The major nasal tip support mechanisms are the lower lateral cartilages, the fibrous attachments of the medial crura to the caudal septum, and the scroll ligament between the lower and upper lateral cartilage. In the classic, closed rhinoplasty procedure, with transfixion and intercartilaginous incisions and cephalic trim, all of these structures are damaged.1
Five distinct layers above the cartilaginous and bony nasal structure have been described: skin, the superficial areolar layer, the fibromuscular or superficial musculoaponeurotic system (SMAS) layer, the deep areolar layer, and the perichondral/periosteal layer. The nasal SMAS divides into deep and superficial layers at the level of the nasal valve. Each layer has medial and lateral components. The superficial medial layer runs caudally above the interdomal ligament into the columella. The deep medial layer runs beneath the interdomal ligament but above the anterior septal angle into the membranous septum and then downward toward the anterior nasal spine.2
Pitanguy described a “dermacartilaginous ligament” occurring in the nose of blacks and in bulbous noses. To Pitanguy, this ligament starts from the derma of the upper third of the nose, runs to the junction of the medial crus, and penetrates anteroposteriorly to help the formation of the fibrous septum. Pitanguy recommended transecting the ligament to eliminate tip dependency, thereby improving tip rotation, and/or resecting it to eliminate bulbosity.3 In contrast to Pitanguy, anatomic studies show that this ligament corresponds to the deep medial SMAS expansion.2,4
After a closed rhinoplasty, new tip projection can be achieved with numerous techniques, such as septocolumellar suture, intradomal sutures, and strut grafts. For the best nasal tip definition, it is necessary to operate on the components of the nasal SMAS.2 Recently, Cakir et al.5 suggested plication/resection and repair of Pitanguy’s midline ligament. Different from all of these, the author describes a new and simple way to reposition the point, thereby increasing the tip support mechanism and a creating a good supratip break point using the deep medial SMAS layer.
This closed-approach procedure begins with a bilateral standard intercartilaginous incision. After nasal dorsum elevation, bilateral transfixion incisions are made. A sharp scissor is used to expose the medial deep layer at the level of caudal septum. It is easy to detect this layer because separations of the anterior and superior are simply done, but at the top of the caudal septum where the deep layer attaches to the septum, it is necessary to cut for separation. After identification of the deep layer, a 4/0 Vicryl suture passes several times from the deep layer and the deep layer is cut from the caudal septum (Fig. 1). With the rotation of pulling suture, a new attachment point of the deep layer is determined. After deciding the point, the suture is passed deeply from the nasal cartilaginous dorsum and is anchored (Fig. 2). With this suture, 4 to 5 mm of tip projection can be achieved (Fig. 3).
During rhinoplasty, all anatomic structures and the relationships between them should be protected. If we cannot protect them, we should reconstruct again. In this article, a new and simple way to recreate the relationship between the nasal tip and the septum is described. It may be used as an adjunct method for supporting the nasal tip, controlling tip rotation, enhancing projection, and emphasizing the supratip break.
The author has no financial interest to declare in relation to the content of this article.
Taş Süleyman, M.D.
Department of Plastic, Reconstructive, and
Trakya University Medicine Faculty
Edirne 22030, Turkey
1. Numa W, Johnson CMAzizzadeh B, Murphy MR, Johnson CM, Numa W. Surgical anatomy and physiology of the nose. Master Techniques in Rhinoplasty. 20111st ed Saunders Elsevier:21–30
2. Saban Y, Andretto Amodeo C, Hammou JC, Polselli R. An anatomical study of the nasal superficial musculoaponeurotic system: Surgical applications in rhinoplasty. Arch Facial Plast Surg. 2008;10:109–115
3. Pitanguy I, Salgado F, Radwanski HN, Bushkin SC. The surgical importance of the dermocartilaginous ligament of the nose. Plast Reconstr Surg. 1995;95:790–794
4. Han SK, Jeong SH, Lee BI, Kim WK. Updated anatomy of the dermocartilaginous ligament of the nose. Ann Plast Surg. 2007;59:393–397
5. Cakir B, Oreroğlu AR, Doğan T, Akan M. A complete subperichondrial dissection technique for rhinoplasty with management of the nasal ligaments. Aesthet Surg J. 2012;32:564–574
Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:
- Text—maximum of 500 words (not including references)
- References—maximum of five
- Authors—no more than five
- Figures/Tables—no more than two figures and/or one table
Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We strongly encourage authors to submit figures in color.
We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.