REVIEW

CURRENT
OPINION Minimally invasive techniques in rhinoplasty
Holger G. Gassner a,b, Ashish A. Magdum a, and Abel-Jan Tasman c

Purpose of review
To present criteria of minimally invasive surgery, which include minimal and hidden incision lines, reduced
injury to tissue and application of endoscopic techniques, when feasible; to analyze techniques in
rhinoplasty for their minimally invasive character – in light of recent publications; and to discuss the
techniques that best meet the criteria of minimally invasive surgery.
Recent findings
The nose consists of about 60 percent soft tissue and 40 percent skeletal elements. Surgery causes injury to
both tissue types through various mechanisms, including mechanical traction, separation, incision, heat,
desiccation, and others. Multiple aspects including extent of approach and degree of tissue undermining
determine the minimally invasive character of techniques and maneuvers in rhinoplasty.
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Summary
A single incision endonasal approach, the subperichondrial and subperiosteal septal plane, the
supraperichondrial plane over the cartilaginous dorsum, the subperiosteal plane over the bony
dorsum, limited dorsal undermining with endoscopic visualization when feasible, conventional
straight lateral osteotomy or percutaneous curved lateral osteotomy; percutaneous transverse
osteotomy; conventional straight paramedian osteotomy; piezo and drill paramedian ostectomy;
dorsal uncapping osteotomy; conventional rasp gross dorsal contouring; piezo or drill fine dorsal
contouring; (cartilaginous) middle vault ‘let down’; and minimal access subperiosteal turbinate bone
resection were found to best fulfil the criteria of minimally invasive surgery. A classification system
for the degree of minimally invasiveness of rhinoplasty techniques is proposed as a basis for
discussion.
Keywords
endonasal approach, minimally invasive rhinoplasty, soft nasal surgery

INTRODUCTION b) a precise understanding of the mechanisms of

With regard to surgical techniques, the term ‘mini-
mally invasive’ is defined as causing the smallest
possible trauma (injury) to tissues and creating the
smallest possible scar. Placement of incisions inside
body orifices and utilizing endoscopic instrumenta-
tion are listed as important aspects of minimally
invasive surgery.
With regard to rhinoplasty, degree of tissue
injury, minimization of skin incision, and use of
endoscopic techniques will be analyzed in the
present discussion.
tissue injury; and
c) a good comprehension of the effects and
sequelae of tissue injury.
Definition of the target tissues
The nose consists of about 60 percent soft tissue and
40 percent skeletal elements, i.e. cartilage and bone.
Main functions of the soft tissues and the skeleton
include:

a
Finesse Center for Facial Plastic Surgery Regensburg, bFaculty of
STRATEGIES TO MINIMIZE TISSUE Medicine, University of Regensburg, Regensburg, Germany and cENT-
TRAUMA IN RHINOPLASTY Department of the Cantonal Hospital in St. Gallen, Switzerland
A sound analysis of strategies to minimize tissue Correspondence to Holger G. Gassner, Froehliche – Tuerken – Strasse
trauma requires 8, 93047 Regensburg, Germany. E-mail: info@drgassner.eu
Curr Opin Otolaryngol Head Neck Surg 2020, 28:218–227
a) a clear definition of the target tissues; DOI:10.1097/MOO.0000000000000639

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 Minimally invasive techniques in rhinoplasty Gassner et al.

Bio – physiologic
KEY POINTS Desiccation
 A sound analysis of strategies to minimize tissue trauma
Toxic (injection)
requires a clear definition of the target tissues, a
precise understanding of the mechanisms of tissue
injury and a good comprehension of the effects and Effects and sequelae of injury
sequelae of tissue injury. Effects and sequelae of injury must be understood
 Access and approach represent a cardinal determinant
and – as far as possible – weighed in order to assess
of minimal invasive surgery. the minimally invasive character of a surgical
technique.
 A sober analysis of cumulative tissue injury allows to
identify the least invasive technique for most aspects Skin – soft tissue envelope
of rhinoplasty.
Color changes, texture changes, variations in thick-
 Endonasal approaches, conventional or percutaneous ness, contour irregularities, abnormal pliability.
lateral osteotomy, rasp gross dorsal contouring, fine
powered dorsal contouring, uncapping dorsal Vascular
osteotomy, and middle vault ‘let down’ were identified Hyperemia, hypoperfusion, lymphatic obstruc-
among the techniques meeting the criteria of minimally
invasive surgery.
tion, edema.

 A classification system for the degree of minimal Neural

invasiveness of rhinoplasty techniques is presented as An-, hypo-, and dysesthesias, neurovascular dys-
a base for further discussion. function, neurovascular atrophy.

Skeletal
Contour irregularities, loss of support, loss of
Soft tissues
pliability / softness, changes in physiologic pro-
External contour
cesses and resulting effects.
Natural softness
Protection
Color The ideal ‘reference’ result
Texture
Assessment of the degree of ‘minimal invasiveness’
Perfusion
requires definition of the ideal reference result,
Sensation
which any given technique would ideally allow to
Airway patency (external valve) &&
obtain [1 ]. The following are suggested features of
the ideal nose:
Skeleton
External contour
(1) Beautiful external contour
Natural softness
(2) Patent airway with physiologic degree of resis-
Protection
tance
Airway patency
(3) Uncompromised physiologic functions, including
warming, humidification, and immune defense
Mechanisms of injury and their avoidance
(4) Natural softness and feel
Surgery causes injury to tissue. Multiple mecha- (5) Natural configuration of skeletal elements
nisms of injury exist. Their global cumulative effect (6) Uncompromised hemoperfusion and lymphatic
on the nasal tissues is considered when evaluating drainage
minimally invasive techniques for effectiveness and (7) Absence of grafts, suture material, injury and
justification. Mechanisms of injury include: scars

Mechanical
Incision and transection A grading system for the degree of minimal
Stretch and shear invasiveness in rhinoplasty
Crush and shatter All agree that only nature can fully achieve the above
Vibration and shock listed ideal nose. Any surgical maneuver will invari-
ably compromise one or more of the above listed
Thermal aspects of the ideal nose, while hopefully improving
Coagulation, heat others. The following discussion represents the

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Facial plastic surgery

authors’ best attempt at grading established and

recently described techniques with regards to their
impact on the global goals of minimal invasiveness,
that is minimal tissue injury and avoidance / incon-
spicuous placement of incisions / scars.
A semi-quantitative system to grade and compare
the techniques analyzed is suggested as a basis for
discussion. This is based on ideal execution of any
given technique. The relative risk of complications
resulting from technical error are not weighed. It is
stressed that the degree of invasiveness should not be
interpreted as a predictor for the achievable outcome
that an individual technique is associated with.
Scores are utilized, as described below (Table 1).
The publications discussed in the present
report represent aspects of rhinoplasty that have
received particular attention over the past years:
access and approach, planes of dissection, osteot-
&&
omy / piezo, and ‘preservation’ techniques [1 ,2,
& &&
3 ,4 ,5,6].

Access and approach

Access and approach represent cardinal determi-
nants of minimal invasive surgery. For reconstruc-
tion of a cruciate ligament, cholecystectomy, or
prostate resection, minimal access approaches
have proven superior to conventional open inci-
sions. In rhinoplasty, diverging trends are develop-
ing. On the one hand, minimally invasive FIGURE 1. Placement of incision lines for minimally invasive
techniques through endonasal approaches are rhinoplasty approaches. The actual incision line represents a
gaining popularity. On the other hand, the use of transcartilaginous placement, the caudal dotted line indicates
larger powered instruments, extensive skeletal an infra-cartilaginous incision, the cephalic line shows the
manipulation and grafting techniques performed location if an intercartilaginous incision.
through open and ‘extended’ open approaches are
frequently utilized [2].
According to established definition, endonasal Minimally invasive approaches are categorized
approaches fulfill the criteria of minimally invasive according to their relative degree of invasiveness as
surgery: they spare the external skin and reduce follows (Table 2):
tissue injury, most notably dissection of the mem- Figure 2a–c show completion of bilateral
&&
braneous septum and infratip lobule [1 ]. Figure 1 marginal incisions, complete endonasal release
shows the incision lines (Fig. 1). approach, and wide dorsal access for correction

Table 1. Minimal invasiveness score for techniques in rhinoplasty

Score Invasiveness of the techniques used

1 Best possible reduction of injury to the treated target. No increase in trauma to other tissues. No need to expand
approach or extend incisions.
2 Relevant reduction in trauma for the treated target. Minimal to moderate increase in injury to other tissues or extent of
approach; upon global elevation, marked reduction in tissue injury.
3 Reduction in trauma and / or injury to one target tissue is about equally outweighed by increased trauma or injury to
other tissues or extent of approach. Overall, minimally invasive character of the procedure remains greatly
unchanged.
4 Reduction in trauma and / or injury to one target entails more pronounced trauma, injury to other tissues and / or
disproportionate expansion of approach. Overall, the technique is associated with increased invasiveness.

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 Minimally invasive techniques in rhinoplasty Gassner et al.

Table 2. Minimally invasive rhinoplasty approaches listed according to their relative degree of invasiveness. Use of endoscope
to limit undermining indicates lesser degree of invasiveness; placement of hemitransfixion or full transfixion incision and their
connection with intercartilaginous incisions indicate greater degrees of invasiveness
Type of approach Technique Remark

Endonasal single incision

Intercartilaginous incision approach
Transcartilaginous incision approach
Infracartilaginous incision approach
(transvestibular approach Fuleihan)
Endonasal double incision
Delivery approach
Endonasal extended
Endonasal complete release approach
Combination of intercartilaginous incision with hemitransfixion
incision indicates greater degree of invasiveness
Can allow access for complex revisional cases; represents least
invasive access for such cases when feasible
Combination of intercartilaginous incision with hemitransfixion
incision indicates greater degree of invasiveness
Feasible through marginal and paracolumellar incision, addition
of intercartilaginous incision and combination with
hemitransfixion incision indicate greater degree of invasiveness

of a congenital asymmetric nasal deformity.
Figure 3a–c depicts the preoperative appearance,
Fig. 4d–f the postoperative result.
Planes of dissection
The most minimal invasive plane of dissection min-
imizes injury to relevant structures and resulting
sequelae. The following are appreciated when eval-
uating the impact of dissection:
Preservation of vascular supply
Preservation of structural integrity
Minimization of resulting injury
The following tissues routinely provide for
layers of dissection during nasal surgery: the nasal
septum, the turbinates, the cartilaginous skeleton,
and the bony skeleton.
The nasal septum
The most vulnerable tissue of the septum is the
septal mucosa. Supraperichondrial dissection
would sever the vascular supply and structural sup-
port that the perichondrium provides to the
mucosa. Therefore, subperichondrial and subper-
iosteal dissection is the preferred plane of dissec-
tion. The same considerations apply to the bony
septum, where subperiosteal dissection is regarded
the most minimally invasive option. Both are
assigned a score of 1; endoscopic dissection further
enhances the minimally invasive character of the
dissection [7].

FIGURE 2. (a): Minimally invasive techniques are employed: A single incision endonasal approach is created with bilateral
infracartilaginous (marginal) incisions. (b) Access though infracartilaginous incisions allows for completion of an endonasal
complete release approach with full delivery of the lateral crura into the vestibule. (c) Wide dorsal undermining allows for
unrestricted manipulation of the upper and middle thirds of the nasal skeleton.

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Facial plastic surgery

FIGURE 3. (a–c) Case 1: 25-year-old female patient presents with nasal obstruction secondary to septal deviation, nasal valve
obstruction and turbinate hypertrophy. Axial deviation to the right is identified.

The turbinates tissue – i.e. bone – is resected through a small

Preservation of the vascularized soft tissues – incision and subperiosteal dissection [8].
submucosa and mucosa – are vital to maintain Subperiosteal bone resection through a minimal
physiologic functions. Volume reduction is least and / or endoscopic approach is assigned a score
invasive, when the functionally least valuable of 1.

FIGURE 4. (d–f) Case 1: One-year follow – up after partial lateral release of the lower lateral cartilages, bilateral deep
straight and left double lateral osteotomy, percutaneous transverse and conventional straight paramedian osteotomies,
placement of conventional spreader grafts, fixation with clocking sutures, placement of alar strut grafts. Changes to the shape
of the nasal tip were not requested. These would have required an endonasal complete release approach. The patient was
inconspicuous to the public at the time of cast removal on postoperative day 9.

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 Minimally invasive techniques in rhinoplasty Gassner et al.

The cartilaginous skeleton allows to place curved incision lines in con-

Two planes of dissection are described: subperichon-
&
drial and supraperichondrial [3 ]. The anatomic and
physiologic situation differs from that of the septum
profoundly: separation of the septal mucoperichon-
drial flap causes important injury to the septal
mucosa. For the nasal dorsum, no such injury to
the much thicker skin - soft tissue occurs. In contrast
to the septum, the cartilages of the lower two thirds
represent the most vulnerable tissues involved. Ele-
vation of the perichondrium severs the vascular
supply and the tension banding support that the
overlying perichondrium provides for the cartilages
of the tip and the middle third, thus exposing them
to devascularization injury and scarring. The supra-
perichondrial plane is therefore suggested as the less
invasive option and is assigned a score of 1.
The bony skeleton
Subperiosteal dissection allows for complete preser-
&
vation of the periosteum [3 ]. Supraperiosteal dis-
section would incur important injury of the
periosteum, when uncapping osteotomies or rasp-
ing is performed. Subperiosteal dissection of the
bony dorsum is assigned a score of 1.
trolled fashion and without relevant risk of
bone shatter.
Piezo and power drill lateral osteotomy require
extensive soft tissue elevation and the majority
of authors prefer an open approach to utilize
the instrument.
For the lateral osteotomy, the conventional
straight osteotomy seems the least invasive
technique, when the following conditions are
met: placement through a preexisting endo-
nasal incision, no relevant effect on nasal airway
(anterior inferior turbinate bone resected or suf-
ficient residual airway), straight osteotomy, sub-
periosteal elevation to fully avoid soft tissue
trauma, endoluminal mucoperiosteal preserva-
tion (e.g. through hydrodissection). When these
conditions are met, minimally invasive score is
1. Figure 5 shows the completion of a linear
lateral conventional osteotomy without collat-
eral bone trauma.

Osteotomies
&
Yazar et al. [9 ] presented data from a caprine model
to show the impact of various osteotomy techni-
ques. The authors performed straight conventional,
percutaneous, and piezo osteotomies. Critical eval-
uation of the data shows that all osteotomy techni-
ques allow for shatter-free bone cuts, when they are
performed in a linear fashion. The conventional
osteotomy did shatter bone, when a curved trans-
verse osteotomy was attempted. This observation is
shared by other authors. When the available tech-
niques are faced with each other, important distinc-
tions are based on location of osteotomy:

(1) Lateral osteotomy

The following analysis is based on selection of
the least invasive endonasal approach suitable
for the given case:
Conventional osteotomy through a preexisting
intercartilaginous or transcartilaginous incision
and after narrow subperiosteal tunneling
achieves a reliable straight bone cut without
risk of shatter, when the osteotomy is straight.
Effect of medialization of the turbinate bone
must be considered. Percutaneous osteotomy FIGURE 5. A conventional straight osteotome allows for
requires a small external skin incision. Degree linear, shatter-free bone cuts and represents the least
of subcutaneous preperiosteal dissection invasive method of placing linear lateral osteotomies. When
appears about equal to that of the conventional a curved lateral osteotomy is required, a percutaneous
straight osteotomy. Percutaneous osteotomy method through a minimal stab incision is preferred.

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Facial plastic surgery
The percutaneous osteotomy requires a small
skin excision and cannot spare the extraluminal
periosteum, injures the subcutaneous tissues to
a modest degree and is less suitable to spare the
endoluminal muco-periosteum. It appears pref-
erable to a curved conventional osteotomy,
which carries risk of bone shatter; for curved
lateral osteotomy, percutaneous osteotomy
receives a minimally invasive score of 1, when
approach is minimally invasive.
The piezo and power drill lateral osteotomy
&
achieves shatter-free bone cuts [10 ]. It requires
extensive lateral tunneling. Injury to soft tissue
and the risk of burn should be minimal when
performed under direct vision with sufficient
undermining and moderate tissue stretch. The
technique is classified as slightly more invasive
than the percutaneous osteotomy for curved
lateral osteotomies and receives a score of 2,
when approach is minimally invasive.
(2) Transverse osteotomy
&
The study by Yazar et al. [9 ] shows that con-
ventional transverse osteotomy carries an
important risk of bone shatter, i.e. tissue injury.
Even when curved osteotomes allow for rela-
tively far medial extension, manual fracture
completion is often required. Minimally inva-
sive score of 3 is assigned.
Piezo transverse osteotomy achieves precise
bone transection, but requires extensive soft
tissue elevation. When this is achieved without
extension of the approach, that is through a
single incision unilateral endonasal access, min-
imally invasive score is 2.
Percutaneous transverse osteotomy introduces a
skin incision, albeit usually very limited (2 mm)
&
[11 ]. It does not require extension of access. The
bone cuts are predictable. Overall, the percuta-
neous technique appears to provide for the least
invasive transverse osteotomy. Minimally inva-
sive score 1.
(3) Paramedian osteotomy
Conventional, piezo and rotating drill osteot-
omy are prevalent techniques. For straight para-
median osteotomy, the conventional straight
osteotomy requires the least amount of dissec-
tion and is assigned a minimally invasive score
of 1. Both piezo and drill osteotomy require
larger access and are given a relative score of 2
when completed through an endonasal
approach. When paramedian ostectomy is
required, conventional osteotomes are associ-
ated with greatly reduced predictability and risk
of bone shatter. Piezo and conventional drill
achieve the desired volume removal with
reduced collateral bone trauma. When
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ostectomy is performed through a minimally
invasive approach, score 1 is assigned for both
piezo and drill.
Dorsal bone contouring
Various scenarios are considered when evaluating
the minimally invasive character of dorsal contour-
ing techniques:
(1) Gross substance reduction
When a larger volume of bone is amendable to
contouring rather than cap osteotomy, a man-
ual rasp allows to minimize soft tissue elevation
and can be performed through a single incision
&
endonasal approach [11 ]. Transmission of heat
and vibration to bone is minimal.
The use of powered instruments like Piezo and
drill are described by many authors to require
more extensive exposure, that is open or even
‘extended open’ approaches. Moreover, an
increased amount of energy is transmitted to
bone. Especially the novel piezo technology
transmits considerable vibratory energy. The
potential risk of reactive increased bone remod-
eling and callus formation must be considered
and will require future study.
For gross substance reduction, the conventional
rasp is assigned a minimally invasive score of 1.
Piezo and conventional drill are assigned a score
of 2, when performed through minimally inva-
sive approach and without extension of tissue
elevation.
(2) Fine bone remodeling
Fine bone remodeling represents a different sce-
nario when compared to gross substance reduc-
tion. Fine bone remodeling is required after
gross substance reduction and osteotomies have
been completed and residual bony contour
irregularities are present, for example at the
rhinion. In this scenario, the use of a conven-
tional rasp carries an important risk to avulse
the upper lateral cartilages and to dislodge
mobile bone segments. The piezo instrument,
when introduced through an endonasal
approach and applied with a narrow, long spatu-
lated tip, allows for less invasive re-contouring.
A narrow and long diamond burr is capable of
achieving the same with minimal trauma. The
use of an endoscope may enhance the mini-
mally invasive character of fine piezo or drill
remodeling. This also applies to revisional cases
where minor dorsal contour irregularities can be
smoothened with piezo or burr, e.g. through a
unilateral intercartilaginous incision approach
and with limited, endoscopic dorsal
Volume 28  Number 4  August 2020

undermining. For fine bone remodeling, piezo
and burr are assigned a minimally invasive score
of 1, when completed through a minimally
invasive approach and with limited dorsal
undermining.
Dorsal reduction concepts
Different concepts of dorsal reduction osteotomy
are discussed: component hump reduction, com-
posite hump reduction, variations of ‘push down’
and ‘let down’, the ‘Skoog technique’, and subdorsal
septal strip resection with bone reduction (’spare
&& &&
roof’) [2,4 ,5,12–15,16 ,17].
The minimally invasive character of these tech-
niques is determined by the extent of access, the
degree of tissue injury and the extent of undermin-
ing. A differentiated analysis of treated anatomic
targets is presented:
(1) The bony dorsum
Reduction of the bony dorsum requires either an
‘uncapping’ osteotomy (component and com-
posite hump reduction), ‘spare roof technique’
and ‘Skoog technique’ or reduction of the base
with osteotomies placed through the frontal
processes of the maxilla, the bony septum and
the nasal root. Weighing these concepts in
terms of degree of injury applied to the bony
skeleton seems to favor the uncapping concept.
The osteotomies of the push down / let down
concepts are more extensive, incur more injury
to bone, and are carried into more critical areas
than the more limited cuts required for the
‘uncapping’ techniques. Uncapping techniques
may also be effectively performed with a con-
ventional burr, and potentially with greater
energy transmission and bone trauma with
the piezo instrument.
(2) The middle vault
The release of the upper lateral cartilages from
the septum represents an important discrimina-
tor between the conventional and the ‘let down’
concepts. The middle vault is an intricate ana-
tomic structure, transection introduces impor-
tant injury, and efforts at reconstruction with
variations of spreader graft techniques appear
not to reproduce natures ideal to the fullest
extent. The added septal strip resection required
to complete any of the ‘let down’ concepts
should not introduce important additional
trauma.
For the middle vault, ‘let down’ techniques
seem to allow a more minimally invasive pro-
ceeding than component and composite hump
reduction, albeit both concepts allow for low
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Minimally invasive techniques in rhinoplasty Gassner et al.
injury manipulation when applied through an
endonasal approach and with minimal soft
tissue undermining.
For dorsal reduction concepts, an uncapping
technique of the bony dorsum in combination
with a ‘let down’ technique of the middle vault
represents the least invasive concept when com-
pleted with minimal access incisions and mini-
mal undermining. Both are assigned a
minimally invasive score of 1.
DISCUSSION
The analysis of minimally invasive techniques in
rhinoplasty shares the important limitations that
outcome-based research has faced since its incep-
tion. The number of studies is small, Level 5 evi-
dence dominates, comparative studies are scarce,
and the quality of execution seems to impact out-
come more than the selection of approach and
technique. This explains how a vast expansion of
more extensive methods and approaches could take
hold over the past decades without sound compara-
tive outcome analyses – very much in contrast to
virtually all other fields of surgery.
Extended open approaches, powered instru-
mentation, extensive manipulation of the bony
dorsum, distant graft harvest, and multiple grafting
techniques have gained popularity. Although these
undoubtedly introduce a greater degree of invasive-
ness, outcomes appear to justify their application
when the current literature is analyzed. A steeper
learning curve, surgeon comfort, and excellent
teaching and presenting opportunities represent
additional important factors contributing to the
popularity of the more invasive proceedings.
On the other hand, at least for primary rhino-
plasty the results of minimally invasive endonasal
techniques that prevailed until the 1990s have never
been shown to be surpassed by more involved
approaches.
Likely, a valid comparison between the two
concepts will not be available in the foreseeable
future. Outcome analysis would have to follow
new concepts. This could entail independent fol-
low-up of patients operated by representative groups
of surgeons. Such independent follow-up may
become more easily feasible in the future with digi-
tal technology and smart phone-based apps. Analy-
sis certainly needs to involve neglected aspects of
outcome research, including the tactile feel of the
nasal tissues and the frequency and severity of revi-
sion surgery incurred.
The current analysis is certainly not without its
shortcomings. Where reliable data were scarce, the
authors invested best academic judgement to
www.co-otolaryngology.com 225
Facial plastic surgery
classify key techniques according to their minimally
invasive character. This was based on a commonly
applied definition of minimally invasive surgery. It
must be stressed that no statement is made about
the potential outcome that individual techniques
are capable of generating. Individual convictions
will certainly continue to fuel further controversy.
The degree of minimal invasiveness of global
rhinoplasty concepts and individual techniques has
never been quantified or classified. The present
discussion presents a classification system. The need
for validation and further development is self-evi-
dent.
With the present discussion, inconsistencies
of our terminology have been identified. Terms
like ‘preservation’ bear important connotations of
minimally invasive surgery. Such terminology may
suitably be applied to describe, for example the
isolated preservation of the cartilaginous middle
vault. Application of the term to concepts or
approaches that involve extended open access or
extensive bone cuts may project the incorrect
impression that such ‘preservation’ techniques
are minimally invasive.
CONCLUSION
Minimally invasive concepts per definition mini-
mize and hide scars, reduce tissue injury, and
employ endoscopic techniques, when possible.
The following techniques are suggested as most
minimally invasive in rhinoplasty: a single incision
endonasal approach, the subperichondrial and sub-
periosteal septal plane, the supraperichondrial
plane over the cartilaginous dorsum, the subperios-
teal plane over the bony dorsum, limited dorsal
undermining with endoscopic visualization when
feasible, conventional straight lateral osteotomy, or
percutaneous curved lateral osteotomy; percutane-
ous transverse osteotomy; conventional straight
paramedian osteotomy; piezo and drill paramedian
ostectomy; dorsal uncapping osteotomy; conven-
tional rasp gross dorsal contouring; piezo or drill
fine dorsal contouring; (cartilaginous) middle vault
‘let down’; minimal access subperiosteal turbinate
bone resection. The degree of minimal invasiveness
makes no statement about the outcome of
individual techniques.
Current trends in rhinoplasty appear to be
increasingly diverging. On the one hand, more
extensive approaches, larger powered instrumenta-
tions and more involved tissue manipulation have
become popular. Teaching, training, and a steeper
learning curve may be important supporting factors.
On the other hand, an important trend favors mini-
mally invasive techniques, limited access and
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reduced tissue manipulation. Shortened recovery,
decreased need for general anesthesia and patient
comfort seem to favor the minimally invasive con-
cepts. Minimally invasive techniques can be
adapted to treat virtually the entire spectrum of
nasal pathology, including complex congenital
and revisional scenarios.
Likely, both concepts generate similar results
and thus deserve sound justification. Further
research is required to better understand the best
indications for each concept. Improvements in out-
come analyses are required and should include
assessment of the tactile feel of the nose, degree
of tissue conservation, and frequency and extent
of revisional surgery.
The degree of invasiveness of individual rhino-
plasty techniques and approaches lack a classifica-
tion system. This study presents such a system,
which may serve as a base for discussion, scientific
scrutiny and further development.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
No conflicts of interest to disclose.
REFERENCES AND RECOMMENDED
READING
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been highlighted as:
& of special interest
&& of outstanding interest
1. Gassner HG. Finesse in Caucasian endonasal rhinoplasty The S.O.F.T.
&& concept. Otolaryngol Clin N Am 2020; 53:213–235.
A didactic concept is presented that streamlines the surgical options available and
facilitates inclusion of the endonasal operation in any established rhinoplasty
practice.
2. Goksel A, Saban Y. Open piezo preservation rhinoplasty: a case report of the
new rhinoplasty approach. Facial Plast Surg 2019; 35:113–117.
3. Patron V, Hitier M, Gamby R, et al. How to perform subperichondrial and
& subperiosteal rhinoplasty. Eur Ann Otorhinolaryngol Head Neck Dis 2019;
136:325–329.
An excellent technical paper describing the subperichondrial and subperiosteal
dissection. Performed correctly, limits soft tissue and especially muscle damage,
allows preservation of the SMAS and sensory nerve contingents, which are
important for nasal sensitivity and postoperative facial expression.
4. Kosins AM, Daniel RK. Decision making in preservation rhinoplasty: a 100
&& case series with one-year follow-up. Aesthet Surg J 2020; 40:34–48.
The dorsal preservation maintains the dorsal structures while eliminating the
dorsal hump by using septal resection followed by osteotomies to reduce the
height of the dorsal line, thus modifying the dorsum without destroying its
normal anatomy. Preservation rhinoplasty is composed of elevating the skin
sleeve in a subperichondrial–subperiosteal plane, preserving the osseocarti-
lagenous dorsum and maintaining the alar cartilages with minimal excision and
suture tip plasty. Dorsal preservation is only one component of the preservation
rhinoplasty.
5. Taş S. Response to commentary on: dorsal roof technique for dorsum
preservation in rhinoplasty. Aesthetic Plast Surg 2020; 8–11.
6. Alam DM. Minimally invasive advance beautification rhinoplasty. Int J Innov
Res Med Sci 2019; 4:651–655.
Volume 28  Number 4  August 2020

7. Ali Y, Alandejani T. Rhinoplasty assisted by endoscopic septoplasty: precise
job and an educational tool. J Craniofac Surg 2020; 31:847–850.
8. Rudes M, Schwan F, Klass F, Gassner HG. Turbinate reduction with complete
preservation of mucosa and submucosa during rhinoplasty. HNO 2018;
66:111–117.
9. Yazar SK, Serin M, Rakici IT, et al. Comparison of piezosurgery, percutaneous
& and endonasal continuous osteotomy techniques on a caprine skull model. J
Plast Reconstr Aesthetic Surg 2019; 72:107–113.
Quality of osteotomies was evaluated in a carpine skull model with parameters like
bone gaps, comminuted fractures with three dimensional CT scan and the amount
of nasal mucosal trauma.
10. Tsikopoulos A, Tsikopoulos K, Doxani C, et al. Piezoelectric or conventional
& osteotomy in rhinoplasty? A systematic review and meta-analysis of clinical
outcomes. ORL J Otorhinolaryngol Relat Spec 2020; 1–18. [Epub ahead of
print]
This study shows that lateral piezoelectric osteotomy in rhinoplasty decreases
postoperative pain, edema, ecchymosis, and intraoperative mucosa injuries com-
pared to the conventional osteotomy technique with a chisel. However, it con-
cludes by saying that most of the included trials were deemed to be at an unclear
risk of bias, and recommends conducting high-quality trials in the future.
1068-9508 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Minimally invasive techniques in rhinoplasty Gassner et al.
11. Berkhout MC, Menger DJ. The use of osteotomies in nasal profileplasty. Facial
& Plast Surg 2019; 35:458–466.
This article provides an overview of the instruments used for osteotomies, and the
indications and techniques for osteotomies in nasal profileplasty.
12. Montes-Bracchini JJ. Nasal profile hump reduction using the let-down tech-
nique. Facial Plast Surg 2019; 35:486–491.
13. Cabbarzade C. A new algorithm for hump reduction according to dynamics of
dorsal preservation. Aesthetic Surg J 2019; 39:N547–N549.
14. Perkins SW, Shadfar S. Complications in reductive profileplasty. Facial Plast
Surg 2019; 35:476–485.
15. Kosins AM. Expanding indications for dorsal preservation rhinoplasty with
cartilage conversion techniques. Aesthet Surg J 2020. [Epub ahead of print]
16. Gonçalves Ferreira M, Santos M, Rosa F, et al. Spare roof technique: a new
&& technique for hump removal-the step-by-step guide. Plast Reconstr Surg
2020; 145:403–406.
Prospective data describing method of reducing bony dorsum without extensive
osteotomies and of lowering the middle vault while preserving its anatomic continuity.
About 60% performed through minimally invasive, endonasal approaches.
17. Daniel RK. Commentary on: Dorsal roof technique for dorsum preservation in
rhinoplasty. Aesthetic Surg J 2020; 40:276–280.
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