Preservation Rhinoplasty for the Dorsum and Tip

By performing a preservation rhinoplasty, the surgeon can achieve natural and stable results by intraoperative replacement of resection with preservation and excision with manipulation of ligaments, cartilages, soft tissues, and the osseocartilaginous dorsum. In this article, the authors explain step by step the dorsal preservation rhinoplasty with low septal strip and a combination of nasal bones osteoplasty and osteotomies, the tip preservation rhinoplasty based on nose tip polygons, and the authors’ technique for modify the nasal tip projection and rotation with a posterior strut or anterior septal strip.

Key points

  • The main purpose of preservation rhinoplasty is to maintain cartilages, ligaments, and the osseocartilaginous dorsum to provide the patient with natural aesthetic and functional results.

  • This new approach marks a change from both resection and structural rhinoplasty and is leading to a new terminology, “preservation rhinoplasty.”

  • In the authors’ technique, the posterior strut can be used to change the final position and projection of the tip and modify the length and angle of the columella.

The main purpose of this innovating surgical technique is the preservation of the nasal cartilages, ligaments, and the osseocartilaginous dorsum by performing an elevation of the skin in a subperichondrial and subperiosteal plane. If the preexisting nasal dorsum can be kept intact, then it is possible to preserve the natural aesthetic dorsum as well as nasal function. In addition, one can avoid many of the secondary deformities that lead to revision surgery.

Preservation rhinoplasty has some principles that keep the philosophy of “less is more”:

  • 1.

    Elevating the skin sleeve in a subperichondrial or subperiosteal dissection plane

  • 2.

    Preservation of osseocartilaginous dorsum

  • 3.

    Maintaining cartilages

  • 4.

    Maintaining ligaments

  • 5.

    Achieving natural and aesthetic dorsal lines

To achieve these statements, the surgeon must have advanced surgical skills as well as a knowledge of the surgical anatomy and the variations of the preservation rhinoplasty techniques for the dorsum and the tip.

The goal is to replace resection with preservation, excision with manipulation, and secondary rib reconstruction with minimal revisions. In summary, this new approach marks a change from both resection and structural rhinoplasty, thus leading to a new terminology, that is, preservation rhinoplasty.

Preservation rhinoplasty for the dorsum

In order to perform a preservation technique for the nasal dorsum, the surgeon must consider the indications and contraindications ( Fig. 1 ).

  • Indications:

    • 1.

      Naturally shaped dorsum with overprojection (tension nose); septum is midline

    • 2.

      Short nasal bones with cartilaginous hump; normal radix position

    • 3.

      Straight dorsal aesthetic lines but deviated from midline

    • 4.

      Older patients with dorsal hump and thin skin envelope

  • Relative indications:

    • 1.

      Caudal septum not in midline

    • 2.

      Deformed nasal septum

    • 3.

      Deep radix with a convex profile

    • 4.

      Wide nasal dorsum

    • 5.

      Mildly asymmetric middle third

  • Contraindications:

    • 1.

      Previous rhinoplasty surgery by a different surgeon

    • 2.

      Previous submucous resection of the nasal septum

    • 3.

      Marked third asymmetry

    • 4.

      Saddle nose requiring augmentation

Fig. 1
Young female patient with deep radix, “S”-shaped dorsum and nasal hump.
( Courtesy of Dr. Abraham Montes de Oca and Dr. Laura Navarro A.)

A decision whether to do a push-down (PD) procedure, whereby the osseous pyramid is squeezed and dropped inside the pyriform aperture, or a let-down (LD) procedure, whereby a bony segment of the nasal process of the maxilla is resected either directly or by ostectomy, depends on whether the lateral aesthetic lines need to be narrowed. , In simple words, the technique selection for the preservation rhinoplasty of the dorsum depends on the wideness. If it is adequate, the LD technique can be performed; if it is too wide, then the PD technique is indicated. The decision to use either the LD or PD technique may depend on several factors. Another consideration point for these techniques is the hump; if the dorsal hump is greater than 4 mm, then a PD technique may not be adequate for the needed descent of the nasal pyramid. Therefore, the LD technique has been advocated for humps greater than 4 mm.

These 2 methods of dorsal preservation can be described as follows: the PD technique basically consists of a high or low septal resection followed by lateral and transverse osteotomies, and subsequent impaction of the bony vault downward into the pyriform aperture. The LD technique consists of a high septal resection followed by resection of a portion of the ascending frontal process of the maxilla, with subsequent downward positioning of the bony vault on the process of the maxilla.

These techniques preserve the dorsum instead of the traditional structural rhinoplasty that consists of hump removal, and it can be performed under an open or close approach. If the technique is used properly, a natural nasal dorsum will be achieved, but if the techniques are overdone, then a saddle dorsum can occur.

Taking that into consideration, there are some advantages and disadvantage of dorsal preservation:

  • Advantages:

    • 1.

      Allows both open and closed approach

    • 2.

      Low septal strip allows threat of septal deviation

    • 3.

      Allows a block bony pyramid rotation and mobilization

    • 4.

      Preserves the anatomy of nasal dorsum and dorsal aesthetic lines

    • 5.

      Natural-looking dorsum as a result, without any rhinoplasty stigma (inverted-V deformity)

    • 6.

      Preserves the internal valve

    • 7.

      No need for midvault reconstruction

  • Disadvantages:

    • 1.

      Impossible to perform after the classical block hump removal

    • 2.

      Septal surgery more demanding (inexperienced surgeons)

Preservation of the osseocartilaginous dorsum is in fact the biggest advance in rhinoplasty surgery ( Fig. 2 ). Instead of removal of the hump by excising the dorsum, this technique lowers it by a subdorsal septal strip or caudal septal strip and by osteotomies performed over the nasal and maxillary bones.

Fig. 2
Lower lateral cartilages and upper lateral cartilages differentiated by colors and its relationship with nasal and maxillary bones.
( Courtesy of Dr. Abraham Montes de Oca and Dr. Laura Navarro A.)

Management of the Septum

The concept of preserving the dorsum while reducing the height of the dorsal bridge is not new. Goodale reported his experience with an aesthetic case of dorsal reduction that preserved the dorsum using a combination of a high septal strip excision and PD technique, and 2 years later, he followed up this case report with a series of 22 posttraumatic rhinoplasties using a similar “push-over” technique. , Then, over the next century, the concept of PD technique was used by Cottle. The Cottle PD technique favored a tripartite septal excision.

An alternative to subdorsal cartilage resection classically consisted of a 3-part resection: (1) vertical 4-mm segment at the bony-cartilaginous junction (from keystone to vomer), (2) triangular resection of the ethmoid bone, and (3) inferior strip of cartilage along the maxillary spine (corresponding to the amount of desired dorsal reduction). The remaining nasal septum is sutured to the maxillary spine. This technique is the technique used by the authors in terms of preference to perform a dorsum preservation rhinoplasty.

Exposure

In the traditional technique, the hemitransfixion incision or Killian incision was performed in the anterior border of the septum; in the authors’ technique, the incision takes place 3 to 3.5 mm posterior involving the total thickness of the septum and leaving the anterior portion fixed and attached to the membranous septum; then, mucoperichondrial tunnels are performed on both sides of the septum involving the cartilage portion, vomer, and ethmoidal perpendicular plate; also, inferior tunnels must involve the maxillary crest ( Figs. 3 and 4 ).

Fig. 3
The traditional or Killian incision represented by the anterior border of the septum and author technique, where the incision is made 3 to 3.5 mm posterior.
( Courtesy of Dr. Abraham Montes de Oca.)

Fig. 4
The hemitransfixion incision posterior to the anterior border of the septum leaves an anterior strip of cartilage attached to the membranous septum of the anterior nasal spine of the maxillary bone.
( Courtesy of Dr. Abraham Montes de Oca.)

Septal Cartilage Resection

After exposure of the septal cartilage is achieved, resection can be performed. A low septal strip in a wedge fashion is completed by a transversal incision in the basal portion of the septal cartilage, taking special attention around the projection of this resection in the final result of the aesthetic dorsum and its hump reduction. Taking this into consideration, the strip must be wider at the bony-cartilaginous junction; then, the strip is disarticulated from the maxillary bone ( Figs. 5–7 ).

Fig. 5
Bony structures related to the nasal septum ( purple ); nasal bones, maxillary, vomer, and the perpendicular plate of ethmoid bone.
( Courtesy of Dr. Abraham Montes de Oca and Dr. Laura Navarro A.)

Fig. 6
The representation of the author incision for the anterior cartilage strip (posterior strut) that follows the natural shape of the septum (red arrow).
( Courtesy of Dr. Abraham Montes de Oca and Dr. Laura Navarro A.)

Fig. 7
The low septal strip (red) avoiding the posterior strut.
( Courtesy of Dr. Abraham Montes de Oca and Dr. Laura Navarro A.)

When the low septal strip is completed, the cartilaginous septum is disarticulated from the perpendicular plate of ethmoid at the bony-cartilaginous junction (from keystone area to vomer), and then a vertical posterior incision is made to remove 3 mm of the posterior cartilaginous septum in order to take a septal strip.

In that way, the septum is turned into a cartilaginous flap that remains attached to the upper later cartilages but free in the anterior posterior and lower border, which allows the septum to be moved to any desired position ( Fig. 8 ). Also, a resection of the ethmoid bone below the keystone area can be performed to allow the PD/LD movement ( Fig. 9 ).

Apr 19, 2021 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Preservation Rhinoplasty for the Dorsum and Tip
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