A complete subperichondrial dissection technique for rhinoplasty with management of the nasal ligaments

Overview

The skin of the nose can be lifted at several depths. The authors dissect in the deepest plane, directly on the cartilage membrane and bone membrane, so the soft tissue, ligaments and blood supply stay together as one layer. They then repair two ligaments, the scroll ligament and Pitanguy's midline ligament, to stabilize the internal valve and the tip.

Sections of note

• Retrospective chart review of 228 consecutive patients, May 2008 to April 2011, one surgeon (BC).
• 182 women, 46 men; ages 18 to 54, mean 24.3.
• 203 primary, 14 secondary and 11 revision rhinoplasties.
• Open approach in 92; closed dome delivery in 136.
• Follow-up 9 months to 3 years.
• Scroll ligament repaired to stabilize the internal valve; Pitanguy's midline ligament repaired to stabilize tip position.
• Less swelling and faster recovery than the authors' prior sub-SMAS experience; re-elevation in the same plane was easier in revision cases.
• The abstract gives no measured swelling scores, satisfaction data or complication counts.

What it means for a patient

• Dissecting in this deepest plane is intended to reduce swelling, scarring and recovery time by leaving the soft tissue layer intact.
• Repairing the nose's own ligaments is used in place of some grafts to hold the tip and valve.
• The comparison is with the surgeon's own earlier experience, not a controlled group, and no numbers back the recovery claim.

Why this paper matters

This paper by Cakir launched the subperichondrial, ligament-preserving approach that underpins much of the later preservation rhinoplasty movement. Objective comparisons of swelling and outcomes against other planes remain to be published.

Terms

• Subperichondrial dissection: lifting the tissue directly off the membrane covering the cartilage.
• Subperiosteal dissection: lifting the tissue directly off the membrane covering the bone.
• SMAS: the superficial musculoaponeurotic system, the muscle and fibrous layer under the skin.
• Scroll ligament: the fibrous junction where the tip cartilages meet the upper lateral cartilages.
• Pitanguy's midline ligament: a fibrous band running down the midline from the bridge into the tip.
• Dome delivery: a closed technique in which the tip cartilages are pulled out through the nostril incision for shaping.