Complete subperichondrial rhinoplasty: A good tip for a good tip

By Christopher Walsh

A new and unconventional rhinoplasty technique minimizes soft tissue disruption, reducing bruising, edema, and numbness and making for a more speedy appearance of the final result, say researchers.

Unlike traditional approaches, the new technique also preserves ligaments that are crucial for maintaining the stability of internal and external nose structure. As a result, surgeons are able to repair and reconstruct those ligaments upon completion of the surgery.

According to Baris Çakir (Terrace-Fulya, Istanbul, Turkey) and colleagues, repair of Pitanguy's mid-line ligament allows surgeons to "control tip rotation, enhance projection, and emphasize a supratip break, while reconstruction of the scroll ligament provides stability of the internal nasal valve."

In an accompanying commentary in the Aesthetic Surgery Journal, Ronald Gruber (Division of Plastic and Reconstructive Surgery, University of California, USA) and co-authors commend the researchers on the skills necessary to carry out this intricate procedure.

However, they question whether it is in fact the preservation and repair of these ligaments rather than some other surgical variable that yields the observed results. In conclusion, they call for comparative, evidence-based studies to confirm the underlying mechanisms: "How much improvement in airway and supratip appearance actually results from the extra effort remains to be seen."

The researchers performed 228 complete subperichondrial and subperiosteal plane dissection (SSD) rhinoplasties and retrospectively reviewed the results over 9 months to 3 years of follow up. The surgeons used either the open or closed approach (in 92 and 136 patients, respectively).

Postoperative supratip deformity was observed in 17 (7%) patients, and overprojection of the tip in five patients. In total, only 12 (5%) patients required revised surgery.

Traditional rhinoplasty involves elevating the nose's soft tissue envelope in the subcutaneous or, more commonly, the sub-superficial musculoaponeurotic system (SMAS) plane. However, both of these approaches cause significant swelling and scar tissue remodeling, which delay the appearance of the final result.

The researchers claim that their approach, which minimizes disruption of the soft tissue, reduces the incidence of bruising, swelling, and numbness versus the sub-SMAS dissection technique.

Grubal and co-authors also question the finding that the SSD technique reduces edema, however, and they hypothesize that this reduction "may be related to their use of the closed approach in the majority of cases."

For those few patients who do return for revised rhinoplasty, there is comfort in the finding that repeated SSD is "easier in revision patients who had undergone a previous SSD procedure compared with primary or secondary cases in the series."

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