Aesth Plast Surg
https://doi.org/10.1007/s00266-019-01436-z
ORIGINAL ARTICLE
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
Introduction In rhinoplasty operations, concavity and
convexity have a particular place in terms of aesthetic and
functional problems. To fix the problems associated with
concavity and convexity, several techniques were reported
for straightening of the lower lateral cartilage (LLC). The
scroll ligament and its associated tissues can be preserved,
and a better nasal tip can be obtained after the surgery. The
purpose of this research is to present a new, more com-
fortable and more practical technique to overcome the
problems associated with LLC.
Methods The records of 190 patients who were operated
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
functional improvement was achieved. Additionally, the
scroll ligament was preserved, so this technique prevented
the accumulation of skin at the nose tip. Patients were
evaluated using the ‘‘Rhinoplasty Outcome Evaluation’’
(ROE) 12 months after the surgery.
Results The median patient age was 24.3 years. Among 190
patients, 23 were male (12.1%) and 167 were female (87.9%).
All patients included in the study completed the ROE ques-
tionnaire. Patient satisfaction was excellent, registering at 95%
of the included cases. In the assessment of nasal obstruction, it
was found that the patients’ patency score increased to 8.8
from 6.2 (out of 10) after the 12-month follow-up (p \ 0.001).
Revision surgery was not needed in any patient.
Conclusion The ability to have control over the LLC for
all shapes via suturing two different points together is a
& Güncel Öztürk
info@guncelozturk.com
1
Private Practice in Istanbul, Turkey
RHINOPLASTY
noteworthy benefit of this technique. This is a safe, con-
trolled and easily applicable technique that can be applied
to generally every patient without the need for additional
grafts.
Level of Evidence IV 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 www.springer.com/00266.
Keywords Rhinoplasty
Scroll ligament
Lower lateral
cartilage
Introduction
Rhinoplasty is a leading type of plastic surgery, and the
number of rhinoplasty operations performed becomes
higher every day. According to the data of the International
Society of Aesthetic and Plastic Surgeons, there will have
been 877,254 rhinoplasty operations by the year 2017, and
in the USA, 38,659 patients had rhinoplasty operations by
the year 2017 [1, 2]. Because of the popularity of rhino-
plasty, there have been many techniques developed for
improving both the medical and cosmetic results. The
lower lateral cartilage (LLC) is the main anatomical
structure for enhancing the shape and function of the alae.
The position of the lower lateral cartilage is particularly
critical for sufficient valve function, and this cartilage is the
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
external nasal valve during deep inspiration [9–11]. The
cephalic trim of the LLC has been considered as a tradi-
tional procedure for fixing and increasing the nasal tip
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rotation and leaving the alae more aesthetic. This method
was reported to be performed to correct a boxy tip, unro-
tated tip or over-projection [12, 13]. Beside the advantages
of this method, some disadvantages can be regarded, such
as aesthetic issues including alar retraction, pinched tip and
postoperative nasal asymmetry.
In rhinoplasty operations, concavity and convexity have
a particular role in aesthetic and functional problems. To
fix the problems associated with concavity and convexity,
several techniques were reported for straightening of the
LLC. Other common techniques for solving the problems
related to concavity are lateral crural graft and suturing the
LLC over itself after dividing it vertically and flipping it
over [5, 14]. The domal suture technique is the most
popular procedure for fixing the convexity [15]. Addi-
tionally, the lateral crural graft, transdomal suture, lateral
crural strut, lateral crural spanning suture, transdomal
suture and superior-based sliding flap were reported to be
effective for fixing the convexity problem [16–18].
The purpose of this research is to present a new, more
comfortable and more practical technique to overcome the
problems associated with LLC.
Materials and Methods
The present study was designed to be retrospective. The
records of patients admitted to our private clinic for
rhinoplasty operation were assessed. The data of 360
patients admitted for rhinoplasty operations were investi-
gated. The inclusion criteria were as follows: having
unoperated nasal deformities, having a delivery approach
including a medially elongated infracartilaginous incision
and unilateral cephalically positioned transfixion incision
and admission for rhinoplasty operation. In detail, patients
who have been suffering from long noses or nasal defor-
mities in normal-length noses were included. Patients were
candidates for these techniques as follows: (1) patients
without alar wing retraction; (2) patients who had an LLC
larger than 6 mm; and (3) patients who were willing to be
operated on with this technique after they received detailed
information about the procedure. Exclusion criteria were as
follows: (1) patients with alar wing retraction; (2) patients
who had an LLC smaller than 6 mm; and (3) patients who
did not accept this technique after being informed.
According to inclusion and exclusion criteria, the records
of 190 patients were considered to be included the study.
The median age was 24.3 years. Among 190 patients, 23
were male (12.1%) and 167 were female (87.9%). All
patients included in the study completed the ROE ques-
tionnaire after the 1-year follow-up. The follow-up period
ranged between 12 and 26 months (median of
15.2 months). The same surgeon performed all procedures
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Aesth Plast Surg
between 1 March 2016 and 2 February 2018. All proce-
dures were performed under general anaesthesia.
The present research was performed according to the
Declaration of Helsinki for biomedical research on human
subjects. Before the operations, all patients were informed
that their photos could be published for scientific purposes,
and all patients whose records were used in the present
study approved written informed consent.
Patients were evaluated using the ‘‘Rhinoplasty Out-
come Evaluation’’ (ROE) 12 months after the surgery. The
ROE questionnaire is an objective instrument to assess
patient satisfaction with postoperative rhinoplasty results
[19]. This scale was created with Alsarraf for evaluating
the results from facial aesthetic procedures according to
patient satisfaction. The main factors that influence patient
satisfaction concerning the surgery are: the physical issue,
assessed by patient satisfaction in terms of nasal shape and
function; the emotional issue, estimated by the degree of
confidence and desire to change appearance; and the social
factor, assessed by social, professional and family accep-
tance. This scale is useful for objectively assessing the
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
4 representing the best score. The final score was multi-
plied by 100 after being divided by 24. A final score greater
than 85 was accepted as an excellent score and denotes
high patient satisfaction.
The subjective evaluation was carried out with a ques-
tionnaire in which each patient scored their breathing
quality with a respiratory score of 1 (poor) to 10 (excel-
lent). The patency score was assessed based on these
reports before and after the surgery.
Surgical steps were as follows;
Step 1 General anaesthesia was given to the patient.
Adrenaline was injected at a dilution of 1:100,000. Inner
nasal hair was cut. Closed rhinoplasty was performed.
Step 2 An infracartilaginous incision was made on the
caudal edge of the lower lateral cartilage (Fig. 1).
Step 3 Lower crural cartilages were delivered (Figs. 2,
3). The LLC was straightened. The LLC was measured
and found to be 11 mm (Fig. 4). On the caudal side of
the alar cartilage, 6 mm of tissue was maintained intact
(Fig. 5). The area 6 mm below the caudal side of the alar
cartilage was marked for undermining (Fig. 6). The
cranial side was also undermined. The part of the alar
cartilage placed at the superior side and fixed to the
scroll ligament was signed for replacing this part on the
inferior side (Fig. 7). The additional 2 mm of cartilage
was excised (Fig. 8). The scroll ligament was protected
with the 3-mm superior-based sliding flap technique
Aesth Plast Surg
Fig. 1 Incision on the caudal edge of the lower lateral cartilage
Fig. 2 Lower crural cartilages were delivered. LLC lower lateral
cartilage, LSL longitudinal scroll ligament, SL scroll ligament
Fig. 3 Lower crural cartilages were delivered
Fig. 4 Measurement of alar cartilage
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. 11).
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Fig. 6 Signing the caudal side of the alar cartilage for undermining
Fig. 7 Signing the part of the alar cartilage which was placed at the
superior side fixed to the scroll ligament
Results
The postoperative results were satisfactory. After physical
examination and assessment of postoperative photographs,
it was noted that there was no asymmetry or functional
problems in all participants.
Twelve months after the surgery, ROE Scores ranged
between 80 and 100 points. The median score was 90.5
points. Patient satisfaction was excellent in 95% of the
included cases.
In the assessment of nasal obstruction, it was found that
the patient patency scores increased to 8.8 from 6.2 (out of
10) after 12 months follow-up (p \ 0.001). There was no
need for revision operation in any patient during the
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Aesth Plast Surg
Fig. 8 Demonstration of protection of the scroll ligament. Excising
the additional cartilage
Fig. 9 Excising the additional cartilage
follow-up process. The results were highly sufficient for
patients and the surgeon (Figs. 12, 13, 14).
Discussion
The anatomical structure of the nasal tip is mainly
approached on the factors of the nasal tip size, shape,
symmetry and contour. There is a close relationship
between the morphologies of the septum and lower lateral
cartilage (LLC) and these factors. A commonly seen
deformity of the nose is called droopy tip, where nasal tip
inferior rotation can be observed. Ensuring a solid structure
for the nasal anatomy comes down to the strengths, shapes
and volumes of the following areas: upper to lower lateral
cartilage attachment of soft tissue, the medial crura to
Aesth Plast Surg

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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 Aesth Plast Surg

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

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Aesth Plast Surg

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

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 Aesth Plast Surg

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