control.

Methods

This technique article is based on the senior author’s iterative clinical use of ISS in structural rhinoplasty. The original ISS concept was expanded into a practical classification based on the anatomic site of force application. A dorsal pulley suture modification was also developed to reduce bowstringing in selected cases.

Results

Four main ISS variants were identified: domal-ISS, shield-ISS, intercrural-ISS, and septal extension graft (SEG)-ISS. Each provides cephalic support through a different anatomic structure and may be selected according to cartilage characteristics, graft configuration, and tip geometry. Asymmetric dorsal passage may allow minor coronal plane adjustment. Pulley sutures can selectively reduce bowstringing and modify the traction vector.

Conclusion

ISS may be understood as a flexible family of adjunctive support maneuvers rather than a single fixed technique. This functional classification may improve conceptual clarity and reproducibility, while pulley sutures offer an additional option for vector refinement in selected cases. These maneuvers are intended to complement established structural tip support techniques.