The Keystone, Scroll Complex, and Interdomal Area of the Nose: Histologic and Anatomical Observations

Interdomal ligament of the nose: Clarifying the anatomy through a cadaveric study

BACKGROUND

Over the years, the anatomical description of the nasal ligaments has been revisited several times. Although several authors have studied the structures supporting the nasal tip, there is a lack of literature that consistently describes the anatomy of the interdomal ligament. This study analyzed the anatomical variations of the interdomal ligament by describing the possible shapes and dimensions and confirming its ligamentous nature histologically.

METHODS

Twenty-five fresh cadaver noses of Caucasian descent, without signs of previous nasal surgery were dissected using an open approach. The interdomal ligament was identified, isolated, measured, and sent for histological examination. The statistical analysis was conducted using Prism9.

RESULTS

The average area of the interdomal ligaments of the whole cohort was 0.39±0.22 cm2. The mean ligament depth was 0.16±0.05 cm, and the mean interdomal distance was 1.38±0.32 cm. Overall, 58.3% of the ligaments showed a fusiform shape and the rest showed a trapezoidal shape. A correlation between the interdomal distance and length of the ligament was demonstrated with r=[0.7536]. The histological analysis of the interdomal ligament displayed a "fibrous-connective nature of the structure compatible with a ligament."

CONCLUSIONS

This study confirmed the ligamentous nature of the interdomal ligament and demonstrated its consistent presence in 24 cadavers, with the depth from the dome ranging from 0.10 to 0.24 cm. The data demonstrated that this ligament may have a fusiform or trapezoidal shape with a mean area of 0.39±0.22 cm2. Furthermore, a correlation exists between the major base of the ligament and the interdomal distance, with a ratio of 1.633.

Scroll Ligament Repair in Dorsal Preservation Rhinoplasty: A Cartilage as a Guide on Nasal Skin Envelope for Suturing

BACKGROUND

The scroll ligament provides support to the internal and external valve, and its repair in rhinoplasty provides good functional and aesthetic results. In this study, it was aimed to repair the scroll ligament complex by leaving cartilage in the nasal skin envelope, and clinical results were shared.

PATIENTS AND METHODS

216 patients who underwent closed preservation rhinoplasty with modified low septal strip septoplasty were included in the study. A 10 x 1 mm of cartilage is left in the nasal skin envelope at the midpoint of the cranial part of the lateral crus of the LLC, leaving it as a guide to repair the scroll ligament complex in the anatomically correct place. Demographic data, complications, revision surgeries, follow-up periods and satisfaction of the patients were analyzed retrospectively.

RESULTS

Residual humps were observed in 2 patients. Inferior turbinate hypertrophy was observed in 4 patients. In 1 patient, total septal reconstruction was performed. Two hundred and three patients were evaluated the results as poor, moderate, good and very good. One hundred and sixteen patients rated the functional outcome as very good, 80 patients as good, 4 patients as moderate and 3 patients as poor. One hundred and twenty-eight patients rated the aesthetic result as very good, 72 as good and 3 as moderate.

CONCLUSION

Repairing the scroll ligament complex provides both internal and external valve support, better redraping and eliminating the dead space. Leaving cartilage on the nasal skin envelope as a guide helps to repair the scroll ligament complex in the anatomically correct place at the end of the surgery.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors  www.springer.com/00266 .

[The alar vertical section or résection technique in rhinoplasty]

Nasal tip plasty is a real functional and aesthetical challenge in rhinoplasty. Many techniques have been described with different degrees of variability. The classic technique is the vertical division of the domes with section of the intermediate domes and directed healing without suture or cartilaginous grafting. The technique is based on an alar section or resection combined with a transdomal suture (STD) which allows control of the projection and rotation of the nasal tip.

The "3 Points Compartmentalization" Technique in Subperichondrial-Subperiosteal Dissection in Primary Rhinoplasty to Reduce Edema and Define Contour

Proper control of postoperative edema in rhinoplasty matters significantly, both regarding patient satisfaction and preventing loss of definition and aesthetic surface contour in the dorsum and tip. The "3 points compartmentalization" technique described in this paper aims to fulfill the above goals by (1) dissection in a subperichondrial-subperiosteal plane and (2) reducing the dead space by three strategically placed key sutures that compartmentalize the nose and redrape the single-plane dissection in an anatomically correct position.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Rhinoplasty Dissection Planes (Subcutaneous, Sub-SMAS, Supra-perichondral, and Sub-perichondral) and Soft Tissues Management

Rhinoplasty as an operation is akin to a game of chess, where every maneuver will influence the eventual outcome. Undoubtedly, more than one approach to the nasal soft tissues envelop can produce beautiful and safe results as will be described in the paper namely, the subcutaneous, sub-superficial musculoaponeurotic system, supra- and sub-perichondral planes. For different justifiable reasons surgeons have their preferences, regarding dissection planes on the tip, middle and upper thirds, and regarding the manipulation of the soft tissue layers and nasal ligaments. The concept of the nasal layers and the presence of relevant ligamentous structures and how to restore them in an anatomical fashion, will help to understand the logic behind various approaches.

Preservation Dorsal Hump Surgery: A Changing Paradigm

Preservative dorsal hump surgery is an old approach that has revitalized recently. Preservation rhinoplasty aims to shape the existing structures instead of resection/reconstruction approaches. A thorough understanding of the applied anatomy of the nose is the backbone of preservative hump surgery. In preservative hump surgery keystone works as a joint, and by lowering this joint the hump is eliminated.