Guidelines for Dorsum Preservation in Primary Rhinoplasty

Abstract

The multiplication of scientific articles related to the fast-growing interest in preservation rhinoplasty (PR) may lead to confusion in the decision-making process, thus requiring a need for guidelines through a focus on benefit–risk ratio and revisions. This study analyzes a 352 consecutive primary rhinoplasties series during a 3 year (2016 to 2019) period with 1-year follow-up. The evaluation of the most appropriate procedure to the patient's nasal anatomy and expectations requires to correlate (1) a convenient classification of nasal profile lines; (2) a review of the dorsum preservation techniques (DP) classified as: full DP, DP + resurfacing, bony cartilaginous disarticulation, and finally traditional rhinoplasty; (3) the role of septoplasties, subdividing this series in two main groups; (4) analyzing the revisions in the different subgroups and to the literature. Thirty-five revisions (9.94%) were done. Correlations between profile lines, surgical procedures, and revisions show (1) 129 straight noses underwent full DP in 88 cases with 5.68% revisions; however, DP+ hump resurfacing in 32 patients with no revision. (2) Among 71 tension noses, 33 underwent full DP with 6 revisions (18.18%), while 32 patients had bony cap resurfacing, 1 revision (3.13%). (3) Among 109 kyphotic noses, 64 patients underwent DP + resurfacing with 10 revisions (15.63%); 27 patients had cartilage-only DP with two revisions (7.41%). (4) In the 43 difficult noses group, revisions were done equally in DP + resurfacing and cartilage-only subgroups. Septum stability modifies the correlations, introducing Cottle's septorhinoplasty in the paradigm. The revision rate is jumping ×2.50% when a septoplasty is associated with the rhinoplasty. Correlated to the benefit–risk ratio and the revisions, the following guidelines may be suggested in primary rhinoplasty: (1) Straight noses: full DP, (2) tension noses: DP + dorsum resurfacing and/or Cottle's variations, (3) kyphotic noses: cartilage-only DP, and (4) difficult noses: traditional rhinoplasties.

A Systematic Analysis of the Nasal Septum in Crooked Noses and Suggested Treatment Algorithm According to Preservation Rhinoplasty (PR) Principles

“…Eligible reports were full papers written in English language reporting on septal deviation. On the basis of septal deviation according to the nasal axis, we suggest a septoplasty classification Type 1-4 with various PR techniques (Table 1) [9][10][11] to achieve the desired straight nasal dorsum and optimal function.…”

Nasal Bones Anatomy and Analysis for Dorsal Preservation Rhinoplasty

“…To describe patients and to aid in better understanding and teaching dorsal preservation techniques, Saban and de Salvador and Neves et al proposed a segmental analysis of the dorsal profile lines, dividing these into: radix, nasal keystone area, supratip segment, and nasal tip, the latter being beyond the scope of this Letter. 2 , 3 These segments should be analyzed both individually as part of the surgical planning of the rhinoplasty and also together to better understand their relationship with the nose profile and the ideal aesthetic profile.…”

“…Another group, whose members not candidates for preservation techniques, consists of “lorgnette” or Assyrian noses. 2 …”

“…Patients may have straight nasal bones but a hump in profile view due to cartilaginous hypertrophy and do not require nasal bone resurfacing, with a Type 1 dorsal preservation procedure (without dorsal soft tissue elevation) being a good option for improving the dorsal profile lines. 2 , 4 …”

“…Therefore, they are suitable candidates for Type 1 dorsal preservation procedures, with no soft tissue and skin elevation. 2 , 4 …”