Key points

Introduction

For rhinoplasty surgeons, surgery of the dorsum is increasingly dynamic and exciting. An expanding repertoire of reproducible techniques offers excellent results that can be difficult to attain in certain patients using conventional methods. Once surgeons understand dorsal preservation (DP), they will look for every opportunity to preserve the dorsum. An enlarging body of techniques is evolving as the most creative and innovative rhinoplasty surgeons push the limits of the philosophy. For beginners, easier techniques should be chosen initially on patients with the most appropriate indications. As the learning curve progresses, it makes sense to advance to the next phase of the preservation journey and to learn the more complicated operations. Each DP operation builds on the others, and, over time, these philosophies make clinicians not only better surgeons of the nasal dorsum but also better surgeons of the septum and the nose in general. To understand DP, surgeons needs to gain a new appreciation of the septum, the perpendicular plate of ethmoid, osteotomies, and anatomy of the nose where they rarely operate with traditional L-strut philosophy. Through this journey, I have evolved as a surgeon, and now I approach rhinoplasty in ways that I did not before. The result is more natural and beautiful noses where the anatomy has been preserved.

Personal experience with dorsal preservation

My introduction to DP came in 2016. The concept was intriguing: preserve the dorsum by lowering the osseocartilaginous vault into the pyriform aperture. Because the keystone would remain intact and the middle vault would not be opened, irregularities/asymmetries/contraction could potentially be avoided. In addition, the prospect of a narrow but stable middle vault was exciting. Up to that point in my career, I learned the hard way that the only way to maintain stability was restructuring, which sometimes widened the middle vault and/or deteriorated over time. After dozens of hours of discussion with Drs Yves Saban and Rollin Daniel, I did my first DP at the end of 2016. Over the next year, other surgeons, including Drs Baris Cakir, Milos Kovacevic, Olivier Gerbault, Charles East, Peter Palhazi, and Abdulkadir Goksel, also began in parallel performing high septal strip DP as advocated by Saban and colleagues. Through hundreds of hours of casual conversations, emails, roundtable discussions, presentations, and meetings, we learned the technical details and were able to understand how to perform the high septal strip push/letdown technique and to achieve stable and predictable results. With 2 years of experience performing the high septal strip DP operation, I found that one-third of my primary rhinoplasty patients were good candidates. What came next was astounding:- the resurgence, development, and modification of techniques that expanded my indications for DP. Throughout 2018 to 2019, several techniques came to the forefront of rhinoplasty surgery, including Valerio Finnochi’s modification of the Cottle technique, as well as the cartilage pushdown techniques championed by Ferreira and colleagues and Ishida and colleagues. More than half of my patients can now successfully undergo DP with excellent results using a variety of techniques, each with its own best indications.

The spectrum of dorsal preservation (types 1–4)

Preservation rhinoplasty is not just DP, and DP is not just a pushdown or letdown impaction procedure. DP is a spectrum of techniques whereby the surgeon preserves all or part of the osseocartilaginous dorsum. More simply, DP can be divided into both impaction techniques as well as surface dorsal modification (DM) techniques. Impaction techniques lower the entire osseocartilaginous vault by (1) first separating the nose from the septum, followed by (2) separating the nose from the face. In contrast, surface or DM techniques lower only the central cartilaginous vault (with or without the bony cap), and the bones are treated separately as in component reduction. Technically, surface techniques are easier to learn and to execute for surgeons beginning DP. In addition, surface techniques widen the applications of the preservation philosophy ( Fig. 1 ).

The different DP procedures in order of increasing complexity. Types 1 and 2 are surface techniques whereby the cartilage is lowered, and the bones are treated separately without impaction of the osseocartilaginous vault. Types 3 and 4 are foundational techniques. A septal strip is removed either directly under the septum (type 3) or from the floor of the septum (type 4) and the nose is then impacted into the pyriform aperture.

As surgeons become more experienced with DP, it is preferable to preserve the dorsum and to avoid midvault reconstruction in select patients. Although some surgeons prefer a specific technique for all patients, I prefer to apply the optimal technique for each patient. A summary of my indications for each DP procedure follows, in order of increasing complexity. I have not invented any of these techniques, nor do I prefer 1 technique. I have used all these techniques in hundreds of cases over a 3.5-year period and have become aware of each technique’s inherent advantages and disadvantages in different patients. Each surgeon selects which technique to use based on personal experience and the patient population. The step-by-step technical details of these procedures are summarized elsewhere in this issue, so this article focuses on indications and thought processes.

Type 1 Surface Technique: Dorsal Modification/Cartilage Vault Modification

Cartilage vault modification (CVM) is the simplest technique for DP and an easy entry for beginner surgeons.

CVM modification is a hybrid DP technique that consists of 4 parts:

• 1.
  

  Incremental modification and ostectomy of the bony cap to convert the bony dorsum to cartilage

  
  
• 2.
  

  Shaving excess upper lateral cartilage shoulders and/or dorsal septum without opening the mucosa

  
  
• 3.
  

  Piezoelectric rhinosculpture and/or osteotomies to narrow and to sculpt the bony pyramid

  
  
• 4.
  

  Closing any cartilage defect over the underlying mucosa and shaping the upper lateral cartilages ( Fig. 2 )

  
  

  
  

  
  

  

  
  

  
  

  Piezoelectric removal of the bony cap followed by shaving of the shoulders of the upper lateral cartilage without opening the middle vault. This is DM/CVM.

  
  

Thus, CVM is a surface technique whereby only the bony cap is removed, and the cartilaginous vault is modified/lowered. The bones are dealt with separately (as in a component reduction) and no impaction of the osseocartilaginous vault into the pyriform aperture is performed.

My indications are as follows ( Fig. 3 ):

• •
  

  Small hump/convexity less than 2 mm

  
  
• •
  

  Small hump with need for tip projection

  
  
• •
  

  Small hump with wide bones and/or need for osteotomies

DM/CVM. A 20-year-old woman presents with a 2-mm dorsal hump, a bulbous tip, wide nasal bones, and plunging tip on smiling. She has an underprojected nasal tip. The patient is shown preoperatively ( left ) and postoperatively ( right ) after removal of the bony cap with piezoelectric surgery and modification of the cartilaginous vault. The upper lateral cartilages and a small amount of the dorsum are shaved with a 15-blade without opening the middle vault mucosa. Medial oblique, low-to-low, and transverse osteotomies were performed with piezoelectric instruments. A septal extension graft was used to support the nasal tip. Her tip was dissected sub–superficial musculoaponeurotic system (SMAS) and her dorsum in a subperichondrial plane. Her ligaments were preserved, and no cartilage was removed from her alars (only tip suturing). Therefore, she underwent a complete preservation rhinoplasty. Postoperatively, she shows improved dorsal aesthetic lines, relief of the dorsal hump, and excellent tip contour.

The main advantage of the CVM technique is simplicity, particularly in an open approach. With a small osseocartilaginous hump, the osseous part is removed up to the desired profile line, and any excess cartilage is shaved. The cartilaginous vault is kept mostly intact, as is the internal valve mucosa. Because the upper lateral cartilages have not been separated from the dorsal septum, there is no need for midvault reconstruction. In addition, endonasal spreader grafts can easily be placed in submucosal pockets to treat asymmetries. The bones are modified as needed with standard osteotomies for narrowing dorsal or base bony width. Of note, the septum remains available for septoplasty and harvesting of graft material, and, if the surgeon gets in trouble, conversion to a standard component reduction is simple.