Dermocartilaginous Ligament Research Articles

The Role of the Depressor Nasi Septi Muscle in Nasal Air Flow

BackgroundMusculus depressor septi nasi and its tendon, the dermocartilaginous ligament, play an important role in external nasal valve and nasal respiration. If the ligament is cut during septorhinoplasty operations, nasal functions of the nose and facial expressions are affected. Therefore, the aim of this study was to investigate the role of M. depressor septi nasi in nasal respiration at open rhinoplasty operations using rhinomanometry and electromyography.MethodsThe study included 29 patients who had only external nasal deformity (nasal hump deformity). All patients underwent open rhinoplasty. The dermocartilaginous ligament of the patients in the study group (DCL + group) was repaired but not in the control group (DCL − group). Rhinomanometry and electromyography were applied to all patients preoperatively and postoperatively.ResultsIn the DCL − group, right and left nasal airflow values were significantly lower in post-op (562.92 cm3/s and 548.57 cm3/s), whereas right, left, and total nasal resistances were significantly lower in pre-op (0.28 Pa/cm3/s, 0.22 Pa/cm3/s, and 0.11 Pa/cm3/s). Statistically significant differences were not found between rhinomanometric measurements in pre-op and post-op values of the DCL + group. Post-op right, left and mean values of M. depressor septi nasi amplitude in the DCL + group (2.05 mV, 2.0 mV, 2.02 mV) were significantly higher than those in the DCL − group (1.52 mV, 1.61 mV, 1.57 mV).ConclusionRepair of the dermocartilaginous ligament during open rhinoplasty operations enhances nasal respiratory functions by expanding the external nasal valve through M. depressor septi nasi and allows the nose to participate in mimic movements.Level of Evidence IVThis 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.

Adjunctive Use of the Dermocartilaginous Ligament for Dorsal Irregularities in Primary Rhinoplasty.

Nasal dorsal irregularity is a common postrhinoplasty complication in spite of meticulous smoothing. Utilization of the dermocartilaginous ligament in 2 different fashions for different purposes was described before. A novel utilization of the dermocartilaginous ligament as a flattened and pedicled flap from the cephalic attachment for nasal dorsal irregularities was presented in this article. This surgical technique was applied in 11 cases. Eight of them had thin skin, 2 had skin with medium thickness, and 1 had thick skin. They were followed on an average for 27 months (between 6 and 37 months). All of the patients had satisfactory esthetic results, and there was no apparent irregularities observed over the nasal dorsum. No complications such as infection or hematoma occurred during the early or late follow-up periods. Instead of discarding the dermocartilaginous ligament, it can be used adjunctively to conceal the nasal dorsal irregularities to attain a smoother dorsal nasal surface by increasing soft tissue cushion over the osseocartilaginous dorsum. Transposing of the dermocartilaginous ligament also relieves dynamic drooping of the nasal tip, shortening of the upper lip, and undesirable gingival display.

Commentary on: The Lower Nasal Base: An Anatomical Study

In “The Lower Nasal Base: An Anatomical Study,” Dr Daniel and his coauthors undertook the dissection of 45 cadaver noses to fully appreciate the anatomy of the lower nasal base. This is an often neglected and not fully understood anatomical region1,2 consisting of the columellar base, nostril sills, and alar lobules. Their dissections are simply some of the best that our readers will ever see. The authors begin by clearing up some common misconceptions: (a) there is, in fact, a distinct lower nasal base consisting of the columellar base, nostril sills, and alar lobules; (b) the medial border of the levator labii superioris alaeque nasalis (LLSAN) becomes the defining muscle of the alar crease; (c) more than 1 muscle depresses the nasal tip (eg, the LLSAN), although the depressor septi nasalis (DSN) is usually attributed to be the only muscle responsible for that; (d) the transverse line or fold that occurs on forceful smiling represents the junction between 2 components of the orbicularis; and (e) the entire alar lobule is actually devoid of cartilage. The authors also clarify some debatable issues, including the idea that the DSN is a paired muscle that originates from the maxilla just above the medial incisor and the concept that Pitanguy's ligament is not a true dermocartilaginous ligament because if it were, it would contradict the 5-layer laminate concept of the nasal soft tissue envelope.3 Their video gives a nice demonstration of the distinct tether that allows the tip to be pulled down by muscular contracture, an action that involves …

Treatment of Hyperdynamic Nasal Tip Ptosis in Open Rhinoplasty: Using the Anatomic Relationship Between the Depressor Septi Nasi Muscle and the Dermocartilaginous Ligament

Smiling causes a deformity in some rhinoplasty patients that includes drooping of the nasal tip, elevation and shortening of the upper lip, and increased maxillary gingival show. The depressor septi muscle leads this deformity. The dermocartilaginous ligament originates from the fascia of the upper third of the nose and extends down to the medial crus, merging into the depressor septi muscle. In this study, 100 primary rhinoplasty patients were studied for hyperdynamic nasal tip ptosis. Of these patients, 36 had hyperdynamic nasal tip ptosis due to hyperactive depressor septi nasi muscle. The dermocartilaginous ligament was used as a guide to reach the depressor septi muscle in open rhinoplasty. Muscle excision was performed just below the footplates of the medial crura. A strong columellar strut graft was placed between the medial crura to avoid narrowing of the columellar width resulting from tissue excision and to withstand activation of depressor septi muscle remnants. No complications such as infection or hematoma occurred in the early postoperative period. The technique corrected the hyperdynamic nasal tip ptosis, increased upper lip length, and decreased gingival show when patients smiled. There was no narrowing of the columellar width. No depression in the columellar-labial junction due to distal resection of the depressor septi muscle was observed. The dermocartilaginous ligament can be used as a reliable guide to reach the depressor septi muscle in open rhinoplasty. Therefore, the hyperactive depressor septi muscle can be definitively identified and treated without an intraoral approach. 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 at www.springer.com/00266.

Intranasal Approach for Manipulating the Depressor Septi Nasi

A hyperactivated depressor septi nasi is an important factor contributing to nasal tip drooping. Although many studies have examined this, its treatment remains controversial. This study presents a surgical intervention based on an anatomic study.Ten fresh cadavers with large noses were used for the anatomic study. Between April 2008 and September 2010, 20 patients underwent surgical intervention for hyperactivated depressor septi nasi.In all of the cadaver dissections, the depressor septi nasi was present, although it was difficult to identify the muscle clearly in 6 of the cadavers. We found that the depressor septi nasi in the other 4 cadavers consisted of 3 fascicles. The medial fascicles were divided into superficial and deep fibers. Both the deep and superficial fibers were inserted into the dermocartilaginous ligament in the nearby nasal tip. After the superficial fibers were interdigitated with the orbicularis oris, they originated from the alveolar bone. The deep fibers originated at the anterior nasal spine. The intermediate fascicles inserted to the footplates of the medial crus and caudal septum. After interdigitating with the medial fascicles and orbicularis oris, they also originated from the alveolar bone. The drooping nasal tips were improved in all cases using an intranasal approach to manipulate the depressor septi nasi. No specific complication was seen. Surgical intervention of a hyperactivated depressor septi nasi using an intranasal approach was a useful method for correcting a drooping nasal tip.

An Anatomical Study of the Nasal Superficial Musculoaponeurotic System

To give a unifying description of nasal muscles and ligaments corresponding to anatomical and surgical findings such as the dermocartilaginous ligament described by Pintanguy in 2001. In 30 fresh cadavers of white individuals, nasal dissections were performed, divided into 3 different approaches: from radix to nasal tip, from nasal tip to radix, and from midline to lateral. The anatomical and surgical planes of dissection were followed to isolate the nasal superficial musculoaponeurotic system (SMAS). Correlations between the nasal SMAS and the nasal framework were noticed. In 9 specimens, the left nasal wall was resected for histologic examination. The nasal SMAS consists of a unique layer, and it divides at the level of the nasal valve into deep and superficial layers. Each layer has medial and lateral components. The dermocartilaginous ligament corresponds to the deep medial expansion. Both the deep and the superficial medial expansions correspond to the lowering ligaments of the nasal tip; the cephalic rotation of the nasal tip is allowed by their cut. The histological examination showed that the deep lateral expansion is composed of fat. This description of the nasal SMAS explains the relationship between the nasal muscles and ligaments, including the dermocartilaginous ligament described by Pitanguy. Furthermore, it is helpful to surgeons during rhinoplasty.

Updated Anatomy of the Dermocartilaginous Ligament of the Nose

Pitanguy conducted a series of anatomic studies on the dermocartilaginous ligament of the nose. However, information on its structure is as yet insufficient. In addition, some of the histologic findings described by Pitanguy are controversial. The present study was undertaken to clarify the anatomy of the dermocartilaginous ligament. Sixteen cadaver noses were examined macroscopically and histologically to determine the presence, origin, insertion, composition, and relationship of the dermocartilaginous ligament with surrounding structures. There was no direct connection between the dermocartilaginous ligaments and dorsal nasal skin. This structure originated from the deep layer of the transverse nasalis muscle and terminated at the caudal edge of the septal cartilage and orbicularis oris muscle in some cases. Our histologic findings were incompatible with the use of the term ligament and demonstrated that it was in fact a fascia. Unlike Pitanguy's findings, no muscle fibers or chondrocytes were identified within the dermocartilaginous ligament.

The Effect of Releasing Tip-Supporting Structures in Short-Nose Correction

Correction of a short nose has been regarded as one of the most challenging and at times vexing procedures in rhinoplasty. One surgical option used to prolong nasal length is the freeing of the alar cartilages from adjacent structures by dividing the nasal tip supporting tissues. Five fibrous connections are known to be important in maintaining the nasal tip shape: fibrous tissues between the upper lateral and lower lateral cartilages; the lateral border of the lower lateral cartilages at the pyriform aperture; the interdormal ligament and anterior septal angle; the footplate of the medial crus and septal cartilage; and the dermocartilaginous ligament. This study was designed to determine which of the fibrous connections providing nasal tip support offer the most effect of lengthening when these structures are divided. We performed 10 open rhinoplasties on fresh cadavers, and we sequentially divided the previously mentioned tip-supporting structures, except the dermocartilaginous ligament. The mucoperichondrium of the upper lateral and septal cartilages was also elevated, in accordance with the usual order of being released in a short-nose correction procedure. We measured the distance between the anterior septal angle and tip-defining points by using calipers while the middle crura of the lower lateral cartilages were stretched with a skin hook. We found that the most effective length was gained by severing the lateral crus from the upper lateral cartilages, and moderate gain was noted from the release at the pyriform aperture and mucoperichondrium of the upper lateral cartilage. Release of other tip-defining structures was not statistically effective.

The “Levator Septi Nasi Muscle” and Its Clinical Significance

It is strange that all textbooks of anatomy describe the depressor septi nasi muscle singly, without an antagonist. Incidentally, in 1986, a small rod of soft tissue was found between the medial crura of the two alar cartilages during a rhinoplastic operation with the external approach technique of Anderson and Ries. From 1990 through 1995, anatomic dissections of the nasolabial region under 3.5× loupe magnification were performed on 14 Chinese formalin-preserved cadavers, one fresh Chinese cadaver, and one fresh American white female cadaver. The small softtissue rod was found in every one of the dissected cadavers, and it was seen to be a pair of muscles. Each one of these paired small muscles arose from the aponeurosis on the dorsum of the nose and inserted into the muscular substance of the upper lip at the base of the columella and to the anterior spine of the maxilla. Histologic examinations of these muscles stained with hematoxylin and eosin and Masson trichrome showed that they were striated muscles. According to its origin and insertion, this newly found muscle was called the “levator septi nasi.” Its clinical significance in cleft lip deformity and its relations to the orbicularis oris muscle, the dermocartilaginous ligament of Pitanguy, and the nasal superficial musculoaponeurotic system of Letourneau and Daniel are all discussed. (Plast. Reconstr. Surg. 109: 1707, 2002.)

Anatomy of the median part of the septum depressor muscle in aesthetic surgery.

When a person smiles and talks, everyone in his or her own specific way, it can be noticed that the tip of the nose drops and the upper lip shortens, making the nasolabial angle more acute. The importance of the upper lip in the dynamics of the nose makes necessary a more detailed study of the morphology and anatomical relations of the median part of the nasal septum depressor muscle, contributing in this way to new techniques in plastic surgery. The authors proposed to study the anatomy of the nasal septum depressor muscle and its relationship with the dermocartilaginous ligament of Pitanguy and the upper lip, important components of the nasal dynamics of facial expression. In this way they seek to contribute to the treatment of the nasal tip in aesthetic rhinoplasties.

The Surgical Importance of the Dermocartilaginous Ligament of the Nose

The dermocartilaginous ligament of the nose, as first described by the senior author, has been shown to influence the equilibrium of the dorsum-tip relationship. In some noses, this is manifested by a residual convexity after routine rhinoplastic management of the osteocartilaginous structures. The anatomic findings are reported, and surgical considerations are analyzed. A system of classification based on the thickness of the ligament has been shown to be helpful in the intraoperative evaluation of this structure.

The Surgical Importance of the Dermocartilaginous Ligament of the Nose

The Surgical Importance of the Dermocartilaginous Ligament of the Nose

Revision Rhinoplasty

The increasing number of secondary surgeries following rhinoplasty is generally due to excessive removal of cartilage, bone, and lining. The patient is often dissatisfied and demanding, and the surgeon must analyze an altered anatomy with inadequate tissues. A proper diagnosis will reveal specific problems; the functional, psychological, and cosmetic aspects of each case should be considered. The nasal deformity should be analyzed in the context of the face as an aesthetic unit. Surgery is usually deferred until resolution of healing and softening of tissues has occurred. In most cases secondary correction requires the placement of additional tissue, which should always be of autogenous origin. In some cases the drooping-tip deformity can be treated by the simple dissection and division of the dermocartilaginous or Pitanguy's ligament of the nose.

Gortarez, J. L. M., et al. Rhinopolasty in mestizo nose—Sectioning of the dermocartilaginous ligament of Pitanguy and use of the chip graft on the nasal tip (300 consecutive cases). (English—Portuguese)

Gortarez, J. L. M., et al. Rhinopolasty in mestizo nose—Sectioning of the dermocartilaginous ligament of Pitanguy and use of the chip graft on the nasal tip (300 consecutive cases). (English—Portuguese)