Manipulation of the Nasal Superficial Musculoaponeurotic System to Enhance Midvault and Supratip Contouring

Management of dorsal dead space and the aesthetics of a supratip break are paramount to achieving reproducible and reliable results in rhinoplasty.

The authors present a modified technique of redraping the nasal soft tissue envelope in structural rhinoplasty by utilizing the nasal superficial musculoaponeurotic system (SMAS) to help obliterate dorsal dead space and restore normal anatomy, thereby enhancing midvault and supratip contouring.

A standard open rhinoplasty approach is utilized. A planar transition from supraperichondrial to subperichondrial/subperiosteal is completed during the dorsal dissection. The open structural rhinoplasty then proceeds as previously published by the senior author. After any desired tip work is completed, the cephalically based SMAS layer is reconstituted with suture fixation laterally along the caudal border of the upper lateral cartilages. A more robust technical discussion is borne out in the manuscript.

At submission, the senior author has performed >100 rhinoplasties employing this technique over roughly 1 year. Subjectively, patients have had better immediate supratip contour with less residual dorsal soft tissue edema. A case example with photographs is included at a 1 year postoperative time point.

Using this described technique, surgeons can employ an open, structural, approach to rhinoplasty while using restoration of natural anatomy to achieve a refined postoperative result, accentuating supratip break while minimizing dorsal soft tissue dead space.