Push down technique with ostectomy

Partial Release of Pyriform Ligament to Prevent Deformities on Keystone Area

The dorsal hump deformity is common among Western countries based on the nasal structure of Caucasians. Dorsal preservation techniques which leads keeping the keystone area intact can bring positive outcomes such as obtaining aesthetic dorsal lines and better functional results. The positions of soft tissue in the face are supported with a combination of static and dynamic ansatomy. The static support is maintained by ligaments and their associations. Among the ligaments, the pyriform ligament takes a particular role in terms of supporting the alar base, lower lateral cartilages, and nasal tip. In the present research, it was aimed to investigate the beneficial effects of releasing pyriform ligament partially in patients who received dorsal preservation rhinoplasty. The data of the patients who had dorsal rhinoplasty operations for hump deformity were screened retrospectively. A total of 139 patients were included according to inclusion and exclusion criteria and their records were assessed (112 females and 27 males). Twelve months after surgery, the median Rhinoplasty Outcome Evaluation score increased from 52.5 to 91.5 points ( P <0.001). Patient satisfaction was excellent in 86.95% of the included cases according to the Rhinoplasty Outcome Evaluation score. The present study shows a new, suitable, and easy approach for releasing the pyriform ligaments partially and as well as also were left intact. It is suggested that manipulation of the pyriform ligament during push-down and let-down procedures seems to be essential for obtaining a better nasal tip as well as narrowing the nose base and getting better functional outcomes.

Exploring the Resurgence of the Preservation Rhinoplasty: A Systematic Literature Review

INTRODUCTION

The underlying principles of preservation rhinoplasty (PR) center around maintaining the soft tissue envelope, dorsum, and alar cartilage through surgical manipulations and tip suture techniques. In particular, the let-down (LD) and push-down (PD) techniques have been described, although reports of indications and outcomes in the literature are sparse.

METHODS

A systematic review of the literature was performed using search terms "preservation" OR "let down" OR "push down" AND "rhinoplasty" on PubMed, Cochrane, SCOPUS, and EMBASE databases. Patient demographic information, operative details, and surgical outcomes were recorded. Sub-cohorts for patients who underwent LD and PD techniques were analyzed utilizing Fischer's exact test for categorical variables and Student's t test for continuous variables.

RESULTS

Overall, there were 5967 PR patients in 30 studies in the final analysis, with 307 patients in the PD cohort and 529 patients in the LD cohort. The Rhinoplasty Outcome Evaluation Questionnaire showed a significant increase of patient satisfaction after PR compared to before PR (62.13 vs 91.14; p < 0.001). There was a significantly lower rate of residual dorsal hump or recurrence of 1.3% (n = 4) in the PD when compared to 4.6% (n = 23) in LD cohorts (p = 0.02). The revision rate of PD (0%, n = 0) was also significantly lower than that of LD (5.0%, n = 25) (p < 0.001).

CONCLUSION

Based on these published articles, it seems that preservation rhinoplasty is safe and efficacious procedure with improved dorsal aesthetic lines, reduced dorsal contour irregularities, and claimed excellent patient satisfaction. In particular, the PD technique has fewer reported complications and revisions than LD approach, although PD is often indicated in patients with smaller dorsal humps.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

State of the Evidence for Preservation Rhinoplasty: A Systematic Review

Preservation rhinoplasty encompasses a number of techniques that minimize disruption of the native cartilaginous and soft tissue nasal architecture. These techniques have gained popularity resulting in an increase in publications relevant to preservation rhinoplasty. However, many studies that present patient outcomes are of low-level evidence and do not incorporate validated patient-reported outcome measures. While these studies do consistently report positive outcomes, there are few high-level comparative studies that support the theoretical benefits of preservation relative to structural rhinoplasty. As contemporary preservation rhinoplasty techniques will continue to evolve and become incorporated into clinical practice, there will be the need for parallel emphasis on robust clinical studies to delineate the value of these methods.

Common Dorsal Flaws Following Preservation Rhinoplasty: A Systemic Analysis

BACKGROUND

There has recently been a resurgence of interest in preservation rhinoplasty (PR) for dorsal hump elimination or dorsal projection reduction. However, no studies have scrutinized aesthetic outcomes to identify common pattern of flaws seen in published images to aid those with ardent enthusiasm for this technique to become aware of the frequency of these flaws and find ways to reduce imperfections.

METHODS

A systematic literature review was performed using search terms ("preservation" OR "let down", "push down") AND "rhinoplasty" on PubMed, Cochrane, SCOPUS, and EMBASE databases for studies between January 2000 and December 2022. Patient images from these studies were analyzed by three reviewers (MWW, IAC, and BG) for dorsal flaws. Raw interrater agreement percentage and Krippendorff's alpha were calculated to determine interrater reliability. A descriptive and comparative analysis with Fisher's exact test was performed for the aggregate data.

RESULTS

There were 59 patient images with 464 views from 24 studies included for final analysis. Optimal dorsal aesthetic lines (DAL) were noted in 12 patients (20.3%), while optimal profile was observed in 15 patients (25.4%) (p = 0.66). Combined ideal front and profile view of dorsum was not observed on any patients. The most common flaws were DAL irregularities (n = 45; 78.0%), dorsal deviation (n = 32, 54.2%), and residual hump (n = 25, 42.4%). There was excellent interrater agreement.

CONCLUSIONS

While PR may have some advantages, it has shortcomings in outcomes, particularly dorsal irregularities, dorsal deviation, and residual humps. Awareness of these imperfections may compel those performing this procedure to modify their techniques and improve their results.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

New Suturing Approaches for Patients with Nasal Hump and Septal Deviation

ABSTRACT

Rhinoplasty is one of the most common applied aesthetic surgery procedures worldwide. Dorsal hump deformity is common in western countries due to nasal profile of Whites. Septal deviation deformity is another common problem among patients who goes through aesthetic and plastic surgery. The estimated rate of septal deviation was reported to be 77% to 90% in the general population. The patients who had dorsal hump and septal deviation simultaneously are considered to be challenging for surgeons. In this research, the author presents new suturing approaches, which would be beneficial in dorsal preservation techniques in terms of fixing the septal deviation. One hundred and seventeen patients met the inclusion and exclusion criteria, and their records were assessed retrospectively. The patients who underwent either push-down and let-down techniques or septorhinoplasty were applied "8" shaped or loop suturing approaches. In addition, 33 patients with the same inclusion and exclusion criteria in whom classical loop suturing technique was used were included in the study. The Rhinoplasty Outcome Evaluation scores ranged between 80 and 100 points after 1 year. The initial median Rhinoplasty Outcome Evaluation score was 52.5, and it increased to 91.00 points at 12 months after surgery (P < 0.001). Patient satisfaction was excellent in 92.68% of the study group, and it was 72.72% in the control group. Excellent satisfaction rate was higher in the study group (P = 0.01). This study is the first to demonstrate the beneficial effects of loop and "8"-shaped sutures in patients who had nasal hump and septal deviation deformities. These suturing approaches will allow better long-term outcomes.

Combining Open Structural and Dorsal Preservation Rhinoplasty

There has been a resurgence in dorsal preservation rhinoplasty (DPR) caused by theoretic aesthetic and functional advantages compared with conventional hump takedown rhinoplasty. Classically, the push-down and let-down maneuvers have been described for management of the bony nasal vault. There have been a variety of modifications in the septal resection that is a requisite for dorsal lowering in DPR. Partial dorsal preservation techniques, including cartilage-only preservation, have also been described. Although several studies have reported aesthetic and functional success with a variety of techniques, few have used objective or patient-centered subjective measures.

Global Practice Patterns of Dorsal Preservation Rhinoplasty

Background: Dorsal preservation rhinoplasty (DPR) has recently received significant academic attention in part due to theoretical benefits over excisional surgical methods. The purpose of this study was to assess the global practice patterns regarding this technique. Materials and Methods: An 11-item questionnaire was electronically distributed to regional academies/societies representing rhinoplasty surgeons worldwide. Respondent exposure to and use of DPR were assessed based on geographic location. Results: Eight hundred thirty-six responses were received. Despite early publications on DPR originating largely from Western Europe and the United States, Turkey and Mexico have the greatest use of DPR techniques currently. The familiarity across many regions with preservation techniques appear to be secondary to courses and conferences rather than incorporation into training. Mexico demonstrates the greatest exposure to DPR during training. One hundred twenty-five respondents had previously used but abandoned dorsal preservation techniques. Poor results, less predictability, and complications (largely hump recurrence) are cited as common reasons for this. Conclusion: There is variability in the global practice of DPR across regions and this will likely continue to evolve.