Management of the nasal dorsum remains a challenge in rhinoplasty surgery. Currently, the majority of reduction rhinoplasties results in destruction of the keystone area (K-area), which requires reconstruction with either spreader grafts or spreader flaps, both for aesthetic and functional reasons. This article will present the senior author's current operative technique for dorsal preservation in reduction rhinoplasty based on 320 clinical cases performed over a 5-year period. The author's operative technique is as follows: (1) endonasal approach; (2) removal of a septal strip in the subdorsal area whose shape and height were determined preoperatively; (3) complete lateral, transverse, and radix osteotomies; and (4) dorsal reduction utilizing either a push down operation (PDO) or a let down operation (LDO). The PDO consists of downward impaction of the fully mobilized nasal pyramid and is utilized in patients with smaller humps (Less than 4 mm). The LDO consists of a maxillary wedge resection and is performed in patients who need more than 4 mm of lowering. A total of 320 patients had a dorsal preservation operation (DPO). Postoperatively, there were no dorsal irregularities nor inverted-V deformities. Among our 44 personal revision cases, 27 patients (8.74%) had had a previous DPO, 16 of whom required tip revisions with no further dorsal surgery. Of the remaining 11 patients, the main problems were either hump recurrence and/or lateral deviation of the dorsum or widening of the middle third, which required simple surgical revision. Based on the authors' experience, adoption of a PDO/LDO is justified in selected primary patients. The key question before any primary rhinoplasty procedure should be "Can I keep the nasal dorsum intact?" Precise analysis and surgical execution are required to preserve the dorsal osseocartilaginous vault and K-area. Dorsal preservation results in more natural postoperative dorsum lines and a "not operated" aspect without the need for midvault reconstruction. Moreover, this technique is quick and easy to perform by any rhinoplasty surgeon. Rhinoplasty surgeons should consider incorporating dorsal preservation techniques in their surgical armamentarium rather than relying solely on the Joseph reduction method or an open structure rhinoplasty.

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The use of diced cartilage grafts in rhinoplasty surgery was recently revived by Erol with the publication of his technique for "Turkish delight" grafts (i.e., diced cartilage grafts wrapped in Surgicel). The present study details the authors' experience with 50 consecutive diced cartilage grafts used in three configurations during a prospective study of 50 primary and secondary aesthetic rhinoplasty procedures performed by the senior author (Daniel). Part I consists of 22 diced cartilage grafts wrapped in Surgicel and placed in the radix (n = 14), radix/upper dorsum (n = 4), and full-length dorsum (n = 4). All grafts were performed adhering meticulously to Erol's technique without modification. This portion of the study was halted abruptly at 4 months because of the unexpected absorption and clinical failure of all diced cartilage grafts wrapped in Surgicel. Subsequently, five patients had revision surgery, and biopsy specimens were taken at the prior grafting site and analyzed histologically. After this clinical failure, part II of the study began, consisting of 20 patients who had diced cartilage grafts wrapped in fascia. The range of applications was comparable: radix (n = 12), radix/dorsum (n = 3), and full-length dorsum (n = 5). Because of our prior practice of overcorrecting by 20 percent with diced cartilage grafts wrapped in Surgicel, we had excessive amounts of material in six of our initial diced cartilage wrapped in fascia radix grafts, but no subsequent grafts. The overcorrections were easily reduced at 6 weeks to 11 months postoperatively using a pituitary rongeur under local anesthesia, and the material was sent for histologic analysis. Minimum 1-year follow-up of all 20 cases has shown maintenance of the grafts without evidence of absorption. Part III of this study comprised eight patients who had diced cartilage grafts without a fascial covering placed throughout the nose, including on the sides of osseocartilaginous rib grafts to the dorsum. At 14 months, there was no evidence that any of these grafts had been absorbed. Histologic analysis of the biopsy specimens from the diced cartilage grafts wrapped in Surgicel showed evidence of fibrosis and lymphocytic infiltrates with small amounts of Surgicel visible on birefringent microscopy. Remnants of cartilage were present but were metabolically inactive on the basis of negative glial fibrillary acidic protein staining. Control specimens of fresh septal cartilage and banked septal cartilage were remarkably similar to each other and demonstrated normal cartilage architecture and cellular activity. The diced cartilage grafts wrapped in fascia showed coalescence of the diced cartilage into a single cartilage mass, with viable cartilage cells and normal metabolic activity on the basis of glial fibrillary acidic protein staining. All of the diced cartilage grafts wrapped in Surgicel absorbed and failed to correct the clinical problem for which they were performed. All of the diced cartilage grafts wrapped in fascia and pure diced cartilage grafts did cor...

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