Dorsal Preservation: The Push Down Technique Reassessed

Abstract

Management of the nasal dorsum remains a challenge in rhinoplasty surgery. Currently, the majority of reduction rhinoplasties results in destruction of the keystone area (K-area), which requires reconstruction with either spreader grafts or spreader flaps, both for aesthetic and functional reasons. This article will present the senior author’s current operative technique for dorsal preservation in reduction rhinoplasty based on 320 clinical cases performed over a 5-year period. The author’s operative technique is as follows: (1) endonasal approach; (2) removal of a septal strip in the subdorsal area whose shape and height were determined preoperatively; (3) complete lateral, transverse, and radix osteotomies; and (4) dorsal reduction utilizing either a push down operation (PDO) or a let down operation (LDO). The PDO consists of downward impaction of the fully mobilized nasal pyramid and is utilized in patients with smaller humps (<4 mm). The LDO consists of a maxillary wedge resection and is performed in patients who need more than 4 mm of lowering. A total of 320 patients had a dorsal preservation operation (DPO). Postoperatively, there were no dorsal irregularities nor inverted-V deformities. Among our 44 personal revision cases, 27 patients (8.74%) had had a previous DPO, 16 of whom required tip revisions with no further dorsal surgery. Of the remaining 11 patients, the main problems were either hump recurrence and/or lateral deviation of the dorsum or widening of the middle third, which required simple surgical revision. Based on the authors’ experience, adoption of a PDO/LDO is justified in selected primary patients. The key question before any primary rhinoplasty procedure should be “Can I keep the nasal dorsum intact?” Precise analysis and surgical execution are required to preserve the dorsal osseocartilaginous vault and K-area. Dorsal preservation results in more natural postoperative dorsum lines and a “not operated” aspect without the need for midvault reconstruction. Moreover, this technique is quick and easy to perform by any rhinoplasty surgeon. Rhinoplasty surgeons should consider incorporating dorsal preservation techniques in their surgical armamentarium rather than relying solely on the Joseph reduction method or an open structure rhinoplasty.

Level of Evidence: 4

In most white noses, dorsal hump reduction is an essential step consisting of resecting portions of both the bony and cartilaginous dorsum. After dorsal height reduction, the keystone junction area is destroyed and must be reconstructed for both aesthetic and functional reasons. Thus, it is our opinion that 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 revisional surgery.

The obvious question is: how can the surgeon reduce the dorsal profile line without resecting the dorsum? The answer is by utilizing the “push down technique” popularized by Cottle^1,2 as an alternative to the dorsal resection technique championed by Joseph.^3,4 Based on our experience utilizing dorsal preservation techniques in 320 primary rhinoplasties over a 5-year period, we have been able to achieve the following goals: (1) to simplify the technique, making it easier and quicker for all surgeons including those with less experience; (2) to keep the nasal dorsum intact while reducing the dorsal hump from 2 mm to 8 mm in height; and (3) to obtain excellent aesthetic and functional results.

OVERVIEW OF DORSAL PRESERVATION TECHNIQUES

Many younger rhinoplasty surgeons are not familiar with the push down operation (hereinafter PDO) and its major differences from the Joseph resection rhinoplasty. Thus, a brief review of the PDO is essential before delving into its technical nuances. The fundament goal of the PDO is to preserve both the keystone area (K-area) and the continuity of the cartilaginous vault. This conservative approach avoids nasal valve collapse, with its adverse effects on respiration and the dorsal aesthetic lines. In addition, lowering the intact cartilaginous vault during the PDO produces a vertical vector downwards on the scroll area junction between the upper lateral cartilages (ULCs) and lower lateral cartilages (LLCs), which in turn causes a cephalic rotation of the LLCs.⁵ The concept of dorsal preservation in nasal surgery was first introduced by Lothrop in 1914.⁶ He demonstrated a good aesthetic and functional result in one case of tension nose. His technique consisted of “nasal impaction” utilizing the following 3 basic steps: (1) resection of a high strip of septal cartilage and perpendicular plate of ethmoid, (2) triangular bony resections of the frontal processes of the maxilla, and (3) direct percutaneous osteotomy of the radix. His pioneering work was followed by Sebileau and Dufourmentel in France in 1926.⁷ They proposed a resection of the 3 nasal pillars done in the posterior portion of the nose, thereby leaving the nasal dorsum intact. Subsequently, in 1940, Maurel⁸ reported his experience with the Lothrop technique of high septal resection followed by lateral bony resection of the frontal processes of the maxilla.

In 1946, Cottle et al^1,2 described the push down technique (PDO), in which the nasal dorsum continuity was preserved by impaction of the bony and cartilaginous hump around the keystone point. This maneuver prevented collapse of the ULCs and closure of the valve area. In addition, the rotation of the quadrangular septal cartilage was an essential but difficult surgical step. Cottle’s PDO technique became popular in the 1960s. In 1989, Gola⁹ refined the concept of lowering the bony cartilaginous dorsum simply by removing a strip of nasal septum below the nasal dorsum. Central to the procedure is the location of the septal excision, which can be subdivided into the classic low location of Cottle^1,2 with its associated anterotation vs the high subdorsal resection championed by Saban,^10,11 which permits a direct lowering. The reader should review Figure 1 to understand the differences in the location of the septal resection.

Drumheller,¹² in his review of Cottle’s technique, and Huizing¹³ reassessed the basic PDO technique by adding osseous wedge resections from the frontal ascending processes of maxillary bones, thus allowing the nasal pyramid to descend freely. This modification became known as the “let down” operation (LDO). Thus, the 2 approaches for managing the lateral bony wall are the following: (1) osteotomy only with push down into the nasal fossa (PDO)) or (2) lateral bony wedge resection with lowering of the bony pyramid onto the frontal process of the maxilla (LDO).

Although the results of dorsal preservation techniques were generally good to excellent, the techniques were gradually abandoned for 3 reasons. First, the classic Cottle PDO^1,2 involved complex and challenging septal surgery, especially in the preendoscope era.^14,15 Second, the techniques were not versatile enough to be utilized in a wide range of rhinoplasties, ie, the preoperative dorsum must be relatively natural rather than distorted. Third, the open approach offered greater visibility, more accurate control of structures, and facilitated teaching.¹⁶ What has changed that justifies a reassessment of dorsal preservation techniques? Currently, rhinoplasty surgeons have begun to realize the aesthetic and functional consequences of destroying the K-area. Why should we reconstruct something if we can preserve it? To simplify the text of this article, we will primarily utilize 3 terms: dorsal preservation operation (DPO), push down operation (PDO), and let down operation (LDO).

SURGICAL ANATOMY

Anatomic dynamics of the K-area are essential to understand before performing any primary reduction rhinoplasty. Two main anatomic structures comprise the osseocartilaginous K-area: the overlap of the bony cap and the cartilaginous vault underneath. Contrary to popular belief, these 2 structures are not rigidly fused, but rather joined together as a chondro-osseous joint.^16,17

The periosteum on the deep surface of the bony cap¹⁸ fuses with the perichondrium on the superficial aspect of the cartilaginous vault (Figure 2A, B). The result is a flexible dorsum that allows the convexity of the dorsum to be eliminated by reducing the underlying cartilaginous septal support. Thus, the vault can be modified from convex to concave without losing its continuity. The subdorsal K-segment of the cartilaginous septum is a critical area.¹⁹ The upper part of the quadrangular septal cartilage is crucial in maintaining the height and stability of the dorsal vault. Anatomically, there is a subdorsal portion of the cartilaginous septum that extends very high cephalically toward the radix. Thus, there is almost no bony septum under the bony cap (Figure 2C, D). The starting point of the upper bony septum occurs at the anterior angle of the perpendicular plate of the ethmoid, below the nasal spine of the frontal bone. Moreover, the younger the patient, the greater the cephalic extent of the subdorsal septal cartilage.^18,19

The upper septum must be divided or removed to allow the elimination of the dorsal hump. In Cottle’s technique,^2,12 a complete vertical splitting disarticulation between the perpendicular plate of the ethmoid and the quadrangular cartilage is mandatory to allow further anterotation of the septum/cartilaginous vault. In Gola’s^20-22 and Saban’s^11,23,24 techniques, a strip excision of subdorsal septal cartilage as close as possible to the dorsal beam is done just below the bony cap, which allows lowering of the dorsum into the newly created space. The height of the cartilaginous strip excision correlates with the desired dorsal reduction. The more convex the dorsal vault, the greater the septal resection.

In the conventional hump reduction, this M-shaped arch is removed and the ULCs become semimobile “flying wings” that no longer articulate with the septum. Thus, the ULCs can collapse toward the septum, resulting in functional and aesthetic problems. For this reason, spreader grafts and spreader flaps are utilized to reconstruct this anatomic unit.^25-30 However, it is our opinion that preservation is far superior to any reconstruction.

PREOPERATIVE ASSESSMENT

Pertinent to dorsal preservation cases, preoperative evaluation of the nasal dorsum should include external examination of the size, shape, and orientation of the dorsum, as well as palpation of the cartilaginous and bony components of the nasal pyramid. The rhinoplasty surgeon must answer the critical question, Can I keep the dorsum intact? Many times, the answer is that the dorsum appears natural and can be preserved. Also, the more cartilaginous the dorsum, the greater the indication for a preservation technique. Preoperative diagnosis of deviations and asymmetries are of great importance in selecting the method of septoplasty and osteotomies. A careful analysis of the nostrils is done regarding their size, orientation, and aesthetic landmarks. In tension noses, the nostrils are narrow and present an excess of height whereas the nasal lobule appears shorter. After dorsal lowering is performed utilizing impaction techniques, the nostrils will flare and the internal nasal valve will open. Sometimes, this sequelae are an expected and desirable result, but if it is excessive, an alar base reduction must be performed at the end of the procedure.

Additionally, a careful clinical and endoscopic examination of the septum and nasal cavity is completed by utilizing a flexible endoscope to assess septal deviation or deflection, especially when it is high in its upper portion. These septal deformities can lead to postoperative dorsal distortion, asymmetry, and deviation. Moreover, turbinate abnormalities and concha bullosa should be diagnosed before surgery, because they will be corrected as the first steps in the septorhinoplasty procedure.

Standard photographs and computer simulations are done in collaboration with all patients. The amount of dorsal resection is planned on the computer simulation by comparing the present patient profile with the simulated one. The shape of the planned septal resection will follow the shape of the dorsum so that: (1) the higher line will correspond to the preoperative dorsal shape; (2) the lower line can be straight or concave depending on the desired dorsal shape simulation; and (3) the intervening area becomes the planned septal strip resection.

In most cases, a cone-beam CT scan is done to assess bony septal abnormalities, turbinate pathology, and sinus disease. Correction of bony septal deviation is a critical component of septoplasty. When necessary, a swinging door technique is utilized to preserve as much septal cartilage support as possible after unilateral mucoperichondrial undermining. The resection or the sagittal repositioning of the bony septal abnormalities include vomerine spur, deviation of the ethmoid lamina perpendicularis, or maxillary crest deviation according to the preoperative assessment. The full analysis is made together with the patient, and the findings from the cone-beam examination are explained.²⁴

SURGICAL TECHNIQUES

Ninety percent (90%) of our patients are operated on in an outpatient surgery center. General anesthesia with endotracheal intubation or a laryngeal mask is utilized. Total intravenous anesthesia (TIVA) propofol (10 mg/mL) and midazolam (5 mg/mL) are given. In addition, a local regional anesthetic block is injected 10 minutes before the incision utilizing ropivacaine (2 mg/mL) and adrenaline 0.005 mg/mL in a 5 mL syringe with a 31-gauge needle. The operative steps pertinent to dorsal preservation will be discussed in depth (Video 1, available online as Supplementary Material at www.aestheticsurgeryjournal.com). Because the concepts of dorsal preservation and hump reduction seem contradictory and virtually impossible, one should observe the changes that occur clinically (Figure 3).

Exposure

An endonasal approach is done in all primary rhinoplasties. An open approach can be added, but only in cases with difficult tips or when it is the surgeon’s preference. A unilateral interseptal-columellar incision is performed on the right side at the caudal border of the quadrangular cartilage utilizing a #15 blade. After exposure of the caudal septum, a unilateral submucoperichondrial undermining is done on the right side utilizing the tip of Converse scissors or Cakir’s subperichondrial elevator. Next, a superior tunnel is made on the contralateral left side. Exposure of the septum is continued until the keystone junction area is reached. Then a partial elevation of the perichondrium-periosteum from the deep aspect of the dorsum is performed. Essentially, one is creating a major extramucosal tunnel as advocated by Robin.³¹ The dissection is generally performed utilizing an endonasal endoscope with video monitoring, and by feeling the contact of the smooth cartilage and then the rough bone with the tip of the elevator.

Next, the soft tissue covering of the dorsum is undermined starting at the anterior septal angle and continuing upward up to the glabella and laterally to the maxilla. Dissection can be done either in the subsuperficial muscular aponeurotic system (sub-SMAS) plane or the subperichondrial/subperiosteal plane. Thus, a degloving of the nasal pyramid is done, but with attachment being maintained at the scroll area through the vertical scroll ligament.³² At this point, the nasal skeleton is under complete vision and the Y-shaped septum/ULCs junction has been freed in 3 areas: superficial soft tissue above as well as right and left submucoperichondrial below. This exposure permits visual assessment of the septal anatomy and precise surgical control.

Septal Cartilage Resection

The amount and shape of the subdorsal septal resection is critical, because it determines how much septum remains, which in turn correlates directly will the height and shape of the desired nasal dorsum (Figure 4). Under direct or endoscopic visualization, the cartilaginous resection starts just below the level of the ULCs/septal junction near the anterior septal angle. Utilizing a V-tip sharp scissors, the incision proceeds from the anterior septal angle directly under the dorsal vault until there is bony contact at the perpendicular plate of the ethmoid beneath the bony cap. At this point, a saddle deformity of the middle third, which has to be evaluated to avoid excess cartilaginous septal resection, already appears. Then, a second incision is made below the first at a lower level. The amount and shape of the intervening septum to be excised depends on the preoperative planning that was done. In general, the upper cut is truly subdorsal and therefore reflects the contour/convexity of the dorsal deformity. The lower cut is relatively straight and its location determined by the planned amount of hump reduction. This incision continues cephalically until it makes contact with the ethmoid perpendicular plate. Then, utilizing the tip of a Joseph elevator, a disarticulation between the cartilage and the bone is performed and the cartilaginous strip is removed. Next, a Blakesley straight endonasal forceps 4 mm in width, is introduced into the freed septal space just below the dorsal vault, and a portion of the ethmoid bone is removed. This resection can be done safely as this site, because it is far from the lamina cribriformis and the skull base. Gola et al^20-22 reported a 2 to 4 mm cartilaginous excision in patients with major kyphotic hump deformities. In our experience, we have resected cartilaginous strips greater than 8 mm in some patients with a very high dorsum. This cartilage resection allows one to obtain a very large hump reduction while preserving the dorsum.

Bony Pyramid Mobilization

One can arbitrarily divide the bony mobilization into complete osteotomies with push down for small humps and complete osteotomies with lateral wedge resection for larger humps. In all cases, the entire bony vault is mobilized “en bloc” with separation of the nasal bony pyramid from the frontal processes of the maxillary bones and the nasal spine of the frontal bone. This maneuver requires complete lateral and transverse osteotomies²⁰ (Figure 5). At this point, a clear understanding of the difference between a PDO and a LDO is essential and is shown in both Figures 1 and 6.

In case of small humps and/or minimal reduction, we prefer complete lateral osteotomies performed percutaneously. For the lateral osteotomy, the tip of the osteotome must be perpendicular to the lateral bony wall. A true horizontal cut is important, because it allows a better sliding of the bony surfaces and facilitates the push down maneuver while reducing the risk of excessive narrowing of the base. Next, a percutaneous perpendicular transection of the nasal spine of the frontal bone is done according to Gola’s technique.^20-22 A 2 mm osteotome is pushed through the skin at the nasion and a transverse root osteotomy of the nose is completed. Additional transverse cuts can be made from the cephalic termination of the lateral osteotomy upward toward the nasion. The result must be a totally mobilized nasal pyramid allowing for transverse movement.

If a more extensive lowering of the nasal pyramid (more than 4 mm) is required, the a let down technique (LDO) is usually preferred by performing a triangular bony wedge resection of the frontal processes of the maxilla (Figure 6D-F).^12,33-35 This excision must be done very low laterally, in the nasofacial groove to avoid any palpable or visible step. An endonasal approach is utilized. The site of the intranasal incision is at the transition from nasal vestibular skin to mucosa just superior to the attachment of the head of the inferior turbinate. A small artery lies within the soft tissues at this point between the skin of the face and the nose. To avoid any bleeding, it is best to make the incision utilizing a bipolar cautery or a Colorado needle.³³

The incision is made perpendicularly to the skin/mucosa junction until bony contact is made. Then, utilizing the tip of Converse scissors, the anterior crest of the pyriform aperture is exposed on both the internal and external sides. This space must be wide enough to allow passage of the instruments and facilitate a precise bony resection. A subperiosteal undermining is performed on both the internal and external surfaces of the frontal processes of the maxillary bone. The undermining proceeds first onto the deep aspect of the maxillary process. On the endonasal surface, the exposure continues upward to the lachrymal bossa and the head of the middle turbinate. The external subperiosteal undermining is done until the anterior insertion of the medial canthal tendon, which can be lifted with the elevator, is reached. Then, bony wedges of the frontal processes of the maxilla are resected on both the left and right sides at the level of the facial plane. This lateral basal resection can be done either through precise osteotomies under direct vision or by utilizing bone rongeur forceps, or even piezoelectric instruments. Once the bony wedges are resected, then the bony pyramid can descend freely until it rests on the maxillary bone.

Lowering the Dorsum

At this point in the operation, the septum has been divided from the nasal dorsum and its height has been reduced according to the preoperative planning. In addition, the lateral bony walls of the nose have been divided and the entire nasal pyramid is completely mobile. The bony-cartilaginous dorsum can be lowered or impacted in between the facial bones utilizing the following 3 steps: (1) transversal mobilization of the whole nose separated from the face; (2) pinching the bony sides of the nasal vault symmetrically; and (3) performing a downward movement of the nasal bony pyramid into the nasal fossa (Video 2, available online as Supplementary Material at www.aestheticsurgeryjournal.com). With this push down process (PDO), the lateral nasal walls slide inside the frontal processes of the maxilla. In the meantime, the bony-cartilaginous vault goes down onto the remaining septum (Figure 6A-C). When performing an LDO, the nasal pyramid comes to rest on the midline septal central pillar, while laterally the bony lateral walls simply come down and rest on the frontal process of the maxilla (Figure 6D-F).

Thus, the new height of the nose is determined by the level of the septum, which acts as the central pillar of the nasal framework. If further lowering is required, another strip of cartilaginous septum can be incrementally resected until the desired result is achieved. If a straight nasal dorsal contour is desired, then the lower cut of the septal strip is cut straight. A more concave dorsal contour can be achieved by making the lower cut of the septal cut concave. At this point, it is important to check the upper septum just below the K-area to avoid a rocker effect. Essentially, one palpates the dorsum by gently pushing downward on the dorsum, making sure that the dorsum is in contact with the septum and that it does not rock downward, ie, no teeter-totter, see-saw movement. If such a movement occurs, then additional septal resection is done until the desired final shape of the dorsum is achieved. We prefer a slight overcorrection near the K-area, but we always avoid an excess of cartilage resection in the supratip area, which can lead to a saddle deformity. The resected cartilaginous strips can be reserved as a graft for subsequent use, often as a columellar strut or alar rim grafts.

To fixate the dorsum, one or two Vicryl 4/0 sutures on a round needle are placed between the dorsum and the underlying septum near the anterior septal angle. If necessary, a percutaneous nylon suture can be placed through the ULCs and the septum, maintaining the desired position, and stitched externally on a “bourdonnet” dressing. Alternatively, a small hole can be drilled through the nasal bones on both sides and a transosseous suture can be inserted. The treatment of the tip is done later, according to necessity. Because impaction of the dorsum will change tip position and rotation, it is always better to start the rhinoplasty with modification of the bony vault. In patients with a high convex dorsum, the lowering of the vault will open the K-area, leading to a longer dorsum following simple mathematic rules. In these cases, it is mandatory to excise part of the new anterior septal angle to allow for rotation of the tip.

After checking the position, shape, and symmetry of the dorsum, endonasal sutures are performed utilizing a Vicryl rapid 5/0 suture, and the dressing is performed in the standard manner with support on the glabella to avoid any movement of the bony pyramid. We usually leave the inner dressing in place for 4 days with Doyle silicone splints on both sides of the septum in the nasal fossae. The cast is removed after 8 days.

CLINICAL SERIES

We reviewed 740 septorhinoplasties and nasal valve surgeries performed by the senior author (Y.S) between January 2011 and June 2016. The study was conducted in accordance with the Declaration of Helsinki. A total of 156 (21.1%) cases were secondary septorhinoplasties performed on patients operated elsewhere. Among the 584 personal cases, 540 (92.5%) were primary septorhinoplasties and 44 (7.5%) were personal revision cases. A total of 320 (54.8%) patients had a DPO. The age range of the patients who had these primary rhinoplasties was from 13 years old (deviated nose with nasal obstruction) to 71 years old (nasal valve surgery) with a mean age of 29. The mean follow-up time was 2 years and 5 months (range, 6 months to 5.5 years). The sex ratio was 9:1 with females predominating (286 females, 34 males). In these 320 primary DPO rhinoplasties, various techniques were utilized according to their pathology and preoperative assessment. In 57.2% of all primary rhinoplasties, a push down technique (PDO) or let down technique (LDO) was performed. Selection of which technique to utilize was determined by the size of the planned dorsal reduction: a push down procedure (PDO) was preferred when the dorsal reduction planned was less than 4 mm, whereas a lateral wedge resection (LDO) was done when a reduction of more than 4 mm was planned. Essentially, there was a virtually even distribution between the 2 techniques in our clinical series.

Our complications from this series consisted of 44 revision cases with tip revisions performed in 16 patients. Of the remaining 11 revision cases, the main problems were either hump recurrence, lateral deviation of the dorsum, or widening of the middle third. Thus, the revision rate for our dorsal preservation procedure was 3.4% (11/320). It should be noted that none of the following complications occurred in our series: saddle deformity, cerebrospinal fluid (CSF) leak, anosmia, or nasal obstruction. With hump recurrence (2 cases), a closed roof rhinoplasty was performed utilizing simple rasping. In 9 cases, the patients underwent a complete revision of the rhinoplasty utilizing a closed approach: the septoplasty was redone and an additional strip of septal cartilage was removed. At the same time, mobilization of the bony pyramid was performed without the need for redoing the osteotomies, because the bones were stable but mobilized, similar to a pseudarthrosis. The mobilization associated with the revisional septoplasty allowed correction of the lateral deviation. When widening of the middle third was the indication for revision, an incomplete division of the ULCs from the septum was performed from the caudal junction, with resection of a small triangular amount of ULCs as advocated by Kern.³⁶ At the same time, this is also an excellent way to reduce the nasal length, preserving the valve function by rebuilding the anatomy. In 6 patients (0.02%), a classic Cottle technique^1,2 or a disarticulation technique^37,38 with bony cap resection and K-area preservation was done because of difficult posttraumatic septal deformities, which involved septal cartilaginous resections and loss of septal support, making the dorsal strip resection impossible. A true Cottle procedure is always time consuming and it is a bit difficult to position the new dorsum.

CASE STUDIES

Case Study #1: Tension Nose, Let Down Procedure

A 29-year-old woman complained of having a high dorsum, a high frontonasal angle, and a closed nasolabial angle (Figure 7). Because the dorsum had good aesthetic lines, the procedure performed consisted of an endonasal approach utilizing an interseptal columellar incision, undermining of the dorsal soft tissues, creating superior bilateral septal tunnels, subdorsal incremental 8 mm septal strip resection, subperiosteal lateral bony wall undermining on the internal and external sides, and bony wedge resection utilizing a 4 mm wide bone rongeur. This was completed through endonasal low to low osteotomies and radix percutaneous osteotomies, followed by a let down maneuver. The tip rotation was achieved through a 3 mm caudal septal angle triangular trim. Utilizing a marginal approach, tip refinement was done, after lateral cranial crus reduction, through cranial tip and interdomal sutures as proposed by Kovacevic³⁹ and fixed with a 4-0 Vicryl round needle suture. Alar base reduction was performed to reduce alar flare. The results are shown preoperatively, 8 days postoperatively, and 1 year postoperatively. Note the lack of bruising and swelling at 8 days even with the extensive exposure from maxilla to maxilla and after bony resection and complete osteotomies.

Case Study #2: Deviated Nose, Asymmetric Push Down Technique

A 35-year-old woman complained of a deviated nose and nasal obstruction (Figure 8). The patient had no history of nasal trauma or surgery. She presented with a thin-skin, deviated bony-cartilaginous dorsum and septum, and she did not want to change her profile lines or nasal tip. Speculum examination and cone-beam CT scan revealed a significant S-shaped septal deviation with a cephalic convexity toward the right and a caudal convexity toward the left. An endonasal approach was utilized beginning with an interseptalcolumellar incision. Then a wide undermining of the soft tissue envelope was done. The septal surgery consisted of the following: (1) superior bilateral septal tunnels and unilateral septal complete undermining on the right side; (2) a swinging door endoscopically video-assisted technique with resection of the deviated bony components: vomer, maxillary crest, and part of the ethmoidal perpendicular plate; and (3) repositioning of the quadrangular cartilage on the midline without septal cartilage resection. Asymmetric osteotomies were done with a low to low osteotomy on the left side (long side) and complete percutaneous osteotomies on the right (short side). Finally, an asymmetric push down technique was done by rotating the nasal pyramid en bloc onto the left side. The results are shown preoperatively, 8 days postoperatively, and 1 year postoperatively. Note the symmetry of the dorsal lines. At the patient’s request, there were no changes in the profile or the tip.

DISCUSSION

In rhinoplasty, there is no universal technique to utilize, because there are different noses, different patients, and different clinical histories. The goal of a dorsal preservation technique is to keep intact the K-area and the entire osseocartilaginous vault. The dorsal hump should be eliminated, and no irregularities or discontinuity should be found either by the patient or the surgeon. Functionally, the competence of the internal valve should be preserved and all valves should be opened through the enlargement of the nasal base and its reorientation following the rotation processes. Transversally, the ULCs act like springs and open the internal valve angle (Figure 9). Longitudinally, the lowering of the ULCs modify the scroll area, which is untouched during the procedure.^9,11,22,33 A definite improvement in nasal respiration was reported by the 309 patients who underwent a dorsal preservation rhinoplasty. Within this series of patients, a subset of 30 patients was given a NOSE questionnaire for assessing nasal respiration preoperatively and postoperatively. There was a definite improvement in 90% (27/30) of patients, with the remaining 3 patients stating that they had no change and no worsening. As with all nasal surgeries, appropriate functional procedures are incorporated on an as-needed basis, including laser-assisted partial turbinectomy and septoplasty. This persistence of improved respiration is in direct contrast to resection rhinoplasty, in which the quality of respiration tends to deteriorate with time because of age-related thinning and retraction of the surgically altered musculocutaneous layer overlying the modified cartilaginous dorsum.^40,41

Technical Challenges

Problems that can occur utilizing the dorsal preservation technique are represented by hump recurrence and possible lateralization of the nasal pyramid. To avoid these complications, we believe that it is mandatory to fixate and to better stabilize the dorsum in the new position. Any residual hump can be corrected easily under local anesthesia, with a simple rasping through a closed approach. Ishida et al³⁸ reported a partial hump recurrence of 15% in 120 patients who underwent a conservative rhinoplasty, caused by the difficulty to know and to quantify the size of the septal strip that should be resected and the consequence of the memory of the soft tissues. A minor revision was needed in these cases, resulting in a satisfactory final aesthetic result. Reviewing Ishida’s technique,³⁸ the septal resection is done at a lower midlevel than our preferred subdorsal septal location. Thus, precise evaluation of dorsal lowering is more difficult and recurrence is more common.

Obviously, certain technical questions arise as to how to adapt standard reduction techniques within the context of dorsal reservation. As with all rhinoplasty surgery, appropriate septal surgery is required. Bony septal deviation and vomerine spurs are rested as necessary to improve respiration. Caudal septal deviations are mobilized, relocated, and fixed to the anterior nasal spine. Once the septal trip resection has been completed, then additional cartilage can be harvested from the cartilaginous body provided that a 10 mm L-shape septal strut remains. In many cases, the excised septal strip will be sufficient for a columellar strut or alar rim grafts. One of the inherent advantages of dorsal preservation techniques is that there is no need for spreader grafts. In cases of a wide dorsum, one can control width to a limited degree by pushing down the bony vault, which leads to narrowing of the bony vault width. When a truly wide or very asymmetric cartilaginous dorsum is present, other procedures should be considered. One advantage of DPO procedures is the necessity for a complete transverse osteotomy, which allows for radix reduction in particularly reducing the distance from the nasion to the corneal plane. Because complete mobilization occurs in the radix area, pushing downward on this point will reduce the radix.

In our series, we did not have that many recurrent humps, which we attribute to the following: (1) the resection is done high, just beneath the vault; and (2) fixation of the ULCs/ septum junction is done routinely. It is critical that the septal resection be done flush with the dorsum. Any small residual amount of subdorsal septum will prevent changing the shape of the dorsum from convex to concave. Moreover, the preoperative measurement of the planned dorsal reduction can be directly transposed to the intraoperative septal height resection. Thus, it is possible to immediately evaluate the lowering of the dorsum by measuring the height of the septal strips that have been removed, and if necessary, any additional correction can be done just by resecting another strip of septal cartilage. Compared to Cottle’s classical push down technique,^1,2 our technique does not require any deep or extensive septal surgery and thus has a shorter operative time and quicker recovery with safer postoperative outcomes.

In contrast to Gola,^20-22 it is our opinion that undermining the dorsal skin envelope is an essential step in the procedure. We begin with an interseptocolumellar approach, done on the caudal border of the septum posterior to the membranous septum, thus avoiding any injury to the nasal ligaments and nasal SMAS extensions.³² Once the caudal septum is exposed, undermining of the dorsum in the subperichondrial and subperiosteal plane is easily completed. Gola’s rationale for not elevating the dorsal soft tissues is that there is no damage to the skin envelope and a shorter operative time. However, we think that elevation of the dorsal soft tissue is necessary, especially in the deviated noses, because the skin participates directly in maintaining the shape of the deformity. Moreover, in unilateral let down, the excess of skin needs to redrape to avoid the risk of incarceration in the freed space. If undermined in the proper plane, the skin will redrape freely after the procedure and without damage to the SMAS and neurovascular structures.

Indications/Contraindications

Dorsal preservation is limited to primary reduction rhinoplasties. As previously stated, patient selection is a critical part of rhinoplasty planning and dorsal preservation is not a universal operation. In evaluating patients, the main question to answer is: can we keep the nasal dorsum? For example, a “cartilaginous” nose is an excellent indication for dorsal preservation of the K-area, because it avoids any collapse of the ULC after dorsal resection. In contrast, the very kyphotic bony hump with a deep nasofrontal angle or an irregular bony pyramid is not a good indication for dorsal preservation. A conventional Joseph rhinoplasty was required for 41% of our patients. The initial shape of the dorsum and its susceptibility to be changed was the primary limiting factor. When the K-area is not anatomically correct because of asymmetry, depression, or scars, preservation of the dorsal shape is impossible. A wide dorsum is not a contraindication, because multiple lateral and intermediate osteotomies can narrow the nose. As previously stated, 156 (21.1%) cases were secondary septorhinoplasties previously operated elsewhere and thus were not candidates for a dorsal preservation technique, because the dorsum had been destroyed previously. An algorithm based on the patient’s presenting deformity is offered to guide in the selection of the appropriate technique (Figure 10).

One point that must be stressed is that modifications of the dorsum must be the first step before any nasal tip surgery is done, because dorsal lowering can dramatically alter many of the extrinsic tip characteristics. In tension noses, it is quite common to see the overprojected, downwardly rotated tip achieve attractive characteristics once the dorsum has been corrected. Dorsal preservation techniques are especially indicated in the following noses: (1) the straight nose with or without a moderate kyphotic hump; (2) the straight deviated nose; (3) the cartilaginous nose with small nasal bones and weak cartilages; and (4) the tension nose that often has elongated vertical nostrils (external nasal valve) and narrow internal nasal valves that tend to collapse.^20,22

CONCLUSIONS

Dorsum preservation techniques should become a part of every rhinoplasty surgeon’s repertoire. Whenever possible, dorsal preservation is preferred to resection and destruction with its obligate reconstruction. Obviously, the question is, “can we keep the nasal dorsum?” This must be answered through precise preoperative assessment. As described by Lothrop⁶ a century ago, the concept is to reduce the height of the nose by removing or cutting the 3 pillars of the nasal pyramid. A septoplasty is the essential first step. A strip of septal cartilage, whose height corresponds to the desired and planned preoperative measurements, is removed just below the nasal bony-cartilaginous vault. Depending on the height and shape of the septal resection, the dorsum is converted from convex to a straight or concave shape. The lateral basal bony resections or osteotomies are extended by a transverse osteotomy across the radix, thus separating the nasal pyramid from the face. With this total mobilization, the nose is impacted, or descends into the facial plane, in between the maxillary processes, followed by fixation in its correct position.

Because this procedure is generally quick, it saves time for difficult tips. Because it is simple and does not lead to tissue injuries, difficult revisions are avoided. The nose often appears untouched postoperatively, with no impingement on the nasal valves and no disruption of the aesthetic dorsal lines, so there is no need for midvault reconstruction. Although conventional reduction techniques must also be mastered, surgeons should consider learning dorsal preservation techniques with their functional and aesthetic benefits.

Supplementary Material

This article contains supplementary material located online at www.aestheticsurgeryjournal.com.

Disclosures

Dr Daniel receives royalties from Springer Publishing (New York, NY). The other authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES

Author notes