Invited Discussion on: New Approaches for the Let-Down Technique
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EDITOR’S INVITED COMMENTARY
Invited Discussion on: New Approaches for the Let-Down Technique Enrico Robotti1
Received: 19 June 2020 / Accepted: 19 June 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 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. Invited discussion. The proper role of the discussant of a paper should be to provide an analysis, succinctly integrate with other pertinent techniques, and, primarily, provide to readers an unbiased overview of the perceived pros and cons of the article. Understandably, any author is inherently enthusiastic about his work, but this is where a broader perspective serves most. This article introduces several variations of essentially one technique, i.e., dorsum let-down, according to a series of allegedly different indications. The technique consists essentially of an endonasal approach, subperichondrial/subperiosteal dissection, release of the dorsum from the septum by a longitudinal septal incision including a portion of the ethmoid plate, reduction in dorsal height by progressive excision of a high septal strip, end-to-end (when directly approximated) or side-to-side (when overlapped) septal sutures, and circumferential osteotomies. The dorsal complex is lowered according to the let-down principle with excision of a bony wedge from the frontal process of the maxilla. Interestingly, oscillating microsaws are used for precise osteotomy. It is evident that fine power tools, as well as piezo, find a specific application here. While my personal preference and experience goes to piezoelectric technology [1], I can well see the point in & Enrico Robotti [email protected] 1
Bergamo, Italy
using a power instrument in a closed approach, which would not be feasible with piezo. The seven variations described are defined as ‘‘new approaches’’ in the title of the paper. Fifty-one patients are assessed, all with humps equal to or greater than 4 mm, and subdivided into 7 subgroups, each representing one of the proposed variations. Thick-skinned patients are excluded from the case series, although the reason for this choice is not explained. Careful reading will help understand each technical modification, and a rather complex algorithm is proposed to clarify choices between the options. The underlying assumption is that dorsal preservation, referred to as the let-down technique, is superior to conventional dorsal reduction and can be applied to a wide variety of patients. The video clip showing endoscopic use of the prevalent technical steps is well informative and should be viewed by readers. There are quite a number of issues that stand to my attention after a close reading of this paper: First: the number of patients is limited. Subdividing 51 patients into seven groups restricts the
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