SPECIAL TOPIC

Structural Preservation Rhinoplasty: A Hybrid

Approach
AQ1 Dean M. Toriumi, M.D.

Summary: Structural preservation rhinoplasty merges two popular philoso-

Milos Kovacevic, M.D. phies of rhinoplasty—structure rhinoplasty and preservation rhinoplasty—in
Aaron M. Kosins, M.D.
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an effort to maximize patient outcomes, aesthetics, and function. This allows

Chicago, Ill.; Hamburg, Germany; and
Orange and Newport Beach, Calif.
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 sup-
port. 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 rhi-
noplasty patients. The authors discuss these structure concepts and their appli-
cability to dorsal preservation.  (Plast. Reconstr. Surg. 149: 1105, 2022.)

S
tructural preservation rhinoplasty is a combi-
nation of two philosophies: (1) dorsal pres-
ervation techniques in combination with
structural grafting to optimize patient outcomes
for the nasal dorsum, and (2) structural graft-
ing techniques to manage the lower third of the
nose. Both philosophies have similar underlying
principles that center around “optimizing nasal
structure” to maximize long-term aesthetic and
functional outcomes. These two philosophies ini-
tially appeared to be conflicting in nature; however,
efforts made by a small group of committed sur-
geon educators brought the two schools together
in 2018.1 Surgical indications were stressed as tech-
nical details improved, and it became clear that
certain patients benefit from preservation, cer-
tain patients benefit from structure, and certain
patients benefit from a hybrid approach. This is
true not just for dorsal preservation, but also for
the other two components of preservation rhi-
noplasty: soft-tissue envelope and alar cartilage
preservation. A tailored approach seemed more
appropriate for each individual patient.
Structure rhinoplasty was first introduced in
1989 by Johnson and Toriumi when Open Structure
Rhinoplasty was published, describing the use of
structural grafting to support the nasal structures
by means of the open rhinoplasty approach.2 This
technique initially involved the use of columellar
From Rush University Medical School and Toriumi Facial
Plastics; private practice; and University of California,
Irvine School of Medicine.
Received for publication February 6, 2021; accepted August 19,
2021.
Copyright © 2022 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000009063
struts and shield tip grafts to shape the nasal tip.2
A traditional Joseph dorsal resection approach was
used to remove the dorsal hump, using spreader
grafts to reconstruct the middle nasal vault.2,3
Structure rhinoplasty evolved over the years with
the incorporation of the caudal septal extension
graft to support the nasal base, replacing the colu-
mellar strut.4 Shield tip grafting was used less fre-
quently and was replaced with dome suturing with
alar rim grafts or lateral crural strut grafting with
or without repositioning.5–10 Nasal tip contour-
ing focused less on narrowing and more on mov-
ing shadows into more favorable positions using
suture and grafting maneuvers.7
The term “preservation rhinoplasty” was
coined by Rollin K. Daniel and the philosophy
focused on “preservation” of as much of the native
nasal structure as possible.11 The early innova-
tors of the dorsal preservation techniques were
Goodale in 1898 and Lothrop in 1914.12,13 Many
would agree that Yves Saban is the primary per-
son responsible for the resurgence of dorsal pres-
ervation in this era.14 Baris Cakir, Aaron Kosins,
and Rollin K. Daniel have championed all com-
ponents of preservation rhinoplasty that include
(1) elevation in a subperichondrial/subperiosteal
plane with preservation of supporting ligaments,
Disclosure: The authors have no financial interests or
conflicts of interest to declare in relation to the content
AQ12
of this article.
Related digital media are available in the full-text
version of the article on www.PRSJournal.com.

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 Plastic and Reconstructive Surgery • May 2022

(2) preservation of the nasal dorsum to avoid the
“open roof”(dorsal preservation), and (3) preser-
vation of the alar cartilages with minimal excision
and shaping using sutures.11,15,16
In structural preservation rhinoplasty, dorsal
preservation techniques are used to manage the
upper two-thirds of the nose in appropriate pri-
mary rhinoplasty cases, whereas structural car-
tilage grafting techniques are used to optimize
dorsal aesthetic lines (in combination with dor-
sal preservation) and to structure the nasal tip.
Dorsal preservation techniques have the strongest
indications for primary rhinoplasty cases with cer-
tain anatomical criteria such as a V-shaped dorsal
hump, normal radix height, and uncomplicated
deviations involving axis deviation.16 Surface mod-
ifications (bony cap removal, trimming upper lat-
eral cartilages, and radix grafting) are well known
and can be used to convert primary cases to allow
effective execution of dorsal preservation tech-
niques.17 However, structure techniques such as
spreader grafting can be used in some cases that
would otherwise not be good candidates for dorsal
preservation to expand the indications. Subdorsal
septal work can also take on a “structural” con-
cept as directional forces are used to control dor-
sal contour while treating septal deformities. The
following article will discuss patient selection and
structural techniques that can be combined with
dorsal preservation to expand indications for dor-
sal preservation. In addition, structural grafting of
the nasal tip will be discussed in the context of our
dorsal preservation procedure.
flattening, such as reduction of the bony cap,
placement of a radix graft, and maximal stretch-
ing of the dorsal hump.16 Cartilage vault modifica-
tions, piezoelectric rhinosculpture, and cartilage
vault preservation techniques were developed to
deal with these issues that mostly occurred in the
native nasal bony anatomy such as S-shaped nasal
bones, wide nasal bones, nasal bone asymmetries,
and a low radix. These techniques largely sepa-
rated the cartilaginous vault from the nose, with
or without the bony cap, and lowered it separately
from the nasal bones. The nasal bones were then
treated with traditional osteotomies. However,
certain issues have still persisted even with these
techniques that principally affect the cartilaginous
vault of the nose. These include cartilage vault wid-
ening and asymmetries, cartilage vault concavities,
and caudal septal deformities. Surgical techniques
are discussed for the treatment of the above-men-
tioned surgical problems.
SURGICAL TECHNIQUES
Dorsum
Plane of Dissection
Two planes of dissection have been tra-
ditionally used for dissection of the nasal

PATIENT SELECTION
Traditional dorsal preservation involves (1)
removal of a septal strip to release the dorsum
from the septum, (2) osteotomies to release the
dorsum from the face (foundation methods),
and (3) a push-down or let-down of the dorsum
to lower the nasal profile and to flatten a dorsal
hump. Although this was shown to work well in a
subset of patients, certain dorsa can be converted
to optimize dorsal aesthetics. The shape of the dor-
sal convexity is important in selecting good candi-
dates for dorsal preservation techniques. V-shaped
dorsal humps have a straight-line configuration
from nasion to rhinion, whereas an S-shaped dor-
sal hump has a distinct angulation from nasion to
kyphion (most prominent point of the dorsum) Fig. 1. (Left) V-shaped dorsal hump with a straight line from
and minimal curvature from kyphion to rhinion17,18 nasion to rhinion. (Right) S-shaped hump with curvature from
F1
(Fig. 1). The V-shaped humps are ideal for dorsal nasion to kyphion. (Reprinted with permission from Toriumi DM,
preservation, whereas the S-shaped humps may Davis RE. Marina Medical Rhinoplasty Cadaver Dissection Course
require surface modification to allow adequate Videos. St. Louis: Quality Medical Publishing; 2021.)

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 Volume 149, Number 5 • Structural Preservation Rhinoplasty
dorsum—subperichondrial/subperiosteal and
sub–superficial musculoaponeurotic system.
Surgeons have the option to dissect in the subp-
erichondrial and subperiosteal tissue planes and
to preserve the supporting ligaments (Pitanguy
ligament, scroll ligament, and nasomaxillary
suture line ligament).16 Cakir developed this dis-
section plane using an open approach and con-
verted to a closed approach.15 The benefits are
a thicker and preserved soft-tissue envelope and
theoretically less swelling and soft-tissue damage.
The authors prefer the subperichondrial/sub-
periosteal plane even in an open approach. The
full open approach can be used if piezosurgery is
being used, or a limited dorsal dissection over the
nasal dorsum can be used performing the bony
work through small stab incisions externally or
subdorsally with subperiosteal tunnels laterally.
Septum-Subdorsal Z-Flap Technique for
Reducing Dorsal Humps
One of the most important concepts in dor-
sal preservation is the lowering and flattening of
the dorsal hump using caudal/posterior forces at
a pivot point on the undersurface of the dorsal
convexity. With the high septal strip technique
as advocated by Saban, the hump is lowered and
flattened as the osseocartilaginous vault relaxes
in a posterior direction. With the low septal strip
techniques, a septal rotation-advancement flap
is “pulled” posteriorly and caudally to flatten the
hump. The use of this particular maneuver is
most helpful in cases with larger or S-shaped dor-
sal humps where maximal flattening is needed.
Dorsal preservation techniques that have power-
ful stretching capability include the Cottle tech-
nique, Finocchi’s simplified preservation quick
rhinoplasty, Neves’ segmental preservation rhi-
noplasty technique (Tetris concept), and oth-
ers.16,19–21 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 “struc-
tural” forces that are acting on the undersurface
of the dorsal prominence to flatten the dorsal
hump.
The “subdorsal Z-flap” technique was intro-
duced by Milos Kovacevic to stretch and flatten the
dorsal hump. This dorsal preservation technique
incorporates a subdorsal triangle-shaped attach-
ment to the undersurface of the dorsal hump to
allow for posterior and caudal traction on the
F2 middle vault22 (Fig.  2). [See Video  1 (online),
AQ2 which demonstrates the subdorsal Z-flap.] This is
Copyright © 2022 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
a simplified form of the classic Cottle technique,
which incorporates the entire cartilaginous sep-
tum as a reverse Z-flap (as opposed to a simplified
subdorsal Z-flap). After exposure is complete, a
needle is placed exactly on the top of the keystone
area, and the subdorsal cuts are made. The first
cut goes from the keystone area approximately 7
to 10 mm posteriorly into the septum, and the sec-
ond cut moves caudally, creating a triangle toward
the supratip. Whether or not the caudal exten-
sion reaches the W-point depends on whether the
supratip needs to be lowered. Now that the sub-
dorsal triangle can be moved out of the way, a third
cut is made under the cranial dorsum underneath
the nasal bones up to the area of the proposed
radix osteotomy. We leave a 2- to 3-mm strip of car-
tilage below the cartilaginous midvault to prevent
deformation of the middle vault. One should avoid
leaving cartilage and/or bone below the bony pyr-
amid, as this can frequently act as a blocking point
that can result in a recurrent hump. This cartilage
and/or bone can be removed with a Takahashi or
Blakesley forceps or with the Piezotome (Acteon, AQ3
Mount Laurel, N.J.) if available. AQ4
Once the osteotomies are completed (as
detailed below), a strip of cartilage is removed
from below the triangle to allow posterior and
caudal movement. Depending on the shape and
extent cranially of the hump, a strip of cartilage
and possibly some bone are then removed from
below the upper dorsum extending to the radix
osteotomy. The benefit of the subdorsal Z-flap lies
in the ability to stretch flat the dorsal hump and
allow for significant cartilage harvest below the
triangle still leaving a 1-cm strut of dorsal support
F3
(Fig. 3). In addition, the triangular shape helps to
prevent drop of the dorsum in the supratip area.
It is important to note that Goksel advocates
the lateral keystone release (ballerina maneuver)
to allow proper stretching and flattening of the
dorsal hump. This maneuver can be performed
sharply with a no. 15 blade or sharp scissors, allow-
ing release of the bony attachment to the upper
F4
lateral cartilages16 (Fig. 4). We believe this is par-
ticularly important in patients with larger dorsal
humps and deviated noses. Once the hump is
allowed to lower and flatten, incremental strips of
cartilage can be removed from below the triangle
to further lower the dorsum.
Osteotomies
The osteotomies are performed only after
the initial septal cuts to release the septum from
the osseocartilaginous vault are executed. This
is necessary to avoid excessive forces applied
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 Plastic and Reconstructive Surgery • May 2022

Fig. 2. Subdorsal Z-flap technique in the straight nose. (Left) Subdorsal Z-flap
is indicated by the dotted red line. Also noted is the extension of the subdorsal
cut to meet the oblique radix osteotomy. A segment of cartilage is removed
from below the subdorsal Z-flap. (Right) The Z-flap is pulled inferior and cau-
dally and fixated with two 4-0 polydioxanone sutures. (Reprinted with permis-
sion from Toriumi DM, Davis RE. Marina Medical Rhinoplasty Cadaver Dissection
Course Videos. St. Louis: Quality Medical Publishing; 2021.)

to the ethmoid bone at the skull base. For the
bony work, our preference is the let-down over
the push-down to remove any potential block-
ing points such as Webster’s triangle. A strip of
bone is removed at the site of the lateral oste-
otomies, and bilateral transverse osteotomies are
to allow full release of the bony vault and allow
a let-down maneuver to reduce the bony hump.
If the bony vault has an axis deviation, a bone
strip is removed on the side opposite the devia-
tion of the bone and a conventional osteotomy
is executed on the side of the deviation (Fig. 6). F6

finally connected to an obliquely oriented radix
F5 osteotomy (Fig. 5). [See Video 2 (online), which
AQ5 demonstrates bone cuts for let-down.] Once the
osseocartilaginous vault has been released from
the face, the pyramid can be lifted with a long
speculum and any excess cranial part of the
remaining strip is removed under direct vision.
This maneuver allows for incremental reduc-
tion of the cephalic part of the hump and also
prevents axis shift postoperatively, which can
occur if the subdorsal remnant shifts off midline.
Using these techniques, Kovacevic observed no
hump recurrences in 57 consecutive cases over a
6-month period.
As stated above, a full open approach is
used over the osseocartilaginous vault or a lim-
ited dorsal dissection combined with a lateral
dissection along the ascending process of the
maxilla to provide exposure. With the full open
approach, the Piezotome is used to remove bone
strips bilaterally to perform a let-down maneuver.
When a limited lateral dissection is used, a bone
rongeur is introduced through lateral endona-
sal incisions. Transverse osteotomies can be per-
formed with a 2-mm osteotome or Piezotome
or through small percutaneous stab incisions.
Likewise, the radix osteotomy can be performed
with a 2-mm osteotome through a small stab inci-
sion from above or from below the bony vault, or
with the Piezotome. The bone cuts are created
This will allow the bony vault to tilt back to the
midline.
Fixation
Once the dorsum has been released from the
face with osteotomies and is allowed to descend,
a forceps is used to stretch and flatten the hump
longitudinally. Incremental strips of cartilage are
removed from underneath the triangle caudally
and underneath the bone cephalically to fur-
ther lower the dorsum. The dorsal keystone is
in essence a “joint” that can be flexed by pulling
down posteriorly and caudally on the undersur-
face of the hump. With the firm grip provided by
the subdorsal Z-flap in combination with the let-
down bone cuts and lateral keystone area release, AQ6
maximal stretching and flattening of the dorsal
hump is possible. Finally, fixation is performed
with one or two sutures of 4-0 polydioxanone
attaching the triangle down to the remaining sep-
tal strut.
If there is an axis deviation of the nasal dor-
sum, the subdorsal triangle can be overlapped
to the contralateral side of the underlying sep-
tal strut to allow straightening of the dorsum.
Instead of excising the cartilage, the triangle is
overlapped and sutured, giving maximal strength
F7
to the repair (Fig.  7). This overlapped fixation
provides maximal “structural” support to prevent
hump recurrence in addition to straightening the
F8
nose (Fig. 8).

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 Volume 149, Number 5 • Structural Preservation Rhinoplasty

Fig. 3. Patient with V-shaped dorsal hump and deviation to the right
treated using overlapping subdorsal Z-flap. Lateral crural strut grafts with
dome sutures (no repositioning) were placed to flatten the lateral crura.
(Left) Preoperative frontal, lateral, and base views. (Right) One-year postop-
erative frontal, lateral, and base views.
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 Plastic and Reconstructive Surgery • May 2022

Fig. 4. Lateral keystone release. (Left) A knife or sharp scissors are used to release
the upper lateral cartilage from nasal bone laterally. (Right) This allows the
upper lateral cartilage to release caudally and stretch the hump flat. (Reprinted
with permission from Toriumi DM, Davis RE. Marina Medical Rhinoplasty Cadaver
Dissection Course Videos. St. Louis: Quality Medical Publishing; 2021.)

Fig. 5. Osteotomy and bone cuts for let-down. (Left) Red lines indicate path of bilateral bone strip excision, transverse osteotomies,
and radix osteotomies. (Center) Osteotomies completed. (Right) Gaps closed and hump reduced. (Reprinted with permission from
Toriumi DM, Davis RE. Marina Medical Rhinoplasty Cadaver Dissection Course Videos. St. Louis: Quality Medical Publishing; 2021.)

EXPANDING DORSAL PRESERVATION lateral cartilage “horns,” particularly when a

TECHNIQUES WITH STRUCTURAL
MODIFICATIONS
One of the key aspects of this article is to provide
the reader with “structural” surgical techniques to
expand the indications of dorsal preservation to
cases that otherwise would be poor candidates.
Segmental Spreader Flaps
One major limitation of dorsal preservation
is a wide cartilaginous vault or prominent upper
subperichondrial dissection is used and/or with
removal of the bony cap. Often, the bony cap is
convex, and this will not flatten by simply removing
a subdorsal strip of septal cartilage and lowering
the osseocartilaginous vault. The bony convexity
can be rasped or reduced using the Piezotome to
decrease some of the curved component of the
convexity. These are “surface” techniques of dor-
sal preservation as described by Ferreira et al.,
Gerbault et al., Zholtikov et al., and others.23–26 It

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 Volume 149, Number 5 • Structural Preservation Rhinoplasty

Fig. 6. Osteotomy bone cuts for deviated nasal dorsum. (Left) Deviated nasal dorsum requiring bone strip on side opposite
the deviation and lateral osteotomy on side of deviation. (Center) Bone cuts completed. (Right) bony vault tilts back to midline.
(Reprinted with permission from Toriumi DM, Davis RE. Marina Medical Rhinoplasty Cadaver Dissection Course Videos. St. Louis:
Quality Medical Publishing; 2021.)

Fig. 7. Subdorsal Z-flap for deviated nose. (Above, left) Proposed septal cuts.
(Above, right) Z-flap incised with vertical limb at rhinion. (Below, left) Subdorsal
triangle pulled inferior and caudal to stretch hump flat. (Below, right)
Subdorsal triangle overlapped on side opposite deviation and sutured into
place. (Reprinted with permission from Toriumi DM, Davis RE. Marina Medical
Rhinoplasty Cadaver Dissection Course Videos. St. Louis: Quality Medical
Publishing; 2021.)

is preferable to avoid removing the entire bony
layer of the hump; otherwise, Y-shaped rhinion
horns may protrude up, recreating the hump
or causing dorsal irregularity in thin-skinned
patients.16,17 The rhinion horns can be trimmed
without opening the mucosa in thicker skinned
patients. In patients with thin skin or a wide nose,
one can perform “segmental spreader flaps” to
turn in the prominent area of the upper lateral
cartilages to reduce the rhinion horns and/or to
narrow a wide middle vault.27 The upper lateral
cartilages at the site of the rhinion horns or wide
middle vault are divided from the dorsal sep-
tum, rolled in, and sutured to the dorsal septum

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 Plastic and Reconstructive Surgery • May 2022

Fig. 8. Patient with deviated nose to the left and S-shaped dorsal hump. The
patient was treated with removal of bone strip on left and conventional lat-
eral osteotomy on the right to tilt the bony vault to the midline. Subdorsal
Z-flap overlapped on the left as well. Lateral crural strut grafts and dome
sutures for her tip (no repositioning). (Left) Preoperative frontal, lateral, and
base views. (Right) One-year postoperative frontal, lateral, and base views.
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 Volume 149, Number 5 • Structural Preservation Rhinoplasty

F9 to flatten the prominence (Fig. 9). [See Video 3
AQ7 (online), which demonstrates segmental spreader
flaps.] A perichondrial flap can be sutured over
the top of the spreader flaps to secure the width
and positioning of the segmental spreader flaps.
Submucosal Spreader Grafts
In many primary rhinoplasties, there are some
anatomical features that do not lend themselves
to dorsal preservation techniques. Kosins and
Daniel popularized cartilage vault modification
techniques that can be used to transform many
suboptimal primary cases into appropriate candi-
dates for dorsal preservation.28 These maneuvers
include bony cap resection, trimming the upper
lateral cartilage shoulders without opening the
mucosa, radix grafting, and placing spreader
grafts concurrent with dorsal preservation.16,17
Our preference for placing spreader grafts when
performing dorsal preservation techniques is
to place “submucosal spreader grafts,” that are
positioned under the mucosal layer of the upper
lateral cartilage, or in a tunnel along the superior
aspect of the septum where an area of mucosa is
left intact/attached to the septum.10
Treating Concavity
Submucosal spreader grafts can be placed at
sites of asymmetries of the upper lateral cartilages
to correct unilateral concavities and allow execu-
tion of dorsal preservation techniques in primary
patients who would otherwise be poor candidates.
In patients where there is a unilateral concavity of
the middle vault with one upper lateral cartilage
positioned inferomedially, 5 to 8  mm of mucosa
is left attached high on the septum during the
septal dissection. A narrow subperichondrial
tunnel is created separately from the septal dis-
section using a narrow Cottle elevator (Fig.  10). F10
[See Video  4 (online), which demonstrates sub- AQ8
mucosal spreader grafts.] A key point is that the
tunnel for the spreader graft is positioned at the
junction between the upper lateral cartilage and
dorsal septum, and not solely against the sep-
tum. As the Cottle elevator is advanced into the

Fig. 9. Segmental spreader flaps. (Above, left) Wide middle nasal vault. Dotted
lines indicate planned incisions. (Below, left) Perichondrial flap elevated off of
the middle vault. (Above, right) Spreader flaps turned in and sutured with 5-0
polydioxanone sutures. (Below, right) Spreader flaps sutured to dorsal septum
narrowing middle vault. Perichondrium sutured over the top of the middle
vault. (Reprinted with permission from Toriumi DM, Davis RE. Marina Medical
Rhinoplasty Cadaver Dissection Course Videos. St. Louis: Quality Medical
Publishing, 2021.)

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Fig. 10. Submucosal spreader graft placed unilaterally to correct
concavity. Note the mucoperichondrium left attached around
the spreader graft. (Reprinted with permission from Toriumi DM,
Davis RE. Marina Medical Rhinoplasty Cadaver Dissection Course
Videos. St. Louis: Quality Medical Publishing; 2021.)
subperichondrial tunnel, it must be gently rotated
to allow the instrument to slide over the cartilage
and not cut through the cartilage. The end of the
spreader graft should be beveled to allow easy pas-
sage into the tunnel. Most spreader grafts are 2
to 3  mm in thickness and should span the area
of concavity. As the spreader graft passes into
the tunnel, one will note the lateralization of the
upper lateral cartilages. A 6-0 Monocryl (Ethicon,
Inc., Somerville, N.J.) suture can be placed cau-
dally to fix the graft into position. One advantage
of the Z-flap over a high septal strip procedure
is the ability to place these grafts without having
to release the upper lateral cartilages. The graft
F11
can span the entire length of the Z-flap (Fig. 11).
It should be noted that with larger humps, asym-
metries of the dorsum can occur if a unilateral
spreader graft is placed and the hump is flattened.
For this reason, unilateral spreader grafts should
only be placed when smaller humps are reduced
F12
to avoid deformity (Fig. 12).
Treating a Narrow Cartilaginous Vault
Bilateral spreader grafts can be placed to
widen an overly narrow middle vault by making
bilateral submucosal tunnels under the medial
margin of the upper lateral cartilages as they meet
the dorsal septum. In this case, bilateral mucop-
erichondrial flaps are elevated off of the septum,
leaving mucosa attached to the upper 5  mm of
the dorsal septum as it meets the upper lateral
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Copyright © 2022 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • May 2022
cartilages. If this method is used to place bilat-
eral spreader grafts, a subdorsal Z-flap, modified
Ishida intermediate strip, and other dorsal pres-
ervation techniques can be used to flatten the
hump (Fig.  13).29 Patel et al. describe a similar F13
lower strip excision that allows for placement of
spreader grafts bilaterally as well.30
Extended Spreader Grafts
Submucosal spreader grafts can be left longer
to extend beyond the anterior septal angle to sta-
bilize an end-to-end septal extension graft. The
extended spreader grafts can also straighten slight
deviations or deformities of the caudal septum.
Extension Grafted Cottle Rotation-Advancement
Flap
The extension grafted Cottle rotation-advance-
ment flap is a dorsal preservation technique that
incorporates a caudal septal reconstruction into
the Cottle rotation flap for the treatment of
patients with severe caudal fractures of the sep-
tum. In 1994, Toriumi published the subtotal sep-
tal reconstruction technique, where segments of
the septum are excised, and the L-shaped septal
strut is reconstructed.31 In this operation, a dor-
sal remnant is left attached to the ethmoid bone
and the remainder of the cartilaginous septum is
removed, followed by reconstructing the L-strut.
The extension grafted Cottle rotation flap allows
for caudal septal reconstruction in patients with
a fractured or severely deviated caudal septum,
while also performing dorsal preservation.22
Unlike our traditional Z-flap, this technique
must be combined with a full release of the quad-
rangular cartilage, not just a triangle. Initially, a
complete reverse Z is cut in the septum (Cottle
procedure) releasing it from the ethmoid bone,
vomer, and maxillary crest, including the nasal
spine. Some septal cartilage is left on the vomer,
ethmoid, and posterior maxillary crest to allow
harvesting septal cartilage for a septal extension
graft. The cartilaginous flap is left attached to
the undersurface of the middle vault cartilages
and the flap is rotated caudally and posteriorly
to stretch and flatten the dorsal hump. The frac-
tured or deviated segment of the caudal septum
is excised, shortening the cephalocaudal septal
length. Then, the posterocaudal corner of the sep-
tal flap is fixed into a notch made in the nasal spine
with two 4-0 polydioxanone sutures. In addition,
a notch can be made along the inferior margin
of the septal flap to allow the septum to sit firmly
F14
in the spine and not shift cranially (Fig.  14). To
maximize caudal support and open the nasolabial
 Volume 149, Number 5 • Structural Preservation Rhinoplasty

Fig. 11. Submucosal spreader grafts are placed along the base of the subdorsal Z-flap. (Left) Note positioning of spreader grafts at
junction between upper lateral cartilage and dorsal septum. (Center) After Z-flap rotated with graft in place. (Right) Z-flap sutured
into position overlapping on the right side of the septum. (Reprinted with permission from Toriumi DM, Davis RE. Marina Medical
AQ9
Rhinoplasty Cadaver Dissection Course Videos. St. Louis: Quality Medical Publishing; 2021.)

angle, the notch can be placed in front of the
nasal spine to prevent cranial displacement. If the
nasal spine is off midline, it can be fractured back
to the midline with a 5-mm straight osteotome.10
The fixation to the nasal spine is critical and must
be stable to avoid loss of dorsal septal support.
To reconstitute appropriate septal length, a
caudal septal extension graft is sutured end-to-end
and fixed with slivers of cartilage or vomer bone
to stabilize the reconstruction and to extend the
caudal dimension of the septal flap. The size and
shape of the extension graft is based on the need
for projection, rotation, and/or nasal length. The
septal cartilage for the extension graft is either the
repurposed segment that was removed caudally or
a segment that can be harvested from the poste-
rior inferior septum. Using this technique, a dorsal
hump can be corrected in addition to reconstruct-
ing a severely deviated caudal septum (Fig.  15).
F15 [See Video  5 (online), which demonstrates an
AQ10 extension grafted Cottle rotation-advancement
flap. This is a video of the patient in Fig. 15.]
Key points with this technique are to initially
assess the amount of harvestable septal cartilage
that is available. If only small amounts of harvest-
able septal cartilage are available, one may need
to harvest costal or auricular cartilage to complete
the reconstruction. One can estimate the size of
the extension graft needed based on the fractured
segment. It should be noted that some vomerine
bone can be harvested and thinned out to use in
the reconstruction. This bone can be used to help
fixate the caudal septal extension graft to the cau-
dal end of the septal flap. There should be mini-
mal tension on the septal flap when transposed to
minimize any bending or deformity. The medial
crura are then sutured to the caudal septal exten-
sion graft in a “tongue-in-groove” fashion to set
nasal tip position. Care must be taken to ensure
adequate nasal length and to avoid overrotation
of the nasal tip. A medial crural footplate suture
should be placed to maximize stability of the base
of the nose.10
One of advantages of this technique is that
the nose can be straightened without perform-
ing a subtotal septal reconstruction. In the past,
we would have removed the caudal septum and
reconstructed with extended spreader grafts and
a caudal septal replacement graft. This would
likely have required going to the ear or rib to have
adequate cartilage to complete the reconstruc-
tion. The advantage of the Cottle technique is
that by releasing the septum from the nasal spine,
maxillary crest, vomer, and ethmoid, the forces on
the septum are allowed to relax and straighten.
By leaving the middle vault intact, the need for
spreader grafts is eliminated, allowing this opera-
tion to be performed using the patient’s existing
septal cartilage. The authors believe this to be a
significant advantage of this technique.
SURGICAL TECHNIQUES: TIP
Plane of Dissection
As originally championed by Cakir in a
closed approach, and later Kosins in a full open
approach, surgeons have the option to dissect
in the subperichondrial and subperiosteal tissue
planes and to preserve the supporting ligaments
(Pitanguy ligament, scroll ligament, and naso-
maxillary suture line ligament).16 By using a sub-
perichondrial dissection over the lateral crura,
surgeons should be aware that surface tension,
especially of thin cartilage, can be altered. As a
consequence, the lower lateral cartilage may lose
its elasticity and can fracture or deform when tip
sutures are used. This can leave visible bossae in
patients with thin skin.

1115
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 Plastic and Reconstructive Surgery • May 2022

Fig. 12. Patient with a deviated nose and concave right upper lateral carti-
lage. She underwent placement of a unilateral submucosal spreader graft
to correct the concavity. (Left) Preoperative frontal, lateral, and base views.
(Right) One-year postoperative frontal, lateral, and base views showing
improved dorsal aesthetic lines.
1116
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 Volume 149, Number 5 • Structural Preservation Rhinoplasty

Fig. 13. Submucosal spreader grafts placed high on the septum in the submucoperichondrial tunnel above intermediate level
Ishida type septal strip. (Left) Note the position of spreader graft above the septal cut. (Center) Note vertical releasing incision to
allow stretching. (Right) Hump reduced, stretched flat, and sutured into position. (Reprinted with permission from Toriumi DM,
Davis RE. Marina Medical Rhinoplasty Cadaver Dissection Course Videos. St. Louis: Quality Medical Publishing; 2021.)

Fig. 14. Extension grafted Cottle rotation-advancement flap. (Left) Reverse Z-shaped septal flap with planned septal incisions.
(Center) Septal cuts made and rotation of septal flap with resection of the deviated/fractured caudal septal segment. (Right) The
caudal septal extension graft is used to extend the length of the septum after deformed caudal septum has been excised. Note
the notched base of the septal flap caudal to the nasal spine to prevent cranial displacement of the fixation point. (Reprinted with
permission from Toriumi DM, Davis RE. Marina Medical Rhinoplasty Cadaver Dissection Course Videos. St. Louis: Quality Medical
Publishing; 2021.)

In the case where the surgeon may dissect
the vestibular skin off of the undersurface of the
lateral crura (e.g., when performing lateral cru-
ral strut grafts), we recommend dissecting over
the lateral crura in a supraperichondrial plane to
keep perichondrium on one surface of the lateral
crura. Perichondrium should be left on at least
one surface to ensure adequate support and vas-
culature to the cartilage. We will frequently dissect
supraperichondrially over the tip and then in a
subperichondrial and subperiosteal plane for the
nasal dorsum. The ultimate choice for plane of
dissection of the nasal tip depends on the strength
of the cartilage and the need for vestibular muco-
sal dissection.
Structure Tip Techniques
With structural preservation rhinoplasty, struc-
tural grafting techniques are used to treat the
lower third of the nose. We have already discussed
how structural grafting maneuvers can be used to
enhance dorsal preservation techniques (exten-
sion grafted Cottle rotation-advancement flap and
submucosal spreader grafts). The most important
structural graft used in the lower third of the nose
is the caudal septal extension graft.4,7,10 The caudal
septal extension graft provides maximal tip sup-
port to aid in setting tip position and preventing
postoperative loss of tip projection. In most cases,
we prefer an end-to-end placement of the caudal
septal extension graft stabilized with extended
submucosal spreader grafts, slivers of cartilage, or
ethmoid bone. When performing dorsal preser-
vation techniques, torque can be placed on the
caudal septum, resulting in deviation or curvature
of the caudal septum. In these cases, an overlap-
ping caudal septal extension graft can be used to
straighten, support, and set midline tip position.
Our preference for managing the tip cartilages
is a progressive approach starting with obliquely

1117
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 Plastic and Reconstructive Surgery • May 2022

Fig. 15. Patient with severely deviated nose with large dorsal hump and
severe caudal septal deviation. Treated with extension grafted Cottle rota-
tion-advancement flap. (Left) Preoperative frontal, lateral, and base views.
(Right) One-year postoperative frontal, lateral, and base views.

1118
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 Volume 149, Number 5 • Structural Preservation Rhinoplasty
oriented domes sutures or cranial tip sutures.7,10,32
Alar rim grafts with or without articulation can
support the junction between tip lobule and alar
lobule and promote favorable tip shadowing.6,7,10,33
AQ11
With cephalically oriented lateral crura, and asym-
metric and/or overprojected tip cartilages, we will
frequently use lateral crural release, placement of
lateral crural strut grafts, and repositioning.7,10,34,35
Shield tip grafts have particular utility in patients
with an underprojected tip with thicker skin.7,10,34
At the end of the procedure, one may wish
to reattach the Pitanguy ligament to the anterior
septal angle to reset the position of the supratip
skin.18,27 Proper realignment of the Pitanguy liga-
ment may not be possible if the nasal tip is length-
ened, shortened, rotated, or counterrotated.22 It
is also possible to reattach the scroll ligaments.27,36
The significance of this maneuver is not clear;
however, it is likely beneficial to decrease dead
space, to preserve the vestibular valve, and to
decrease the chance of cephalic displacement of
the lateral crura during the healing process.
CONCLUSIONS
With the incorporation of dorsal preservation
techniques into our practices, the need for mid-
dle vault reconstruction and dorsal camouflage
has decreased dramatically in primary rhinoplas-
ties. This provides more cartilage for other grafts
such as the caudal septal extension graft, alar rim
grafts, and/or lateral crural strut grafts. Use of
submucosal spreader grafts in select situations has
expanded the indications for dorsal preservation
techniques in primary rhinoplasty. This shift to
dorsal preservation has almost completely elimi-
nated the need to harvest ear or rib cartilage or
fascia in primary rhinoplasty patients. We believe
the advantages of dorsal preservation over the
Joseph method include the following: (1) preserv-
ing the favorable attributes of the nose on frontal
view; (2) decreased need for spreader grafts and
spreader flaps (no need for middle vault recon-
struction); (3) decreased number of cartilage
grafts used; and (4) more rapid healing of the
upper two-thirds of the nose. From an aesthetic
point of view, we believe there is less likelihood of
creating excessive width or collapse of the middle
vault and nasal bone deformities.
Structural preservation rhinoplasty is a hybrid
approach to the primary rhinoplasty patient.
Dorsal preservation allows maintenance of the
favorable features of the nasal dorsum with the
potential for surface modifications if needed.
Structure rhinoplasty techniques can be used in
Copyright © 2022 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
the lower third of the nose for both stability and
long-term lateral wall support to maximize nasal
function.10,34,35 Eliminating the resection of the
roof of the bony dorsum and cartilaginous mid-
vault removes the potential for long-term issues
with dorsal irregularity or progressive narrowing
(inverted-V deformity) over time. In addition,
the possibility of creating excessive width with
spreader grafts is no longer an issue. Structural
preservation rhinoplasty will likely continue to
evolve as more surgeons embrace this hybrid
approach to primary rhinoplasty.
Dean M. Toriumi, M.D.
Toriumi Facial Plastics
60 East Delaware Place, Suite 1425
Chicago, Ill. 60611
PATIENT CONSENT
Patients provided written informed consent for the
use of their images.
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