Preservative dorsal hump surgery is an old approach that has revitalized recently. Preservation rhinoplasty aims to shape the existing structures instead of resection/reconstruction approaches. A thorough understanding of the applied anatomy of the nose is the backbone of preservative hump surgery. In preservative hump surgery keystone works as a joint, and by lowering this joint the hump is eliminated.
Preservative dorsal hump surgery is an old approach that has revitalized recently.
Preservation rhinoplasty aims to shape the existing structures instead of resection/reconstruction approaches.
A thorough understanding of the applied anatomy of the nose is the backbone of preservative hump surgery.
There are few techniques for preservative hump surgery, but the mainstay is to remove a strip from the septum, then to reset the osteocartilaginous vault in a lower position.
In preservative hump surgery, keystone works as a joint, and by lowering this joint, the hump is eliminated.
The preservative technique may facilitate simultaneous orthognathic and rhinoplasty.
Historically dorsal hump surgery has been a smooth and very unequivocal step in rhinoplasty, and for a long time, Josef’s reductive technique and later Sheens reductive/reconstructive approach , have been the gold standard in dorsal hump surger. Although these traditional approaches have shown to be effective in many long-term follow-ups, it is frequently shown that this approach may need a revision in 10% to 15% of cases. This secondary surgery may be a subtle touch-up or a major reconstruction surgery with rib, conchal cartilage, and/or fasciae grafts, which will be a big challenge for both the aesthetic surgeon and rhinoplasty patient. ,
New anatomic findings may be the other main reason for rethinking about dorsal hump surgery. Soft tissue envelope and osteocartilaginous vault have been comprehensively evaluated during the past decade. Soft tissue envelope is shown to be more than a simple cover of the nose. It consists of skin, subcutaneous tissue, the superficial musculoaponeurotic system (SMAS), blood vessels, and nasal ligaments. The SMAS is shown to be a continuous layer from the glabella to the nasal tip. The nasal ligaments have been shown to have a determinant role in stabilizing the anatomic element and transferring the muscular function. Keystone has been shown as a complex anatomic structure that is very difficult or sometimes impossible to reconstruct.
As a result, many rhinoplasty surgeons tried to reassess preservative dorsal hump surgery techniques that were mostly overlooked in rhinoplasty literature. These rhinoplasty surgeons believe that by preserving the structure of the dorsum many of these potential problems may be avoided. , They advocate preservative techniques to bring down the existing dorsum instead of resection of the excessive part, and in this way, the convex contour (nasal hump) is corrected. In fact, preservative techniques aim to eliminate the destruction-reconstruction cycle that happens in conventional hump reduction.
This article provides an overview of related literature. History of the preservation dorsal surgery, current trends, and future perspectives are discussed. It is attempted to provide practice recommendations and key points where indicated.
Daniel in 2018 proposed the term preservation rhinoplasty that may be a turning point in rhinoplasty to bring many sporadic rhinoplasty findings under one umbrella.
Surprisingly, the first documented preservation hump surgery dates back to 1899 when Goodale reported his technique in treating an exaggerated Roman nose (big hump) in a 13-year-old girl ( Fig. 1 ).
In this case, by performing 2 incisions on the nasal septum, a subdorsal strip of the cartilage and bone was removed. Then, after doing lateral osteotomies on the bony vault by nasal saws, the nasal bridge was pressed done and the excessive hump was eliminated. It is noteworthy that the nasal patency was not affected by this procedure. This technique was modified and developed by Cottle in 1954. , The method is currently growing very fast, known as the push-down technique.
Lothrop in 1914 described another approach and designed a bone-cutting forceps for his technique. In his technique, a stripe of subdorsal cartilage is removed (similar to Goodale’s approach) ( Fig. 2 A ), then a bony wedge is resected from the nasofacial junction on both sides of the bony vault ( Fig. 2 B and C), and finally by doing a transverse osteotomy at radix, whole bony vault is pressed down and the excessive hump is eliminated ( Fig. 3 ). Lothrop was surprised that despite creating a smaller nose, airway was improved after this procedure. This technique is frequently modified, but the general concept is commonly used in modern rhinoplasty and is known as let-down procedure.
Despite some well-executed studies such as that by Jammet and colleagues in 1989 on 87 patients and Ishida’s comprehensive report on 125 patients (1999) that demonstrated the potentials of preservative techniques, these brilliant pioneer works have been mostly overlooked for a long time in favor of Josef’s reductive techniques. Saban and his colleagues reported their extensive work on the soft tissue envelope of the nose. They showed that the nasal SMAS extends from glabella to nasal tip and particular regions give few ligamentous extensions that these ligaments transfer the functions of the nasal muscles to the osteocartilaginous framework of the nose.
Therefore, mechanical reconstruction of the nose by spreader grafts will not restore the whole internal nasal valve functioning. Cakir proposed subperichondrial/subperiosteal dissections to save the integrity of nasal ligaments and minimize the trauma to soft tissue components such as nerves, vessels, and muscle.
Saban and colleagues had a dominant role in the repopularization of the preservative techniques. They reassessed the push-down and let-down techniques and demonstrated a very practical modification that solved most complexities of the original Cottle’s technique.
Kosins (2020) performed a comprehensive review of his cases and classified common indications and approaches and showed how the proper treatment plan may alleviate some limitations of preservative hump surgery and add indications that were excluded from these approaches beforehand.
Soft Tissue Envelope
The soft tissue of the nose encompasses several distinct layers. The SMAS is a critical component that carries vessels, nerves, and muscles of the nose. This layer extends from glabella up to the base of columella. The dissection plan in rhinoplasty may be subcutaneous, sub-SMAS, or subperichondrial. , Cakir and colleagues were the first who advocated subperichondrial dissection. They demonstrated that this new approach can preserve all critical elements inside the SMAS and provides a bloodless field intraoperatively and considerably reduces postoperative complications.
Nasal ligaments and their clinical implications are the other emerging challenges in the applied anatomy of the nose. , Several definitive ligaments keep the stability of the nose and translate the functions of the nasal muscles to underlying structures. Destruction of the ligaments may affect both the aesthetic and functions of the nose. Some investigators suggest the techniques to avoid these ligaments or to restore them by suturing back the ligaments to their place. , , Main nasal tip ligaments are discussed in the following section.
The scroll ligament is a longitudinal fibrous extension from the deep SMAS to the perichondrium of the scroll area (junction of the upper lateral and lower lateral cartilages) ( Fig. 4 ). , Recently, it has been shown that transverse muscles of the nose are attached to this ligament and elaborate their function on controlling nasal valves by this ligamentous attachment. This ligament can easily be damaged in cephalic trimming and as a result, the normal function of the nasal muscles will be disturbed or disabled.
The interdomal ligament is a narrow strip of fibrous tissue that connects 2 dome segments at the cephalic portion of the cartilage. ,
Intercrural Ligament (Suspensory Ligament)
Intercrural ligament (suspensory ligament) is a ligamentous connection between the cephalic border of entire alar cartilages. It holds to lower lateral cartilages together.
Pitanguy Midline Ligament
Ivo Pitanguy described a dermatocartilaginous ligament that originates from midline subcutaneous tissue and extends to domes and medial crura. , Later studies showed that the Pitanguy ligament is a fibrous extension of the medial SMAS that extends in 2 layers over and under the interdomal ligament. The upper segment is usually disrupted in open approach rhinoplasty. The lower branch extends to the membranous septum and attaches to the anterior nasal spin. , Some investigators believe that the Pitanguy ligament is critical in the stability of the nasal tip and need to be restored after tip plasty ( Fig. 5 ).