The Best and Worst of the Structural Preservation Rhinoplasty

Abstract

Aims and Backgrounds

To discuss good and poor outcomes in Structure and Preservation rhinoplasty.

Historical Perspectives

Dorsal preservation and structure rhinoplasty are time tested techniques.

Anatomy

Pertinent anatomy will be discussed.

Technology

Use of the piezotome is mentioned.

Patient Selection

Proper indications will be covered.

Technique

Structure and preservation techniques are discussed.

Postoperative Care

Postoperative care is discussed.

Conclusion

Structure and preservation rhinoplasty are effective techniques in rhinoplasty.

Keywords

structure rhinoplasty - preservation rhinoplasty - structural preservation rhinoplasty - hybrid structural preservation rhinoplasty - dorsal preservation

Structure and preservation rhinoplasty are two very important philosophies of rhinoplasty that have evolved over the years. Structure rhinoplasty was developed as an alternative to reductive rhinoplasty in 1989 with the Open Structure Rhinoplasty book.[1] Structure rhinoplasty incorporated the use of reduction with structural grafting to help prevent some of the potential long-term effects of the reductive maneuvers (component dorsal hump reduction, tip reduction, etc.). Structure rhinoplasty incorporated grafts such as spreader grafts, septal extension grafts, and tip grafts.[2] [3] [4] [5] The spreader grafts were used to prevent the potential narrowing of the middle vault, resulting in the inverted-V deformity and the associated functional issues. The caudal septal extension graft was used to prevent the postoperative loss of nasal tip projection associated with the dissection of the nasal tip support mechanisms. Structural rhinoplasty has become very popular and is likely to be used by most practicing rhinoplasty surgeons worldwide.

Some form of preservation rhinoplasty has been around for many years, with the early innovators of “dorsal preservation” techniques dating back to Goodale in 1898 and Lothrop in 1914.[6] [7] The initial terminology “preservation rhinoplasty” was coined by Rollin Daniel in 2018, and focused on preserving as much of the native anatomy of the nose as possible. Preservation rhinoplasty incorporates “preservation of the leading edge of the nasal dorsum (middle vault), preservation of the ligaments (Pitanguy and scroll ligaments), and preservation of the nasal tip cartilages.”[8]

Yves Saban has been the most influential single person responsible for the resurgence of dorsal preservation techniques over the past decade.[9] Baris Cakir, Aaron Kosins, and others have further advanced the teachings of preservation rhinoplasty.[10] [11] [12] [13] Preservation rhinoplasty is growing and becoming more popular with the introduction of the many techniques available today, including the high strip,[9] [14] the low strip (Cottle, SPAR B, and SPQR),[15] [16] [17] and the Tetris and subdorsal Z-flap.[18] [19] The increasing popularity of preservation techniques has been astounding and exponential in its growth.

The Best and Worst of Structure Rhinoplasty

Best of Structure Rhinoplasty

The best of structural rhinoplasty lies in its ability to stabilize a deformed or weakened nasal structure and provide long-term aesthetic and functional outcomes. There is no other option other than structural rhinoplasty for patients with weakened, depleted, or deformed nasal structures. These cases include the severely traumatized nose, the more severe congenital nasal deformities, the contracted nose, and most secondary rhinoplasty cases.[2] In many of these cases, autologous costal cartilage is used to manage the more severe, cartilage-depleted cases, or those requiring extensive structural support.

The primary means of reconstruction in these cases involves placement of a caudal septal extension graft or caudal septal replacement graft to stabilize the nasal base ([Fig. 1]). A caudal septal extension graft is stabilized off the existing caudal septum and stabilized with extended spreader grafts and/or thin cartilage splinting grafts ([Fig. 1A]).[2] If the caudal septum is inadequate to act as a stabilization point, then a caudal septal replacement graft is fixed into a notch made in the nasal spine/premaxilla and then fixed to extended spreader grafts ([Fig. 1B]).

Fig. 1 Caudal septal extension graft and caudal septal replacement graft. (A) A caudal septal extension graft was placed end-to-end with bilateral spreader grafts to stabilize the graft. Slivers of cartilage are placed inferiorly to stabilize the lower margin of the graft. Note the triangular shape to minimize downward pressure on the upper lip. (B) Caudal septal replacement graft fixed to the nasal spine and stabilized with bilateral spreader grafts. (Adapted with permission from Toriumi.[2])

Once the caudal septal extension/replacement graft is in place, the nasal tip cartilages can be reconstructed. This technique involves amputating whatever remnant of the lateral crural that remains at the medial crura level, then resuturing the lateral crural replacement grafts to the caudal septal extension/replacement graft. Then, lateral crural strut grafts are sutured to the undersurface of the lateral crural replacement grafts to provide the necessary lateral wall support ([Fig. 2]). This time-tested technique has been used for over 30 years with excellent long-term follow-up. It is important to ensure the lateral crural replacement grafts are appropriately positioned, and the lateral crural strut grafts are positioned with the concave surface of the grafts facing the airway. This is critical to ensure a good airway and proper tip contour. The lateral crural strut grafts typically measure 30 to 34 mm in length, 4 to 5 mm in width, and 1 to 1.5 mm in thickness. I will frequently leave the native costal perichondrium on the undersurface to help ensure proper curvature with the concave surface facing the airway. Then the lateral crural strut grafts are placed into caudally positioned pockets to stabilize the lateral wall of the nose ([Fig. 3]). If needed, lateral crural extension grafts can be placed to further control the position of the alar margins and to help correct alar retraction.[2] If there is a deficiency in vestibular lining, composite skin/cartilage grafts can be placed in the marginal incisions to allow closure of the marginal incisions and to ensure proper positioning of the alar margins.

Fig. 2 Lateral crural replacement grafts fashioned from existing lateral crura dissected from the vestibular skin. The lateral crural replacement grafts were sutured to the caudal septal extension graft and then stabilized with lateral crural strut grafts. Note the anterior positioning of the caudal margin of the lateral crural replacement grafts. (Adapted with permission from Toriumi.[2])

Fig. 3 Pocket placement for lateral crural strut grafts with repositioning. The lateral pocket is initiated at the end of the marginal incision and extended caudally toward the upper lip. The pocket differs from an alar rim graft as it passes caudally along the supraalar groove. (Adapted with permission from Toriumi.[2])

Structural rhinoplasty is key to the successful management of the cleft nasal deformity due to its weakened and asymmetrical supportive structures.[2] [20] The primary example of this lies in the asymmetrical nasal tip cartilages and deficiencies of the platform of the nasal base in the unilateral cleft nasal deformity. Keys to management include managing the skeletal deficiencies and the asymmetrical nasal tip cartilages.[20] One of the biggest strengths of open structure techniques is the ability to create symmetrical tip cartilages from asymmetrical cartilages or no cartilages.[2] [20] These cases typically require harvesting costal cartilage to provide adequate structural grafting to manage the tip asymmetries.

Case #1: Patient with Unilateral Cleft Nasal Deformity and Deficient Nasal Base

This patient presented after undergoing multiple prior surgeries for the unilateral cleft nasal deformity. She had a significant left premaxillary deficiency and asymmetric nasal tip cartilages. She also complained of nasal obstruction. Management required major augmentation of her left premaxilla and complete reconstruction of her nasal tip cartilages. The nasal tip reconstruction starts with the placement of a caudal septal extension graft that sets the foundation for the reconstruction. After placing the caudal septal extension graft, the nasal tip cartilages are dissected from the vestibular skin, amputated at the level of the medial crura, and then sutured to the caudal septal extension graft. Then, 32 mm long lateral crural strut grafts are sutured to the undersurface of the lateral crural replacement grafts and placed into caudally positioned pockets ([Fig. 4]).

Fig. 4 (A) Intraoperative frontal view showing asymmetric alar insertions with much higher insertion on the right. (B) Intraoperative base view showing marked deficiency in skeletal support under the left alar insertion. (C) Segments of the seventh and eighth ribs were harvested with attached native perichondrium. (D) Asymmetric tip cartilages with caudal and inferiorly oriented left lateral crus. (E) Placement of bilateral extended spreader grafts and caudal septal replacement grafts fixed to the nasal spine. (F) Asymmetric lateral crura were amputated at the level of the medial crura. (G) Lateral crural replacement grafts were sutured to the caudal septal replacement graft. (H) Longer lateral crural strut grafts were sutured to the lateral crural replacement grafts. (I) Lateral crural strut grafts show a favorable contour with the concave margin facing the airway. (J) Y to V maneuver planned for the left alar base. (K) Inferior alar rim graft to contour alar lobule. (L) Premaxillary graft to be placed under left alar insertion. (M) Tip at the end of the operation. (N) Preoperative frontal view showing asymmetries of tip and alar insertions (left). Two-year postoperative frontal view showing improved tip symmetry and improved symmetry of alar insertions (right). (O) Preoperative lateral view (left). Postoperative lateral view (right). (P) Preoperative oblique view (left). Postoperative oblique view (right). (Q) Preoperative base view showing asymmetries of skeletal support (left). Postoperative base view showing improved symmetry of her nasal base. (R) Preoperative close-up frontal view (left). Postoperative close-up frontal view showing improved symmetry (right). (S) Preoperative midrange frontal view showing asymmetries of alar base and alar insertions (left). Postoperative midrange frontal view showing improved symmetry of alar base and alar insertions (right). (Adapted with permission from Toriumi DM, Kosins A, Saban Y, Cakir B, Daniel RK, Goksel A, Palhazi P. Structural Preservation Rhinoplasty. St. Louis: Quality Medical Publishing, 2025.)

In this patient, multiple cartilage grafts were placed under the left alar base to augment the position of the left alar insertion and to improve symmetry of her nasal base. Additional work was performed to align her nostrils by performing a Y to V advancement flap to create a nostril sill, combined with an inferiorly positioned alar rim graft to shape the alar lobule.

Postoperatively, the patient has done well years later with improved tip symmetry and improved symmetry of the alar base.

Case #2: Patient with Bilateral Cleft Nasal Deformity and Severely Underprojected Nasal Tip

This patient presented with a bilateral cleft nasal deformity after undergoing multiple prior surgeries. His nasal tip was severely underprojected with an amorphous nasal tip. To manage his nose, the costal cartilage was harvested with attached native perichondrium. Bilateral submucosal spreader grafts were placed and then fixed to a caudal septal replacement graft fixed to a notch in his nasal spine. Wide dissection was performed around the nasal spine to allow the columella to be aggressively advanced anteriorly to open the nasolabial angle and increase nasal tip projection. This maneuver was very important to allow closure of the columellar incision, as there otherwise would be too much tension on the closure ([Fig. 5]).

Fig. 5 (A) Intraoperative frontal view showing an amorphous tip with thick skin. (B) Intraoperative lateral view showing severely ptotic underprojected nasal tip with acute nasolabial angle. (C) Base view showing very thick skin with retracted columella. (D) Intraoperative view of the nasal tip with scarring and asymmetries. (E) Making a notch in the vicinity of his nasal spine. (F) Large caudal septal replacement graft from his rib. (G) Caudal septal replacement graft fixed to bilateral spreader grafts. (H) Caudal septal replacement graft from the side view. (I) Wide release of the nasal base around the nasal spine and premaxilla. (J) Aggressive anterior elevation of the nasal base to move the lip forward. (K) Scarring across the nasal valve is causing airway obstruction. The yellow arrow points to the scarring of the right nasal valve. (L) The yellow arrow points to the scarring of the left nasal valve. (M) Lateral crura were amputated at the level of the medial crura. (N) Composite graft harvested from the right cymba concha. (O) An additional composite graft was harvested from the cavum concha of the same ear. (P) Hinged composite graft sutured into position from above to allow good access to the nasal valve. (Q) Lateral crural replacement grafts were sutured to the caudal septal replacement graft. (R) Lateral crural strut grafts are sutured to the undersurface of the lateral crural replacement grafts. (S) Lateral crural strut grafts from below. (T) Nasal tip at the end of the operation. (U) Endoscopic view of the hinged composite graft into the right nasal valve. The yellow arrow points to the composite graft. (V) Preoperative frontal view showing an amorphous nasal tip (left). Six-year postoperative frontal view showing improved tip contour with more tip definition (right). (W) Preoperative lateral view showing severely ptotic nasal tip (left). Postoperative lateral view showing increased tip projection and an elevated tip. Also, note the dramatic anterior movement of the columella upper lip junction (right). (X) Preoperative oblique view (left). Postoperative oblique view (right). (Y) Preoperative base view showing ptotic tip (left). Postoperative base view showing increased columellar length and increased tip projection (right). (Z) Preoperative close-up frontal view showing an amorphous nasal tip (left). Postoperative close-up frontal view showing improved tip contour (right). (Adapted with permission from Toriumi DM, Kosins A, Saban Y, Cakir B, Daniel RK, Goksel A, Palhazi P. Structural Preservation Rhinoplasty. St. Louis: Quality Medical Publishing, 2025.)

With the caudal septal replacement graft in place, the lateral crura were dissected, amputated at the level of the medial crura, and sutured to the caudal septal replacement graft. Then, lateral crural strut grafts were placed to set the position of the alar margins and to support the lateral wall. The patient had stenosis of the nasal valve due to poorly performed prior intercartilaginous incisions. To correct this, bilateral composite grafts were placed to reline the nasal valve and vestibule.

The patient has done well years after his reconstruction with excellent nasal function.

Case #3: Patient with Pinched Overprojected Tip with Nasal Obstruction and Deviation

This patient presented for secondary rhinoplasty due to an operated-looking nose with nasal obstruction. She desired a more natural look with less projection, a straight dorsum, and correction of her nasal blockage ([Fig. 6]).

Fig. 6 (A) Intraoperative frontal view showing a pinched nasal tip and lateral wall deformity. (B) Intraoperative lateral view shows an over-rotated tip lobule and low dorsum. (C) Intraoperative base view shows deviation and a narrow nasal airway with nasal valve obstruction. (D) Costal cartilage harvested with native perichondrium on the rib. (E) Intraoperative view of the tip cartilages shows over-reduction and asymmetry. (F) View of cartilages from below shows significant asymmetry. (G) Bilateral tall spreader grafts were carved with notches cranially. (H) Tall spreader grafts were placed and sutured to the caudal septal extension graft. (I) View of the spreaders and septal extension graft from the side. (J) Deformed lateral crura were noted after release. (K) Lateral crura amputated. (L) Lateral crural replacement grafts were sutured to the caudal septal extension graft. (M) Curved lateral crural strut grafts are sutured to the undersurface of lateral crural replacement grafts. (N) Lateral crural strut grafts with native perichondrium on the undersurface. (O) Tip at the end of surgery. (P) The vestibular skin is sutured back to the area under the domes. (Q) Preoperative frontal view showing pinched deviated tip (left). One-year and eight-month postoperative frontal view showing improved nasal tip contour (right). (R) Preoperative lateral view showing upturned infratip lobule (left). Postoperative lateral view showing improved tip position and slightly higher dorsum (right). She also has improved chin projection. (S) Preoperative oblique view (left). Postoperative oblique view (right). (T) Preoperative base view (left). Postoperative base view showing improved symmetry (right). (U) Preoperative close-up frontal view (left). Postoperative close-up frontal view showing improved tip contour and good symmetry of alar margins (right). (Adapted with permission from Toriumi DM, Kosins A, Saban Y, Cakir B, Daniel RK, Goksel A, Palhazi P. Structural Preservation Rhinoplasty. St. Louis: Quality Medical Publishing, 2025.)

Management involved harvesting her costal cartilage with attached native perichondrium. Because her dorsum needed to be slightly elevated and narrowed, tall spreader grafts were used to slightly raise and narrow her dorsum. Tall spreader grafts are notched cranially, sit on the nasal bones, and are fixed with a transosseous suture. The tall spreader grafts sit slightly above the existing upper lateral cartilages to raise the dorsum and also to narrow her dorsum. The tall spreader grafts are then fixed to the caudal septal extension graft caudally. The tall spreader grafts were camouflaged with a layer of costal perichondrium.

Then the lateral crural replacement grafts were fixed to her caudal septal extension graft to create new lateral crura. Then, lateral crural strut grafts with attached native perichondrium were sutured to the lateral crural replacement grafts.

The patient has done well for over 2 years with excellent nasal function.

Case #4: Patient who Suffered an Infection and Severe Deformity and Contraction of her Soft Tissue Triangle Facets

This younger patient presented after a prior rhinoplasty and postoperative infection resulting in a severe nasal deformity. She had a very short nose with severe contracture of her soft tissue triangle facets ([Fig. 7]).

Fig. 7 (A) Preoperative close-up frontal view showing severe deformity of the nasal tip and soft tissue triangle facets with columellar retraction. (B) Preoperative base showing deformities of the soft tissue triangle facets. (C) Microfat was cautiously injected into the scarred facets to decrease the depth of the defects and improve the blood supply to the tip and the deformities of the facets. This was performed in the office with local anesthesia. (D) Slight blanch of the facet tissues that resolved in a couple of minutes. The patient went for a series of HBO treatments after the microfat injections. Some microfat injections were also placed at the base of the columella. (E) Improved facets noted at the time of the reconstruction. (F) Base view showing improvement in the depth of the facet deformities. (G) Segment of the seventh rib harvested with attached native perichondrium. (H) Dorsal graft carved to augment the dorsum. (I) Caudal septal replacement graft with attached native perichondrium to protect the graft if it gets exposed. (J) A large vestibular incision was made to release the columella to allow lengthening of the nose (yellow arrow). (K) Caudal septal replacement graft fixed to the notched dorsal graft. (L) Shield tip graft fixed to caudal septal replacement graft with buttress graft. (M) Shield tip graft with articulated alar rim grafts and covered with perichondrium. (N) The entire right conchal bowl was harvested and then split into two composite grafts. (O) A hinged composite graft was placed into the right nasal valve and vestibular skin defect. (P) A hinged composite graft was placed into the left nasal valve and vestibular skin defect. (Q) Perichondrial cutaneous graft to resurface the gap in the columellar closure. (R) Perichondrial cutaneous graft over the columellar defect. Injecting nanofat around the composite grafts. (S) Base view at the end of the operation. (T) Two months postoperatively, after the major reconstruction, the failed perichondrial cutaneous graft. (U) Defect in the columella after failed perichondrial cutaneous graft (yellow arrow). (V) Salvage procedure using a tunneled buccal mucosal flap. Flap marked out on the buccal mucosa. (W) Buccal mucosal flap elevated. (X) A hemostat is used to create a tunnel to the columellar defect. (Y) Buccal mucosal flap tunneled under the lip and brought out through the columellar defect. (Z) Tunneled buccal flap sutured into the vestibular defect and the columellar defect. Injecting nanofat around the buccal flap. (Z1) One-year and six-month postoperative frontal view after salvage operation using a tunneled buccal flap. (Z2) One-year and six-month postoperative lateral view showing inadequate tip projection. (Z3) One-year and six-month postoperative base view showing healed columellar defect. (Z4) Major reconstruction using costal cartilage with attached native pericondrium. (Z5) Caudal septal replacement graft with attached native perichondrium. (Z6) Curved spreader graft used to straighten the nose. (Z7) Caudal septal replacement graft in place. (Z8) Tip at the end of the operation. (Z9) Minor procedure to excise the fistula around the tunneled buccal flap. The marked area notes the opening to the fistula. (Z10) Probe used to follow the fistula. (Z11) Excised fistula on the probe. (Z12) Preoperative frontal view showing severe tip deformity with scarred facets (left). Four years since initial reconstruction showing increased nasal length and correction of severe tip deformity (right). (Z13) The preoperative lateral view shows a short nose with an over-rotated nasal tip and retracted columella with a long upper lip (left). Postoperative lateral view showing a longer nose with a shorter upper lip and correction of retracted columella (right). (Z14) Preoperative oblique view showing a short nose with over-rotated nasal tip (left). Postoperative oblique view showing counter rotation of the nose with correction of the defect of the soft tissue triangle facet (right). (Z15) Preoperative base view showing deformity of soft tissue triangle facets (left). Postoperative base view showing correction of facet deformity and a more normal nostril shape (right). (Z16) Preoperative close-up frontal view showing retracted columella and defect of soft tissue triangle facets (left). Postoperative close-up frontal view showing a normal appearing nasal tip and correction of the retracted columella (right). (Adapted with permission from Toriumi DM, Kosins A, Saban Y, Cakir B, Daniel RK, Goksel A, Palhazi P. Structural Preservation Rhinoplasty. St. Louis: Quality Medical Publishing, 2025.)

The patient's nasal tip skin was severely compromised, requiring a nanofat injection with follow-up hyperbaric oxygen treatments to help recover the blood supply to her nasal tip skin. She was also asked to stretch her nose for 1 minute at least twenty times a day to break up the scarred tissues and allow lengthening of her nose. After several months of stretching, a reconstructive surgery was performed using costal cartilage for her caudal septal replacement graft. Native perichondrium was left on her cartilage to help protect the cartilage grafts and to enhance vascular ingrowth. This was very important in her case, as she had diminished blood supply and also had a history of a prior infection.

Her tip was managed with a shield tip graft and alar rim grafts due to the compromised blood supply to decrease the amount of dissection and preserve the blood supply to her tip skin. There was inadequate skin coverage to allow closure of the columellar incision. The patient did not want the scarring of a melolabial flap reconstruction. Therefore, a perichondrial cutaneous graft was used to line the gap in the columellar closure. Unfortunately, the perichondrial cutaneous graft failed, necessitating another procedure.

In a secondary procedure, a gingivobuccal flap was harvested from the gingival mucosa, tunneled through a tunnel into the columella defect. The gingivobuccal flap did well and resurfaced the columellar defect.

At a later date, the patient underwent another procedure to divide the pedicle of the gingivobuccal flap and close the fistula to the oral cavity.

At a final surgery, another rib graft was harvested to allow for the placement of another caudal septal extension graft and additional nasal tip reconstruction to reestablish good nasal tip projection.

The patient is now several years postoperative and doing well with a much improved tip contour and excellent nasal function. This case illustrates the complexity of such reconstructions and how, sometimes, things do not work out and surgical correction may be necessary. In these cases, it is imperative to keep the patient fully informed, work to fix the problem, and keep their confidence.

Case #5: Patient with Severely Underprojected Nasal Tip after Columellar Skin Necrosis

This patient presented after suffering columellar skin necrosis after undergoing simultaneous open revision rhinoplasty and upper lip lift. The patient was noted to have a full-thickness skin necrosis of her columella after the upper lip lift with revision rhinoplasty. The previous surgeon ended up suturing the nasal tip to her upper lip, creating a severe nasal deformity with a severely underprojected nasal tip. She had near-complete stenosis of her nasal vestibules, making it nearly impossible to breathe through her nose ([Fig. 8]).

Fig. 8 (A) The skin on her nasal base was poorly vascularized. A preparatory nanofat injection was performed to enhance the blood supply to the base of the nose and remaining infratip skin. The nanofat injection was performed 6 weeks prior to her reconstruction. (B) Intraoperative lateral view showing severely underprojected nasal tip. (C) Intraoperative base view showing severe vestibular stenosis with infratip skin sutured to her upper lip. (D) Intraoperative view of deficient tip structure. (E) Large caudal septal replacement graft with attached native perichondrium for protection of the graft. (F) Supratip onlay graft with a notch to help stabilize the caudal septal replacement graft. (G) Caudal septal replacement graft in place, showing deficiency in columellar skin coverage. (H) With the anticipated tip projection, there would be a 12 mm columellar defect. (I) Perichondrial lateral crural replacement grafts were used as no other option was available. (J) Lateral crural strut grafts are sutured to the perichondrial lateral crural replacement grafts. (K) Lateral crural strut grafts with native perichondrium on the undersurface to protect the grafts if they should become exposed postoperatively. (L) Left melolabial flap marked out on the left cheek. (M) The melolabial flap is being elevated. (N) Melolabial flap with adequate length to reach the right nasal vestibule. (O) Note a large defect that will be covered with the melolabial flap, which includes the columella and nasal vestibule. (P) Composite graft for coverage of a vestibular defect in the left nasal vestibule. (Q) Melolabial flap in place. Injecting nanofat around the composite graft in the left nasal vestibule. (R) At the end of the first stage of the reconstruction, a flap was placed with a lateral wall splint on the left to keep the airway open. (S) At the second stage of the reconstruction, the flap was debulked, and multiple z-plasties were used to camouflage the inferior suture line and prevent pin cushioning. (T) At the third stage, a long, narrow tip graft was placed to add tip projection. (U) The pedicle of the flap was divided, thinned out, trimmed, and set into place. (V) At the end of the third stage, the defect was covered, but there was some bulk left on the left side of the flap. (W) In a minor revision procedure, the left side of the columella was debulked to create proper contour. (X) Preoperative frontal view (left). Postoperative frontal view 1 year after debulking of the left nasal vestibule showing improved tip contour and good nostril symmetry (right). (Y) Preoperative lateral view showing severely underprojected nasal tip (left). Postoperative lateral view showing good nasal tip projection and normal columella upper lip transition (right). (Z) Preoperative oblique view showing underprojected nasal tip (left). Postoperative oblique view showing improved tip projection. (Z1) Preoperative base view showing severe nasal vestibular stenosis (left). Postoperative base view showing much-improved airway bilaterally (right). (Z2) Preoperative close-up frontal view (left). Postoperative close-up frontal view showing improved tip contour (right). (Adapted with permission from Toriumi DM, Kosins A, Saban Y, Cakir B, Daniel RK, Goksel A, Palhazi P. Structural Preservation Rhinoplasty. St. Louis: Quality Medical Publishing, 2025.)

To correct this problem, the patient underwent nanofat injections into her tissues followed by multiple HBO sessions.

She ultimately underwent definitive reconstruction using a costal cartilage caudal septal replacement graft with tip reconstruction using lateral crural replacement grafts and lateral crural strut grafts. The projected tip structure left over a 1.2 cm columellar defect.

Management of the columellar skin deficiency required a right-sided melolabial flap to cover the columella and to reline her nasal vestibule. In the first stage, the structural grafting was placed, and the melolabial flap was inset from her right cheek to close the columellar defect. In the second stage of the reconstruction, the melolabial flap was debulked, and additional tip projection was added. In the third stage, the flap was further debulked and the columella contoured. An additional minor nasal revision surgery was needed to further refine the shape of the columella.

She has done well over the years with much improved nasal tip projection, correction of her severe nasal obstruction, and excellent healing of her cheek donor site scar despite her darker-complexioned skin. She also now has excellent nasal function and bilateral patent airways.

Worst of Structure Rhinoplasty

One of the biggest problems with structural rhinoplasty is the need to use structural grafting to reconstruct what was removed, damaged, or altered during the reduction of the nasal structures. This includes the use of spreader grafts to reconstruct the middle vault after component dorsal hump reduction, placement of a caudal septal extension graft to reestablish support to the nasal base, and tip grafting to stabilize the lateral wall of the nose.

Use of Spreader Grafts to Reconstruct the Middle Vault

Component dorsal hump reduction involves removing the roof of the bony and cartilaginous dorsum. Then, the middle vault must be reconstructed using spreader grafts or spreader flaps. The removal of the roof of the dorsum introduces the potential for irregularities after reduction and subsequent reconstruction. This is particularly problematic in patients with thinner nasal skin and can show over time.

Case #6: Patient with Dorsal Hump and Ptotic Tip with Long-Term Deformity

This patient presented with a large dorsal hump and ptotic nasal tip. She underwent dorsal hump reduction using classic removal using a Rubin osteotome, followed by osteotomies and reconstruction using spreader grafts. Her nasal tip was managed using a tongue-in-groove setback with lateral crural release, placement of lateral crural strut grafts, and repositioning into caudally positioned pockets. She initially did well but over the years developed left-sided dorsal irregularities, including a visible, prominent left nasal bone and medialization of the left upper lateral cartilage ([Fig. 9]).

Fig. 9 (A) Intraoperative lateral view showing a large dorsal hump. (B) Taking down the dorsal hump using a Rubin osteotome, removing the upper lateral cartilage and bony hump. (C) Dorsal excision from frontal view. (D) Dorsal excision from side view. (E) A large defect was created in the roof of the bony and cartilaginous vaults (yellow arrows). (F) Bilateral spreader grafts were placed to reconstruct the middle vault. (G) Preoperative frontal view showing a narrow nose with near-perfect dorsal aesthetic lines (left). Eight-year postoperative frontal view showing prominent left nasal bone and collapse of left middle vault with irregularities (right). (H) Preoperative lateral view showing long nose with ptotic tip and dorsal hump (left). Postoperative lateral view showing a shorter nose with a rotated nasal tip and improved profile (right). (I) Preoperative oblique view (left). Postoperative oblique view (right). (J) Preoperative base view (left). Postoperative base view (right). (K) Preoperative close-up frontal view showing ideal dorsal aesthetic lines (left). Postoperative close-up frontal view showing prominent left nasal bone and medialized left upper lateral cartilage (right). The yellow arrow points to the prominent left nasal bone, and the blue arrow points to the medialized left upper lateral cartilage. (L) Postoperative closeup frontal views: L1: one month; L2: three months; L3: six months; L4: one year; L5: three years; L6: six years; L7: eight years.

This case demonstrates a patient who experienced problems related to the classic reduction of the dorsal hump, and despite middle vault reconstruction, developed late changes with visible deformities on her frontal view, with disruption of favorable dorsal aesthetic lines.

This case exemplifies one of the many reasons I have adopted dorsal preservation in my practice. If performed today, this patient would have been an ideal candidate for dorsal preservation. I likely would have performed a slight rasping of her dorsal cap with a letdown and Tetris to reduce her dorsal hump. By leaving the roof of her nasal dorsum intact, she likely would have healed well with none of the long-term problems seen after this patient underwent reduction followed by structural reconstruction of the middle vault.

In this case, a Rubin osteotome was used to take down the dorsal hump. I have not used a Rubin osteotome in over 6 years since adopting dorsal preservation. I have removed the Rubin osteotome from my rhinoplasty tray.

The Best and Worst of Preservation Rhinoplasty

Best of Preservation Rhinoplasty

The best of preservation rhinoplasty involves the preservation of the roof of the nasal dorsum, particularly the roof of the middle vault.[5] [8] In the past, I would always worry about the possible late changes that can occur in the upper two-thirds of the dorsum of the nose, as swelling resolves, healing occurs, and skin contracts over time. This was illustrated in Case #6 ([Fig. 9]).

Using dorsal preservation techniques, the roof of the nasal dorsum is left intact, with no destruction of the roof of the middle vault. Postoperatively, the long-term follow-up shows minimal, if any, changes in the dorsal aesthetic lines over time. Most patients stabilize quickly with little change. This is particularly prevalent in cases where the dorsal nasal skin is left undissected. With no dissection, the dorsal hump is reduced with little if any alteration of the dorsal aesthetic lines. With no dorsal skin dissection, the dorsum essentially looks the same as the day the cast is removed.

Case #7: Patient with Dorsal Hump Treated with no Dorsal Skin Elevation

This patient presented for dorsal hump reduction and some improvement in nasal tip contour ([Fig. 10]).

Fig. 10 (A) Subdorsal Z-flap was designed and marked out with the vertical limb at the rhinion. (B) Subdorsal Z-flap marked out and incised. A strip of cartilage was also removed below the Z-flap to allow end-to-end fixation. (C) Subdorsal Z-flap was moved caudally and inferiorly and sutured end-to-end with a 4–0 PDS suture. (D) A caudal septal extension graft was placed in an overlapping fashion to straighten and strengthen the caudal septum. (E) Caudal septal extension graft overlapped on the left side and splinted with a smaller splinting graft on the right side. (F) Seven-day postoperative frontal view after the cast was removed, showing minimal bruising and swelling (left). Seven-day postoperative lateral view showing minimal dorsal edema (right). (G) Preoperative frontal view (left). Two-year postoperative frontal view (right). (H) Preoperative lateral view (left). Postoperative lateral view (right). (I) Preoperative oblique view (left). Postoperative oblique view (right). (J) Preoperative base view (left). Postoperative base view (right). (K) Preoperative close-up frontal view (left). Postoperative close-up frontal view (right). (Adapted with permission from Toriumi DM, Kosins A, Saban Y, Cakir B, Daniel RK, Goksel A, Palhazi P. Structural Preservation Rhinoplasty. St. Louis: Quality Medical Publishing, 2025.)

To treat her, a no dorsal skin elevation dissection was used, with dissection up to the supratip and no dissection over the nasal dorsum. A subdorsal Z-flap with letdown was used to manage her dorsal hump.

Postoperatively, she has been doing well for over 3 years. Her nasal dorsum looks the same as on postoperative day 7 when her cast was removed. This level of preservation of the dorsal aesthetic lines is a game-changer and significantly alters the potential problems that can occur over time.

With preservation rhinoplasty, there are several options for management. One can use surface or foundational techniques. Surface techniques localize management to the modification of the bony cap with or without subdorsal work, without bone cuts made at the base of the bony vault.[21] Foundational work typically involves bone cuts made to mobilize the bony vault to allow impaction of the bony vault ([Fig. 11]). This involves either a pushdown or letdown. Both involve radix and transverse bone cuts. The pushdown uses bilateral lateral osteotomies to allow the bones to slide into the piriform aperture. The letdown removes banana-shaped bone strips to allow the bony vault to impact posteriorly.

Fig. 11 Foundational bone cuts for push down and let down. (A) 1. Planned bone cuts for a push down. 2. Bone cuts made for push down. 3. Bone cuts healed after push down. (B) 1. Planned bone cuts for a let-down with banana bone strip excision. 2. Bone cuts performed for let down. 3. Bone cuts healed after bony vault impacted. (Adapted with permission from Toriumi DM, Davis RE. Bringing You the Masters 1: Virtual Cadaver Live 2020. St. Louis: Quality Medical Publishing, 2021.)

Subdorsal work can be performed at a high level (high strip), intermediate level (subdorsal Z-flap, Tetris, etc.), or low level (low strip, SPQR, SPAR B, and Cottle; [Fig. 12]). Each of the techniques has its indications, but most are interchangeable and can even be combined.

Fig. 12 High strip, intermediate strip, and low strip subdorsal septal work for dorsal preservation. Also note the angled sliding radix bone cut to allow reduction of the dorsal hump without losing radix position. (A) Saban style high strip. Subdorsal strip excised with planned incision of subdorsal keel (dotted red lines) to release the tension band under the rhinion (left). Dorsal hump stretched flat after two fixation sutures were placed, reducing the dorsal hump (right). (B) Subdorsal Z-flap. Planned incisions for subdorsal Z-flap and cartilage excision below the bony hump and planned septal cartilage harvest site (left). Subdorsal Z-flap incised, strip removed, and subdorsal Z-flap sutured end to end to stretch and flatten the dorsal hump (right). (C) Tetris flap. Planned incisions for Tetris flap (left). Note the excision to allow end-to-end fixation (right). (D) Low strip. Note the proposed incisions for the low strip with subdorsal cartilage excision and angled radix bone cut (left). Note the excised cartilage and freeing the quadrangular septal flap from all bony attachments, and leaving it attached to the undersurface of the middle vault with an angled radix bone cut (middle). Note rotation of the quadrangular septal cartilage flap, stretching of the hump flat, and fixation to the nasal spine with addition of a septal extension graft to set appropriate nasal length (right). (Adapted with permission from Toriumi DM, Davis RE. Bringing You the Masters 1: Virtual Cadaver Live 2020. St. Louis: Quality Medical Publishing, 2021.)

Case #8: Patient with Dorsal Hump, High Radix, and Bulbous Tip Treated with Dorsal Preservation with Planned Radix Drop

This patient presented for rhinoplasty to eliminate her dorsal hump and make a smaller nose. She disliked her dorsal hump and wanted it made smaller. She had a high radix and desired a lower radix. She wanted a conservative reduction of her nasal length and to avoid a turned-up tip ([Fig. 13]).

Fig. 13 (A) Intraoperative frontal view showing a wide nose with a bulbous nasal tip and deviation. (B) The lateral view showed a long nose with a large dorsal hump and high radix. (C) Endoscopic view of the cartilage and bone removed from below the nasal bones to allow the dorsum and radix to drop in a controlled fashion. Excision marked by yellow lines. (D) After completing the radix bone cut, lateral bone strip removal, and transverse bone cuts, the subdorsal Z-flap was overlapped on the left side and sutured into position. (E) Rasp was used to take down the frontal bone step-off. (F) Caudal septal extension graft ready for placement. (G) Caudal septal extension graft sutured in an overlapping configuration. (H) Lateral crural strut grafts are sutured to the undersurface of the released lateral crura. (I) Tip at the end of the procedure. No cephalic trim was performed. (J) Preoperative frontal view showing a deviated long nose with bulbous tip (left). One-year and six-month postoperative frontal view showing a narrower profile with less nasal tip bulbosity (right). (K) Preoperative lateral view showing a large dorsal hump with high radix and long nose (left). Postoperative lateral view showing lower radix, removal of the dorsal hump, and slightly shorter nose (right). (L) Preoperative oblique view (left). Postoperative oblique view (right). (M) Preoperative base view (left). Postoperative base view (right). (N) Preoperative close-up frontal view showing a wide nose with bulbous tip (left). Postoperative close-up frontal view showing a narrower nose with improved tip contour (right). (Adapted with permission from Toriumi DM, Kosins A, Saban Y, Cakir B, Daniel RK, Goksel A, Palhazi P. Structural Preservation Rhinoplasty. St. Louis: Quality Medical Publishing, 2025.)

She was treated with a subdorsal Z-flap with letdown and controlled radix bone drop. This was accomplished by performing release of the dorsum via a subdorsal Z-flap with modest removal of cartilage and bone from below the bony hump. A letdown was performed with a radix bone cut performed from below, lateral banana-shaped bone strips removal, and transverse bone cuts. The bony dorsum and radix were mobilized and allowed to drop a couple of millimeters.

Structural techniques were used in the nasal tip with release of the lateral crura, placement of lateral crural strut grafts, and repositioning of the lateral crura. This is an example of structural preservation rhinoplasty, the hybrid approach.

She has done well over 2 years postoperatively with lowering of her radix and dorsal hump with a stable nasal tip position and good nasal function.

Case #10: Patient with Deviated Nose and Deviated Septum

This patient presented with a severely deviated nose, dorsal hump, and nasal obstruction. He wanted to have his nasal airway problem corrected and his nose straightened. He was also interested in reducing his dorsal hump ([Fig. 14]).

Fig. 14 (A) Severely deviated caudal septum noted. (B) Low strip performed, the septum was released from the ethmoid bone, vomer, maxillary crest and nasal spine. (C) The septal flap was rotated caudally to stretch the dorsal hump flat and sutured to the nasal spine. (D) Caudal septal extension graft created from deviated septal cartilage. (E) The septal bone is used to stabilize a caudal septal extension graft. (F) Caudal septal extension graft fixed to the septum. (G) Preoperative frontal view showing a deviated nose (left). Five-year postoperative frontal view showing straight nose (right). (H) Preoperative lateral view showing a large dorsal hump (left). Postoperative lateral view showing straight dorsum (right). (I) Preoperative oblique view (left). Postoperative oblique view (right). (J) Preoperative base view (left). Postoperative base view (right). (K) Preoperative close-up frontal view showing severely deviated nose (left). Postoperative close-up frontal view showing a straight nose with slight depression above the left nasal tip (right). (Adapted with permission from Toriumi DM, Kosins A, Saban Y, Cakir B, Daniel RK, Goksel A, Palhazi P. Structural Preservation Rhinoplasty. St. Louis: Quality Medical Publishing, 2025.)

In the past, this type of deformity would be treated with a subtotal septal reconstruction using a costal cartilage graft. The plan going into the surgery was to perform a subtotal septal reconstruction using his rib cartilage. His chest was prepped, and he was consented for costal cartilage harvest. The primary problem was that his septum was fractured, making him a poor candidate for a low strip SPQR.

At the time of surgery, knowing that we could always fall back and perform a subtotal septal reconstruction, we decided to perform a low strip SPQR technique. His cartilaginous septum was released from the nasal spine, maxillary crest, vomer, and ethmoid bones, leaving the quadrangular cartilage attached to the undersurface of the middle vault. His septum (QC flap) was just long enough to reach the nasal spine and was fixed with a couple of 4–0 PDS sutures. However, the caudal septum was too short due to the septal fracture. To allow appropriate nasal length, a caudal septal extension graft was placed and stabilized with ethmoid and vomer bone, with holes drilled into it to allow suturing. This is another instance where a hybrid structural preservation approach was employed.

The nasal tip was managed using shorter lateral crural strut grafts without repositioning.

The patient has done well with excellent nasal function over 4 years postoperatively. This patient surely would have been treated with a subtotal septal reconstruction using his costal cartilage. This operation would have taken over 4 hours with the risk of potential warping of the rib cartilage. With the dorsal preservation technique used, we did not use any cartilage from a secondary site; his operation was less than 3 hours.

Case #11: Patient with Severely Deviated Nose with Large Dorsal Hump and Middle Vault Asymmetries

This patient presented with a severely deviated nose with a large dorsal hump and nasal obstruction ([Fig. 15]).

Fig. 15 (A) Intraoperative frontal view showing the deviation. (B) Plan showing bone strip removal on the left and lateral osteotomy on the right. (C) Placement of left-sided submucosal spreader graft. (D) Caudal septal extension graft in place. (E) Lateral crural release with lateral crural strut grafts to move domes medially and decrease tip projection. (F) Tip at the end of the operation. (G) Preoperative frontal view showing deviation (left). One-year postoperative frontal view showing a straight nose (right). (H) Preoperative lateral view showing dorsal hump and overprojected nose (left). Postoperative lateral view showing decreased projection and straight dorsum (right). (I) Preoperative oblique view (left). Postoperative oblique view (right). (J) Preoperative base view (left). Postoperative base view (right). (K) Preoperative close-up frontal view showing deviation (left). Postoperative close-up frontal view showing a straight nose (right). (Adapted with permission from Toriumi DM, Kosins A, Saban Y, Cakir B, Daniel RK, Goksel A, Palhazi P. Structural Preservation Rhinoplasty. St. Louis: Quality Medical Publishing, 2025.)

He was treated with a low strip SPQR with structure to manage his nasal tip. He underwent release of his lateral crura with placement of lateral crural strut grafts and repositioning. His domes were moved medially to decrease nasal tip projection, and the lateral crural strut grafts stabilized his lateral wall.

He has done well with excellent nasal function and a straight nose over 2 years postoperatively.

Case #12: Patient who Underwent Prior Rhinoplasty with a Dorsal Hump and Ptotic Tip

This patient presented after undergoing rhinoplasty with a dorsal hump and ptotic nasal tip. She requested to have her dorsal hump removed and her nasal tip lifted ([Fig. 16]).

Fig. 16 (A) Intraoperative frontal view showing pinched tip. (B) Intraoperative lateral view shows a dorsal hump and an underprojected nasal tip. (C) Endoscopic view shows a subdorsal Z-flap incised. (D) Endoscopic view of the subdorsal Z-flap overlapped on the right and sutured. (E) Asymmetric dissected lateral crura. (F) Lateral crural replacement grafts were sutured to the caudal septal extension graft. (G) Septal cartilage lateral crural strut grafts were sutured to the lateral crural replacement grafts. (H) Lateral crural strut grafts from below. (I) Nasal tip prior to closure with onlay tip graft. (J) Preoperative frontal view (left). One-year and three-month postoperative frontal view showing a straight nose (right). (K) Preoperative lateral view (left). Postoperative lateral view showing rotated and projected nasal tip with no dorsal hump (right). (L) Preoperative oblique view (left). Postoperative oblique view (right). (M) Preoperative base view (left). Postoperative base view showing symmetric nasal base (right). (N) Preoperative close-up frontal view (left). Postoperative close-up frontal view showing a straight nose with improved tip contour (right). (Adapted with permission from Toriumi DM, Kosins A, Saban Y, Cakir B, Daniel RK, Goksel A, Palhazi P. Structural Preservation Rhinoplasty. St. Louis: Quality Medical Publishing, 2025.)

At the time of her surgery, it was noted that she had her septum intact. Despite planning on harvesting her rib cartilage, we proceeded to perform her surgery without harvesting the rib cartilage.

Her dorsal hump was treated using a subdorsal Z-flap with a letdown. Because her middle vault was not opened, she did not need spreader grafts. With the extra septal cartilage available, we were able to place a caudal septal extension graft and lateral crural strut grafts to stabilize her nasal base and lateral wall. No cartilage was harvested from a secondary site.

Because I was able to perform her surgery using dorsal preservation, I was able to avoid taking ear cartilage or her rib. If I needed spreader grafts I would have had to take ear or rib for the spreaders. This case demonstrates how the use of dorsal preservation conserves cartilage and allows us to avoid secondary cartilage harvest sites, which shortens the operation and also decreases postoperative morbidity.

Case #13: Patient with a Deviated Nose and Asymmetric Middle Vault

This patient presented with a severely deviated nose with a dorsal hump and asymmetric middle vault. Her asymmetric middle vault made her a suboptimal candidate for a dorsal preservation technique ([Fig. 17]).

Fig. 17 (A) Subdorsal Z-flap incised. (B) Subdorsal Z-flap overlapped and sutured in an overlapping configuration. (C) A narrow Cottle elevator is used to create a narrow submucosal tunnel. (D) The elevator creates a tunnel under the upper lateral cartilage. (E) Placing a submucosal spreader graft on the right side. (F) Released lateral crura. (G) Lateral crural strut grafts are sutured to the undersurface of the lateral crura. (H) Lateral crural strut grafts from below. (I) Tip at the end of the procedure with lateral crura repositioned and onlay tip graft in place. (J) Preoperative frontal view showing deviated nose and concave right middle vault (left). Four-year postoperative frontal view showing straight nose (right). (K) Preoperative lateral view showing dorsal hump (left). Postoperative lateral view showing straight profile and lifted tip (right). (L) Preoperative oblique view (left). Postoperative oblique view (right). (M) Preoperative base view (left). Postoperative base view (right). (N) Preoperative close-up frontal view showing a deviated nose with concave right middle vault (left). Postoperative close-up frontal view showing a straight nose with symmetric dorsal aesthetic lines (right). (Adapted with permission from Toriumi DM, Kosins A, Saban Y, Cakir B, Daniel RK, Goksel A, Palhazi P. Structural Preservation Rhinoplasty. St. Louis: Quality Medical Publishing, 2025.)

To manage this case, a hybrid structural preservation approach was used. A unilateral submucosal spreader graft was placed on the right side to lateralize the medialized upper lateral cartilage. This maneuver converted her middle vault to one that could be treated with dorsal preservation. In this case, a subdorsal Z-flap was used and overlapped on the side opposite the deviation. Additionally, a swinging door septoplasty was performed to straighten her caudal septum. This involved freeing the caudal septum from the nasal spine, trimming the size of the septum, and then resuturing it to the nasal spine. This combined approach allowed treating the patient with a hybrid dorsal preservation technique and avoiding harvesting auricular or costal cartilage.

She has done well for over 3 years postoperatively with much improved nasal function.

Case #14: Patient with Dorsal Hump and Bulbous Tip Treated with Closed Approach

This patient presented for rhinoplasty, requesting the removal of her dorsal hump and narrowing of her bulbous tip ([Fig. 18]).

Fig. 18 (A) Intraoperative frontal view showing bulbous nasal tip. (B) Intraoperative lateral view showing dorsal hump. (C) Nasal tip cartilages delivered. (D) Nasal tip cartilages after lateral crural steal (4 mm). (E) Endoscopic view of marked out Tetris flap with needle through rhinion aligned with cranial limb of the Tetris flap. Note the perichondrium on the cartilage to prevent cheese wiring of the sutures. (F) Tetris flap incised with cranial limb aligned with the needle at the rhinion. (G) Triangular segment of cartilage removed from below the bony hump (yellow arrow). (H) Tetris flap with incision to mark cartilage strip removal to allow end-to-end fixation (yellow arrow). (I) Tetris flap sutured end to end to reduce the dorsal hump with two 4–0 PDS sutures. (J) Preoperative frontal view showing bulbous nasal tip (left). Eight-month postoperative frontal view showing improved tip contour (right). (K) Preoperative lateral view showing dorsal hump (left). Postoperative lateral view showing a straight profile with increased tip rotation (right). (L) Preoperative oblique view (left). Postoperative oblique view (right). (M) Preoperative base view (left). Postoperative base view showing slight nostril asymmetry (right). (N) Preoperative close-up frontal view showing bulbous tip (left). Postoperative close-up frontal view showing improved tip contour (right). (Adapted with permission from Toriumi DM, Kosins A, Saban Y, Cakir B, Daniel RK, Goksel A, Palhazi P. Structural Preservation Rhinoplasty. St. Louis: Quality Medical Publishing, 2025.)

She was treated with an endonasal approach with Baris Cakir's polygon tip surgery. The closed approach was chosen in this patient as she was an ideal candidate with symmetric, strong tip cartilages and good tip projection.

Incorporating the closed-polygon tip surgery has been an exciting addition to my armamentarium of techniques to manage the primary rhinoplasty patient.

Case #15: Patient with Severely Contracted Nose, Septal Perforation, and Dorsal Hump Treated with Spare Roof B to Preserve Bony Support

This patient presented with a subtotal septal perforation with a dorsal hump and severely contracted right alar margin due to vasoconstrictive agent use ([Fig. 19]).

Fig. 19 A large caudal septal replacement graft was used in combination with long lateral crural strut grafts to support his lateral wall and lower his right alar retraction. An interpolated melolabial flap was needed to close the intranasal mucosal deficiency. This was a three-stage melolabial flap reconstruction. (A) Preoperative close-up frontal view showing a wide nose with severe right alar retraction. (B) Preoperative close-up right lateral view showing severe alar retraction due to contracture of the internal lining. (C) Preoperative close-up right oblique view showing severe alar retraction. (D) Endoscopic view of subtotal septal perforation. Yellow arrows point to the edges of the septal perforation. Minimal subdorsal septum is noted. (E) Six-centimeter segment of the seventh rib harvested with attached native perichondrium. (F) Caudal septal replacement graft with attached native perichondrium cross-hatched to avoid bending. (G) Caudal septal replacement graft sutured to a notch in the nasal spine. (H) Caudal septal replacement graft in place viewed from above and stabilized with two subdorsal spreader grafts. (I) Piezotome used to remove bilateral bone triangles for spare roof type B. (J) Bilateral long lateral crural strut grafts to support the lateral wall and correct the alar retraction. (K) Right-sided melolabial flap marked out with Dopplered vessel. (L) Melolabial flap incised. (M) Endoscopic view of the mucosal defect with exposed lateral crural strut graft due to mucosal lining deficiency (yellow arrow). (N) A melolabial flap was transposed into the right nasal vestibule to close the mucosal lining deficit. (O) Melolabial flap sutured to the margins of the intranasal mucosal defect. (P) End of procedure with melolabial flap in place and cheek defect closed. (Q) End of procedure from base view showing flap in position. (R) One month postoperative after the initial stage of reconstruction, showing the melolabial flap in position. The second stage involved debulking the flap intranasally. (S) After the third stage, with the division of the pedicle. (T) End of the third stage with the flap tailored to the defect and the cheek defect closed. (U) Preoperative frontal view showing severe right-sided alar retraction (left). One-year postoperative frontal view showing correction of right alar retraction and well-healed donor site (right nasolabial fold; right). (V) Preoperative lateral view showing dorsal hump and severe right alar retraction (left). Postoperative lateral view showing improved dorsal profile with correction of alar retraction (right). (W) Preoperative oblique view showing severe right alar retraction (left). Postoperative oblique view showing correction of alar retraction and improved dorsal aesthetic lines (right). (X) Preoperative base view showing severe contraction of the right alar margin and closure of the right nasal vestibule (left). (Y) Preoperative close-up frontal view showing severe right alar retraction (left). Postoperative close-up frontal view showing correction of the right alar retraction (right). (Z) Preoperative midrange frontal view showing severe right alar retraction (left). Postoperative midrange frontal view showing correction of alar retraction and well-healed right cheek donor site (right). (Z1) Preoperative close-up right oblique view showing severe right alar retraction (left). Postoperative close-up right oblique view showing correction of alar retraction (right). (Adapted with permission from Toriumi DM, Kosins A, Saban Y, Cakir B, Daniel RK, Goksel A, Palhazi P. Structural Preservation Rhinoplasty. St. Louis: Quality Medical Publishing, 2025.)

The patient was treated with a spare roof type B to allow management of the dorsal hump without compromising the bony support. The bony vault supported the entire reconstruction and required a technique that would not compromise the stability of the bony structure. The spare roof type B allowed flattening the dorsal hump using purely surface techniques without using foundational bone cuts. Foundation bone cuts could result in the collapse of the entire reconstruction due to the lack of an underlying septum.

A subdorsal spreader graft was used to help support the middle vault in combination with a caudal septal replacement graft.

A right-sided interpolated melolabial flap was needed to provide the vestibular lining necessary to replace the missing tissue and correct the contracted right alar margin. Structural grafting using a caudal septal replacement graft with lateral crural strut grafts was needed to support the base of the nose and lateral walls. After the right alar margin was brought down, a large vestibular defect was noted that was filled with the right cheek skin from the melolabial flap. This was a three-stage operation.

The use of dorsal preservation, in this case, allowed management of the dorsal hump without compromising dorsal bony support and risking the loss of foundational support. Conventional dorsal hump reduction with lateral osteotomies could compromise support to the entire reconstruction. This case illustrates the utility of the hybrid structural preservation rhinoplasty and how it can be used to reconstruct severe nasal deformities.

Worst of Preservation Rhinoplasty

Preservation rhinoplasty works well in most primary rhinoplasty cases without complicated deformities. When dorsal aesthetic lines are not ideal and require modification, dorsal preservation may not be the best option. In some cases, a hybrid technique can be used to convert a suboptimal candidate into an acceptable candidate (Cases #11 and #13).

In some cases, if preservation techniques are used beyond accepted indications, there is a chance of problems with suboptimal outcomes. I will frequently stretch the indications of dorsal preservation with excellent outcomes. However, on occasion, the postoperative outcome is suboptimal.

Case #16: Patient with Acute Nasal Fracture Treated with High Strip and Pushdown

This patient presented with an acute nasal fracture and a deviated nose with a deviated septum. She underwent prior septoplasty as well. A decision was made to perform an early correction to repair her deviated nose ([Fig. 20]).

Fig. 20 (A) Axial plane CT scan showing fracture of the nasal bones and deviated nasal septum. The arrow points to the nasal bone fracture. (B) Coronal plane CT scan showing ethmoid deviation and missing septal cartilage. (C) Intraoperative frontal view showing a deviated nose with abrasion of the upper nasal dorsum. Supraalar pinching is noted as well, indicating lateral wall weakness and collapse. (D) Intraoperative lateral view showing dorsal hump and abrasion of the dorsum. D.Harvested a 3.5 cm segment of the seventh rib with attached native perichondrium. (E) Endoscopic view of the nasal septum showing a fractured septum from injury (yellow arrow). (F) Subdorsal strip excised for Saban style high strip (yellow arrows). (G) Costal cartilage caudal septal extension graft ready for placement. (H) Caudal septal extension graft in place and stabilized with two subdorsal spreader grafts that also acted to support the middle vault and prevent saddling. (I) Note how the subdorsal spreader grafts are fixed to the caudal septal extension graft. (J) Caudal septal extension graft from below, showing native costal perichondrium on the left side of the graft. (K) Lateral crural strut grafts are sutured to the undersurface of the released lateral crura. (L) Note the native costal perichondrium left on the undersurface of the lateral crural strut grafts. Also note the favorable curvature of the lateral crural strut grafts with the concave surface facing medially toward the airway. (M) Lateral crural strut grafts are placed into caudally positioned pockets along the supraalar groove. Note the nasal tip is tilting to the right. (N) The Base view at the operation's end shows a slight tilt of the nasal base to the right side. (O) Intraoperative frontal view at the end of the operation showing left bony prominence (red arrow), shift of the middle vault to the right (green arrow), and shift of the nasal base to the right (yellow arrow). These issues could have been noted at the time of surgery and corrected. Failure to do so resulted in the unfavorable outcome. (P) Intraoperative base view at the end of the operation showing a slight shift to the right (yellow arrow). (Q) Preoperative frontal view showing acute nasal trauma with deviation to the right and abrasion on the upper dorsum (left). One-year postoperative frontal view showing bony dorsal deviation and middle vault to the left and tip shifted to the right with high arched right alar margin (right). (R) Preoperative lateral view showing dorsal convexity and abrasion on the nasal dorsum. Postoperative lateral view showing dorsal convexity (right). (S) Preoperative oblique view of dorsal convexity and abrasion on the nasal dorsum (left). Postoperative oblique view showing dorsal convexity (right). (T) Preoperative base view showing lateral wall pinching (left). Postoperative base view showing tilt of the nasal tip to the right (right). (U) Preoperative close-up frontal view showing deviation of the bones and middle vault to the left and the tip curving back to the right (left). Postoperative close-up frontal view showing nasal bones to the left, middle vault to the right, and the nasal tip tilting back to the right, with high arched right alar margin and low left alar margin (right). (V) Intraoperative frontal view of revision surgery showing nasal bones and middle vault shifted left and nasal tip shifted to the right with arched right ala and hooded left ala. (W) Intraoperative lateral view of revision surgery showing dorsal convexity. (X) Intraoperative base of revision surgery showing tilted nasal base and blockage of the left nasal airway. (Y) Intraoperative view of the tip cartilages showing asymmetric tip structure. (Z) View of exposed caudal septal extension graft showing curved caudal septal extension graft (yellow arrow). (Z1) Caudal septal extension graft from below showing curvature (yellow arrow). (Z2) The lateral crural strut grafts were dissected and found to be properly oriented. (Z3) A lateral crural extension graft is applied to the right lateral crural strut graft to bring the right alar margin down. The left lateral crural strut graft was positioned more cranially to bring that margin up. (Z4) Lateral crural extension graft sutured into place. (Z5) The tip at the end of the operation shows symmetric alar margins. (Z6) View from below showing symmetric alar margins. (Z7) Preoperative frontal view showing deviation and asymmetric alar margins (left). One year postoperative, after revision, frontal view showing a straight nose with symmetric alar margins (right). (Z8) Preoperative lateral view showing dorsal hump (left). Postoperative lateral view showing the slightest dorsal convexity (right). (Z9) Preoperative oblique view (left). Postoperative oblique view (right). (Z10) Preoperative base view showing tilted nasal base (left). Postoperative base view showing a symmetric base with an open airway bilaterally (right). (Z11) Preoperative close-up frontal view showing deviated nose with asymmetric alar margins (left). Postoperative close-up frontal view showing a straight nose with symmetric alar margins (right). (Adapted with permission from Toriumi DM, Kosins A, Saban Y, Cakir B, Daniel RK, Goksel A, Palhazi P. Structural Preservation Rhinoplasty. St. Louis: Quality Medical Publishing, 2025.)

She was treated using an open rhinoplasty approach with a high strip and pushdown. The high strip was chosen to allow possible conversion to structure, opening the middle vault, and treating with spreader grafts if needed. Costal cartilage was necessary due to her prior septoplasty.

Postoperatively, she was noted to have a residual dorsal hump with a persistent deviated nose.

A revision surgery was performed to correct her deviation and deformity. It was noted that her septum was deviated, and there was some deformity of the cartilage grafts. The deviation was corrected by adjusting the lateral crural strut grafts and placing a right-sided lateral crural extension graft.

She has done well 1 year after her revision surgery, with a straight nose and excellent nasal function.

In this case, the indications for dorsal preservation were extended with a resultant suboptimal outcome necessitating revision surgery. In retrospect, it would have been better to use structure to correct her problem and possibly wait until her nose healed more before performing her reconstruction.

Conclusion

Structural and preservation rhinoplasty have profound capabilities to manage a multitude of rhinoplasty deformities. Structural rhinoplasty is particularly useful in cases requiring adding, replacing, or reconstructing depleted or damaged nasal structures. Preservation rhinoplasty is particularly useful in primary rhinoplasty cases that require reduction of a dorsal hump with preservation of the dorsal aesthetic lines. The combination of structure and preservation rhinoplasty provides the surgeon with an opportunity to employ the features of both philosophies to manage a wide range of nasal deformities. Structural preservation rhinoplasty will likely become the gold standard in rhinoplasty surgery as more surgeons learn and practice both techniques.

Conflict of Interest

None declared.

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Eingereicht: 04. August 2025

Angenommen: 21. August 2025

Artikel online veröffentlicht:
14. November 2025