A Segmental Approach in Dorsal Preservation Rhinoplasty

Rhinoplasty has become a detail-dependent surgery. With precise techniques better results have been achieved. We are continually searching for the ideal technique to offer predictable, accurate, and desired long-term results. Conservative rhinoplasty techniques have been described for more than 100 years as an alternative to dorsal resective surgeries and have reemerged as the new fashion among rhinoplasty surgeons. This article presents our philosophy when approaching the nasal dorsum regarding its segments and their specific anatomic aspects and surgical demands. We describe our intermediate septal strip approach, the intermediate split and the Tetris concept, and discuss their advantages and limitations.

Key points

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Dorsal Preservation Rhinoplasty has seen considerable advances in the recent years since many doctors have improved and developed new ideas on the subject.
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The Split Preservation Rhinoplasty showed the real advantage of the intermediate resection in stabilizing the rhinion position by putting a suture from our free anterior dorsal septal cartilaginous flap to the basal posterior stabile septum.
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The Split Tetris is an evolution of the Intermediate Split Approach whose fundamental goal is the stabilization and predictability of the nasal dorsum final position. It was designed to avoid conceptual weakness, mainly regarding coronal axis deviations and causal septal border instabilities.

Video content accompanies this article at http://www.facialplastic.theclinics.com .

Introduction

Conservative dorsal rhinoplasty, until recently called the push-down rhinoplasty, has been written about extensively. Since the end of the nineteenth century, some works have shown how to reduce a projected dorsum without impairing the surface anatomy of the nasal pyramid. By many, it was seen as an uninteresting and perhaps mistaken concept but by a few it was seen as the logical approach for preserving structures and avoiding massive complications. Recently, we have observed the rebirth of dorsal conservative concepts. In some cases, the technique is incorrectly assumed to be new, and in others they are philosophies and details that really represent a step forward to achieving the best results in an accurate and predictable fashion.

Dorsum conservative techniques

Even though the concept of dorsal preservation was already more than one-half of a century old, it was Cottle ^, who popularized the “push-down technique” in 1946, combining several steps described by other surgeons. The principle of the technique was to preserve the continuity of the nasal dorsum by impacting the bony and cartilaginous hump around the keystone point. His technique consisted of a basal strip resection of the septal cartilage, 1 or 2 paramedian osteotomies, the preservation of the keystone area, and lateral osteotomies allowing him to move the nasal pyramid downwards and inwards (or outwards) into the frontal process of the maxilla ( Fig. 1 , push down).

After the push down technique became popular, there were other surgeons such as Huffman and Lierle in 1954 and Huizing in 1975 who made variations of the technique as they argued that the amount of reduction that could be obtained in this way was limited. The “let-down technique” was then popularized, even if authors like Lothrop in 1914 had already described the resection of a triangular bony wedge of the lateral nasal wall. This considerably facilitates the downward movement of the nasal bones and avoids the narrowing of the nasal cavity (see Fig. 1 , let down).

In Lothrop’s work, we can see that he already addressed the septum by removing cartilage and ethmoidal plate below the nasal vault. In the 1980s Gola and in the 1990s Saban and associates ^, refined the high strip approach. At the same time, Dewes developed his concept, the septum and pyramid adjustment and reposition technique; his technique consisted in 2 possible conservative surgeries to reduce the septal height (type A, based on Gola’s high septal strip concept, and B, based on low septal strip Cottle’s concept, the approach more often performed) and one to augment the dorsum (type C). Later, many surgeons published modifications of these dorsal conservative techniques, such as Ishida and colleagues, who in 1999 published an intermediated septal approach (see Figs. 3–8 ) that they have been performing for several years ( Fig. 2 ).

The main author, a disciple of Dewes since 2008, gradually changed his preference from the low septal strip to the intermediate septal strip, as explained elsewhere in this article, having taken into consideration the ideal indication of each case. Regarding the lateral wall, in the majority of cases the let-down technique is used.

The segmental preservation approach

Whenever there are a considerable number of techniques describing how to achieve the same final surgical purpose, it means that the ideal technique has not yet been found. We can also apply this rule to rhinoplasty techniques, and specifically to dorsal preservation concepts. Some disadvantages can be attributed to the push-down technique/let-down technique family. Bringing the nasal semirigid pyramidal unit down as a whole structure without addressing each segment for refinement can be the main disadvantage. The main disadvantages are a low radix and radix step, residual dorsal hump (being caused by a global hump relapse or by the inability to correct the residual bony hump), supra-tip saddle, wide dorsum, and eventual impairment of the nasal airway. Based on that factor, the pyramid must be addressed by segments and not as a single block. The Tetris concept in combination with the let-down technique aims to control each of them, regarding position and shape.

The main author has been doing preservation techniques for more than 10 years, with his preference being the intermediate approach. He has developed 1 modification of the let down technique with a septal intermediate resection, the split preservation rhinoplasty ( Fig. 3 A) that showed the real advantage of the intermediate resection in stabilizing the rhinion position by putting a suture from our free anterior dorsal septal cartilaginous flap to the basal posterior stabile septum. In fact, this is a critical stitch for predictably keeping the rhinion in the desired position with great accuracy.

The Tetris concept ( Fig. 3 B) is an evolution of the split preservation technique, with some advantages, which include suturing the free anterior septum (the Tetris block) in 2 vectors, craniocaudal and posteroanterior, conferring more stability to the pyramid in 2 axes and preserving a natural caudal septal strut, which allows us to control the supra-tip area and keep the caudal border and its relationship with the anterior nasal spine stable. As a general concept, these 2 techniques share the most relevant factor, the design of an intermediate fragment of cartilage below the rhinion to be anchored and consequently creating stability to the final dorsal profile.

For more details of the surgical technique we invite you to read the original articles “The Split Preservation Rhinoplasty, The Vitruvian Man Split Maneuver” and “The Segmental Preservation Rhinoplasty, The Split Tetris concept.”

Surgical technique

Osteotomies and Pyramid Mobilization

The let-down technique is our preference for approaching the lateral nasal wall because it gives us better mobilization of the pyramid and avoids bone impaction into the nasal cavity ( Fig. 4 ).

First, a transverse osteotomy is performed using a hand saw or an ultrasonic device under direct vision or alternatively a 2-mm osteotome that can be used percutaneously. The cut is made from the level of the medial canthal ligament up to the level of the lateral dorsum ( Fig. 5 A). The lateral osteotomy is part of the let down technique. It consists of 2 osteotomies followed by the removal of the intervening triangular bony wedge from the frontal process of the maxilla ( Fig. 5 B–D). The excision must be done very low laterally, in the nasofacial groove, to avoid any palpable or visible step ( [CR] ).

The lateral wall split maneuver

To create the flattening of the dorsal profile, the lateral walls must show some plasticity. To achieve that goal, the lateral articulation between the upper lateral cartilage (ULC) and the nasal bones in its posterior cephalic border can be released so that the Lateral Wall Split Maneuver movement is facilitated. Recently, Goksel and Saban also described this maneuver as the ballerina maneuver.

After the lateral bony wedge is removed, we dissect the inner surface of the lateral in a subperiosteal plane, to protect ULC and soft tissues. The pyriform ligaments are also liberated. This dissection will allow for an anterior and caudal sliding movement of the middle third of the lateral wall (see Fig. 4 ; Fig. 6 , [CR] ).

Septal Resection

Conceptually, in preservation techniques the septum can be addressed lower in its base, by keeping the attachment with the cartilaginous vault intact and bringing all the structure down as a unit, and it can be addressed higher at the junction with the ULCs, exclusively pushing down the cartilaginous vault. It can also be addressed by splitting the septum in a strategic medial position, bringing the ULCs and the remaining attached septum down. Each one of these approaches has its pros and cons.

The intermediate split preservation rhinoplasty

The intermediate split preservation rhinoplasty consists of the following essential steps. (1) A tapered intermediate resection (that represents the amount of hump deprojection) begins at the caudal border of the septum and extending to the perpendicular plate of ethmoid, with its highest point in the most prominent aspect of the hump, at the rhinion level. (2) A vertical chondrotomy just toward this prominent point of the hump is performed, at the K-point or, most often, caudal to it. (3) A suture is placed for fixation from the free anterior dorsal septal cartilaginous flap to the basal posterior stabile septum ( Fig. 7 ).