Invited Discussion on: Posterior Cephalic Soft Triangle of the Nose: Surgical Implications
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Aesth Plast Surg
https://doi.org/10.1007/s00266-020-02032-2
EDITOR’S INVITED COMMENTARY
Invited Discussion on: Posterior Cephalic Soft Triangle
of the Nose: Surgical Implications
Nuri A. Celik1
Received: 21 October 2020 / Accepted: 21 October 2020
Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2020
Level of Evidence V This journal requires that authors issues related to this tiny specific anatomical zone. They
assign a level of evidence to each article. For a full found the most common pathology in the PCST was over-
description of these Evidence-Based Medicine ratings, resection of the posterior segments of LLC’s during pri-
please refer to the Table of Contents or the online mary surgery. En bloc medialization of the PCST is the
Instructions to Authors www.springer.com/00266 second in frequency. Their treatment consisted of trian-
The authors bring a new insight to the topic of external gular on-lay grafting of the PCST and lateralization of the
valve insufficiency [1]. They define a new anatomic sub- caudal edge of the nasal bone. They present excellent
unit of the external nasal valve. This involves the area results of their technique.
between the lower lateral cartilage, upper lateral cartilage The external nasal valve area is a controversial subject.
and the distal nasal bone, forming the posterior cephalic Constantian and Martin think this lack of consensus is
soft triangle (PCST). hindering rhinoplasty education [2]. Some authors refer to
This anatomic segment overlies the pyriform ligament. the external valve as a volume [3]. The internal and
There is a detailed description of this specific anatomic unit external nasal valves are distinct anatomic areas; though
of the posterior cephalic soft triangle and its functional there is no consensus on their boundaries, they share a
correlations. Their evaluation shows this area to be an common border at the scroll. Some authors refer to the
important component of the external nasal valve, possibly PCST zone as a part of the internal nasal valve [4].
the weakest. The authors present their approach for the It is well documented in the literature that reduction
management of the problems associated with the posterior techniques play a major role in unsatisfactory results fol-
cephalic soft triangle of the nose in this retrospective study lowing a rhinoplasty. The reduction in the caudal portion of
paper. Their data are mostly descriptive and clinical rather the ULCs is not an exception. In today’s understanding,
than quantitative. The schematic and clinical pictures are there is no need to excise the caudal portion of the ULCs.
self-explanatory. The authors use ultrasonic rhinoplasty Quite contrarily, there is often a need for reinforcement of
that requires a wider dissection in this area that enabled ULCs in this area. As spreader flap use became a routine
them to observe the anatomical problems more clearly. procedure in my own practice; the anatomy, length,
During open approach rhinoplasty in a two-year period, thickness and resilience of the upper lateral cartilages
they detected twenty-four cases in which the PCST was became very important topics. To overcome the problems
either weak or deformed and developed surgical techniques with attenuated ULCs, I started using septal cartilage
to overcome the structural and functional issues. They support for the lateral caudal portion of the ULC’s
should be congratulated for their systematic evaluation of (Figs. 1,2,3). These grafts provide support and treat the
the anatomical and functional components of breathing lateral nasal wall insufficiency and offer improved aes-
thetics erasing the supra alar notching deformity. Although
they appear bulky initially at the time of surgery, they
& Nuri A. Celik attenuate in time and never become palpable.
nuri.celik61@gmail.com The authors also mention their own observation that
1 triangular PCST grafts lose their initial volume and
Private Practice, Istanbul, Turkey
123
Aesth Plast Surg
Fig. 3 Cephalic trim and
undersurface grafting of the
LLCs. Two septal cartilage
grafts placed lateral to the pos-
terior lateral portion of the
LLCs to support the area. The
grafts abut the pyriform aper-
ture. The diced cartilage graft-
ing helps camouflage the dorsal
contour irregularities
The reduction in the nasal dorsal height invariably
interferes with nasal breathing quality and the nasal dorsal
aesthetic lines [5]. The authors mention that the reason
behind the failure of their reconstruction was inadequate
lateralization of the caudal nasal bone. They stress the
importance of the osteotomy technique in their practice to
prevent respiratory compromise; however, the patients
Fig. 1 Posterior distal portion of the ULCs found to be weak and presented in Figure 8 and 9 both show a further loss of the
convoluted intraoperatively height of the nasal dorsal profile and attenuation of the
nasal dorsal aesthetic lines. This is the main controversy of
the authors. The loss of nasal dorsal height is the main
reason behind failure of control of the nasal bony segments.
The dorsal bony resection should be avoided in short nasal
bone patients as is the case in Figure 9 to prevent
unpredictable outcomes.
Overall, this is a cleverly thought of and written article
presenting a new spectrum for preoperative evaluation and
intraoperative assessment of the transitional area between
the internal and external nasal valves. The surgical phi-
losophy and approach of the authors are simple, repro-
ducible and versatile and should be in the armamentarium
of a rhinoplasty surgeon.
Compliance with Ethical Standards
Conflict of interest The author has no conflicts of interest to
disclose.
Human and Animal Rights This article does not contain any studies
with human participants or animals performed by any of the authors.
Informed Consent For this type of study, informed consent is not
required.
Fig. 2 Spreader flaps are formed. The ULCs are separated from
underneath the nasal bones, and the bone is ready to be reduced with References
the help of the Power Burr
1. Bitik O, Kucukguven A, Konas E (2020) Posterior cephalic soft
strength after 3–6 months. Figure 8 shows a patient result triangle of the nose: surgical implications. Aesth Plast Surg.
https://doi.org/10.1007/s00266-020-01993-8
at 7 months and Figure 9 at 4 months. It would be an 2. Constantian MB, Martin JP (2015) Why can’t more good surgeons
excellent opportunity for us to be able to evaluate one-year learn rhinoplasty? Aesthet Surg J 35:486–489
result for both cases.
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Aesth Plast Surg
3. Hamilton GS 3rd (2017) The external nasal valve. Fac Plast Surg lines in rhinoplasty. Plast Reconstr Surg 114(5):1298–1308
Clin North Am 25(2):179–194 discussion 1309-12
4. Vaezeafshar R, Moubayed SP, Most SP (2018) Repair of lateral
wall insufficiency. JAMA Fac Plast Surg 20(2):111–115
5. Rohrich RJ, Muzaffar AR, Janis JE (2004) Component dorsal Publisher’s Note Springer Nature remains neutral with regard to
hump reduction: the importance of maintaining dorsal aesthetic jurisdictional claims in published maps and institutional affiliations.
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