Preoperative Assessment

In addition to the ever-important psychologic evaluation of the patient and their reasons for desiring rhinoplasty, the surgeon must categorize the “nose type” in order to select the appropriate surgical technique.

In DP cases, it is crucial to preoperatively assess the nasal dorsum by examining its size, shape, and orientation externally and palpating its cartilaginous and bony elements. The rhinoplasty surgeon needs to determine, ‘Is it possible to maintain the dorsum intact?’ Often, the conclusion is that the dorsum has a natural appearance and is preserveable.

Furthermore, a more cartilaginous dorsum makes a stronger case for preservation methods. Diagnosing deviations and asymmetries preoperatively is crucial for choosing the appropriate septoplasty and osteotomy methods. An in-depth examination of the nostrils focuses on their size, orientation, and aesthetic markers. In tension noses, the nostrils are slim with excessive height, while the nasal lobule seems shorter. After employing impaction methods for dorsal lowering, the nostrils might widen and the internal nasal valves expand. At times, these outcomes are anticipated and preferred, but if overdone, a concluding alar base reduction is necessary.

DP works better in V-shaped nasal bones than in S-shaped bones.

Without additional contouring maneuvers, S-shaped noses are more likely to develop an osseous residual hump.

Previously, we published the guidelines for dorsum preservation in primary rhinoplasties, where we classified approaches based on the nose type summarized as follows:

Type 1 (straight noses) PR: complete preservation of the dorsum without any dissection of the soft tissue envelope;

Type 2 (tension noses) PR: DP with bony cartilaginous resurfacing;

Type 3 (kyphotic humpy noses) PR: Cartilaginous-only preservation with bony-cartilaginous disarticulation and push-down of the cartilaginous vault.

In the event of a severely deviated and unstable septum, the Cottle procedure or its modifications or structural techniques must be considered.

Briefly, Type 1 PR is mainly applied to straight noses. The procedure is less traumatic and allows dorsum lowering. Type 2 PR is indicated when bony cap resurfacing or resection is needed, that is, for patients with minor bony bumps, S-shaped nasal bones, patient with tension nose deformity and aesthetically pleasing dorsal lines. Either the sub-superficial musculoaponeurotic system (SMAS) or subperichondrial/subperiosteal plane is utilized for skin and soft tissue elevation. The nasal bones are then reshaped (using a rasp or osteotome), and the superior bony margins are smoothed.

Type 3 PR is indicated for individuals with humpy and kyphotic nasal deformities that necessitate the use of disarticulation procedures. The surgical procedure includes the removal of a bony hump in conjunction with the K-A cartilaginous push-down technique.

Step 1: Approach to the Dorsum and High Septum

Reduction rhinoplasty and DP often necessitate the exposure of the caudal and dorsal septum, unless the nose is straight (Type 1), in which case dorsal undermining can be avoided. The procedure is commonly carried out via an endonasal inter-septum-columella route, a standard technique in septoplasty, without any lateral intercartilaginous extension.

The septal incision involves the mucoperichondrium along the caudal septum up to the anterior septal angle. Next, bilateral septal superior tunnels, very similar to the L-strut shape septoplasty procedure, in a limited submucoperichondrial dissection, along the dorsal cartilaginous septum toward the radix is performed and the W-point is identified and preserved. There is no need to elevate the mucoperichondrium off the entire cartilaginous septal framework. If the perpendicular plate of the ethmoid (PPE) is long, requiring excision in the area corresponding to the dorsal convexity, submucoperiosteal dissection over the anterosuperior angle of the perpendicular plate of the ethmoid bone is needed.

Step 2: Septal Incision

The septum is incised just below the dorsum, so as not to leave any remnant of the upper cartilaginous septum under the K-area, which could result in a “coat-hanger effect.” This section must begin where the cartilaginous septum and upper lateral cartilages (ULCs) diverge, at the W-point. The dorsal septal area supporting the supratip region, extending from the anterior septal angle cephalically for about 10 mm, termed the W-ASA segment, must be left intact at this point in the procedure.

The division of the cartilaginous septum below the dorsum will continue until the bony junction of the PPE, easily felt through the bony contact at the tip of the instrument. Then, if needed, using a 2 mm bone rongeur, the ethmoid perpendicular plate anterior bony angle will be resected incrementally up to the radix region. This maneuver is only necessary if the PPE blocks the descent. It is crucial to always verify the position of the instrument’s tip when approaching the radix or base of the cranium to prevent cribriform plate mobilization.

To verify that the division has been completed, an elevator is positioned in the left superior septal tunnel beneath the K-area and moved horizontally along the dorsal vault to the contralateral superior tunnel. This movement must be unimpeded. If not, the residual bridge must be excised. At this point, the septum and dorsum are no longer interconnected.

Step 3: Excision of the Septal Strip

Using fine scissors, a second cartilaginous incision will be made, almost parallel to the first, starting at the W-point, and ending at the bony contact in depth, from anterior to posterior. This cartilaginous strip incision will stop at the junction of the perpendicular plate of the ethmoid. At this point, the cartilaginous strip will be disarticulated from the PPE. The cartilaginous portion is then extracted, with relative ease. This first strip will typically be 3 mm in height and almost 30 mm length following a grossly triangular shape. This cartilaginous segment is preserved in saline for future use as a graft, if necessary.

Using a delicate bone rongeur or Caplan scissors, the superior anterior angle of the perpendicular plate of the ethmoid (called the E-point, E for ethmoid) can be removed, with high precision and soft hands, just under the nasal bones.

Step 4: Complete Mobilization of the Nasal Pyramid

Lateral, transverse, and radix osteotomies are necessary to render the bony pyramid wholly mobile and detached from the craniofacial skeleton. Typically, the choice of technique is determined by the surgeon preference . The following is a brief overview of these osteotomy techniques:

Sutures

The aim of the sutures is not only to close the skin but also to close the dead spaces created by the subperichondrial undermining. A few Vicryl Rapid 5-0 sutures are placed on the vestibular approach. One is done under the plica nasi to close the upper dead space below the ULC. It is important to avoid catching the cartilage or the external dermis to avoid granulomas or distortions. In open approach, the columellar incision is closed with a series of interrupted 6-0 fast absorbing gut sutures.

Dressing

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  Internal dressing: In cases of minimal septal manipulation, transseptal sutures to close dead space are sufficient. If signficant elevation of the mucoperichondreal flaps has occurred, or additional functional (IT reduction, sinus surgery, etc) maneuvers have been performed, silicone internal nasal splints are placed and kept in place for 1 w.

  
  
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  External dressing: With the use of external dressings, we aim to stabilize the bony cartilaginous pyramid in the proper position, to control the tip position, and to reduce the deadspace and swelling. Further, the idea dressing must be stable yet easy to remove without pulling up on the nose. To achieve these goals, a non-adhesive dressing is placed over the dorsum; then steri-strips are applied firmly over the non-adhesive dressing as to push the nose inward, that is, perpendicular to the face. A rigid cast is fixated over the nose in a stable fashion that is removed 8 to 10 d postoperative.

Post-Operation Recommendations

In post-rhinoplasty care, patients should be informed to avoid actions that increase intranasal pressure, such as Valsalva maneuvers and forceful nose blowing. They should also follow standard instructions, including avoiding strenuous activity, not sneezing through the nose, keeping the head elevated while sleeping, and practicing caution when sneezing to minimize the risk of bleeding, swelling, and ecchymosis.

Local cleaning involves the use of hydrogen peroxide and ointment gently applied with a cotton tip applicator to incisions only. Patients should refrain from inserting any objects into the nose or attempting to remove the nasal cast for cleaning or shape assessment. To alleviate swelling, a regimen of oral Prednisolone at a dosage of 40 mg or higher for a duration of 5 d or more is prescribed, along with phenylephrine to aid with nasal decongestion.

Post-Operation Visit

Whenever possible, it is better to see the patient on postoperative days 4 and 8. Early postoperation is useful for cleaning the nose, checking the patient status, and reviewing postoperative instruction. On day 8, patient returns for cast removal (and splint if placed) and to answer any questions patient may have.

Functional Concerns

Not every undesirable rhinoplasty outcome necessitates revisional surgery. The majority of these concerns can be managed with time and prudent management. Therefore, it is beneficial to evaluate these concerns over time and not rush to aggressive intervention. Here, we will briefly discuss some of the transient and long-term possible complications of dorsal preservation.

Nasal obstruction is the most common early functional finding following nasal surgery. Early nasal obstruction is typically caused by nasal and turbinate mucosal edema and typically resolves on its own within 3 mo; however, in certain cases, intranasal corticosteroids or vasoconstrictors may expedite the recovery. Although nasal obstruction caused by turbinate hypertrophy in the early postoperative phase may be edematous and temporary, persistent turbinate hypertrophy due to bony or mucosal redundancy may necessitate surgical inferior turbinoplasty.

Early postoperative internal edema may also contribute to the transient olfactory disturbances following rhinoplasty; however, we hypothetise that persistent anosmia or hyposmia may be caused by septal or osseous maneuvers that directly or indirectly harm the cribriform area. We have previously presented cases in which patients complained of chronic anosmia without any clinical or radiographic evidence of cranial base or cribriform injury.

Stenorhinia, or an abnormally narrow pyriform aperture, has been identified in less than 3% of our preoperative patients. We urge that patients suspected of stenorhinia (clinically or by computed tomography) be evaluated and counseled about the finding, even in the absence of preoperative nasal obstruction, as modified preoperative planning and surgical maneuvers may be necessary to prevent postoperative obstructive symptoms. It is imperative to note that the push-down procedure, if done properly, does not cause pyriform narrowing any more than traditional nasal bone fractures.

Recurrence or Persistent of the Dorsal Convexity

In cases when a genuine dorsal convexity reoccurs (as opposed to transient inflammatory or callus-type convexities) or is observed as a residual effect due to the incomplete intraoperative hump resolution, a revisionary surgery may become necessary. Conducting a meticulous physical examination is essential in order to accurately determine whether the observed abnormality is indeed a genuine dorsal hump, as opposed to a low radix or supratip saddling that may be disguising itself as a hump.

Axis Deviation

The optimal nasal dorsum has a linear and perpendicular trajectory, effectively bisecting the face into 2 imperfectly symmetric vertical halves. A lateral deviation of the axis is defined as the divergence of the nasal dorsum toward either side of the midline. The occurrence of lateral deviations of the dorsum subsequent to DP surgery may be attributed to the asymmetrical healing of the PDO.

Additionally, residual septal deviation, particularly caudally and dorsally, may cause axis deviation of the dorsum. This undesirable complication can be avoided with performing symmetric push down, adequate fixation, and proper septoplasty. If the deviation is a result of the asymmetry of nasal bone heights, asymmetric PDO, or unilateral wedge resection (as in LDO) in conjunction with PDO may be indicated in the initial surgery. Gubisch emphasized the Cottle axiom “as the septum goes, so goes the nose,” arguing that nasal deviations are always related to or associated with septal deformities. Facing this deviation, the surgeon can perform in-office lateral manipulation very similar to nasal fracture reductions, but done very gently with incremental increasing pressure during about 3mn on a lying patient who is asked to express if any pain occurs. Then a taping is left for a few days. This maneuver can be done painless till 1 y postoperation.

Middle Third Widening and Thickening

PDO and LDO naturally produce a biomechanical widening of the middle vault. This can be prevented intraoperatively by performing a ballerina maneuver or a ULC partial disarticulation from the septum. Early postoperative middle third widening may be attributable to edema and can be treated conservatively with digital massages, taping, possible triamcinolone injections, and time. However, in cases of persistent middle vault fullness, surgical revision may be considered. This widening is frequently observed in the frontal view, resulting in a flared nasal morphology following PDO. Contrary to what may be observed in patients with polly beak deformity, (that has never been observed in our experience after PR) the profile contours of these patients are satisfactory.

A possible cause of middle third widening may be excess or overlap of fibrocartilaginous tissue in the scroll area after PDO, in which scar tissue formation in the proximal scroll area, corresponding to the W-point, or excessive overlap of the caudal ULC scroll at the junction of ULC with lower lateral cartilages (LLC) results in tissue excess in the middle third. Surgical resection of the surplus tissue is the definitive treatment for this untoward finding if medical therapy fails.

Alternatively, the widening of the middle third may be due to the bowing of the ULCs in response to PDO, thereby widening the arch of the cartilaginous vault. If widening of the middle third is not desired, the surgeon must consider preventative maneuvers during the primary DP procedure to account for this bowing. The widening of the middle third correlates directly with the amount of push down, that is, reduction in dorsal height, and this effect is logically magnified in patients with cartilaginous noses and short nasal bones. Notably, the widening is not always undesirable, as it can enhance the aesthetics of a narrow vault and enlarge the internal valve; this is an advantage of DP over structural techniques in such situations.

Supratip Saddling

The W-ASA segment provides structural support for the supratip region. If the superior strip incision begins at the ASA, the descent of the dorsum will always cause the W-ASA height to decrease, resulting in a loss of support and a saddling in the supratip region. For this reason, we advocate always beginning at the W point to maintain the W-ASA height. Once the dorsum has been brought to the appropriate height, the W-ASA height can be adjusted through incremental direct cartilage excisions, allowing for the management of supratip height. Again, prevention is preferable to treatment. Should intraoperative supratip saddling be detected, it can be corrected with solid or fragmented cartilage grafting. In the postoperative period, filler injections should be discussed.

Bony Step Offs

Bony steps can be observed in areas of osteotomy, most frequently in the region of the radix osteotomy, but also in the regions of lateral osteotomy and less frequently in the territory of transverse osteotomy. It is imperative that the surgeon examines these areas of palpable/visible step-offs intraoperatively. In case of visible step-offs either at the radix, or on the lateral walls, we recommend to simply perform what we name “rescue percutaneous osteotomies” to cut the excess of residual bone at a higher level, to drop it inside the fracture line and to forget it there (article unpublished procedure). Sometimes, a simple rasping can frequently enhance the contours and prevent the need for revisional surgery.

Postoperatively, rasping or meticulous infrascturing of proud segments may be performed in a clinic or in the operating room under local anesthesia. The location of a radix osteotomy is crucial in terms of the risk of step deformity. To circumvent this problem, the osteotomy must be conducted cephalically to the intercanthal line. The orientation of the osteotome is also crucial. If the radix is perpendicular to the sellion, it may collapse; if it is angled downward, a hinge is formed that substantially reduces the risk of collapsing. Nonetheless, if an unintended step occurs, the simplest way to correct the problem is to execute another osteotomy via the same percutaneous approach, cutting the bone at a higher level tangential to the glabella, and dropping the bone fragment in the fracture. The same procedure can be readily done percutaneously after too high lateral osteotomies; a technique we refer to as “rescue osteotomies.”

Dorsal contouring with DP is an effective method with exceptional long-term functional and aesthetic results. In this article, we have provided a concise summary of the superior strip technique in dorsal preservation. We have additionally reviewed pertinent indications, advantages, and possible pitfalls in this technique. It goes without saying that the rhinoplasty surgeon must have an in-depth understanding of nasal anatomy, the biodynamics of dorsal preservation, and the technical nuances and philosophy of DP. When the proper DP technique is applied to the proper nose type, the results are astoundingly satisfying and long-lasting.