Superior-Based Transposition Flap: A Novel Technique in Rhinoplasty

Dr. Süleyman Taş describes the superior-based transposition flap as a preservation-oriented method to reshape and reinforce the lower lateral cartilage while supporting the internal and external nasal valves.

Background and Objective

The lower lateral cartilage (LLC) is a key determinant of nasal tip shape, alar contour and the external nasal valve. Traditional cephalic trimming can reduce tip volume but may weaken support, disrupt the scroll area and contribute to pinched-tip deformity, alar retraction or valve collapse. In this study, Dr. Süleyman Taş presents the superior-based transposition (ST) flap as a method to reshape, relocalize and reinforce the LLC while keeping the scroll area intact.

The objective is both aesthetic and functional: refine a bulbous or boxy tip, correct convexity or concavity of the LLC, influence tip rotation, strengthen the lateral crus and support both internal and external valve function without routinely discarding the cephalic portion of the cartilage.

Study Design

Between January 2016 and February 2017, 367 selected patients underwent the described technique in a single-surgeon retrospective series. The cohort included 215 women and 152 men. All selected patients underwent primary closed rhinoplasty. Standard photographs were obtained at postoperative months 1, 3, 6 and 12.

Two independent plastic surgeons evaluated aesthetic outcomes at 12 months, including tip projection and angle, dorsum-supratip relationship, tip-columella relationship, nostril appearance and asymmetry. Palpation assessed tip irregularities. Functional change was assessed with a 0–10 nasal-patency score, and the validated Rhinoplasty Outcome Evaluation questionnaire measured functional, social and aesthetic satisfaction.

Scroll Area and Surgical Anatomy

The scroll area lies between the upper lateral cartilage and the lower lateral cartilage and includes both cartilage relationships and ligamentous attachments. The paper describes deep SMAS and perichondrial structures that connect these regions and contribute to internal valve stability and tip support.

The author’s room concept separates the nose into upper, middle and lower thirds divided by soft-tissue and perichondrial-periosteal relationships. From this perspective, damaging the scroll mechanism may affect tip support, external valve strength, internal valve angle and postoperative scar behavior. The ST flap is designed to bypass rather than destroy this area.

Indications and Patient Selection

The described indications include weak lower lateral cartilages, a need to reduce or redistribute LLC volume, a bulbous or boxy tip, weakness of the internal or external valves, and convexity or concavity of the lateral crus. The technique is not used simply because a patient is undergoing rhinoplasty; it is selected when tip refinement, rotation or reinforcement is required.

Surgical Technique

All cases in the reported series were performed under general anesthesia with a closed approach. Superior and inferior intracartilaginous incisions and a transfixion incision provide access through subperichondrial and subperiosteal planes. The LLC is exposed through an inferior intracartilaginous incision positioned just above its caudal border.

A cartilage incision is made approximately 6 mm from the caudal border of the lateral crus. The superior-based cartilaginous island is dissected toward the scroll area but remains based on that area. It is advanced caudally, transposed over the remaining LLC and fixed with two or three horizontal mattress sutures.

When lateral crural steal or root support is needed, the flap can be moved caudally and laterally while the remaining LLC is moved medially. For concave or convex cartilage, the orientation of the two surfaces and position of the suture knots are adjusted so that the combined cartilage becomes straighter and more supportive.

Clinical Results

Of the 367 patients, 282 completed one-year follow-up and the ROE questionnaire. Their mean age was 24.6 years. The early postoperative period was reported as uneventful, and one-year photographs showed refined nasal tips without palpated irregularity or asymmetry in the evaluated series.

Convexity of the LLC was present in 296 patients and concavity in 71. In 254 patients the flap was moved caudally and laterally; in the remaining patients it was moved caudally. Only two cases required an additional lateral crural strut graft because of serious LLC weakness.

The first independent evaluator scored 230 patients, approximately 81%, as perfect and the second scored 246 patients, approximately 87%, as perfect; neither evaluator assigned a poor score. Inter-rater agreement was 94.6% with a Fleiss kappa of 0.704. Approximately 90% of patients were satisfied according to the ROE questionnaire. Mean nasal patency improved from 4.7 to 8.2 out of 10 at 12 months (P < 0.001). No revision surgery was required during the reported follow-up.

Preservation Philosophy

The discussion places the ST flap within the evolution from excisional rhinoplasty to structural reconstruction and then toward preservation. Rather than trimming and discarding the cephalic LLC, the flap reuses this tissue to increase thickness and strength while preserving the scroll ligament complex.

The technique also allows two cartilage surfaces to be sutured at different angles so that concavity or convexity can be corrected without necessarily introducing an additional graft. By advancing the flap, the internal valve angle may increase while the external valve receives additional structural support.

Limitations

The study is a single-surgeon retrospective series of primary rhinoplasty patients. Secondary noses can be more variable and technically difficult, so results cannot automatically be generalized to every revision case. The publication also notes that the technique does not prevent use of additional grafts when needed.

Conclusion

The ST flap is presented as a main tip-plasty maneuver capable of relocalizing, reshaping and reinforcing the lower lateral cartilage while protecting the scroll area. In appropriately selected patients, the reported series showed both aesthetic refinement and functional improvement of the nasal valves.

Official Publication and External Source

DOI: https://doi.org/10.1093/asj/sjy197

Journal: Aesthetic Surgery Journal. This page is a comprehensive educational presentation derived from the supplied scientific publication and does not replace individualized medical evaluation.