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

Abstract

Background Preservation Rhinoplasty (PR) techniques are continuously evolving in the last two years. Many variations of old-fashioned techniques have been proposed since Daniel coined this term in 2018. Objectives Authors want to describe indications for a new “three level impactions” technique allowing, in selected cases, a complete profile correction and dorsal reduction without the dorsal soft tissue envelope (STE) dissection. Methods Three hundred fifty primary closed rhinoplasty cases were retrospectively studied from January 2018 and October 2019. Age, sex, race and technical details, surgical time and complications have been registered. Ninety-five dorsums were reduced and shaped without dissecting the dorsal soft tissue envelope, combining a 1) swinging door septoplasty with low septal strip resection, 2) endonasal bony cap mosaic osteotomies, and 3) Let down or Push down operation (LDO/PDO). Results All patients showed a dramatic change in profile height and shape without neither dorsal STE dissection nor bony cartilage dorsal tissue resection. The average follow-up time was 14 months (range, 12-16 months). Conclusions In selected patients, dorsum can be preserved without soft tissue envelope dissection. By combining multiple endonasal maneuvers is possible to obtain a dramatic change without dissecting the soft tissue envelope and at the same time avoiding any dorsal tissue resection: mosaic osteotomies for DKA conversion from S to V shaped dorsum, LDO and low septal strip resection for impaction and quadrangular cartilage flap rotation for profile setting. It is a versatile technique in selected patients, which leads to fast recovery and natural results.

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

“…With this impaction osteotomies, one loses control of the bony pyramid (disruption of the bony pyramid from maxillary and frontal bones). More recently, Finocchi et al 14 This concept is also valid for surgeons who want to add rhino sculpture or bony modulation with piezo, rasp, or burs -typically in severe S-shaped nasal bones and/or bony irregularities.…”

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

“…The subdorsal Z-flap described by Kovacevik, Neves's tetris concept, Most's modified midseptal resection, Cottle's low septal resection, and the simple preservation quick rhinoplasty modification by Finocchi all intrinsically incorporate a vertical chondrotomy beneath the dorsal hump in their designs, creating an axis for expansion or rotation at the most projecting point of the hump. [5][6][7][8][9] The high septal strip, predicated on making a subdorsal cut that follows the contour of the convexity, should be treated no differently. Attention should be paid to the presence of any remnant subdorsal cartilage directly beneath the hump and, if removal proves difficult, it should be scored or a vertical chondrotomy made to facilitate expansion.…”

“…These have been derived from the senior author’s (A.G.) extensive experience performing DPR and conducting anatomical studies over his career, and the corroborating reports of other international experts in this field. 6,9,13,15,16 The seven anatomical blocking points in DPR and their respective solutions are summarized in Table 2. Long-term maintenance of the dorsum in its new position is predicated on the release of these relevant blocking points and the secure fixation of the dorsum in its new position.…”

Structural Preservation Rhinoplasty: A Hybrid Approach

“…Dorsal preservation techniques that have powerful stretching capability include the Cottle technique, Finocchi's simplified preservation quick rhinoplasty, Neves' segmental preservation rhinoplasty technique (Tetris concept), and others. 16,[19][20][21] What these techniques have in common is the firm, "structural" connection of subdorsal septal cartilage to the undersurface of the dorsal hump to allow the hump to be pulled posterior and caudally to stretch it flat. These are "structural" forces that are acting on the undersurface of the dorsal prominence to flatten the dorsal hump.…”