Aesth Plast Surg

https://doi.org/10.1007/s00266-019-01436-z

ORIGINAL ARTICLE RHINOPLASTY

Scroll Ligament Preservation and Improvement in Nasal Tip

with the Room Concept
Güncel Öztürk1

Received: 15 February 2019 / Accepted: 18 June 2019

Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2019

Abstract noteworthy benefit of this technique. This is a safe, con-

Introduction In rhinoplasty operations, concavity and trolled and easily applicable technique that can be applied
convexity have a particular place in terms of aesthetic and to generally every patient without the need for additional
functional problems. To fix the problems associated with grafts.
concavity and convexity, several techniques were reported Level of Evidence IV This journal requires that authors
for straightening of the lower lateral cartilage (LLC). The assign a level of evidence to each article. For a full
scroll ligament and its associated tissues can be preserved, description of these Evidence-Based Medicine ratings,
and a better nasal tip can be obtained after the surgery. The please refer to the Table of Contents or the online
purpose of this research is to present a new, more com- Instructions to Authors www.springer.com/00266.
fortable and more practical technique to overcome the
problems associated with LLC. Keywords Rhinoplasty
Scroll ligament
Lower lateral
Methods The records of 190 patients who were operated cartilage
on with this novel technique were assessed retrospectively.
In the present ‘‘superior-based sliding flap’’ technique, the
LLC remained thick and stable; therefore, a particular Introduction
functional improvement was achieved. Additionally, the
scroll ligament was preserved, so this technique prevented Rhinoplasty is a leading type of plastic surgery, and the
the accumulation of skin at the nose tip. Patients were number of rhinoplasty operations performed becomes
evaluated using the ‘‘Rhinoplasty Outcome Evaluation’’ higher every day. According to the data of the International
(ROE) 12 months after the surgery. Society of Aesthetic and Plastic Surgeons, there will have
Results The median patient age was 24.3 years. Among 190 been 877,254 rhinoplasty operations by the year 2017, and
patients, 23 were male (12.1%) and 167 were female (87.9%). in the USA, 38,659 patients had rhinoplasty operations by
All patients included in the study completed the ROE ques- the year 2017 [1, 2]. Because of the popularity of rhino-
tionnaire. Patient satisfaction was excellent, registering at 95% plasty, there have been many techniques developed for
of the included cases. In the assessment of nasal obstruction, it improving both the medical and cosmetic results. The
was found that the patients’ patency score increased to 8.8 lower lateral cartilage (LLC) is the main anatomical
from 6.2 (out of 10) after the 12-month follow-up (p \ 0.001). structure for enhancing the shape and function of the alae.
Revision surgery was not needed in any patient. The position of the lower lateral cartilage is particularly
Conclusion The ability to have control over the LLC for critical for sufficient valve function, and this cartilage is the
all shapes via suturing two different points together is a most important part of the lateral wall [3–8]. Cephalic
malposition of this cartilage can cause inadequate support
to the nasal alae and thus results in insufficiency of the
& Güncel Öztürk
external nasal valve during deep inspiration [9–11]. The
info@guncelozturk.com
cephalic trim of the LLC has been considered as a tradi-
1
Private Practice in Istanbul, Turkey tional procedure for fixing and increasing the nasal tip

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rotation and leaving the alae more aesthetic. This method between 1 March 2016 and 2 February 2018. All proce-
was reported to be performed to correct a boxy tip, unro- dures were performed under general anaesthesia.
tated tip or over-projection [12, 13]. Beside the advantages The present research was performed according to the
of this method, some disadvantages can be regarded, such Declaration of Helsinki for biomedical research on human
as aesthetic issues including alar retraction, pinched tip and subjects. Before the operations, all patients were informed
postoperative nasal asymmetry. that their photos could be published for scientific purposes,
In rhinoplasty operations, concavity and convexity have and all patients whose records were used in the present
a particular role in aesthetic and functional problems. To study approved written informed consent.
fix the problems associated with concavity and convexity, Patients were evaluated using the ‘‘Rhinoplasty Out-
several techniques were reported for straightening of the come Evaluation’’ (ROE) 12 months after the surgery. The
LLC. Other common techniques for solving the problems ROE questionnaire is an objective instrument to assess
related to concavity are lateral crural graft and suturing the patient satisfaction with postoperative rhinoplasty results
LLC over itself after dividing it vertically and flipping it [19]. This scale was created with Alsarraf for evaluating
over [5, 14]. The domal suture technique is the most the results from facial aesthetic procedures according to
popular procedure for fixing the convexity [15]. Addi- patient satisfaction. The main factors that influence patient
tionally, the lateral crural graft, transdomal suture, lateral satisfaction concerning the surgery are: the physical issue,
crural strut, lateral crural spanning suture, transdomal assessed by patient satisfaction in terms of nasal shape and
suture and superior-based sliding flap were reported to be function; the emotional issue, estimated by the degree of
effective for fixing the convexity problem [16–18]. confidence and desire to change appearance; and the social
The purpose of this research is to present a new, more factor, assessed by social, professional and family accep-
comfortable and more practical technique to overcome the tance. This scale is useful for objectively assessing the
problems associated with LLC. results of rhinoplasty in both private settings and research.
It includes six questions about nasal aesthetics and func-
tion. The answers were scored between 0 and 4 points, with
Materials and Methods 4 representing the best score. The final score was multi-
plied by 100 after being divided by 24. A final score greater
The present study was designed to be retrospective. The than 85 was accepted as an excellent score and denotes
records of patients admitted to our private clinic for high patient satisfaction.
rhinoplasty operation were assessed. The data of 360 The subjective evaluation was carried out with a ques-
patients admitted for rhinoplasty operations were investi- tionnaire in which each patient scored their breathing
gated. The inclusion criteria were as follows: having quality with a respiratory score of 1 (poor) to 10 (excel-
unoperated nasal deformities, having a delivery approach lent). The patency score was assessed based on these
including a medially elongated infracartilaginous incision reports before and after the surgery.
and unilateral cephalically positioned transfixion incision Surgical steps were as follows;
and admission for rhinoplasty operation. In detail, patients
Step 1 General anaesthesia was given to the patient.
who have been suffering from long noses or nasal defor-
Adrenaline was injected at a dilution of 1:100,000. Inner
mities in normal-length noses were included. Patients were
nasal hair was cut. Closed rhinoplasty was performed.
candidates for these techniques as follows: (1) patients
Step 2 An infracartilaginous incision was made on the
without alar wing retraction; (2) patients who had an LLC
caudal edge of the lower lateral cartilage (Fig. 1).
larger than 6 mm; and (3) patients who were willing to be
Step 3 Lower crural cartilages were delivered (Figs. 2,
operated on with this technique after they received detailed
3). The LLC was straightened. The LLC was measured
information about the procedure. Exclusion criteria were as
and found to be 11 mm (Fig. 4). On the caudal side of
follows: (1) patients with alar wing retraction; (2) patients
the alar cartilage, 6 mm of tissue was maintained intact
who had an LLC smaller than 6 mm; and (3) patients who
(Fig. 5). The area 6 mm below the caudal side of the alar
did not accept this technique after being informed.
cartilage was marked for undermining (Fig. 6). The
According to inclusion and exclusion criteria, the records
cranial side was also undermined. The part of the alar
of 190 patients were considered to be included the study.
cartilage placed at the superior side and fixed to the
The median age was 24.3 years. Among 190 patients, 23
scroll ligament was signed for replacing this part on the
were male (12.1%) and 167 were female (87.9%). All
inferior side (Fig. 7). The additional 2 mm of cartilage
patients included in the study completed the ROE ques-
was excised (Fig. 8). The scroll ligament was protected
tionnaire after the 1-year follow-up. The follow-up period
with the 3-mm superior-based sliding flap technique
ranged between 12 and 26 months (median of
15.2 months). The same surgeon performed all procedures

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Fig. 1 Incision on the caudal edge of the lower lateral cartilage Fig. 4 Measurement of alar cartilage

Fig. 2 Lower crural cartilages were delivered. LLC lower lateral

cartilage, LSL longitudinal scroll ligament, SL scroll ligament

Fig. 5 Maintaining the caudal side of the alar cartilage

(Fig. 9). The superior part of the LLC was placed and
sutured into the undermined area (Fig. 10).
Step 4 After lower crural cartilages were directed
outward without separating the lower and middle rooms,
they were dissected on the Pitanguy ligament towards
the dorsal side, and the scroll ligament was left intact.
Step 5 A crural steal was made. Horizontal mattress
intradomal sutures were applied on the cephalic dome.
Step 6 Overlapping horizontal sutures were applied on
the medial crurals.
Step 7 Interdomal sutures were applied. Strut grafts were
placed and fixed with horizontal mattress sutures
Fig. 3 Lower crural cartilages were delivered (Fig. 11).

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Fig. 8 Demonstration of protection of the scroll ligament. Excising

the additional cartilage
Fig. 6 Signing the caudal side of the alar cartilage for undermining

Fig. 9 Excising the additional cartilage

Fig. 7 Signing the part of the alar cartilage which was placed at the
superior side fixed to the scroll ligament follow-up process. The results were highly sufficient for
patients and the surgeon (Figs. 12, 13, 14).
Results

The postoperative results were satisfactory. After physical Discussion

examination and assessment of postoperative photographs,
it was noted that there was no asymmetry or functional The anatomical structure of the nasal tip is mainly
problems in all participants. approached on the factors of the nasal tip size, shape,
Twelve months after the surgery, ROE Scores ranged symmetry and contour. There is a close relationship
between 80 and 100 points. The median score was 90.5 between the morphologies of the septum and lower lateral
points. Patient satisfaction was excellent in 95% of the cartilage (LLC) and these factors. A commonly seen
included cases. deformity of the nose is called droopy tip, where nasal tip
In the assessment of nasal obstruction, it was found that inferior rotation can be observed. Ensuring a solid structure
the patient patency scores increased to 8.8 from 6.2 (out of for the nasal anatomy comes down to the strengths, shapes
10) after 12 months follow-up (p \ 0.001). There was no and volumes of the following areas: upper to lower lateral
need for revision operation in any patient during the cartilage attachment of soft tissue, the medial crura to

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Fig. 10 Suturing the superior

LLC into the undermined area

Fig. 11 Interdomal suturing

and placing of strut grafts

Fig. 12 Comparison of external

and internal valves with video
endoscopy images in the sample
patient before and after the
surgery

septal cartilage caudal-end attachment, and both crura. The the tip and incompetence of the external valves are the
nasal tip takes its essential form and is affected in unison varying circumstances where cephalic positioning of the
by the shape, size and position factors of the LLC. lateral crura is being applied.
Underprojection, boxiness and parenthesis deformities of

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Fig. 13 Demonstration of a
sample patient before and after
the surgery-1

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Fig. 14 Demonstration of a
sample patient before and after
the surgery-2

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Different factors are in effect in regard to the result of an

operation on the nasal tip. After cephalic positioning of the
lateral crura, if a negative condition remains either under-
diagnosed or unnoticed, it can lead to complications.
Tip projection, tip angle, dorsum–supratip, dorsum–tip,
tip–columella and columella–nasolabium relationships, rim
axes, nostrils and accompanying asymmetries were the
topics where aesthetic and medical problems were
observed in the patients. Complaints and issues included
that the nose projection and tip are droopy, the nasolabial
angle is 70 degrees, the nose-to-face length ratio is high,
the nasal base is wide, the nostrils are large and loose, the
nasal dorsum–supratip and supratip–nasal tip relationship
is flat, in other words, slightly touching. This problem is
demonstrated in Fig. 14.
The lower room is altered to provide a change of posi-
tion type. While a bilateral infracartilaginous incision is Fig. 16 LLC lower lateral cartilage, ULC upper lateral cartilage, VSL
used to reach the lower room, the scroll and Pitanguy vertical scroll ligament, LSL longitudinal scroll ligament, NB nasal
bone, PAL pyriform aperture ligament, PL pyriform ligament
ligaments are preserved. In the cephalic part of the LLC,
the scroll ligament is left intact and is released by a
Cephalic trimming is a common method that applies a
superior-based sliding flap. To reach the middle and upper
smaller bulbous and upward rotated nasal tip. It is a useful
rooms, only unilateral transfixion and very short upper
technique for aesthetic tip [22]. However, in some cases,
backcut subsequent intercartilaginous incisions are inter-
cephalic trimming of the LLC can cause disruption of the
rupted. In this section, the lower and middle rooms are not
scroll area that results in an unpleasant appearance of the
bonded together, thus creating two separate rooms [20]
tip and functional decay. Furthermore, there can be several
(Figs. 15, 16).
long-term complications such as a disfigured tip which can
The rhinoplasty operations were regarded to be complex
be associated with a damaged scroll area, surgically created
because of the anatomy of the nose. The anatomy of the
dead spaces, scar contractions, weakened cartilaginous
nose was separated into three parts (upper, middle and
support or age-related losses in cartilage [23].
lower) for better understanding by the rhinosurgeons. This
LLC protective techniques have been improved recently
anatomy knowledge has to be regarded particularly for the
[24]. In this technique, the main purpose is increasing LLC
prevention of complications. The upper third zone is sep-
strength and getting more powerful aesthetic results. In
arated from the middle one-third by a perichondrial–pe-
several methods, the cephalic part of the LLC is separated
riosteal junction called the transformation zone. The
from the scroll area and upper lateral cartilage (ULC) and
middle one-third is separated from the lower one-third with
then inserted into a pocket, laid over the remaining part, or
the deep superficial musculoaponeurotic system (SMAS) in
used as mini spreader flaps [25–34]. Although these
the centre and the scroll area in the lateral part [21].
methods were reported to lead to the stability and support
of the LLC and fixation of the concave or convex surfaces,
they could not protect the scroll area. Some authors
reported that this problem could be solved with several
suturing techniques [35, 36]. Indeed, the best way is pro-
tecting the scroll area. Recently, Taş reported that the
scroll area could have been protected with his ‘‘superior-
based transposition flap’’ technique. This is the only study
that mentioned scroll area protection during rhinoplasty
operation [37].
In the present study, the author represents a new tech-
nique named ‘‘superior-based sliding transposition’’. The
superior-based sliding flap (SBSF) technique maintains the
entire association between the ULC and LLC. This tech-
nique leads to the prevention of complications including
Fig. 15 Upper–middle–lower rooms (division of the sections by trapped tip, external and internal valve collapse and
scroll, Pitanguy and pyriform Ligaments)

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projection loss and prevents late complications, such as alar affecting the structure of the alar wing in the concave or
retraction and nasal tip asymmetry. This method will also convex direction. (5) With this technique, the front and
be able to decrease the numbers of revision operations. middle rooms are restored in a separate plane from each
Using an intracartilaginous approach prevents the harmful other. In this way, the vertical and horizontal bonds of the
effects of intercartilaginous incision on the marginal inci- scroll ligament are preserved, which prevents the accu-
sion, shift site and soft triangle. In the present method, mulation of skin at the nose tip. (6) Definition of the nose
superior intercartilaginous and unilateral transfixion inci- has been made more smooth and fine. (7) The scroll liga-
sions were used to reach the nasal dorsum and an ment is cut and then sewn in some other techniques, but it
infracartilaginous incision was applied for the tip plasty. will never provide the definition of the nose as in our
Thus, possible asymmetries that might be associated with technique.
postoperative scar formation were excluded and the sliding The present study has several limitations. An assessment
area continued to be intact. The LLC remained thick and by a single surgeon can be considered to be a limitation.
stable, and therefore, a particular functional improvement The retrospective research design is another limitation of
could be carried out in the external valve by this flap the present study.
technique. In addition, by moving forward on the basis of
the flap shift zone, the angle of the inner valve is increased
and a significant functional improvement can be achieved Conclusion
in the inner valve. Although cartilages are sewn together in
the same configuration, sewing at different angles works to The ability to have control over the LLCs of all shapes via
flatten them, and a more aesthetic configuration can be suturing two different points together is a noteworthy
achieved without using any grafting technique. Because the benefit of this technique. Even though the cartilages are
scroll ligament is completely protected, the lower and sutured together in the same configuration, suturing at
middle rooms are in a stable formation and do not come different angles can straighten them and provide more
together. This prevents rounding in the nose and increases flexibility to meet the aesthetical goals and thus eliminate
the definition of the tip of the nose. The cutting of the scroll the need for suturing a graft. This safe, controlled and
ligament is not as effective as the intact form when it is easily applicable technique can be applied to generally
repaired with sutures. In this technique, the scroll is left every patient without the need for additional grafts.
completely. An infracartilaginous incision to reach the
Compliance with Ethical Standards
lower chamber and a very short upper backcut intercarti-
laginous incision are used to unite the unilateral transfixion Conflict of interest The author reports that he has no conflict of
and reach the middle and upper rooms. An infracartilagi- interest to disclose.
nous incision is used to reach the lower chamber, a uni-
lateral transfixion incision to reach the middle and upper Ethical Approval The present research was performed according to
the Declaration of Helsinki for biomedical research on human
chambers and a very short upper backcut intercartilaginous subjects.
incision to reach the upper end.
Strengths of the present technique can be considered as Informed Consent Before the operations, all patients were informed
follows: (1) there will be no swelling or thickening. The that their photos could be published for scientific purposes, and all
patients whose records were used in the present study approved
outer silhouette appears smoother because the procedure written informed consent.
included less undermining under the alar wing, even
though we presented the undermining as 3 mm on a sample
patient. This depends on the size of the LLC, as under- References
mining could be 2 mm when the LLC was 8 mm, and
undermining could be 3 mm if the LLC was 9 mm. The 1. The International Society of Surgery Aesthetic Plastic of Society
present technique also provides a more similar appearance Surgery (2017) 2017 and 2016 comparison data
2. The American Society for Aesthetic Plastic Surgery (2017)
to normal anatomical structure than the previous tech- Cosmetic Surgery National Databank. The Authoritative Source
niques. In the previous technique, a flap was sewn over the for Current U.S. Statistics on Cosmetic Surgery
LLC, which causes more swelling. (2) The scroll silhouette 3. Constantian MB (1994) The incompetent external nasal valve:
appears very well because the vertical and horizontal bonds pathophysiology and treatment in primary and secondary rhino-
plasty. Plast Reconstr Surg 93(5):919–931
in the scroll ligament are never cut. (3) Because the internal 4. Constantian MB, Clardy RB (1996) The relative importance of
valve is supported, it does not collapse upon inspiration septal and nasal valvular surgery in correcting airway obstruction
(breathing); it affects breathing in a more positive way than in primary and secondary rhinoplasty. Plast Reconstr Surg
previous techniques. (4) This technique provides support to 98(1):38–54
the formation of a more flat alar wing silhouette by

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5. Gunter JP, Friedman RM (1997) Lateral crural strut graft: tech- 21. Tas S, Celik N (2017) New instruments for submembranous
nique and clinical applications in rhinoplasty. Plast Reconstr Surg dissection in rhinoplasty. Aesthet Surg J 37(7):NP73–NP78
99(4):943–952 22. Regalado Briz A (1999) Aesthetic rhinoplasty with maximum
6. Constantian MB (2000) Four common anatomic variants that preservation of alar cartilages: experience with 52 consecutive
predispose to unfavorable rhinoplasty results: a study based on cases. Plast Reconstr Surg 103(2):671–680
150 consecutive secondary rhinoplasties. Plast Reconstr Surg 23. Davis RE (2015) Lateral crural tensioning for refinement of the
105(1):316–331 wide and underprojected nasal tip: rethinking the lateral crural
7. Constantian MB (2004) The two essential elements for planning steal. Facial Plast Surg Clin N Am 23(1):23–53
tip surgery in primary and secondary rhinoplasty: observations 24. Sazgar AA, Amali A, Peyvasty MN (2016) Value of cephalic part
based on review of 100 consecutive patients. Plast Reconstr Surg of lateral crus in functional rhinoplasty. Eur Arch Otorhino-
114(6):1571–1581 laryngol 273(12):4053–4059
8. Constantian MB (2005) The boxy nasal tip, the ball tip, and alar 25. Ashtiani AK, Bohluli B, Bateni H, Fatemi MJ, Sadr-Eshkevari P,
cartilage malposition: variations on a theme—a study in 200 Rashad A (2013) Lateral crural transposition flap in tip correc-
consecutive primary and secondary rhinoplasty patients. Plast tion: Tehran retrospective rhinoplasty experience. Ann Plast Surg
Reconstr Surg 116(1):268–281 71(1):50–53
9. Silva EN, Bittencourt RC (2017) Preoperative and postoperative 26. Boccieri A (2005) Mini spreader grafts: a new technique asso-
assessment of external nasal valve in rhinoplasty. Rev Bras Cir ciated with reshaping of the nasal tip. Plast Reconstr Surg
Plást 32(1):17–27 116(5):1525–1534
10. Toriumi DM, Asher SA (2015) Lateral crural repositioning for 27. Taş S (2014) Modification of the lateral crural suspension flap.
treatment of cephalic malposition. Facial Plast Surg Clin N Am J Oral Maxillofac Surg 72(5):846–847
23(1):55–71 28. Garcı́a-Velasco J, Vidal JT, Garcı́a-Casas S (1998) Increasing the
11. Silva EN (2019) The relation between the lower lateral cartilages length of the middle crura for better tip projection in primary
and the function of the external nasal valve. Aesthet Plast Surg rhinoplasty. Aesthet Plast Surg 22(4):253–258
43(1):175–183 29. Abou Mayaleh H (2011) The onlay folded flap (OFF): a new
12. Rohrich RJ, Adams WP Jr (2001) The boxy nasal tip: classifi- technique for nasal tip surgery. Aesthet Plast Surg 35(1):73–79
cation and management based on alar cartilage suturing tech- 30. Lin J, Tan X, Chen X et al (2006) Another use of the alar car-
niques. Plast Reconstr Surg 107(7):1849–1863 (discussion tilaginous flap. Aesthet Plast Surg 30(5):560–563
1864–1868) 31. Massiha H (1998) Elliptical horizontal excision and repair of alar
13. Rohrich RJ, Adams WP, Ahmad J, Gunter J (eds) (2014) Dallas cartilage in open-approach rhinoplasty to correct cartilaginous tip
rhinoplasty: nasal surgery by the masters, 3rd edn. CRC Press, deformities. Plast Reconstr Surg 101(1):177–182
Boca Raton 32. Ozmen S, Eryilmaz T, Sencan A et al (2009) Sliding alar carti-
14. Gruber RP, Nahai F, Bogdan MA, Friedman GD (2005) Chang- lage (SAC) flap: a new technique for nasal tip surgery. Ann Plast
ing the convexity and concavity of nasal cartilages and cartilage Surg 63(5):480–485
grafts with horizontal mattress sutures, part II: clinical results. 33. Gruber RP, Zhang AY, Mohebali K (2010) Preventing alar
Plast Reconstr Surg 115(2):595–608 retraction by preservation of the lateral crus. Plast Reconstr Surg
15. Toriumi DM, Checcone MA (2009) New concepts in nasal tip 126(2):581–588
contouring. Facial Plast Surg Clin N Am 17(1):55–90 34. Janis JE, Trussler A, Ghavami A, Marin V, Rohrich RJ, Gunter JP
16. Tebbetts JB (1994) Shaping and positioning the nasal tip without (2009) Lower lateral crural turnover flap in open rhinoplasty.
structural disruption: a new, systematic approach. Plast Reconstr Plast Reconstr Surg 123(6):1830–1841
Surg 94(1):61–77 35. Cakir B, Oreroğlu AR, Doğan T, Akan M (2012) A complete
17. Tardy ME, Garner ET (1990) Inspiratory nasal obstruction sec- subperichondrial dissection technique for rhinoplasty with man-
ondary to alar and nasal valve collapse: technique for repair using agement of the nasal ligaments. Aesthet Surg J 32(5):564–574
autogenous cartilage. Oper Tech Otolaryngol Head Neck Surg 36. Bitik O, Uzun H, Konas E (2017) Scroll reconstruction: fine
1(3):215–218 tuning of the interface between middle and lower thirds in
18. Toriumi DM, Josen J, Weinberger M, Tardy ME Jr (1997) Use of rhinoplasty. Aesthet Surg. https://doi.org/10.1093/asj/sjx264
alar batten grafts for correction of nasal valve collapse. Arch 37. Tas S (2018) Superior-based transposition flap: a novel technique
Otolaryngol Head Neck Surg 123(8):802–808 in rhinoplasty. Aesthet Surg J. https://doi.org/10.1093/asj/sjy197
19. Gassling V, Koos B, Birkenfeld F, Wiltfang J, Zimmermann CE
(2015) Secondary cleft nose rhinoplasty: subjective and objective
outcome evaluation. J Cranio Maxillofac Surg 43(9):1855–1862 Publisher’s Note Springer Nature remains neutral with regard to
20. Daniel RK, Palhazi P (2018) The nasal ligaments and tip support in jurisdictional claims in published maps and institutional affiliations.
rhinoplasty: an anatomical study. Aesthet Surg J 38(4):357–368

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