Rhinoplasty Dissection Planes (Subcutaneous, Sub-SMAS, Supra-perichondral, and Sub-perichondral) and Soft Tissues Management

Overview

The article addresses how surgeons separate the skin covering from the nasal framework. Four planes are named: subcutaneous, sub SMAS, supra perichondral and sub perichondral. The authors state more than one plane can produce safe and good results, and that surgeons hold different preferences for the tip, middle and upper thirds of the nose and for how they handle the soft tissue layers and ligaments.

Sections of note

• Review article; the abstract reports no patient numbers, no outcomes, no complication rates and no follow up.
• Four dissection planes are covered: subcutaneous, sub superficial musculoaponeurotic system, supra perichondral and sub perichondral.
• Surgeons' preferences are said to vary by nasal third and by how they treat soft tissue layers and ligaments.
• The authors state understanding the layered anatomy and the ligamentous structures explains the logic behind the different approaches.
• Restoring the ligaments anatomically is presented as part of that logic.

What it means for a patient

• Which layer the surgeon works in determines how much of the nose's supporting connective tissue is divided.
• Ligament restoration is a step some techniques include and others do not.
• This is a review of surgical choices. It reports no comparison of results between planes.
• No evidence appears here that any one plane produces better outcomes.

Why this paper matters

The dissection plane is decided at the start of every rhinoplasty and affects swelling, scarring and how the skin redrapes. The preservation movement made the choice an explicit topic rather than an unstated habit. Which plane gives better long term results has not been settled.

Terms

• Dissection plane: the tissue layer a surgeon separates along when lifting the skin.
• Subcutaneous: just beneath the skin.
• SMAS: the superficial musculoaponeurotic system, a layer of muscle and fibrous tissue under the skin.
• Perichondrium: the membrane covering cartilage; supra means above it and sub means beneath it.
• Soft tissue envelope: the skin, fat and muscle covering the nasal framework.
• Nasal ligaments: fibrous bands connecting nasal structures to one another.