A 3-Level Impaction Technique for Dorsal Reshaping and Reduction Without Dorsal Soft Tissue Envelope Dissection

Bony Dorsal Preservation

Rhinoplasty is undergoing a transformation with the reemergence of dorsal preservation rhinoplasty (DPR) techniques. This article introduces a novel addition to the DPR repertoire, "bony dorsal preservation" (BDP), which has particular application for the correction of crooked noses.This comprehensive overview summarizes current DPR concepts and techniques, the intricate considerations that go into the dorsal osseocartilaginous vault and septal management, and how these are modified to treat the crooked nose. However, current DPR techniques, particularly the low septal strip (LSS), have drawbacks, and the desire to address such issues led to the development of BDP.BDP is ideal for cases where there is no septal base pathology. It maintains the core principle of DPR by lowering dorsal humps without creating open roof deformities. Its unique feature is that it temporarily separates the upper lateral cartilages from the septum while leaving the septal base attachment intact, thus allowing the entire osseocartilaginous vault to be adjusted independently before reconnecting the preserved upper lateral cartilages. This technique offers direct visualization during septal excision and fixation and enables cartilaginous vault movement without sacrificing stability. Compared with LSS, there is more septal cartilage available for harvesting, the risks of a single point of septal fixation are eliminated, and there is the potential to transition to component reduction techniques, if needed. With shared indications and contraindications with other DPR methods, BDP emerges as a valuable addition to the evolving field of rhinoplasty, particularly in addressing the challenges of the crooked nose.

Low Strip Unifying Hybrid Rhinoseptoplasty: A Novel Classification in Dorsal Preservation Surgery

BACKGROUND

Preservation rhinoplasty techniques continue to evolve. Suture tip-plasty with minimal resection and grafting, lateral crural tensioning, minimal excision from the lateral crura, dorsal preservation, subperichondrial dissection, and preservation of the ligaments have become the milestones of modern rhinosurgery. However, every time the dorsal frame is modified by means of rasping, shaving, or osteotomy, or the nasal tip is structured using grafts, surgeons are essentially applying structural concepts to their technique. The term "hybrid rhinoplasty" seems to include a more appropriate definition of this approach.

METHODS

The authors performed a retrospective analysis of the medical records of patients who underwent primary septorhinoplasty using the low strip unifying hybrid rhinoseptoplasty concept from December of 2019 to June of 2022. Patient functional satisfaction and cosmetic satisfaction were evaluated using the Rhinoplasty Health Inventory and Nose Outcome scale.

RESULTS

All reported procedures had low revision rates with good cosmetic and functional outcomes.

CONCLUSIONS

Tailoring the surgical technique is essential in rhinoplasty. The authors present a new technical paradigm to help surgeons choose the best approach for dorsal preservation surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Dorsal Preservation Versus Structural Techniques and Their Application

Structure rhinoplasty and preservation rhinoplasty are 2 popular philosophies that can be used alone or in combination to provide a hybrid approach. Structure rhinoplasty is the leading option for revision rhinoplasty and utilizes cartilage grafting techniques to support and reconstruct the nose. Preservation rhinoplasty spares bone, cartilage, ligaments, and soft tissues to minimize the need for grafting and preserves the favorable features of the nose. Structural preservation rhinoplasty uses dorsal preservation in the upper two-thirds of the nose and structure rhinoplasty in the lower third. This hybrid approach has great utility in primary, revision, and reconstructive rhinoplasty.

Dorsal Preservation Rhinoplasty

Controversies in Preservation Rhinoplasty" explores the nuanced indications, techniques, and challenges in preservation rhinoplasty (PR), featuring contributions from JC Neves, D Toriumi, and A Göksel. Neves recounts his early career under Wilson Dewes and describes the evolution of PR techniques. Toriumi, having started PR in 2019, discusses his initial cautious approach and subsequent expansion to include patients with more diverse nasal deformities. Göksel highlights the critical role of surgical expertise and individualized patient assessment, advocating for methods like dorsum-plasty osteotomies and the Ballerina maneuver to enhance PR's effectiveness.

The Blocking Points: The Keys to Consistent Success in Preservation Rhinoplasty

SUMMARY

Preservation rhinoplasty is a growing area of interest among rhinoplasty surgeons. Dorsal preservation-a tenet of preservation rhinoplasty-is predicated on maintaining the integrity of the nasal midvault and effecting aesthetic change through alterations to the bony nasal pyramid and underlying septum. A challenge that is unique to dorsal preservation is the phenomenon of hump recurrence, because of the existence of anatomical blocking points. Blocking points are resistant tensile forces that either impede dorsal lowering intraoperatively or push the dorsum back to its native convexity over time. Five anatomical blocking points have previously been described, which the authors expand on and include an additional two. The seven anatomical blocking points are as follows: the cartilaginous septum, the perpendicular plate of the ethmoid, the lateral osteotomy site, the Webster triangle, the internal mucoperiosteum of the maxillary bone, the medial canthal ligament, and the lateral keystone area. It is critical that the surgeon be aware of the particular blocking points relevant to his or her chosen technique, and to appropriately and methodically address them to ensure consistent long-term results.

Simplified Septal Stabilization in Closed-Approach Low-Septal-Resection Dorsal Preservation Rhinoplasty

BACKGROUND

Septal fixation is a basic step in low-septal-resection dorsal preservation rhinoplasty. Inadequate septal stabilization can lead to supratip depression or more severe saddle nose deformity. This paper presents a simple surgical maneuver to stabilize quadrangular septal cartilage instead of suture fixation to the anterior nasal spine.

METHODS

Thirty patients who underwent closed-approach low-septal-resection dorsal preservation rhinoplasty between July and December 2021 were included in this retrospective study. Depending on the surgical maneuver performed to stabilize quadrangular septal cartilage, the patients were divided into 2 groups as follows: (1) a group in which the septum was stabilized with transfixion sutures (the transfixion suture group) and (2) a group in which the septum was fixed to the anterior nasal spine with suture (the anterior nasal spine suture fixation group). Standardized postoperative 12-month lateral-view photographs were scanned for the presence of supratip depression or saddle nose deformity that may indicate insufficient septum stabilization.

RESULTS

Supratip depression was observed in 1 patient in the transfixion suture group (n = 16) and in 1 patient in the anterior nasal spine suture fixation group (n = 14; P > 0.05). No saddle nose deformity was observed in either group.

CONCLUSIONS

Transfixion sutures seem effective in providing septal stabilization to prevent supratip depression or saddle nose deformity in closed-approach low-septal-resection dorsal preservation rhinoplasty. Transfixion sutures can be used for septal stabilization in closed-approach rhinoplasty, allowing the surgeon to take advantage of the ease of placement.

Advanced Preservation Rhinoplasty in the Era of Osteoplasty and Chondroplasty: How Have We Moved Beyond the Cottle Technique?

BACKGROUND

Over the last 10 years, many new papers on innovative strategies from different surgeons worldwide have elevated the philosophy of preservation rhinoplasty (PR) to a different level: advanced preservation rhinoplasty.

OBJECTIVES

The goal of this article was to illustrate how 4 experienced surgeons approach important anatomical and functional issues related to PR.

METHODS

M.G.F., A.M.K., B.S., and D.M.T. were asked about how they approach classical problems and relative contraindications for dorsal PR with different modern advanced preservation rhinoplasty techniques.

RESULTS

The answers of each surgeon make clear a new reality in dorsal PR that did not exist in the recent past. These advances in dorsal PR techniques are due to many surgeons' contributions, leading this practice to a different level: advanced preservation rhinoplasty.

CONCLUSIONS

Dorsal preservation is making a dramatic resurgence and is fueled by the many very talented surgeons who are demonstrating outstanding outcomes with preservation techniques. The authors believe that this trend will continue, and a mutual collaboration between structuralists and preservationists going forward will continue to advance rhinoplasty as a specialty.

The Barn Doors Greenstick Fracture-A New 3D Geometry for Common Osteotomies in Rhinoplasty: The First 50 Patients with 1-Year Follow-up

The "barn doors greenstick fracture" is a new concept that includes three contiguous greenstick fractures: one in the central compartment of the nasal dorsum (nasal bones) and two on the lateral walls of the bony nasal pyramid. The present study aimed to describe this new concept and to report the first esthetical and functional outcomes. This prospective, interventional, and longitudinal study was performed on 50 consecutive patients undergoing primary rhinoplasty by spare roof technique B. The validated Portuguese version of the Utrecht questionnaire (UQ) for outcome assessment in esthetic rhinoplasty was utilized. Each patient answered the questionnaire online before surgery and 3 and 12 months after surgery. In addition, a visual analog scale (VAS) was used to score nasal patency for both sides. The patients also answered three questions (yes or no): (1) "Do you feel any step on your nasal dorsum?" if yes: (2) "Is that step visible?" (3) "Does it bother you?"A statistically significant improvement in UQ scores postsurgery was found, demonstrating a high satisfaction index in this patient population. Additionally, the preoperative and postoperative mean functional VAS scores showed a significant and consistent improvement on both sides (right and left). Twelve months after surgery, a step at the nasal dorsum was felt by 10% of the patients, but it was visible just in 4%, which were two females with thin skin.The barn doors greenstick concept provides a new approach to achieve a real and sustainable smooth transition in the dorsal and lateral walls. The association of the two lateral greensticks and the already described subdorsal osteotomy allows a real greenstick segment in the most critical esthetic region of the bony vault-the root of the nasal pyramid.

Dorsal Preservation Surgery: A Novel Modification for Dorsal Shaping and Hump Reduction

BACKGROUND

A new technique for dorsal preservation rhinoplasty that minimizes recurrent hump deformity is introduced.

OBJECTIVES

The authors sought to present a novel dorsal roof flap (DRF) technique for modifying the nasal hump and dorsum while reducing morbidity.

METHODS

Twenty-two primary and 3 secondary rhinoplasty patients had 1 of 2 types of nasal DRF depending on hump composition. A triangular roof flap was created utilizing 2 incisions from W-point to lateral Keystone junction in cartilaginous humps (cartilaginous DRF) and to the nasion in osseocartilaginous humps (osseocartilaginous DRF). Then, septal strip excisions were conducted to lower the profile followed by nasal base narrowing. The DRF was then lowered to the desired profile line, any excess lateral wall height trimmed, and the DRF sutured to the upper lateral cartilages. Preoperative and postoperative nasolabial and nasoglabellar angles were measured on the photos.

RESULTS

Mean follow-up was 10.3 (standard deviation, 4.41) months (range, 6-20 months). A total 22 humps were V-shape and 3 were S-shape. The composition of the hump was cartilaginous in 5 cases, bone in 7 cases, and combined in 13 cases. A cartilaginous DRF was utilized for the 5 cases with a cartilaginous hump and osseocartilaginous DRF was employed in the other 20 cases. There were no complications observed in the follow-up period and thus no revisions.

CONCLUSIONS

The DRF technique allows preservation of the nasal dorsum and elimination of the dorsal hump while minimizing hump recurrence.

LEVEL OF EVIDENCE: 4

Structural Preservation Rhinoplasty: A Hybrid Approach

SUMMARY

Structural preservation rhinoplasty merges two popular philosophies of rhinoplasty-structure rhinoplasty and preservation rhinoplasty-in an effort to maximize patient outcomes, aesthetics, and function. This allows the surgeon to both preserve the favorable attributes of the nose, and also to structure the nasal tip and dorsum with grafts to maximize contour and support. The concept of dorsal preservation is to preserve favorable dorsal aesthetic lines without the creation of an "open roof." However, the addition of some structure concepts can expand the utility of dorsal preservation in primary rhinoplasty patients. The authors discuss these structure concepts and their applicability to dorsal preservation.

Preservation Rhinoplasty: Open or Closed?

BACKGROUND

Preservation rhinoplasty (PR) is an evolving philosophy.

OBJECTIVES

The open approach was used initially, but the author felt a closed approach might be of benefit in certain patients.

METHODS

One hundred sixty-two primary rhinoplasty cases were studied retrospectively between January and July 2020. One hundred cases had at least 1 year of follow-up. Patients had follow-up at 1 week, 1 month, 3 months, and 1 year after surgery. Technical details were recorded including dissection planes, preservation of the dorsum (DP) versus component reductions, surface versus foundational DP techniques, and open versus closed approach.

RESULTS

One hundred patients had at least 1 year of follow-up. Fifty-six patients underwent an open approach, and 44 a closed approach. Eighty-three patients had preservation of the dorsal soft tissue envelope. All patients having a closed approach had preservation of the dorsal soft tissue envelope. Sixty-seven patients underwent DP with 38 having surface techniques and 29 having impaction techniques. Thirty-three patients underwent structural rhinoplasty with piezoelectric osteotomies and mid-vault reconstruction. All structural cases were performed using an open approach. Four revision surgeries were necessary.

CONCLUSIONS

Open and closed approaches have indications depending on the tip and dorsal deformities. A closed, PR is favored with thin skin, minimal dorsal modification, osseocartilaginous preservation (foundation techniques), less complex tip deformities, and overprojected noses. An open, PR is favored for extensive dorsal modification, S-shaped nasal bones, complex tip deformities, and tip augmentation. Structural, dorsal rhinoplasty is always done open and preferred for complex dorsal deformities and severe septal deviations.

Clinical Outcomes in Dorsal Preservation Rhinoplasty: A Meta-Analysis

Background: Dorsal preservation rhinoplasty (PR-D) attempts to preserve as much of the native nasal anatomy as possible when performing a hump reduction, but clinical outcomes are unclear. Objective: In patients undergoing PR-D rhinoplasty, this article investigates the rates of complications and revisions. Methods: This meta-analysis was prospectively registered on the PROSPERO database. The Pubmed, Embase, and Scopus databases were searched. Pooled incidence was calculated in a meta-analysis within a random-effects model. Results: Twenty-two studies representing a cohort of 5660 patients were included in this study. Postoperative hump recurrence rates (4.18%, 95% confidence interval [CI]: 2.41-6.40%), rates of revision rhinoplasty (3.48%, 95% CI: 1.77-5.74%), rates of postoperative nasal deviation (1.13%, 95% CI 0.37-2.28%), and rates of infection (1.89%, 95% CI: 0.35-4.62%) were all found to be low. Conclusion: PR-D has low rates of revision surgery, residual or recurrent hump, postoperative nasal deviation, and postoperative infection.