The Neo-Pitanguy Ligament: A Three-Flap Technique For Skin Tensioning

Background: Creating a stable, long-lasting supratip break continues to be a challenge, particularly in patients with moderate to severe skin thickness. Multiple techniques have been previously described to address this, including Pitanguy’s ligament preservation, re-suturing, and cartilage frame alterations to increase the tip-to-septal angle differential. Each have noteworthy limitations. Methods: The senior author developed a novel technique which utilizes the native Pitanguy ligament augmented by two bilateral, medially-based superficial musculo-aponeurotic system (SMAS)/soft tissue flaps. This reduces supratip dead space, prevents tissue glide while controlling supratip/tip shape and position. Results: Twenty-six (n=26) primary rhinoplasties in which the supratip and tip skin sleeve was of appropriate thickness were selected and followed for 1-year post operatively. The tri-laminar neo-Pitanguy ligament (NPL) technique was employed in all patients. Every patient maintained a varied degree of supratip break at an average follow up time of 14 months (range: 12-16 months). There was one revision requiring local anesthesia. No patients requested or were indicated for a return to the operating room. No cases of post-operative pollybeak deformity were observed. Conclusion: The power of this novel supratip control technique is multidimensional. It allows the surgeon to precisely control the location of supratip break, creating a broad based, diamond-shaped supratip depression. Tri-lamination with the use of the two SMAS/soft tissue flaps provides added strength, control, and long-term stability compared to simple suturing. Soft tissue tensioning above, around, and below the new tip complex prevents dorsal skin tissue glide and further secures the infratip/columella in appropriate position.