SRF | 2021 SRF Session 6 Q&A - Update and clinical importance of nasal anato…
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Questions to Dr. Yves Saban
many thanks for listening the presentation and asking interesting questions. I will try to answer in the best way for clear understanding.
Preliminary remarks regarding nasal ligaments in rhinoplasty
1. Managing the ligaments means to decide:
- to protect, or cut, or even remove them
- to repair or not the attachments
2. In Preservation Rhinoplasty, the goals are
- to reduce the dead spaces that may cause fullness or even fibrosis that delays the healing process and may require cortisone injections or even revision surgery
- to allow for better drainage (vascular and lymphatic) in the postop period, thus reducing the swelling and the postop downtime.
3. How to achieve these aims?
Your 2 first questions are:
1. In patient need much change of the tip shape, we have to inevitably cut the ligament. Is there any difference in cutting the ligament and repairing it, compare to ligament preservation?
2. During the open rhinoplasty, Pitanguy’s ligament is usually cut. Is it can be the reason of supratip fullness?
Almost all patients need to modify their nasal tip, sometimes with important surgical procedures. Tip approach can be done in open or closed. In open if the tip is difficult (this does not mean important changes), in closed if the tip is “easy” or even does not need any change.
- In Closed approach; marginal incision (“open non open”) allows for complete exposure.
o In case of dissection limited to the LLC: No T-ligament injury, as the dissection ends at the level of the scroll, so no need for any repair.
o In closed approach, as well, if the dissection is pushed cranially from the LLC to the ULC or the dorsum, then 2 options:
§ Either the dissection is done subperichondrally; then no ligament injury as it is lifted together with the skin envelope. You can make re-attachment with sutures at the end of the procedure
§ Or the dissection is done sub-SMAS, and you have to pass through the ligament attachments in the scroll area. 2 options: suture it back or not.
o In closed approach, most of the ligaments can be protected
- In open approach we must distinguish the lateral undermining and the dorsal undermining
o Lateral underminingg corresponds directly to the endonasal concepts (see above)
o Dorsal approach requires to decide to pass
§ Either through the T-Ligament (deep Pitanguy); then many surgeons repair it or use it like a string, re-attaching it to the posterior edge of the medial crura.
§ Or to resect it in case of persistant fullness of the supratip related to the soft-tissues
§ Or to dissect vertically the deep medial ligament, without cutting or coagulating it, thus creating a space where we can go through in the direction of the dorsum.
- In my opinion, that needs further scientific researches, cutting the ligaments corresponds to cut a vascular bundle. So, 2 options: undermine them passing in the subperichondrial plan, or work in nasal spaces without damaging the ligaments: concept of “compartmented rhinoplasty”
3 Your 3rd question is: “You said that it is important to remove dead space by fixing T shape ligament on intended point after dissection of T shape ligament. How about taping instead of fixation of this ligament? The reason why I am asking this question is that this is my first time to listen fixation of T shape ligament although I have ever listened the fixation of Pitanguy’s ligament.”
Interesting question as well: Taping the skin Vs fixing the ligaments. In my experience, the question is mainly about the supratip area in the postoperative period of time.
- If the deep medial ligament (“Deep Pitanguy”) is repaired, there is no more dead space between the skin (soft tissues), the anterior septal angle and the domal area: the soft tissues are attached on the cartilages. It may create a fold directly related to the “soft tissues depression” that are pulled and attached in depth. This pseudo-fold will resorb with time in a few weeks, and may require some massages. Then, 2 options:
o if this suture is done on the cranial edge of the medial crura or intermediate segment, it maintains the tip projection at the desired level.
o If it is done onto the anterior septal angle, it keeps the position of the supratip without changing the tip position.
o Note that this procedure can be associated to sutures linking the cranial LLC to the lower ULC and even to the septum (Tebbet’s suture, if my memory is good), that is a very powerful suture.
- If the Deep medial ligament is not re-attached, then the soft tissues may be “floating” above the cartilaginous skeleton. In this inevitable dead space, blood clot, lymphatic swelling and fibrosis may occur. Then, 2 comments can be suggested:
o Taping, in my experience, is not able to apply strongly enough the soft tissues on the cartilages in the supratip area.
o Taping is always done for a limited period of time, always much shorter than the sutures