Transection of Pitanguy's Midline Ligament to Avoid Supratip Depression in Closed-Approach, Low-Septal-Resection Dorsal Preservation Rhinoplasty

Overview

Supratip depression, a dip in the profile just above the tip, is a common complication after preservation rhinoplasty. The paper presents a simple surgical maneuver intended to prevent it: dividing Pitanguy's midline ligament, a fibrous band running down the midline of the nose. Thirty six patients who had closed approach dorsal preservation with low septal resection between January and June 2021 were reviewed.

Sections of note

• Retrospective study of 36 patients.
• Patients were divided by whether Pitanguy's midline ligament was divided, 20 patients, or preserved, 16 patients.
• Standardized side view photographs at 6 months were examined for supratip depression or polly beak deformity.
• The Rhinoplasty Outcome Evaluation scale was applied at 6 months.
• Supratip depression occurred in 4 of the 16 preserved cases and none of the 20 divided cases, P less than 0.05.
• There was no polly beak deformity in either group.
• Satisfaction scores and the number of satisfied patients did not differ significantly between groups.
• The authors conclude dividing the ligament reduces the likelihood of supratip depression without increasing polly beak.

What it means for a patient

• Supratip depression and polly beak are opposite problems in the same region, one a dip and the other a fullness above the tip.
• Dividing the ligament eliminated the dip in this series without producing the opposite deformity.
• Patient satisfaction scores were the same in both groups, so the difference was visible on photographs but not reflected in how patients rated their result.
• Thirty six patients from one centre with six month follow up is small.

Why this paper matters

Preservation rhinoplasty was promoted partly on preserving nasal ligaments, and this study finds that dividing one of them prevents a specific deformity. That runs against the general principle of the technique. Whether the finding holds in larger numbers is untested.

Terms

• Supratip depression: a dip in the profile just above the nasal tip.
• Pitanguy's midline ligament: a fibrous band running down the midline of the nose between the skin and the framework.
• Polly beak deformity: a fullness above the tip giving the profile a beak like outline.
• Dorsal preservation: lowering the natural bridge instead of cutting the hump off.
• Low septal resection: removing a strip of septum near its base to allow the bridge to settle.
• Transection: cutting through a structure to divide it.