Rhinoplasty: A Complete Subperichondrial / Subperiosteal Approach

Goals/Purpose: During a rhinoplasty, the soft tissue envelope is routinely disrupted which can result in significant scarring with prolonged aesthetic resolution and functional consequences. To avoid these problems, we have devised a new approach to rhinoplasty using a complete subperichondrial / subperiosteal dissection plane (hereinafter SSD).  As will be shown, SSD of the nasal framework allows reshaping and redraping of the nasal tip as well as controlled manipulation and repair of essential ligaments without disturbing the overlying soft tissue including the entire nasal musculature. 

Methods/Technique: A total subperichondrial/subperiosteal dissection (hereinafter SSD) was used in 228 rhinoplasties performed between May 2008 and April 2011. Using either a closed or an open approach, athe SSD is begun over the alar cartilages, continued onto the cartilaginous vault and then subperiostealy over the bony vault. Following elevation, modification of the dorsum and tip are completed. The dermocartilaginous (Pitanguy) and intercartilaginous (Saban) ligaments are identified, preserved, and repaired at the time of closure, emphasizing their results on the supratip skin and the internal nasal valve respectively. Tip projection was measured in 10 patients pre, intra and post operatively before and after repair of Pitanguy’s ligament.

Results/Complications: .  Revisional surgery was necessary in 17 cases for which a repeat SSD was performed easily due to minimal fibrosis as compared to a conventional revision. Measurement of the nasal tip projection in the aforementioned 10 patients revealed an average 3 mm loss in tip projection after dissection that was restored completely after the ligament repair. This restored projection gain was also shown to be lasting in the postoperative 1-month and 1-year measurements. Only 15 onlay tip grafts were used throughout the whole series for projection maintenance and only 12 supratip deformities were observed; thanks to the preservation of the tip projection due to ligament repair.  

Conclusion: SSD preserves the integrity and innervations of nasal muscles; and the dynamic effects they have on both the internal and the external nasal valves. The integrity of the external nasal nerve is preserved which minimizes postoperative numbness. Subjectively, the patients had minimal swelling and achieved their final result in a matter of weeks rather than months.