Letter to the Editor New Instruments for Submembranous Dissection in Rhinoplasty Aesthetic Surgery Journal 2017, Vol 37(7) NP73 NP78 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com DOI: 10.1093/asj/sjx084 www.aestheticsurgeryjournal.com Süleyman Taş, MD, FEBOPRAS; and Nuri Celik, MD Editorial Decision date: April 18, 2017. The soft tissue of the nose covers the osseocartilaginous framework, which is composed of 5 layers: (1) the skin; (2) the superficial areolar layer; (3) the superficial musculoaponeurotic (SMAS) layer, separating the deep and superficial layers; (4) the deep areolar layer; and (5) the perichondrial/periosteal layer. 1-3 There are 3 main dissection planes in rhinoplasty: the subdermal, sub-smas, and submembranous planes. 4 The most commonly used plane is the sub-smas plane. On the other hand, submembranous plane (subperichondrial and subperiosteal plane) dissection is an important option, because it is bloodless and much less traumatic; therefore, it creates less postoperative swelling or ecchymosis, and it clearly exposes the cartilages, thus making them easier to shape. However, it is a challenge to traverse the subperichondrial plane; most rhinosurgeons do not even believe in its existence. 4,5 Entering the subperichondrial plane is a very difficult step, because the perichondrium is densely attached to the underlying cartilage. 6 Normally, blades or sharp-tipped scissors are used to find the subperichondrial plane, and this requires loupe magnification. However, the procedure is exhausting and time consuming and may damage the surrounding tissues and cartilage. 5 Therefore, there is good reason for beginners to give up on using this plane. Another factor to consider is the cartilage-bone junction. The perichondrium of the upper lateral cartilage continues with the inner periosteum of the nasal bones. 6 Therefore, passing through from the subperichondrial plane to the subperiosteal plane is another challenge that requires an instrument to separate the tissue layers. Here, the authors present 2 new instruments (TAS 1 and TAS 2, Elektron Medical Company, Ankara, Turkey) that have been designed and developed by the senior author (S.T.) to facilitate technical maneuvering of the submembranous plane. The senior author usually prefers the closed approach; however, the submembranous technique presented herein could also be applied easily in an open approach. 7 The supplemental surgical videos provide tips and tricks for the technique presented herein (Videos 1-4, available online as Supplementary Material at www.aestheticsurgeryjournal.com). Following the infracartilaginous incision, we use TAS 1, which has been developed for subperichondrial dissection. It has a special tip: one side is sharp and the other is blunt (Figure 1A). Its tip is pin point, so it only affects the point at which it is applied without damaging the surrounding tissues (Figure 1B). One can easily incise the perichondrium and go under the perichondrium with the sharp tip and then continue dissecting with the blunt side (Figures 2-3). Following the transfixion and intercartilaginous incisions, again, TAS 1 is used for subperichondrial dissection of upper lateral cartilage (Figure 4). When the dissection reaches the bone-cartilaginous junction (keystone area), it is difficult to enter the subperiosteal plane which is not continuous with the subperichondrial plane due to the complex anatomy of the junction. The perichondrium splits into 2 layers, the superficial and deep perichondrium, close to the osseocartilaginous Dr Taş is an Assistant Professor, Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul Kemerburgaz University, Istanbul, Turkey. Dr Celik is a plastic surgeon in private practice in Istanbul, Turkey. Corresponding Author: Dr Süleyman Taş, Istanbul Kemerburgaz University, Department of Plastic, Reconstructive and Aesthetic Surgery, Bakirkoy, Istanbul, 34145, Turkey. E-mail: drsuleymantas@live.com
NP74 Aesthetic Surgery Journal 37(7) A B Figure 1. (A) Side view of TAS 1 (left) and TAS 2 (right). (B) Anterior view of TAS 1 (left) and TAS 2 (right). Figure 2. Following the infracartilaginous incision, TAS 1 provides a clear subperichondrial plane on the lower lateral cartilages, as demonstrated on a 23-year-old woman. Its sharp tip is used to traverse the plane, and its blunt tip or a regular elevator is used to continue in dissection. Figure 3. This image summarizes the entire procedure, as demonstrated on a 25-year-old woman. As can be seen, the perichondrial layer is extremely thin and densely adhered to the lower lateral cartilage. However, by use of the TAS 1, the perichondrial layer can be easily identified and dissected, and one can observe the surgical planes in terms of bleeding: whereas the sub-smas plane is a bloody plane, the subperichondrial plane is a bloodless plane. junction. The superficial perichondrium is in continuum with the periosteum and the deep perichondrium covers the part of the upper lateral cartilage that extends under the bone (Figure 5). This transition area is called the transition zone. 7 TAS 2 serves to traverse the periosteum from the subperichondrial plane without leaving
Taş and Celik NP75 Figure 4. Following the intercartilaginous incision, TAS 1 also works on the upper lateral cartilage to obtain a subperichondrial plane, as demonstrated on a 28-year-old woman. Figure 5. Schematic demonstration of the keystone area. The perichondrium (blue) splits into two layers, the superficial and deep perichondrium, at the transition zone (red circle). The superficial perichondrium continues with the periosteum (yellow), and the deep perichondrium covers part of the upper lateral cartilage (gray) under the bone (orange). remnant periosteum or perichondrium on the junction. It has a wider, blunt, short, and L-shaped tip. Because its tip is L shaped, it sits on the bone-cartilage transition zone precisely to cut the perichondrium and an excellent bone-cartilage transition is established (Figure 6). In a regular rhinoplasty, the dissection extends to exposure the structures up to reconstruct the deformities. All surgical details and tips about submemranous dissection technique with presented novel instruments are demonstrated in Video 1 with closed approach and in Video 4 with open approach. These instruments have fragile and sensitive tips, so special protection heads are also designed to protect them from damage and extend their life. In addition, TAS 1 is very successful to enter subperichondrial plane during septoplasty and as well as otoplasty (Figures 7-8). The senior author experienced these instruments on 600 cases and the results are uneventful and no complication occurred by using them. Long-term results are demonstrated in Figure 9. Revision surgeries are very different situations because the approach depends on the case. However, we know that sharp dissection is essential in revision cases because a blunt dissection may cause tears and destruction of cartilaginous tissues. TAS 1 and 2 provide a kind and sharp dissection, so in revision cases, they are also successful. Specially, we realized that, in our revisions using the subperichondrial technique, it is much easier to elevate the perichondrium. In Videos 2 and 3, revision cases which underwent a rhinoplasty with the sub-smas technique in other clinics, we are presented with the submemranous technique. Is the subperichondrial dissection more bloodless than the conventional sub-smas plane? Absolutely, it is. As we all know, cartilages supply from perichondrium via diffusion and they do not have exact vessels except for the perichondrium layer. 8 In this layer, we can observe the capillary network and this network is supplied from vessels in the SMAS layer which is over the perichondrium, 9 therefore supraperichonrial dissection disturbs the connection between the capillary network of the perichondrium and vessels in the SMAS layer. Despite that, subperichondrial dissection protects these connections and supplement the perichondrial layer. Also, according to our observations, separation of the perichondrium from cartilages does not weaken the cartilages strength in the long term but it allows them to be shaped easily during the operation. Because, by the submemranous dissection, we protect the perichondrium, the supplement of the cartilages are minimally disturbed with the sub-smas technique. Because, by the sub-smas technique, one cuts all the vessel connections from the SMAS the perichondrium acts as a graft over the cartilages. However, by the submemranous technique, the supply of the perichondrium stays untouched and the cartilages are kept supplied by the perichondrium in a healthier manner (Figure 8). Is the subperichondrial dissection easier than conventional sub-smas? To enter the subperichondrial plane is very hard according to sub-smas but after entery, it is very easy to complete the subperichondrial dissection, it does not matter what you use, any instrument can be used such as a regular elevator, mosquito clamp etc. However, the presented instrument (TAS 1) makes it easier to enter the subperichondrial plane. It acts as a sharp needle tip blade. This design act needle tip surgical blade to puncture and penetrate the strong fiber attachments of the perichondrium at certain anatomical junctional sides. These instruments have fragile and sensitive tips, so special protection heads are also designed to protect them from damage, and to extend their life. In the classic sub-smas dissection rhinoplasty technique, it is impossible to protect the perichondrium, if an additional perichondrial elevation is not performed. 10 However;
NP76 Aesthetic Surgery Journal 37(7) Figure 6. TAS 2 serves to get under the periosteum from the subperichondrial plane without leaving remnant periosteum or perichondrium on the junction, and provides an excellent bone-cartilage transition, as demonstrated on a 19-year-old woman. the perichondrium helps to restore the stability of the cartilage and to achieve extra padding, particularly when the skin is thin. In addition, it provides a bloodless surgical plane, a clear exposure to shape the cartilage easily. 3,4,7,10 As is known, the subperichondrial plane is the standard plane for septoplasty to improve the healing process and prevent complications. Based on this, Çakır et al 4 used this plane for the rest of the nose. In this study, 228 patients were operated on with the subperichondrial technique via an open or closed approach. Although there was not a numeric examination on postoperative outcomes, they concluded that the subperichondrial technique resulted in less edema and a faster recovery compared with the authors previous experience with the sub-smas technique. Gruber et al 5 reported a commentary about this article as, although this is theoretically the correct way to protect the SMAS and ligamentous system, it is in practice hard, especially on upper lateral cartilages, and needs skill, therefore the advantages of this technique are debatable compared to the effort spent. The authors believe that with the new devices presented, this technique will be much easier and more favorable. The submembranous technique is really the only way to protect the soft tissue envelope over the cartilaginous structure. Using this plane, not only the scroll ligament but also the attachment of the scroll ligament to the mucosa can be Figure 7. TAS 1 can be used to enter subperichondrial plane during septoplasty, as demonstrated on a 21-year-old man. Figure 8. A complete submemranous plane elevation provides a complete avascular plane and protection of perichondrial layer, as demonstrated on a 23-year-old man. conserved (unpublished data). However, the Pitanguy system s (deep SMAS layer 2 ) attachment on the anterior septal
Taş and Celik NP77 A B C E Figure 9. (A, C, E, G) Preoperative and (B, D, F, H) 2-year postoperative photographs of a 28-year-old woman who has a 6 mm midline deviation, 16.5 dorsal deviation angle, a serious hump, and smiling deformity. Preoperative patency score was 3 out of 10. Left nasal airway was almost totally obstructed by the deviated nasal septum and there was a large right inferior concha. The surgical procedure included hump removal, rasping of the left nasal bone to correct the convexity, applying bilateral spreader flaps and a left spreader graft following septoplasty, tip plasty (via delivery technique, lateral crural steal to reposition of the dome, interdomal and cefalic intradomal sutures to achieve tip symmetry, deep SMAS layer suture to suspend and relocate the tip on the nasal dorsum), and concha surgery (lateralization and partial submucous resection of the right inferior turbinate). D F
NP78 Aesthetic Surgery Journal 37(7) G H Figure 9. Continued. angle will be disrupted; therefore, it should be repaired, which was also discussed by the senior author. 4 In experienced and adequately trained hands, any sharp instrument has major disadvantages. These instruments are designed for relatively experienced surgeons in rhinoplasty. Potential complications include inadvertent laceration of the cartilages penetration into the mucoperichondrial plane, tear in the mucosa, bleeding cause by in inadvertent injury to the blood vessels. Anyone who is using these instruments should be aware of the fact that they were specially designed for the surgical anatomical junctional sides for experts. Finally, these newly designed instruments have a thin and gentle tip to manage the tissues atraumatically. Thus, the edema and ecchymosis will be less than the routine dissection techniques. As we all know, less trauma, meticulous dissection, and atraumatic surgery will result in a faster healing process, less scar tissue, and optimum postoperative results, both early and late. We believe that the subperichondrial dissection technique may achieve these aims and that the presented instruments will serve to provide a complete submembranous plane dissection easily, quickly, and uneventfully. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures TAS 1 and TAS 2 were designed by the senior author (S.T) and patented by the Turkish Patent Institute (No: 2016/05472). These instruments are not yet commercially available. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Letourneau A, Daniel RK. The superficial musculoaponeurotic system of the nose. Plast Reconstr Surg. 1988;82(1):48-57. 2. Saban Y, Andretto Amodeo C, Hammou JC, Polselli R. An anatomical study of the nasal superficial musculoaponeurotic system: surgical applications in rhinoplasty. Arch Facial Plast Surg. 2008;10(2):109-115. 3. Taş S. A new way for supporting tip projection in closed rhinoplasty: using the medial deep SMAS layer. Plast Reconstr Surg. 2014;133:76e-77e. 4. Cakir B, Oreroğlu AR, Doğan T, Akan M. A complete subperichondrial dissection technique for rhinoplasty with management of the nasal ligaments. Aesthet Surg J. 2012;32(5):564-574. 5. Gruber RP, Belek KA, Barzin A. Commentary on: A complete subperichondrial dissection with management of the nasal ligaments. Aesthet Surg J. 2012;32(5):575-577. 6. Karacalar A, Korkmaz A, Içten N. A perichondrial flap for functional purposes in rhinoplasty. Aesthetic Plast Surg. 2005;29(4):256-260. 7. Taş S. Correcting the alar base retraction in crooked nose by dissection of levator alaque nasi muscle. Ann Plast Surg. 2016;77(4):383-387. 8. Togo T, Utani A, Naitoh M, et al. Identification of cartilage progenitor cells in the adult ear perichondrium: utilization for cartilage reconstruction. Lab Invest. 2006;86(5):445-457. 9. Ozkul HM, Balikci HH, Karakas M, Bayram O, Bayram AA, Kara N. Repair of symptomatic nasoseptal perforations using mucosal regeneration technique with interpositional grafts. J Craniofac Surg. 2014;25(1): 98-102. 10. Cerkes N. Concurrent elevation of the upper lateral cartilage perichondrium and nasal bone periosteum for management of dorsum: the perichondro-periosteal flap. Aesthet Surg J. 2013;33(6):899-914.