Commentary on: A complete subperichondrial dissection with management of the nasal ligaments.

The authors describe a new rhinoplasty operation that is entirely subperichondrial and preserves both Pitanguy's ligament and the scroll ligament. They believe that dissec-tion in the subperichondrial plane is less traumatic than in the sub-superficial musculoaponeurotic system (sub-SMAS) or subcutaneous plane and that restoring the integrity of the ligaments minimizes the potential for a supratip problem and helps restore valvular function. In 228 cases, they had only a 5% revision rate. What is exciting about the subperichondrial approach is that it is theoretically the best plane for dissection. Since the subperichondrial approach is best for the septum, why should it not be best for the rest of the nose? Moreover, restoration of normal anatomy (repairing the ligaments) is one of the most fundamental tenets of surgery. The authors extend the known anatomy of the nose established by Daniel 1,2 one step further and make us aware of the importance of the scroll ligament for valvular function, which has never been emphasized this much before. 3,4 The authors also make us aware of the importance of Pitanguy's ligament. Finally, we are impressed that they are able to perform this type of delicate surgery. We do believe that most surgeons use a subperichon-drial approach on the tip cartilages as they open the nose. However, as the upper lateral cartilages (ULC) are reached, the dissection becomes supraperichondrial because it has generally been considered too much effort to follow the perichondrium into the interstices of the scroll and get under the perichondrium of the ULC. We found that the authors are correct in that the scroll can be dissected out if one takes the time (Figure 1). The only time we remove the perichondrium of the ULC is if we want to be more precise with creation of the spreader flap 5-7 (often referred to as autospreaders 8) (Figure 2). We are not certain most surgeons will have the patience or technical skill to do so, as the authors suggest. Assuming the scroll ligament is necessary for function because it allows the SMAS to pull the ULC open, there is no hard evidence that the ligament does not reattach and provide a comparable result. Clearly, it is wise to bring the skin and scroll region into apposition as the authors suggest. Although it is a " poor man's " way of dealing with the authors' concern, we do inspect the intercartilaginous region in the …