Discussion: The Influence of the Pitanguy Ligament on the Supratip Break Point in Open Rhinoplasty

The authors present an important, impactful, and unique outcomes-based addition to the field of rhinoplasty. Their article, “The Influence of the Pitanguy Ligament on the Supratip Break Point in Open Rhinoplasty,” brings critical attention to a pivotal yet often overlooked anatomical feature.1 The supratip break point is a key determinant of nasal aesthetics, and the Pitanguy ligament acts as a fascial leash, anchoring the nasal tip. This study explores how different surgical approaches to the Pitanguy ligament—leaving it untouched (group 1, n = 40), excising/resecting it (group 2, n = 40), or reconstructing it (group 3, n = 40)—impact the depth of the supratip area in primary open rhinoplasty. Through objective measurements using Adobe Photoshop, the authors quantified supratip depth at 3 and 12 months postoperatively, ensuring reproducibility and precision in their findings. The repair group (group 3), where the Pitanguy ligament was sutured with 5-0 polydioxanone suture to the underlying septal cartilage, demonstrated significantly superior results at 12 months compared with the untouched and excised groups. Notably, the excision group (group 2) exhibited marked changes between 3 and 12 months, suggesting that uncontrolled healing processes following ligament excision exacerbate supratip fullness, contributing to the pollybeak deformity. These results underscore the importance of preserving and reconstructing the Pitanguy ligament to optimize wound healing and maintain nasal aesthetics postoperatively. First described by Pitanguy in 1965, the Pitanguy ligament was later identified as fibers of the superficial musculoaponeurotic system extending toward the nasal tip, where they split into superficial and deep layers above and below the interdomal ligament.2,3 Laterally, these fibers merge with the vertical portions of the scroll ligaments.2–5 As the cartilaginous “tripod” alone may not effectively counteract the soft-tissue forces transmitted by the fascia, an unreleased Pitanguy ligament has been linked to residual nasal convexity, recurrent dorsal humps, and supratip deformities. Dividing this ligament reduces tension on the nasal tip and corrects convexity in the lower third of the nose.6,7 Although its significance in stabilizing nasal structures has been recognized, its specific impact on open rhinoplasty outcomes has not been fully elucidated. In a cadaveric study, Lisiecki et al. showed that in cases of significant repositioning of the nasal tip, the native Pitanguy ligament is typically positioned too distally and caudally relative to the new tip location.8 The Pitanguy ligament is truly an extension of the nasal superficial musculoaponeurotic system layer anatomically. Thus, release and reconstruction of the ligament after achieving the desired cartilaginous structure are required to avoid supratip deformity. This approach is crucial in closing dead space, reducing swelling, minimizing scar tissue formation, and ensuring consistent soft-tissue adaptation. The senior author (R.J.R.) routinely performs ligament reconstruction in reductive open rhinoplasties and revision rhinoplasty and those with thick skin. He has noted improved tip definition, fewer supratip deformities, and faster resolution of postoperative swelling, aligning with the current study findings. Despite its many strengths, especially as it is an outcomes-based rhinoplasty study, the current study has several limitations. The relatively short follow-up period of 12 months, while sufficient to evaluate primary healing, does not provide insight into long-term outcomes such as secondary soft-tissue remodeling or later deformities. The sample size, with only 40 patients per group, may also limit the generalizability of the findings, particularly considering the diversity of nasal anatomy across different populations. In addition, the predominantly female patient population raises questions about whether these results can be extrapolated to male patients, who often present with thicker skin and different structural considerations. In addition, future studies should provide more insights into the technical challenges associated with ligament reconstruction and long-term nasal stability. It is also important to note that although the study focused on primary rhinoplasties, the native fascial structures in secondary cases are harder to distinguish. Therefore, in secondary rhinoplasties, the senior author (R.J.R.) places an analogous suture in the underside of the soft-tissue envelope. This study is commendable for its focus on an underexplored aspect of nasal anatomy in open rhinoplasty. The authors provide a clear rationale for their techniques, grounded in anatomical understanding and supported by prior studies. This study is particularly important for its contribution to the integration of evidence-based principles into rhinoplasty literature, demonstrating the growing role of objective, data-driven methodologies in guiding surgical decision-making. By applying evidence-based medicine principles to a challenging and often subjective field, where a nuanced understanding of anatomical structures is critical for achieving desired outcomes, the authors set a high standard for future rhinoplasty research. These findings provide a strong rationale for incorporating ligament reconstruction into the standard open rhinoplasty technique after the desired cartilaginous structure and tip location are achieved. In conclusion, this study represents an excellent contribution to the rhinoplasty literature, offering valuable evidence-based insights into the role of Pitanguy ligament reconstruction in enhancing supratip aesthetics. The authors should be commended for this important work and contribution to refining open rhinoplasty techniques. DISCLOSURE Dr. Rohrich receives royalties from Micrins and Theime Publishers, and research funding from Allergan, Galderma, and Inmode. Dr. Brown is a paid consultant for Impedimed. Neither author has a financial interest in any of the drugs, products, or devices mentioned in this Discussion or in the associated article.