Keywords
guidelines - preservation rhinoplasty - primary rhinoplasty - dorsum preservation
- revision
First described by Goodale[1] in 1898, the philosophy of preserving the natural nasal structures has seen resurgence
in primary rhinoplasty. Three years after the “Revolution Rhinoplasty” editorial[2] and recent publications including the “Push Down Reassessed”[3] the need for guidelines appeared timely. The publication by Saban et al discusses
dorsum preservation techniques, scoping an alternative for lowering the nasal dorsum
in addition to structure rhinoplasty and Joseph's technique. Recent anonymous polls[4]
[5] of over a thousand surgeons confirmed that while 60% were interested in this philosophy,
only 23% performed the procedure. Recent literature on preservation rhinoplasty (PR)
procedures focuses on revisions,[6]
[7] functional results,[8]
[9]
[10] complications,[11] and a variety of surgical options, but they are creating a cloud of confusion. This
article aims to provide clear guidelines by introducing a classification based on
the patient's dorsum profile lines (DPL) corresponding to specific PR and septorhinoplasty
techniques.
Methods
Study Design
Four-hundred and seventy consecutive patients who underwent septorhinoplasty performed
by the senior author (Y.S.) from June 2016 to June 2019 were assessed retrospectively.
Patients undergoing secondary rhinoplasty (operated elsewhere n = 66), exclusive tip and/or alar base surgery (n = 47), exclusively wide bony dorsum with good profile lines (n = 10), and with < 1-year follow-up were excluded from the study. The final cohort
contained 352 patients who underwent primary rhinoplasty including 129 with septal
deviations who underwent septorhinoplasty.
Informed consent and Helsinki Declaration were applied to all patients. Data included
age, gender, history, assessment, examinations, cone beam computed tomography, and
computer simulation. Follow-up evaluation included functional complains questionnaire,
physical examination, photographs at 1 week, 1 and 3 months, and 1 year. Further data
was collected regarding the revisions and the reason for the revisions.
Classification of Dorsum Profile Lines Through a Dorsum Segmental Profile Examination
According to Neves' analysis, three main dorsal segments are critical.[12] These include three options for the radix (normal, high, low), three options for
the keystone-area (straight, convex, kyphotic including Lazovic[13] S-shaped nasal bones), and two options for the supratip segment (straight or curved),
producing a complex of 18 variations in DPL. To minimize this complexity, the study
uses frequent nasal “morphotypes and the most common DPL” and correlates this to specific
dorsal PR procedure. Consequently, a classification of four types of nasal profiles
is suggested: (1) straight noses, (2) tension noses (classic Roman or Semitic profiles),
(3) “Humpy” or kyphotic noses (classic Aztec nose with humps 6 + mm), and (4) challenging
noses and W-shaped nasal dorsum. A heterogeneous group consisting of “lorgnette,”
Assyrian noses is allocated to nonpreservation group. The radix represents a segment
of the nose where all the bony structures meet, creating a bony block in the intercanthal
area that is difficult to mobilize. Hence, high radix has been considered separately
in the study.
All analyses were performed both by the senior author (Y.S.) and a PhD (non-MD) observer
independently.
Surgical Data Recording and Classification of the Dorsum Preservation Techniques
The original “high strip” dorsum preservation technique has been pioneered by Saban,[14]
[15]
[16] popularizing Gola's procedure[17] with a few changes. Technical details recorded included type of dorsal preservation
procedure, amount of reduction, straightening maneuvers, nasal bone management, cartilaginous
modifications, and bony cartilaginous pyramid fixation.
Type 1 PR: Full Dorsum Preservation Procedure with No Skin and Soft Tissue Elevation
Type 1 PR is mainly applied to the straight noses. The procedure is less traumatic
and allows dorsum lowering. It consists of a sequence of 10 precise steps using an
endonasal approach[18]: (1) Septum step: septal approach through unilateral interseptocolumellar incision
not extending laterally into an intercartilaginous incision, to avoid disruption of
the lateral scroll ligaments. Then, a limited bilateral subperichondrial subperiosteal
undermining in a L-strut shape fashion, creating a “superior tunnel,” till the septum-upper
lateral cartilages (ULC) W-point is identified. (2) Septum first incision is done
precisely at the W-point, then septum is divided from the dorsum vaults and high strip
resection, parallel to the DPL is performed keeping as high as possible below the
vaults. This step often requires resection of a small fragment of the anterosuperior
segment of the perpendicular plate of the ethmoid. This is a safe procedure, done
with a sharp cutting forceps. (3) Complete bony pyramid osteotomies (lateral, transverse,
radix) fully separating the bony pyramid from the face. In case of high bony vault
requiring 4 mm + lowering, lateral osteotomy is replaced by a pyriform bony wedge
resection leading to a “let-down” procedure instead of push-down procedure.[3] (4) Bony cartilaginous pyramid en-bloc horizontal mobilization: this critical maneuver
relies on complete osteotomies. (5) Dorsum impaction, pinching slightly the bony base
and impacting down in between the frontal processes of the maxillae, without forcing
this impaction. (6) DPL alignment by incremental cartilaginous septum resection. (7)
K-area resurfacing-curving by releasing the blocking points causing a “coat-hanger
effect”: mainly septal remnants below the vault must be removed. (8) Cartilaginous
middle third width refinement by reducing the medial part of the ULC scrolls that
create an excess volume due to what we name the “scroll-winding-effect”[19]: a “W-point-shift”[19] will allow for pinching the middle third. (9) Supratip and W-ASA segment alignment.
(10) Bony cartilaginous vault stabilization by sutures, fixing the vaults to the newly
designed stable septum. Two 3–0 Vicryl sutures are recommended: “high suture” is inserted
as cephalic as possible, transosseous being the best choice and the “lower suture”
attaching the ULC to the septum. Finally, tip and alar base procedures are performed
only if required.
Based on this technique, further modifications may be performed to achieve refinements
if required. Three areas of common modification include (1) the bony dorsum resection,
(2) the septal work, (3) dorsal K area and lateral K area (DKA–LKA) bony cartilaginous
disarticulation.
Type 2 PR: Dorsum Preservation Procedure with Bony Cartilaginous Vault Resurfacing
The bony cap resurfacing/resection is mainly indicated in patients with small bony
humps, S-shape nasal bones,[13] with aesthetic dorsum lines. Skin and soft tissue elevation (SSTE) is performed
either in the sub-SMAS or subperichondrial/subperiosteal plane. Then, nasal bones
are reshaped (using rasp for 1 mm bone removal or Rubin's osteotome for ostectomy
of up to 3 mm), and the superior bony edges are smoothened. This when done properly
will not produce an open-roof and osteotomies are not warranted to close the roof,
even if the bony dorsum is flattened to a degree. Objectives achieved are (1) thinning
the nasal bones allowing for hump height reduction, (2) “rhinion-shift”[19]: where cephalad displacement of the bony-cartilaginous junction pivot point gives
the opportunity to hinge the cartilage at a higher level and then reduce the hump
by flattening or even curving downward the dorsal cartilage around this new pivot
point. Occasionally, further disarticulation of both DKA and LKA[20] may become mandatory to drop the dorsum further.
Type 3 PR: Cartilaginous-Only DP Procedure: Nasal Bony-Cartilaginous Disarticulation
and Cartilaginous Push-Down
Three authors Ishida et al,[21] Jankowski,[22]
[23] and Ferreira et al[24] have suggested dorsum lowering through nasal bony-cartilaginous disarticulation
as their preferred technique. Saban[25] presented this technique limiting it to difficult noses. The main difference in
these techniques is related to management of the septum: Jankowski performs a typical
Cottle technique with a low cartilaginous strip and a posterior septal bony-cartilaginous
disarticulation, Ishida uses midseptal division and Ferreira a high subdorsal strip
resection. The “ballerina maneuver” described by Göksel[20] involved completely disarticulating the LKA, without injuring the inner lining allowing
for a true lateral relapse of the blocking points. This maneuver consequently frees
the ULC allowing a cartilaginous lowering without tension and avoiding the “Spring-Effect”[19] or popup phenomenon and is particularly useful in managing the curved dorsum.
Management of Septum is Key in the Dorsum Preservation Procedures
In this series, septorhinoplasty was performed in a subset of these patients as elucidated
below.
-
Group 1 (G1): 210 patients underwent a rhinoplasty without septoplasty.
-
Group 2 (G2): 142 patients underwent a septorhinoplasty. Different philosophies may
be followed for septoplasty. In the author's practice, Cottle's method[26] following the swinging-door technique is the preferred choice, as it allows for
maximum cartilage preservation: the so-called “low-strip” septoplasty. Three other
types include intraseptal fragmentation or limited resections, Killian's[27] L-Strut technique, and[28] intra- or extracorporeal septal repositioning. This forms part of rhinoplasty procedure
keeping with the four types already described in G1.
Revision Cases Analysis
To understand various parameters related to revision surgery,[7] we also analyzed motivations, duration, type of anesthesia, surgical procedures
chosen, and the ease of the surgical intervention.
Correlation between Dorsum Profile Lines and Surgical Procedures
Choice of surgical procedure applied based on DPL takes into consideration two criteria:
(1) Effective and easiest/safest procedure, (2) offering the best aesthetic and functional
outcome, with the least or easiest revisions, both offering high benefit–risk ratio.
Kosins[29] suggests four forms of PR based on the level of difficulty. The senior author (Y.S.)
suggests “sequential rhinoplasty”[30] protocol that involves switching intraoperatively from PR to, or perform d'emblée, non-PR. The decision-making algorithm published in 2018[3] is summarized in [Table 1].
Table 1
Dorsum procedures: basic paradigm in absence of septoplasty associated with rhinoplasty
|
Straight noses
|
Full dorsum preservation
|
|
Tension noses
|
DP and hump resurfacing
|
|
Humpy kyphotic noses
|
Disarticulation techniques: Bony hump resection associated with K-A cartilaginous
push-down
|
|
W-noses and difficult noses
|
Either classic dorsum resection/reconstruction procedures or discuss Cottle's technique
|
Abbreviation: DP, dorsum preservation.
Results
Dorsum Profile Lines
Statistical evaluation of DPL classification related to the multiethnic group of patients
in this series is summarized below.
Straight Noses
One-hundred twenty-nine (36.65%) patients show (quasi)straight dorsum profiles ([Table 2]). They represent the commonest group of patients seeking rhinoplasty including 20
high radix—Greek noses (5.68% of total, 15.50% of straight noses: [Table 3]). Though surprising that a higher number of patients with straight noses seek rhinoplasty,
preoperative photographs confirmed macrorhinia, Pinocchio noses, or “masculine” nose
in females, who desired smaller noses and/or lower radix ([Figs. 1A, B] and [2A, B]).
Table 2
Prevalence of types of surgery correlated to types of dorsum shape in overall 352
patients
|
Dorsum shape
|
Total
|
|
Straight
|
Tension
|
Kyphotic
|
Difficult
|
|
All
|
G1
|
G2
|
All
|
G1
|
G2
|
All
|
G1
|
G2
|
All
|
G1
|
G2
|
All
|
G1
|
G2
|
|
Full DP
|
N
|
88
|
63
|
25
|
33
|
24
|
9
|
10
|
7
|
3
|
3
|
2
|
10
|
134
|
96
|
47
|
|
%
|
25.00
|
30.00
|
17.61
|
9.38
|
11.43
|
6.34
|
2.84
|
3.33
|
2.11
|
0.85
|
0.95
|
7.04
|
38.07
|
45.71
|
33.10
|
|
Hump Resurfacing
|
N
|
32
|
15
|
17
|
32
|
25
|
7
|
64
|
37
|
27
|
20
|
10
|
10
|
148
|
87
|
61
|
|
%
|
9.09
|
7.14
|
11.97
|
9.09
|
11.90
|
4.93
|
18.18
|
17.62
|
19.01
|
5.68
|
4.76
|
7.04
|
42.05
|
41.43
|
42.96
|
|
Hybrid
|
N
|
5
|
2
|
3
|
1
|
0
|
1
|
27
|
8
|
19
|
12
|
5
|
7
|
45
|
15
|
30
|
|
%
|
1.42
|
0.95
|
2.11
|
0.28
|
0.00
|
0.70
|
7.67
|
3.81
|
13.38
|
3.41
|
2.38
|
4.93
|
12.78
|
7.14
|
21.13
|
|
Resection
|
N
|
4
|
2
|
2
|
5
|
3
|
2
|
8
|
4
|
4
|
8
|
3
|
5
|
25
|
12
|
13
|
|
%
|
1.14
|
0.95
|
1.41
|
1.42
|
1.43
|
1.41
|
2.27
|
1.90
|
2.82
|
2.27
|
1.43
|
3.52
|
7.10
|
5.71
|
9.15
|
|
Total
|
N
|
129
|
82
|
47
|
71
|
52
|
19
|
109
|
56
|
53
|
43
|
20
|
23
|
352
|
210
|
142
|
|
%
|
36.65
|
39.05
|
33.10
|
20.17
|
24.76
|
13.38
|
30.96
|
26.67
|
37.32
|
12.22
|
9.52
|
16.20
|
100
|
100
|
100
|
Table 3
Prevalence of radix height and skin quality correlated to dorsum shape
|
Dorsum shape
|
Total
|
|
Straight
|
Tension
|
Kyphotic
|
Difficult
|
|
High radix
|
n
|
20
|
10
|
15
|
1
|
46
|
|
%
|
15.50
|
14.08
|
13.69
|
2.33
|
13.06
|
|
Thin skin
|
n
|
29
|
16
|
21
|
13
|
79
|
|
%
|
22.48
|
22.53
|
19.26
|
30.23
|
22.44
|
Fig. 1 Straight nose. Type 1 full DP endonasal procedure. 24-year-old male patient presenting
a high straight nose a with high radix corresponding to macrorhinia appearance. (A) Preoperative and (B) 4 years postoperative photographs.
Fig. 2 Straight nose. Type 1 full DP endonasal procedure. 29-year-old female patient presenting
a straight dorsum but complaining of male nasal profile. (A) Preoperative and (B) 14 months postoperative photographs.
Tension Noses
This group comprised of humps < 5mm, 71 patients (20.17%) including 10 high radix
(2.84% of total, 14.08% of tension noses) ([Figs. 3A, B] and [4A, B]).
Fig. 3 Tension nose. Type 2 DP endonasal procedure and bony cap resurfacing by rasping.
19-year-old female showing a tension nose and an under projected tip. (A) Preoperative and (B) 1 year postoperative photographs. Nasal tip remodelling by suture through marginal
access.
Fig. 4 Tension nose. Type 2 DP endonasal procedure with bony cap resurfacing. 19-year-old
female patient seeking reduction rhinoplasty for over projected tension nose. She
underwent a type 2 associated to tip deprojection and alar base reduction. (A) Preoperative and (B) 1 year postoperative photographs.
Kyphotic Noses (Hump > 6mm)
One-hundred nine patients (30.96%) including 15 high radix (4.26% of total, 13.96%
of kyphotic noses) ([Fig. 5A, B] and [6A, B]).
Fig. 5 Kyphotic nose. Type 3 DP endonasal cartilage-only PD. 31-year-old female patient
seeking reduction rhinoplasty for humpy nose and high radix, wishing a more feminine
nose. She underwent the procedure with bony dorsum resection and radix deepening,
associated to tip deprojection and cephalic rotation. (A) Preoperative and (B) postoperative photographs.
Fig. 6 Kyphotic nose. Type 3 DP endonasal cartilage-only push-down. 21-year-old male patient
seeking reduction rhinoplasty for over projected kyphotic nose and high radix. He
underwent the procedure with bony dorsum resection associated radix deepening. No
tip surgery. (A) Preoperative and (B) postoperative photographs.
The Difficult Noses
The challenging noses form a group of 43 patients (12.22%) including 1 high radix
(prevalence 0.28% of total, 2.33% of difficult noses). These difficult noses are not
suited for DP procedure. However, in our series, in selected cases, DP procedure was
performed predominantly in men seeking mainly functional improvement. In three cases,
a sequential rhinoplasty, starting in preservation, switching intraoperatively to
resection technique was used ([Fig. 7A, B, C]).
Fig. 7 (A–C) Difficult Nose. Type 3 cartilage-only DP. Young female 19 years old, having a distorted
nose after trauma in childhood. Major septal and nasal pyramid deformity. Discussion
was to decide whether to perform an open approach, a traditional rhinoplasty and a
total septal extracorporeal reposition, or to do an endonasal septoplasty and a cartilage-only
push down with nasal bones resection. As her cartilaginous vault was thin and nice,
we decided to perform a preservation procedure thanks to her youth, and to switch
intraoperatively to a sequential resection, if ever. Thus, she underwent a Type 3
cartilage-only DP and an endonasal septal reconstruction. Tip was approached through
extended marginal incision and suture techniques were done to project and rotate the
LLC.
Key Points: Dorsum Profile Lines and Rhinoplasty
Key Points: Dorsum Profile Lines and Rhinoplasty
-
Straight noses represent the largest group (37%)
-
Difficult noses (12%): no preservation is indicated.
-
Both tension and kyphotic noses are managed with dorsum preservation, but the latter
requires further disarticulation techniques and cartilage-only push-down.
-
High radix prevalence is equal in all types of dorsum (13%).
Do Age and Gender Change the Indications?
-
Age: These demographics are summarized in [Table 4]. It is worth observing that when carefully selected, PR in teenage group provide
fantastic surgical psychotherapy, allowing for harmonious social integration of young
patients ([Fig. 8A, B]). The majority of revisions (15.40% 14 of 91 patients) were in 30 to 39-year-old
group, with lower rates in those patients aged between 18 and 29 years.
-
Gender: classic sex ratio is 1:4, male: females. No significant difference in the
subgroups was observed. Males account for 8.90%, while 91.10% were females: 2/12 sex-ratio
in revisions. This follows the published literature that while body dysmorphic disorder
is more common in males, females are more demanding and are less likely to accept
a slight residual bump, preferring thinner, more curved noses, regardless of their
ethnicity. This study also confirms that PR significantly reduces revision rates in
males compared with other surgical techniques, possibly secondary to a more natural
result and less chance of feminization. Thus, PR looks like a highly recommendable
procedure in male patients.
Table 4
Prevalence of rhinoplasties and revisions related to age and gender
|
Age
|
Female
|
Male
|
Total
|
%
|
|
G1 + G2
|
Revisions
|
G1 + G2
|
Revisions
|
G1 + G2
|
Revisions
|
G1 + G2
|
Revisions
|
|
13–17
|
13
|
0
|
6
|
1
|
19
|
1
|
5.40
|
5.26
|
|
18–29
|
160
|
17
|
31
|
0
|
191
|
17
|
54.26
|
8.40
|
|
30–39
|
75
|
12
|
16
|
2
|
91
|
14
|
25.85
|
15.40
|
|
40–49
|
17
|
2
|
13
|
0
|
30
|
2
|
8.52
|
6.66
|
|
> 50
|
14
|
0
|
7
|
1
|
21
|
1
|
5.97
|
4.74
|
|
Total
|
279
|
31
|
73
|
4
|
352
|
35
|
100
|
9.94
|
|
Sex ratio
|
79.26
|
88.57
|
20.73
|
11.43
|
|
|
|
|
Fig. 8 Surgical social therapy. 13-year-old female patient seeking reduction rhinoplasty
for tension nose and convex profile with retrogenia. She underwent a Type 2 DP endonasal
procedure with bony cap resurfacing associated to tip cephalic rotation by LLC cranial
segment reduction. All the bony cartilaginous fragments harvested during the rhinoplasty
have been transplanted as autologous implants for chin augmentation through an endoral
subperiosteal approach. (A) Preoperative and (B) postoperative photographs.
Key Points: Age and Gender
Key Points: Age and Gender
-
Slightly overdone procedure with bony hump reduction and LKA disarticulation is preferable
in females
-
Age: 15+ adolescent patients, consider performing PR if all inclusion criteria are
met.
-
Considering higher revision rate in females, the beginner PR surgeons are advised
to operate on male patients.
-
Patients belonging to the 30–40 years age group are at higher risk of revision, with
no gender predominance.
Does Thin Skin Change the Results in Preservation Rhinoplasty?
The prevalence of thin skin in the patient cohort was 22.44% ([Table 3]); these patients are excellent candidates for preservation as this procedure significantly
reduces the risks of potential postoperative dorsum irregularities.
Results on Overall Primary Rhinoplasty Procedures Data
These are systematically presented to draw the attention of the reader.
Correlations between Dorsum Profile Lines, Surgical Procedures, and Revision Rate
[Tables 5] and [6]
Table 5
Cross table correlating dorsum shapes to surgical procedures in dorsum shapes subgroups
|
Over all rhinoplasties
|
Dorsum shape
|
Total
|
|
Straight
|
Tension
|
Kyphotic
|
Difficult
|
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
|
Procedures
|
Full preservation
|
88
|
68.22
|
33
|
46.48
|
10
|
9.17
|
3
|
6.98
|
134
|
38.07
|
|
Hump resurfacing
|
32
|
24.81
|
32
|
45.07
|
64
|
58.72
|
20
|
46.51
|
148
|
42.05
|
|
Desarticulation
|
5
|
3.88
|
1
|
1.41
|
27
|
24.77
|
12
|
27.91
|
45
|
12.78
|
|
Classic resection
|
4
|
3.10
|
5
|
7.04
|
8
|
7.34
|
8
|
18.60
|
25
|
7.10
|
|
Total
|
129
|
100
|
71
|
100
|
109
|
100
|
43
|
100
|
352
|
100
|
Table 6
Prevalence of revisions correlated to dorsum shape
|
Dorsum shape
|
Total
|
|
Straight
|
Tension
|
Kyphotic
|
Difficult
|
|
All
|
G1
|
G2
|
All
|
G1
|
G2
|
All
|
G1
|
G2
|
All
|
G1
|
G2
|
All
|
G1
|
G2
|
|
Full DP
|
N
|
5
|
2
|
3
|
6
|
2
|
4
|
1
|
1
|
0
|
0
|
0
|
0
|
12
|
5
|
7
|
|
%
|
5.68
|
3.17
|
12.00
|
18.18
|
8.33
|
44.44
|
10.00
|
14.29
|
0.00
|
0.00
|
0.00
|
0.00
|
8.96
|
5.21
|
14.89
|
|
Hump Resurfacing
|
N
|
0
|
0
|
0
|
1
|
1
|
0
|
10
|
3
|
17
|
5
|
2
|
3
|
16
|
6
|
10
|
|
%
|
0.00
|
0.00
|
0.00
|
3.13
|
4.00
|
0.00
|
15.63
|
8.11
|
25.93
|
25.00
|
20.00
|
30.00
|
10.81
|
6.90
|
16.39
|
|
Hybrid
|
N
|
1
|
0
|
1
|
0
|
0
|
0
|
2
|
1
|
1
|
3
|
1
|
2
|
6
|
2
|
4
|
|
%
|
20.00
|
0.00
|
33.33
|
0.00
|
0.00
|
0.00
|
7.41
|
12.50
|
5.26
|
25.00
|
20.00
|
28.57
|
13.33
|
13.33
|
13.33
|
|
Resection
|
N
|
0
|
0
|
0
|
0
|
0
|
0
|
1
|
1
|
0
|
0
|
0
|
0
|
1
|
1
|
0
|
|
%
|
0.00
|
0.00
|
0.00
|
0.00
|
0.00
|
0.00
|
12.50
|
25.00
|
0.00
|
0.00
|
0.00
|
0.00
|
4.00
|
8.33
|
0.00
|
|
Total
|
N
|
6
|
2
|
4
|
7
|
3
|
4
|
14
|
6
|
8
|
8
|
3
|
5
|
35
|
14
|
21
|
|
%
|
4.65
|
2.44
|
8.51
|
9.86
|
5.77
|
21.05
|
12.84
|
10.71
|
15.09
|
18.60
|
15.00
|
21.74
|
9.94
|
6.67
|
14.79
|
The Role of Septoplasty in Primary Rhinoplasty: Does It Change the Revision Rate and
the Rhinoplasty Procedure?
[Table 2] (G2).
[Table 6]
Note that revision rate increases twofold when a septoplasty is associated with rhinoplasty
procedure.
Deviated Noses and Septoplasties
In this series, 129 patients had deviated noses (36.65%) with 77 demonstrating a straight-deviation
and 52 patients a C- or S-shape-deviation. The vast majority, 117 (90.69%), required
Cottle's septoplasty, and rest high strip procedure in cases of stable septum.[31] Eight (6.84%) revisions were undertaken in this group for recurrence of septal deformity
causing aesthetic concerns, but none for functional issues. The remaining 12 patients
with high deviation (9.3% of deviated noses) did not require septoplasty as the deformity
was corrected with high septal strip (3.41% of 352 procedures).
Discussion
Critical review of our 2018 study[3] raised several questions: First, is it possible to extend the indications of DP
to a wider group of patients, can DP be performed as a primary procedure in patients
with unfavorable/difficult anatomy, can the procedure be safely simplified by removing
surgical steps such as SSTE, neo-dorsum sutures, nasal bone reshaping, and LKA disarticulation.
Finally, is it possible to establish an alternative technique involving variations
in the DP procedures. Consequently, our main aim was to determine the limits of the
different DP rhinoplasty procedures and to perfect the indications regarding these
various surgical procedures, while achieving the highest benefit–risk ratio by designating
one of the 4 discussed procedures to each DPL derived patient group.
Septoplasties and the Revisions
The need for septoplasty may change the basic DP rhinoplasty paradigm.[32] In cases of stable septum, both high strip and Cottle's procedures may be performed
prior to DP. However, if the septum is unstable Cottle technique is preferred. However,
in difficult septoplasties (multiple fractured septum, S-shaped crooked noses, septal
perforations, and L-Strut deformities, etc.) one has to consider the classic reduction
rhinoplasty technique (see [Fig. 7A, B]).
Variations in rhinoplasty procedures
It is imperative to modify procedures depending on intraoperative findings and specific
patient expectations as outlined in [Table 5]. The senior author (Y.S.) alludes to and warns against “sin of pride”—trusting too
much in the type 1 DP technique, ignoring echoes of experience and not following the
recommended sequence of type 2 DP and other procedures resulting in some suboptimal
outcomes.
Key Points
|
Septum
|
Septorhinoplasty paradigms
|
|
Septoplasty is always the first surgical step
|
Rhinoplasty technique depends on septal stability
|
|
✓ Stable septum or no septoplasty
|
 Basic DP rhinoplasty paradigm
|
|
✓ Unstable septum
|
Cottle's technique
|
|
✓ Total septal reposition
|
Structure rhinoplasty, or DP if expert
|
Key Points: Intraoperative Modifications and Postoperative Revisions Related to Surgery
Failures or to Patient's Overexpectations
Key Points: Intraoperative Modifications and Postoperative Revisions Related to Surgery
Failures or to Patient's Overexpectations
-
Respect surgical sequence and steps: do not commit the “sin of pride.”
-
Patients with high expectations or extreme macrorhinia must be aware of revisions
in >10% cases.
-
The more difficult the nose, the higher the revision rate.
-
Lateral LKA disarticulation does not provoke either lateral wall destabilization,
or an inverted V deformity.
-
DKA removal and intraoperative switch to a nonconservative procedure (sequential rhinoplasty)
is always an option.
Dorsal Preservation Stigmata
These include residual or recurrent hump, supratip saddling, radix step-off, axis
deviation, and broader nose mostly middle third widening. The revision rate (9.94%)
in this series appears in hindsight to be related to the failure to follow surgical
steps as recommended and/or an inappropriate choice of procedure for a given patient's
morphology or expectations including incomplete disarticulation in humpy kyphotic
noses, not undermining SSTE and inadequate bony hump resurfacing in tension noses
and poor fixation.
Tüncel and Aydogdu[6]
[7] reported that hump recurrences were in > 4mm group, higher the hump, greater the
recurrence. The complication rate dropped from 12.1 to 5.3% with additional maneuvers
and proper patient selection.
Patients Selection in Primary Rhinoplasties, Focussing on the Indications for Dorsum
Preservation Procedures: Who Are the Good Candidates for Dorsum Preservation?
Straight Noses
These straight dorsum patients only need height reduction, keeping intact the shape,
dorsum lines, nasal valve, and the natural appearance and are best suited for type
1 full DP. When done through an endonasal approach, the nasal tip and the soft tissues
including ligaments are fully preserved. However, in huge macrorhinia reduction is
limited using type 1 DP as cartilaginous vault lowering leads to an overbroadening
of the middle third that necessitates adjunctive maneuvers including cartilage resection,
lateral disarticulation, with pyriform ligament and LKA division.
Tension Noses
Though they look remarkably like straight noses, they remain deceptive. Applying type
1 DP here has resulted in higher revision rate. In practice, one must not only reshape
the bony cap to perform a rhinion-shift, making the DKA more flexible and reducing
a possible small bony hump or S-shaped nasal bones but also ensure this flexibility
by freeing the LKA. The problem is not the convex shape, dorsum height, or the V/S-shape
nasal bones but the lateral restraining forces that must be overcome. Hence, a type
2 hump resurfacing in conjunction with adjunctive maneuvers eliminated revision completely.
Nasal Hump Reduction Preserving Only the Cartilaginous Vault
First described by Ishida et al[22] and known as “cartilage-only push-down” this can create an open roof where the overlying
nasal bones are removed and cartilage irregularities. To avoid these problems and
broaden the spectrum of the cartilaginous push-down technique, Ishida et al[32] preserve the whole DKA during dorsum reduction and performs a “DKA push-down.” Kovacevic[33] also suggests an osteotomy separating the DKA/bony cap from the nasal hump in broad
noses as the first step, followed by a classic push-down, that he named “double let-down
operation.” In the high-strip technique, Saban[25] introduced the concept of complete LKA–DKA bony cartilaginous disarticulation associated
with high septal strip resection and bony dorsum resurfacing through classic osteotomies.
Septum Work
Septoplasty follows two classic schools: (1) Killian: the whole cartilaginous septum
is removed preserving only “L-Strut” for nasal support. (2) Cottle: preserving the
whole cartilaginous septum, performing a “swinging-door” procedure through complete
disarticulation of the quadrangular cartilage from the bony components of the nasal
septum. The partisans of the L-Strut are the “structuralists,” while the “Cottleists”
are “preservers.” The “structuralists” argue the need for a strong L-Strut support
to the dorsum. They suggest preservation philosophy weakens the classic L-Strut structure,
thus reducing the ability to stabilize the dorsum. However, the senior author (Y.S.)
argues that in his experience the high strip PR reduces dramatically the need for
grafting, and eventually follows the L-Strut principles where dorsum is not weakened.
Additionally, the high strip, and particularly swinging door technique require less
cartilage resection; moreover, it keeps the availability of cartilage reserve that
can be harvested if required. Further senior author (Y.S.) uses “Septal-Triangular
Unit Distraction” (STUD) technique for the “push-up” procedure which yields to (1)
lowering of the cartilaginous dorsal hump if required, (2) cartilaginous push-up of
the supratip area, (3) filling the nasolabial angle. Stable fixation of the cartilaginous
posterior septal angle onto the bony anterior maxillary spine is the critical step,
to avoid backward displacement in the postoperative period. It is important to adopt
the procedure to patient's anatomy and aesthetics by partial and incremental resections
of the inferior and/or the caudal edges of quadrangular cartilage to achieve the desirable
result.
Barelli[34] in a series of 100 consecutive cases of septorhinoplasty with Cottle technique reported
12% revisions. Many variations following Cottle’s techinique have been described that
are reliable procedures: SPAR technique by Dewes,[35] Tetris procedure by Neves,[12] and Most[9] introduces an intermediate flap. Neves describes an interesting squared high septal
flap allowing for very stable dorsum lowering and fixation. Finocchi repopularises
the original Cottle’s technique naming this “SPQR”. Kovacevic[36] designs a septal triangular Z-plasty section that he named “subdorsal Cottle.” This
Z-plasty leaves more septum intact below the cartilaginous vault, thus weakening less
the underlying septum and allowing better dorsum stability and more place for septal
cartilage harvesting.
Whatever the procedure, the philosophy of these variations is to handle the septum
together with the ULCs cartilaginous vault in a STUD en-bloc forward mobilization
and firm fixation. The main interest in our opinion lies in the possibility to reshape
the hump corresponding to tension noses.
In summary, considering different techniques and associated benefit–risk ratio, we
suggest that (1) straight DPL should be allocated to type 1 DP procedure performed
through an endonasal approach, preserving the dorsal structural integrity completely,
including SSTE, ligaments, and bony cartilaginous vault. (2) Tension noses, the dorsal
convexity must be straightened or curved. Thus, all the techniques in type 2 DP armamentarium
including bony cap resurfacing and STUD represent excellent indications associated
with LKA partial disarticulation: Saban's type 2 hump resurfacing and high strip procedure,
Kovacevic's Z-plasty flap, Neves' Tetris concept, Most's intermediate, LC Ishida's
DKA preservation with lateral disarticulation. (3) Kyphotic noses with large bony
humps that cannot be reshaped, desire type 3 DP, corresponding to total LKA–DKA disarticulation
and a cartilaginous vault preservation. Ishida, Jankowski, Ferreira, and Saban advocate
cartilage-only push down procedure, the main variation being the septal work. (4)
In difficult noses, one should consider traditional rhinoplasty techniques or structure
rhinoplasty concept. In case of intraoperative difficulty while performing a DP, the
surgeon should consider the possibility to perform a sequential rhinoplasty, by switching
intraoperatively either to a type 3, or even to a traditional or structure rhinoplasty.
Learning Curve
Introducing the preservation concepts in primary rhinoplasty is challenging. PR surgeons
must think in terms of biomechanical surgical anatomy (pivot points, anatomical shifts,
restraining forces, etc.) and not focus exclusively on technical ways to reshape,
change volume, and choose the appropriate grafts. This article aims to shorten and
sharpen learning by offering specific guidelines by an experienced PR Surgeon. One
has to be cognizant that preservation procedures are applicable to primary rhinoplasties
and are not applicable to post-traumatic, complex shapes, and secondary rhinoplasties,
though exceptions do exist in experienced hands. Probably the most appropriate way
to start is to use an open approach in men presenting with a high dorsum. The learning
curve should encompass other philosophies and techniques. At this juncture, the authors
would like to cite D. Toriumi[37]: “After 31 years in practice, changing how I managed the upper two-thirds of the nose
was challenging. However, I thought the upside was significant. Now that I have made
the transition, I do not regret my decision.”
Study Limitations
This retrospective study is based on two cohorts of multiethnic patients (n = 670 in total), of primary endonasal rhinoplasties performed by the senior author
(Y.S.) following the same philosophy through years. Comparing this series to open
approach in PR suggests similarities in classification,[38] but a lower revision rate.[39] The study focuses on surgical techniques and morphological aspects and functional
issues have not been emphasized, as other studies.[8]
[9]
[10]
Further multicenter prospective research is essential to aid the decision-making process,
in a variety of nasal shapes, function, and patient expectations, as well as a range
of procedures from the easiest and safest to the most challenging ones, ensuring that
a high benefit–risk ratio should be the leading parameter.
Conclusion
With the introduction of the preservation concepts and a variety of techniques published
in combination with several variation in nasal shapes one has to deal with, a novice
preservation surgeon has to be able to work to a classification to achieve the best
possible outcome that is set out in this article. Four types of noses have been described
and correlated to four specific rhinoplasty procedures, with a simple paradigm, including
few variations. The role of septoplasty is discussed, which in combination with rhinoplasty
reduces revision rate, improving patient satisfaction while reducing the length of
the learning curve.
Table 7
Summarizing the revision procedures: number of cases and surgery duration
|
Number of patients
|
35
|
Revision duration time
|
Extreme durations
|
Standard deviation
|
|
Bone rasping/upper lateral cartilage shaving
|
23
|
22.74 mn
|
7–47 mn
|
12.69
|
|
Strip procedures
|
11
|
34.18 mn
|
17–73 mn
|
16.69
|
|
Low radix
|
1
|
13.00 mn
|
NA
|
NA
|
|
Lateralization
|
9
|
32.11
|
13–55 mn
|
13.14
|
|
Septoplasty
|
21
|
|
|
|
|
Total of procedures
|
65
|
|
|
|
|
Mean of procedures per patient
|
1.86 Procedures per patient
|
|
|
|
|
Extremes
|
1–3 Procedures per patient
|
|
|
|
