The Nasal Ligaments and Tip Support in Rhinoplasty: An Anatomical Study

Daniel RK, Palhazi P.

What this paper says

Dissecting 24 fresh cadavers, the authors confirmed five nasal ligaments, failed to find two ligaments commonly assumed to exist, and showed the tip domes sit an average 5.7 mm above the anterior septal angle with no direct support from it.

Overview

The classic account of what holds the nasal tip up dates from 1971 and produced the tripod concept. Surgeons have since begun preserving and repairing the nasal ligaments to control tip position, which prompted this reassessment of the anatomy underlying that practice.

Sections of note

Anatomic dissections on 24 fresh cadavers at the time of autopsy, in two groups.
Group 1: 10 cadavers dissected to study the ligaments of the nose.
Group 2: 14 cadavers analyzing the relationship between the alar domes and the anterior septal angle.
Consistently identified ligaments: interdomal, intercrural, Pitanguy's midline, pyriform, and a scroll ligament complex of longitudinal and vertical scroll ligaments.
Not found: a footplate ligament from the medial crus to the caudal septum, and a sesamoid ligament from the accessory cartilage to the pyriform aperture.
The domes projected an average 5.7 mm above the anterior septal angle, range 2.2 to 9.6 mm, and sat 5.5 mm behind it lengthwise, range 2.9 to 9.5 mm, so there is no direct support from the angle to the domes.

What it means for a patient

Tip support comes from ligaments that can be preserved during surgery rather than only from added grafts.
Two supports long assumed to exist were not found, which changes how tip drooping after surgery is explained.
The gap measured between the tip and the front of the septum is why the tongue-in-groove operation can pull the tip out of position if that distance is not accounted for.
Limits: cadaver study of 24 specimens; findings describe anatomy, not surgical outcomes.

Why this paper matters

Preservation rhinoplasty depends on knowing which structures actually hold the tip up, and this corrects two long-standing assumptions. It also gives measured distances for a widely used tip technique. Whether ligament preservation improves long-term tip position in patients is not tested here.

Terms

Ligament: A band of fibrous tissue connecting structures and holding them in position.
Alar dome: The high point of each tip cartilage, forming the point of the tip.
Anterior septal angle: The forward upper corner of the septum, just behind the tip.
Tripod concept: A model treating the tip cartilages and columella as a three-legged support.
Tongue-in-groove: A technique fixing the tip cartilages onto the front edge of the septum.

Summary written by rhinoplasty.cc from the abstract, 2026-09-09; not medical advice. The authors' own abstract follows.

From the abstract

“In 1971, Janeke and Wright1 published a now classic study on the support of the nasal tip in which they found four areas of anatomic support. These findings led to the "tripod concept" of tip support. Recently, surgeons have begun repairing and/or preserving the nasal ligaments as a method to control tip projection…”

Excerpt; the full abstract is on PubMed.