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The authors provide a well-designed anatomic study of the ligaments of the nose.1 They focused on the interdomal, intercrural, pyriform, and Pitanguy ligaments but were unable to find an actual footplate or sesamoid ligament. The authors’ schematics and cadaver photographs were easy to understand. What was most appreciated about their study was the organization and clarity of their rationale regarding the clinical purposes of these ligaments. The only incompletely unanswered questions regarding actual anatomic structural interpretation is whether Pitanguy’s ligament and the scroll ligaments2 are true ligaments or not. Clinically, of course, the answer to that is moot.

The conclusions of the authors did raise certain questions. They proposed a surgical philosophy in which ligament preservation should be a priority. In principle, this is absolutely correct. However, in practice, it is far too difficult and unnecessary. For example, successful secondary rhinoplasty demands the ability to first deconstruct the nose into its components before trying to reconstruct a normal nasal framework. If one starts carving away the fat and scar of an intact nasal framework hoping to find normal cartilage units, disappointment will often result. Thus, doing this often results in the entire nasal complex losing its integrity. It is far better to simply split the tip down the middle and arbitrarily find a division between the upper lateral cartilages (ULCs) and lower lateral cartilages (LLCs) to separate the two components (Figure 1). All important ligaments will be disrupted but at least there will be fundamental units (each of which has some structural integrity) which can then be put together. Even in primary rhinoplasty, ligament release should not be avoided if it means a better display of structural parts. For example, there should be no regard for the intercrural ligaments holding the right and left medial/middle crura together when trying to reshape the domes or to insert a columellar strut. A strut is invaluable to provide integrity, symmetry, and projection. Sutures to replace ligaments easily bring all the components back together. In the case of a bulbous tip, there is no real need to preserve the interdomal ligament. Reconstruction is relatively easy with the interdomal suture and/or the subdomal graft.3

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Rhinoplasty > Original Article
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