Nasal Tip Rotation by Exclusive Superficial Musculoaponeurotic System Deep Medial Ligament Management

Abstract

The nasal tip constitutes the mobile portion of the nose, in direct contraposition to the pyramid that is a fixed structure. Its configuration, position, and shape are derived mainly from the outline and from the thickness of the wing cartilages, important elements of the nasal tip, that together with skin and subcutaneous tissue can deeply influence the configuration and dynamics of this section of the nose as well. In reshaping the nasal tip, 2 fundamental concepts must be considered: projection and rotation; these may be modified, acting on the nasal cartilaginous framework and/or on the superficial nasal fibromuscular structure (SMAS). The aims of this study are to evaluate the nasal tip changes in terms of rotation and projection obtained just acting on superficial muscle aponeurotic deep medial layer without performing any dissection or modification of the nasal tip framework, and to try to explain these possible changes according to the SMAS structure rearrangements only. Twenty-one patients (18 female and 3 male) were subjected to closed rhinoplasty, without tip cartilage dissection/modification. Preoperative and postoperative tip rotation angle, nasolabial angle, and tip projection were measured. The only tip procedure performed was the resection of the SMAS deep medial layer. Our results show significant rotation of the nasal tip and no statistically significant tip deprojection.

Clinical and morphofunctional identity of the nasal SMAS

“…The results of this study support the findings of other authors [ 29 , 30 ] who reported five layers of the nasal region, which are: the subcutaneous fatty layer, the fibromuscular layer, the profound fatty layer, the fibrous longitudinal layer, and a layer that contains interdomal ligaments. We consider that, at this level, the SMAS is represented by a second layer: a fibromuscular one, which interconnects with the alar muscles and distributes power to the dermis.…”

“…This was also observed during the dissection of specimens. At the base of the nasal pyramid, it appears that the superficial and deep fascia are joined in a dense connective structure, most likely the dermocartilaginous ligament [ 29 , 50 ]. To the medial side of the nasolabial groove, the superficial fascia becomes more obvious and mediates the cutaneous insertion of the zygomatic muscles.…”

The use of inter-alar ligaments flap for tip and supra-tip contouring in primary open structural rhinoplasty

“…16 Its surgical section, alone, determines nasal tip rotation. 17 The Pitanguy ligament is the main structural component of our interalar ligament flap. Its preservation and subsequent reattachment during rhinoplasty were previously cited in the literature 3,6,8,18 with conclusions mainly supported by experience (such as those on reduced swelling, tip rotation/ projection stabilization) or absence of a control group.…”