Reconstruction of Scroll and Pitanguy's Ligaments in Open Rhinoplasty: A Controlled Randomized Study

Barone M, Salzillo R, De Bernardis R, Persichetti P.

PubMed 38062265 Publisher (DOI)Free full text (PMC)

What this paper says

In 112 randomized primary rhinoplasty patients followed at least two years, combining ligament repair with grafts and using grafts alone both outperformed ligament repair alone, which needed more secondary procedures.

Overview

Preservation rhinoplasty has put ligament management at the centre of debate, since the fibrous bands around the tip contribute to its support. The authors tested whether repairing them changes results, randomizing primary rhinoplasty patients into three groups and assessing them by questionnaire and blinded photograph rating.

Sections of note

Design: double blinded randomized study. Level of evidence II. Patients and two outcome assessors were blinded to the method used.
112 patients enrolled, 47 men and 65 women, aged 20 to 50. All had open rhinoplasty with at least 2 years of follow up and standardized photographs.
Group 1: ligament reconstruction plus grafts. Group 2: grafts alone, including shield, onlay and umbrella grafts. Group 3: ligament reconstruction alone with a columellar strut.
Outcomes: the FACE-Q satisfaction with nose scale, plus two plastic surgeons rating photographs on a 1 to 5 scale.
Groups 1 and 2 had the better FACE-Q and visual analog scores, and underwent fewer secondary procedures than group 3.
Stated conclusion: combining ligament repair with grafts reduces dead space, improves soft tissue redraping, and gives better control of tip projection, position and rotation.

What it means for a patient

Repairing the tip ligaments without grafts was the weakest option here, producing more return operations.
Grafts alone scored comparably to grafts plus ligament repair, so the added benefit of ligament repair is not clearly separated.
Randomization, blinding of patients and assessors, and a two year minimum follow up make this stronger than most rhinoplasty studies.
Limits: the abstract gives no group sizes or score values, and the sentence reporting results is incomplete as printed.

Why this paper matters

Whether the nasal ligaments matter enough to repair has been argued mostly from anatomy rather than outcomes. A randomized trial with long follow up addresses that directly, and its answer is that ligaments are not a substitute for structural grafts. How much they add on top of grafts is unresolved.

Terms

Scroll ligament: the fibrous connection between the upper and lower nasal cartilages.
Pitanguy ligament: a fibrous band running from the bridge down to the tip.
Shield and onlay grafts: cartilage pieces placed on the tip to shape or project it.
Dead space: an empty pocket under lifted tissue where fluid can collect.
FACE-Q: a validated questionnaire measuring satisfaction with facial appearance.

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

Abstract

Introduction: In the preservation rhinoplasty era, ligament management represents a hot topic. The aim of this study is to analyze the role of ligaments as indispensable elements of support of the nasal tip to have an adequate, safe, and predictable aesthetic and functional result.

Material And Methods: Patients meeting the following criteria were included in the study: primary rhinoplasty, minimum 2-year follow-up, proficiency in Italian language, signed consent, and standardized pre- and postoperative photographic documentation. The study was performed with a double-blinded randomized design; both the patients and two of the authors measuring outcomes were blinded to the treatment methods. All patients were asked to answer the FACE-Q satisfaction with the nose postoperative scale. Two plastic surgeons reviewed all postoperative photographs, rating the outcome on a 1-5 VAS scale.

Results: One hundred and twelve patients were enrolled, 47 males and 65 females, aged between 20 and 50 years. Patients were randomly divided in three groups: group 1, ligament reconstruction and grafts; group 2, only grafts (shield, single and double onlay, umbrella); and group 3, only ligament reconstruction with columellar strut. All rhinoplasties were performed with an open approach. Both the FACE-Q and VAS scores were in groups 1 and 2, which were also the ones undergoing fewer secondary procedures compared to group 3.

Conclusions: The best surgical option appears to be the combination of ligament repair and grafts. It reduces dead space and enables a better redraping of soft tissues, obtaining a better control of tip projection, position, and rotation.

Level Of Evidence Ii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Abstract as indexed by PubMed; the article is open access (PubMed Central).