Preservation Rhinoplasty

Preservation rhinoplasty is a new term for an old technique. The authors have used the endonasal push-down and let-down techniques that are attributed to Dr Maurice Cottle throughout their careers on select patients with excellent success. The endonasal Cottle technique allows the authors to manage the nasal dorsum in a conservative fashion, reducing the need for routine restructuring of the middle third and nasal dorsum. The details of their approach are presented in this publication.

Key points

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Endonasal Cottle rhinoplasty has been a preferred method of nasal surgery for more than 50 years.
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Preservation rhinoplasty is a new term for an established technique.
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The push-down/let-down technique is a tried-and-true method for dorsal reduction and has been used with great success as a conservative approach to the nasal dorsum.

Introduction

Rhinoplasty is a transformative operation aimed at enhancing an individual’s quality of life through improved facial harmony and nasal breathing. A myriad of techniques and approaches has been described in the past, each successful in allowing us to achieve the surgical goals, and each also with its own merits and shortcomings. The minimally invasive endonasal approach challenges the surgeon with a reduced field of view and limited access. The more extensive dissection as practiced with the external approach challenges the surgeon with a need for precise nasal restructuring, often with grafts and leaving an external scar. The endonasal “push-down” and “let-down” techniques, the subjects of this article, have been standard operations taught and practiced in the United States, Mexico, Brazil, Italy, Germany, the Netherlands, and France among many surgeons, with origins dating over a century by Lothrop and Goodale. ^, It should be clear that the techniques described herein are not part of a new surgical trend nor a new surgical technique, but rather a very well-established operation that has been selectively used throughout the authors’ careers and those of surgeons worldwide, including rhinoplasty giants, such as Cottle, Hinderer, Dewes, Sulsenti, Lopez-Infante, Huizing, Barelli, Saban, Drumheller, Goodale, Lothrop, Gray, and others. The long-term results have been very satisfying to both patient and surgeon alike.

Recently, renewed interest in the endonasal approach for rhinoplasty has brought to light Dr Maurice Cottle’s “Push-Down” operation ^, and Dr Egbert Huizing’s wedge resection called the “Let-Down” operation by Dr Vernon Gray of Los Angeles, California. Today’s interest stems from the recent trends to preserve the nasal dorsum during rhinoplasty, which has been newly branded “Preservation Rhinoplasty.” The rebranding of the operation through new terminology has popularized it and reopened possibilities for experienced surgeons to explore something “new” that is actually quite “old.”

Surgeons approach rhinoplasty with options of performing the operation by either the endonasal or external structural approach. Currently, practicing surgeons seem to be embracing and adapting to a specific technique that best resolves a given pathologic condition. The “Push Down” or “Let Down” relies on reducing tension within the nose, whereas the classic external structural rhinoplasty relies on creating tension to insure the new nose can withstand the potentially deforming forces of wound-healing contracture. The reintroduction, popularization, and renaming/reclassifying of previously well-established but lesser-known and often even rejected techniques should not be confused with technical novelty or innovation and should therefore not be met with fear or concern regarding safety and efficacy. Expert rhinoplasty surgeons who have enjoyed decades of outstanding results are trying something old for the first time, and they will contribute to innovations and improvements on the classic “Cottle operation.”

History

In the early to middle twentieth century, the divergent rhinoplasty schools of Jacques Joseph and Maurice Cottle emerged based on differing surgical philosophies. Both the Joseph and the Cottle techniques were performed through the endonasal approach, but Joseph approached the dorsum directly with excision of the “hump,” whereas Cottle reduced the “hump” by lowering the dorsum into the nose from below. Devout surgeons in each of the 2 schools continually worked to improve the basic techniques as they sought ways to optimize patient outcomes. Endonasal and external approaches evolved over time. The minimally invasive endonasal approach challenged the surgeon with reduced visualization compared with the extensive visualization attained by the external approach. The endonasal approach was also more demanding to teach because of limited visualization. The external approach and “hump” resection, although providing superior visualization, challenged the surgeon to construct the resected nasal structures with grafts and sutures. Outstanding techniques evolved out of a need to restructure the destabilized altered nasal dorsum and nasal middle third, in order to allow for excellent esthetic and functional breathing results. External approaches also commonly detach or transect nasal ligaments, structures that have previously been identified as important structures to consider as early as 1965, and to retain in more recent years. ^, Pitanguy and colleagues described specific maneuvers to identify and transect the dermato-cartilaginous ligament: the ligament is bypassed and preserved in most endonasal surgeries, and Pitanguy himself described specific maneuvers useful to access, identify, and transect the ligament for situations he thought necessary.

Although it is more invasive, the external approach gained popularity for numerous reasons: excellent visualization permitting technical precision, visualization allowing anatomic comprehension, and straightforward student’s understanding of the operational concepts. These factors, coupled with the abundance of talented teaching surgeons both training and producing outstanding results, contributed to the establishment of the external structural approach as the prevailing influence in North American and European rhinoplasty for the past 3 to 4 decades. ^, During the period of external approach structural rhinoplasty dominance, the results achieved were outstanding and exceeded the results obtained through earlier endonasal techniques. As a consequence, it appears that fewer surgeons were trained in the older endonasal rhinoplasty techniques. During these last decades, exceptional lessons were learned from the external structural approach. These lessons or pearls were adopted by endonasal surgeons to insure long-term outcomes and to help to avoid common sequelae of “old-fashioned” endonasal reduction rhinoplasty. The endonasal surgeons could also place columellar strut grafts, spreader grafts, spreader flaps, butterfly grafts, lateral crural strut grafts, batten grafts, and use other techniques used by external approach surgeons. Shaping the tip cartilages rather than resecting them, using spreader grafts and auto spreader grafts to straighten and stabilize the middle third, and using cartilage camouflage techniques helped secure strong long-term foundational nasal support by preserving and reinforcing native structures through an endonasal approach. It appears that the external rhinoplasty approaches still dominate the surgical landscape even today.

During the past few years, many surgeons have celebrated surgical success adopting concepts of dorsal preservation techniques. Many of these surgeons who follow the preservation rhinoplasty trend are performing the operation through the external approach. To make it an even more conservative and safe operation, the authors anticipate the future emergence toward endonasal preservation rhinoplasty. They present their long-standing endonasal Cottle surgical techniques and highlight some associated advantages over many of the other surgical techniques that they also use frequently. Through life-long learning and constant striving for improvement, the widespread renaissance or rebirth of the Cottle techniques among surgeons worldwide has added much excitement for the authors as they exchange ideas and explore new perspectives and variations on these traditional techniques. As new perspectives on an old technique emerge, the authors will all reexamine their rhinoplasty methods on the road to even better outcomes.

Technique

The endonasal Cottle technique forms the foundation of the authors’ version of preservation rhinoplasty: a technique that combines various endonasal access incisions and produces comprehensive and enduring aesthetic and functional results. Standard endonasal Joseph access incisions, including a hemi-transfixion (HT) incision and an intercartilaginous (IC) incision, may be used. A Cottle retractor or a wide double skin hook may be used to access the intranasal cavity for these incisions. Alternatively, the Fausto Lopez Infante (FLI) “T” incision provided a nuanced modification of the incision to help prevent the often dysfunctional and potentially cosmetically deforming scar at the junction of the IC and HT incisions that were often found in patients who underwent reduction rhinoplasty through standard Joseph incisions. Using a 4-prong retractor along the rim of the nose for lateral and caudal traction and a single skin hook in the cul-de-sac at the internal valve angle applying medial traction, a left IC incision is made. The single hook is then repositioned toward the base of the columella for downward traction, and a HT incision is made. In the FLI approach, these 2 straight line incisions (HT and IC) come together as a “T” rather than an “inverted U,″ as in the standard Joseph approach, helping to minimize circumferential scarring at the valve angle in the “cul-de-sac.” These incisions are replicated on the right side, thereby providing bilateral nasal access ( Fig. 1 ).