The Neo-Pitanguy Ligament: A 3-Flap Technique for Skin Tensioning

Creating a stable, long-lasting supratip break continues to be a challenge, particularly in patients with moderate to severe skin thickness. Multiple techniques have been previously described to address this, including Pitanguy ligament preservation, resuturing, and cartilage frame alterations to increase the tip-to-septal angle differential. Each has noteworthy limitations.

The senior author (A.G.) developed a novel technique that uses the native Pitanguy ligament augmented by 2 bilateral, medially based superficial musculoaponeurotic system/soft-tissue flaps. This reduces supratip dead space and prevents tissue glide while controlling supratip/tip shape and position.

Twenty-six primary rhinoplasties in which the supratip and tip skin sleeve was of appropriate thickness were selected and followed up for 1-year postoperatively. The trilaminar neo-Pitanguy ligament technique was used in all patients. Every patient maintained a varied degree of supratip break at an average follow-up time of 14 months (range, 12 to 16 months). There was 1 revision requiring local anesthesia. No patients requested or were indicated for a return to the operating room. No cases of postoperative pollybeak deformity were observed.

The power of this novel supratip control technique is multidimensional. It allows the surgeon to precisely control the location of supratip break, creating a broad based, diamond-shaped supratip depression. Trilamination with 2 superficial musculoaponeurotic system/soft-tissue flaps provides added strength, control, and long-term stability compared with simple suturing. Soft-tissue tensioning above, around, and below the new tip complex prevents dorsal skin tissue glide and further secures the infratip/columella in the appropriate position.

Therapeutic, IV.