Sylvie Poignonec

Editor

Clinical Atlas of
Preservation
Rhinoplasty
Steps for Surgeons in Training

123
Clinical Atlas of Preservation Rhinoplasty
Sylvie Poignonec
Editor

Clinical Atlas of Preservation

Rhinoplasty
Steps for Surgeons in Training
Editor
Sylvie Poignonec
Plastic Surgery and Head and Neck Surgery
Centre Esthétique Paris - Eiffel
Paris, France

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Foreword

Rhinoplasty Surgery has changed dramatically over the past 5 years. Surgeons no longer look at
the patient’s profile hump and think of resection. For experienced surgeons, the first question is:
“can I preserve the dorsum anatomically, while eliminating the hump and lowering the profile?”
Preservation Rhinoplasty has become the first choice for primary cases, and hybrid techniques
have begun to evolve for secondary cases. The speed with which this transformation has occurred
is due to two factors: the intrinsic validity that preservation is better than resection/reconstruction,
and its adoption by a cohort of rhinoplasty experts who teach at major meetings.
The problem for surgeons in training and those just entering practice is that they may not
have been exposed to preservation rhinoplasty techniques and only have experience with tra-
ditional structural techniques. Yet, what initially looks like a limitation is in reality a critical
foundation from which to learn. The first step is to develop confidence with a core rhinoplasty
technique based on one’s experience and training. Start with cases that require limited changes
compatible with your expertise and compliant patients. If preservation rhinoplasty is new to
you, begin to read every article and textbook available, watch videos, and attend meetings.
Fortunately, Dr. Sylvie Poignonec has put together a much needed “learner’s guide” to pres-
ervation rhinoplasty. She has not only assembled a world-class list of authors, but had them
adopt a true step-by-step format, filled with tips and tricks that will make learning the operation
much easier. I would suggest that the reader begin their preservation rhinoplasty journey by
reading Dr. Poignonec’s chapter first and then the rest of the book in its order. The reason for
this recommendation is that the beginner surgeon must see and understand the “forest” before
getting lost in the details of the “trees.” Her advice and guidance will help the beginning surgeon
to learn and gain confidence in performing rhinoplasty surgery. One of the first challenges in
learning preservation rhinoplasty is the necessity to understand nasal anatomy from different
perspectives, both biomechanically and histologically. Dr. Saban’s two chapters introduce the
concept of biomechanical anatomy and the value of CT scan analysis in preoperative planning.
The value of being able to “see” the patient’s anatomy preoperatively and use it for planning
their surgery is a recent advance and of particular worth. Dr. Patron summarizes the critical
anatomical junctions of the nose in the format of a series of questions and answers which are
beautifully illustrated. Opportunely, the reader is able to see the application of this knowledge
in his superb case studies. There are three chapters which focus primarily on dorsal preserva-
tion. Drs. Cakir and Coksum’s chapter on dorsal preservation is sheer perfection with a profu-
sion of precise illustrations which, coupled with their videos, allows one to learn the details
which often separate a great result from a mediocre one. Dr. Goksel describes a progression of
techniques applicable to three different groups of patients: it is extremely beneficial for the
surgeon who is just beginning and emphasizes the use of piezoelectric instrumentation. The
“tetra concept” of Dr. Neves is superbly illustrated and will be welcomed by the experienced
surgeon as it offers a more powerful method of correcting hump deformities. Dr. Racy describes
functional factors during a rhinoplasty operation and makes a strong case for a modified sliding
alar cartilage flap (SAC). This procedure maintains the integrity of the scroll ligament complex
while modifying tip shape. The final chapter by Dr. Stubenitsky summarizes the book beauti-
fully and provides great insight into operative ­planning and decision-making, as well as how to
progress from easy to difficult in one’s own clinical series.

v
vi Foreword

Table 1 Level approach to preservation rhinoplasty: building on a foundation operation incorporating new
techniques gradually
Level 1 (Beginner) 2 (Intermediate) 3 (Advanced)
Case selection ALARS Tension nose, males, straight Asymmetric and deviations
Deviations, humps (1–6 mm) Humps (kyphotic and
>6 mm)
Approach Open Closed or open—Your choice Closed or open—Your
choice
STE (soft tissue SUBSMAS ALARS, SUBPERI ALARS, SUBPERI COMPLETE
envelope) SUBPERI OC VAULT OC VAULT SUBPERICHONDRIUM
SUBPERIOSTEUM
DORSUM SABAN SABAN LONGITUDINAL COTTLE INFERIOR
LONGITUDINAL STRIP EXCISION STRIP EXCISION
STRIP EXCISION COMPLETE OSTEOTOMIES COMPLETE
ROUTINE (RADIX, TRANSVERSE, OSTEOTOMIES (RADIX,
OSTEOTOMIES & LATERAL), BONY VAULT TRANSVERSE,
SEPTUM DISARTICULATION LATERAL), BONY VAULT
PUSH DOWN OR LET DOWN DISARTICULATION
PUSH DOWN OR LET
DOWN
ALARS NO EXCISION, NO EXCISION, INCISE & NO EXCISION, INCISE &
INCISE & SLIDE SLIDE SLIDE
STRUT & TIP STRUT & TIP SUTURES STRUT & TIP SUTURES
SUTURES

What is the best strategy for the reader to implement the surgical techniques presented in
this text? Every surgeon has a rhinoplasty operation that they have learned during their resi-
dency and then utilized as they begin their practice. If there are no preservation components,
one should keep the foundation operation and incorporate new techniques gradually. As seen
in the table below, it is my recommendation that surgeons should tackle this challenge with a
level approach—Level 1 (beginner), Level 2 (intermediate), and Level 3 (advanced) (Table 1).
In the first year, concentrate on lowering the dorsum using a combination of a longitudinal
septal strip excision and surface techniques. Preserve the lateral crus using an incise and slide
technique, provide tip support with some type of strut, and shape the tip with sutures. For most
surgeons, the open approach will facilitate learning and with experience one can employ the
closed approach. It should be noted that the open approach was preferred initially by Cakir,
Finnochi, and Kosins during their own learning period as beginners, to gain experience before
reverting to the closed approach. As one gains familiarity and becomes comfortable with elimi-
nating small humps, one can then progress to more challenging cases. The major challenge
will be the incorporation of complete osteotomies (transverse, radix, and lateral) with bony
vault disarticulation followed by lowering the nasal vault using either a Push Down (osteot-
omy) or a Let Down (ostectomy) technique. Also, one can begin doing a subperichondrial
dissection over the alars in patients with moderate to thick cartilages. There will be challenges
as one learns how to deal with “blocking points,” hump recurrences, and complex tip deformi-
ties. It is only with experience that surgeons gain confidence and can progress to more difficult
cases. Level 3 cases often require managing severe septal deviations and osseocartilaginous
vault asymmetries. Total release of the septum is frequently required, and an inferior septal
strip is the optimal solution. Although conceptually simple and easily drawn, its inherent intra-
operative instability can be terrifying for the unwary. An asymmetric approach to the bony
vault is often necessary with a Push Down on one side and a Let Down on the other. A true
preservation approach to the soft tissue envelope and its nasal ligaments is achieved by a com-
plete in-continuity subperichondrial-subperiosteal dissection from the alar rim to the radix
area. Throughout this progression, the surgeon should continue to learn as much as possible
from attending meetings and the internet. However, be skeptical of immediate postings of early
results and non-peer-reviewed publications, as many are more directed to marketing rather
than scientific accuracy.
Foreword vii

In conclusion, every surgical revolution disrupts the status quo, and leads ultimately to
major advances which benefit our patients. The preservation rhinoplasty revolution is no
exception, and it has created opportunities for a new generation of surgeons to advance our
knowledge of the most challenging of all Plastic Surgery operations.

Hoag Memorial Hospital Presbyterian Rollin K. Daniel

Newport Beach, CA, USA
Preface

Il n’y a rien de plus puissant qu’une idée quand l’heure est venue.—(Victor Hugo)

Why another book about rhinoplasty? As a plastic surgeon I am well aware that rhinoplasty
is the most challenging facial plastic surgical procedure. From the statistical point of view,
rhinoplasty procedures are constantly growing (+3.7% in 2020, International Society of
Aesthetic Plastic Surgery ISAPS data), and they represent now 67.9% of the surgical aesthetic
procedures in young patients between 19 and 34 years old; an impressive 852,554 interven-
tions were carried out in 2020 (ISAPS data). Therefore, the plastic surgeon and the maxillofa-
cial surgeon have more and more patients to take care of. Throughout one’s career, the
rhinoplasty surgeon strives to achieve:

–– a safe, reproducible procedure to gain both excellent aesthetic and functional results,
–– a result both visible on the table and durable throughout the patient’s life,
–– a final nose that does not look over-manipulated or “surgerized”.

From its inception, rhinoplasty centered around reducing the nose by removing cartilage,
bone, and underlying structural tissue to obtain thinner, smaller, more refined noses (Jacques
Joseph’s technique of hump reduction in 1899). In the long run, after years of following
patients who underwent significant structural reductions, rhinoplasty surgeons have begun to
see the downsides of the technique. Patients frequently developed alar rim weaknesses, retrac-
tions or collapses, as well as nasal asymmetry, inverted-v deformities, open-roof deformities,
and associated functional problems. Among thin-skinned patients, significant contractures
were commonly observed, a condition worsened by greater underlying reductions.
From these compelling reasons, structural rhinoplasty came to light, developed by Dr. Dean
Toriumi, and granting successful results by very complex and extensive surgical
interventions.
As light was shed on these significant issues with reduction-only rhinoplasty, two alterna-
tive techniques were developed:

–– Structural rhinoplasty, which reconstructs what was deficient or surgically removed with
the aid of cartilage grafts;
–– Preservation rhinoplasty, which aims to conserve the structure including bone, cartilage,
and ligamentous support, to preserve the original anatomy as much as possible.

Preservation rhinoplasty was thus born from the idea of conserving the original anatomy of
patients. As the name suggests, preservation rhinoplasty strives to maintain the structure of the
nose, by reshaping the existing structure instead of removing it. As such, this technique avoids
the need for reconstruction by grafting. Most importantly, preservation rhinoplasty improves
nasal stability over time, yielding a long-lasting result. Preservation rhinoplasty is not new; the
first push down was described in 1898 by Goodale; then came Cottle’s paper published in
1954, mentioning an S-shaped septal excision with push down and let down techniques. In
2018, Dr. Yves Saban described a modified high strip procedure, and Dr. Rollin Daniel and Dr.

ix
x Preface

Baris Çakir made the preservation rhinoplasty popular during the 2018 Istanbul meeting. After
these milestones, multiples techniques in dorsal preservation emerged: Dr. Ferreira described
the spare roof technique in 2018, Dr. Finocchi described the SPQR operation a few years
before in 2010, Dr. Luiz Carlos Ishida in 2020 illustrated the intermediate septal strip and clas-
sical hump excision, and many more then followed.
Respecting the middle nasal vault contour and ligaments at the time of surgery is of great
importance in preservation rhinoplasty. This preservation of the underlying nasal anatomy may
be partial or total. Complete preservation rhinoplasty, with a single dissection of the STE (soft
tissue envelope) as a single sheet of perichondrium and periosteum, without resection and with
a complete dorsum preservation, has very specific indications which are not frequently present.
Dissection is often limited to prevent a weak, floating nose, to avoid external incisions, and to
preserve cartilage obviating the need for grafts. Total preservation rhinoplasty is more of a
philosophical concept, but in confronting reality with its large array of cases and anatomical
variations, the surgeon must adapt to actual surgical possibilities.
Given the large diffusion of social media, and the related inclination of younger patients to
self-representation or posting on all sorts of social networks, the preservation of the existing
anatomy is the safest way to obtain aesthetically harmonic and long-lasting results.
The readers I mainly address here are the surgeons in training. I spent over 20 years in the
head and neck surgery department of the Pitie-Salpétrière Hospital, in Paris, France, teaching
rhinoplasty to my fellow surgeons. They were highly motivated, reading heaps of publications
and many excellent books (to name a few authors Rollins, Toriumi, Çakir) and still were unsure
about the choice of the technique to use in the various cases they were facing, or felt somewhat
lost in the abundant rhinoplasty related literature. This was especially true in the case of pres-
ervation rhinoplasty. Young surgeons in training well understood that a conventional hump
reduction with open roof was frequently complicated by middle vault issues and needing com-
plex grafts. A spreader graft to open the valve could be useful, sometimes dorsal irregularities
needing to be camouflaged later. When authors began to speak about dorsal preservation main-
taining the nasal anatomy, of replacing resection with preservation, and excision with manipu-
lation (as Rollin Daniel put it), we were all very excited, and wanted to move from structural
to preservation. The idea had a flavor of magic, and performing the new technique would spare
us some of our scarce and precious time. Soon enough, we noticed that in some cases the
results were less than perfect and issues still went unsolved: persistent dorsal hump, saddle
noses, deviated noses… As rhinoplasty experts, we felt a need to elucidate the different secrets
of the technique to have an understandable and full picture of all implications, to be able to
communicate them clearly.
The contents feature contributions of 15 different experienced surgeons, and some even
highly reputed, all adhering to the idea of sharing a significant token of their expertise in these
pages, to the benefit of younger fellow surgeons.
Dr. Yves Saban, among the founders of preservation rhinoplasty, introduces the work with
his vast experience, incorporating both anatomy and clinical cases and pairing with Dr.
Alomani in explaining biomechanical anatomy as the fundamental basis of preservation rhino-
plasty. The anatomical and histological considerations are illustrated by Dr. Patron, with the
help of fine microscope pictures, to facilitate the understanding of the inner workings of the
nose.
To assist in surgical decision-making, surgeons should not hesitate in requesting imaging
such as TDM 3D and computed tomography to support the pre-op decision process, especially
in the presence of asymmetric noses and functional problems. While the comprehension of
radiological findings will be bolstered by the related part written by Dr. Saban and Dr. Baldini,
Dr. Lekakis clearly demonstrates the importance of photography and simulation in preserva-
tion rhinoplasty.
My invitation to the reader: be artistic, as rhinoplasty is first and foremost an artistic proce-
dure, one has to be self-confident with the possibilities in one’s hand. Experience also benefits
from the exposure to beauty in art; noses in painting, but also in sculpture, as with Dr. Çakir’s
Preface xi

polygon concept centered around the idea of creating an anatomy that directly translates to the
skin surface without grafts. In their contributions, Dr. Çakir and Dr. Coşkun share the best
practices in decision-making, the choice between intervention variations, safety issues in pres-
ervation rhinoplasty and clinical cases, while I explain stepwise the combination of structure
for the tip and dorsal preservation. Dr. Racy, Dr. Benmoussa, and Dr. Fanous focus their
knowledgeable contributions on how to respect the function of the nasal valve in preservation
rhinoplasty, whereas Dr. Carles answers the question of whether we need camouflage in pres-
ervation rhinoplasty, by integrating technology and new devices. Dr. Stubenitsky masterly
closes our common endeavor with a chapter on the highly sensitive point of complications in
dorsal preservation. In building the framework of the book, we selected specific clinical cases
for each of the chapters, enriching them with photos, drawings, and surgical videos.
As it seems fit to offer some advice to young surgeon readers too, I hope they will keep in
mind that results that appear very nice on the operating table can progressively change with
time. Dean Toriumi conveys this in stating that healing after rhinoplasty could last the patient’s
entire life, especially in patients with thinner skin and short nasal bones due to scar
contracture.
This is a major challenge.
How do we deal with such a difficult surgical procedure and its many complications?
My advice is to keep learning; learn, learn, and learn all your life: read different publica-
tions, watch videos, and travel. If possible, choose to journey around the world, and shadow
other surgeons to pick up their technique. I became a rhinoplasty fan by meeting colleagues,
participating in courses, speaking at conferences, and organizing webinars. A surgeon might
well feel lonely and lost while performing surgery; this feeling is not uncommon, and decreases
with time, as one gains in experience: your confidence will grow.
One should also endeavor to be modest; follow up with patients every 3 months the first
year after surgery and then once per year afterwards, to make one’s own revisions. This is
crucial to learn from mistakes, earn and keep the patient’s trust, and avoid bad reviews.
This book is the result of a collaboration between more senior surgeons who have served as
mentors, and the next generation mentees, who will be the rhinoplasty surgeons of tomorrow.
Ingenious, creative, brilliant: heartfelt thanks to all for their participation in this book.
A concluding note: we do not want to oppose or to replace structural by preservation; dorsal
preservation or partial dorsal preservation is, in our opinion as well, the gold standard for pri-
mary Caucasian rhinoplasty in the majority of cases, although not sufficient to obtain a perfect
tip projection, tip structure, or septum straightening. It is therefore our belief that both of these
techniques should be associated to obtain the best results: adding preservation for the dorsum
to structural for the tip could be the best way to improve aesthetic outcomes.

Paris, France Sylvie Poignonec

March 2023
Contents

1 
Nasal Biomechanical Anatomy as a Fundamental Basis for Preservation
Rhinoplasty�����������������������������������������������������������������������������������������������������������������   1
Yves Saban and Mohammad Alomani
2 
How Histology Is Pertinent for Surgical Approach������������������������������������������������� 15
Vincent Patron
3 
Photography Evaluation and Morphing for Preservation Rhinoplasty����������������� 35
Garyfalia Lekakis
4 Cone-Beam CT or CT Scan Analysis for Routine Pre-Operative
Planning Before Rhinoplasty������������������������������������������������������������������������������������� 43
Nicolas Baldini and Yves Saban
5 
Surgical Steps in Dorsal Preservation����������������������������������������������������������������������� 57
Erhan Coşkun and Barış Çakir
6 
Letdown and Piezo Techniques in Preservation Rhinoplasty��������������������������������� 85
Abdulkadir Goksel and Khanh Ngoc Tran
7 Combination of Structure and Preservation: A Step-by-Step Surgical
Guide to French-Touch Preservation Rhinoplasty ������������������������������������������������� 105
Sylvie Poignonec
8 
Camouflage in Preservation Rhinoplasty����������������������������������������������������������������� 137
Guillaume Carles
9 Functional Considerations for Preservation Rhinoplasty, Nasal Valve,
and Clinical Cases������������������������������������������������������������������������������������������������������� 145
Emmanuel Racy, Amanda Fanous, Grégoire d’Andrea, and Nadia Benmoussa
10 Dorsal Precision Segmental Preservation and How to Avoid
Aesthetic Drawbacks ������������������������������������������������������������������������������������������������� 155
J. Carlos Neves and Diego Arancibia-Tagle
11 
Prevention and Correction of the Most Common Problems in Preservation
Rhinoplasty����������������������������������������������������������������������������������������������������������������� 183
Bart M. Stubenitsky

xiii
Editor and Contributors

About the Editor

Sylvie Poignonec is a French plastic and head and neck surgeon special-
ized in rhinoplasty, recognized and qualified by the French Order of
Medical Doctors and National Health Authority, as well as by the European
Plastic Surgery Board EPOBRAS. Active member of the French Society
of Reconstructive Plastic Surgery & Aesthetic SOFCPRE and member of
the board of SOFCEP executive committee the French society of plastic
and cosmetic surgery, Dr. Poignonec has 25 years of experience in plastic,
oral, and maxillofacial surgery, especially at Bichat and Pitié Salpêtrière
hospitals in Paris, performing over 2000 rhinoplasty interventions both
aesthetic and functional. Adding to her experience, her teaching at APHP
medical school and at a large number of surgery and aesthetic courses and
workshops led her to open her own private clinic, while still working for
the APHP National Health Paris Hospitals as consultant. She has authored
and coauthored several books on cosmetic surgery and antiaging medicine
and been assigned the Best Clinical Case Award in Rhinoplasty at 2015
AMEC congress. Her teaching techniques and didactic concept for sur-
geons in training include clinical examination, photography, tomodensi-
tometry (TDM) in 3D, computer simulations, and the building of a
dedicated checklist that allows a careful patient approach and the best out-
comes for the most frequent rhinoplasty cases .

Contributors

Mohammad Alomani, MD Facial Plastic and ENT Surgery, Kuwait Ministry of Health,
Kuwait City, Kuwait
Diego Arancibia-Tagle, MD, PhD, IBCFPRS Otorhinolaryngology, Head and Neck Surgery,
Hospital Universitari Son Espases, Palma, Spain
Private Practice, Mallorca, Spain
Nicolas Baldini, MD University of Bordeaux College of Health Sciences, Bordeaux, France
Nadia Benmoussa, MD Department of Head and Neck Oncology, Gustave Roussy Cancer
Institute, Villejuif, France
Barış Çakir, MD Private Practice, Şişli, İstanbul, Turkey
Plastic Reconstructive and Aesthetic Surgery, American Hospital, Şişli, Istanbul, Turkey
Guillaume Carles, MD, EPOBRAS Otolaryngology-Head and Neck Surgery, Institut de
Chirurgie Esthétique de Montpellier, Montpellier, France
Clinique Clémentville, Montpellier, France
Erhan Coşkun, MD Private Practice, Şişli, İstanbul, Turkey

xv
xvi Editor and Contributors

Plastic Reconstructive and Aesthetic Surgery, Florence Nightingale Gayrettepe Hospital,

Beşiktaş, Istanbul, Turkey
Grégoire d’Andrea, MD Department of ENT and Head and Neck Surgery, Institut
Universitaire de la Face et du Cou, GCS Nice University Hospital, Antoine Lacassagne Centre,
Côte d’Azur University, Nice, France
Amanda Fanous, MD Division of Facial Plastic Surgery, Department of Otolaryngology-­
Head and Neck Surgery, McGill University, Montreal, QC, Canada
Abdulkadir Goksel, MD RinoIstanbul Facial Plastic Surgery Clinic, Istanbul, Turkey
Garyfalia Lekakis, MD, PhD Department of Otorhinolaryngology Head and Neck Surgery,
Hôpitaux Iris Sud, Brussels, Belgium
Louise Medical Centre, Brussels, Belgium
Department of Otorhinolaryngology Head and Neck Surgery, University Hospitals Leuven,
Leuven, Belgium
J. Carlos Neves, MD, PhD, IBCFPRS, EBCFPRS Private Practice MyFace Clinic, Lisbon,
Portugal
Vincent Patron, MD Department of ENT—Head and Neck Surgery, CHU de CAEN
Normandie, Caen, France
Normandie Université, UNICAEN, EA7451 BioConnecT—Biology of Connective and
Cutaneous Tissues, Caen, France
Sylvie Poignonec, MD, EPOBRAS Plastic Surgery and Head and Neck Surgery, Centre
Esthetique Paris – Eiffel, Paris, France
Emmanuel Racy, MD Maxillo Facial Surgeon, Clinique Saint Jean De Dieu, Paris, France
Department of Otolaryngology-Head and Neck Surgery, Adolphe-Rotschild Foundation,
Paris, France
Yves Saban, MD Private Clinical Practice, Nice, France
Bart M. Stubenitsky, MD, PhD Dr Bart Clinic, Amsterdam, The Netherlands
Khanh Ngoc Tran, MBBS RinoIstanbul Facial Plastic Surgery Clinic, Istanbul, Turkey
Abbreviations

ANS Anterior nasal spine LLC Lower lateral cartilage

ASA Anterior septal angle LSL Longitudinal scroll ligament:
BP Bony pyramid junction between ULC and LLC
BS Bony septum NB Nasal bone
CDS Cephalic dome suture NMSL Naso maxillary suture line
CS Cartilaginous septum ligament
CBCT Cone Beam Computer Tomography PAL Piriform aperture ligament
CTS Cranial tip suture POD Push down
DAL Dorsal aesthetic lines PPE Perpendicular plate of ethmoid
DC Diced cartilage PRF Plateletrich fibrin
DCF Diced cartilage in fascia PRP Platelet-rich plasma
DE Dome equalization suture ROE Rhinoplasty outcomes evaluation
DKA Dorsal keystone area SEG Septum Extension Graft
DTF Deep temporal fascia Sellion Deepest point in the radix area on
K Zone The keystone area: comprises the side view
nasal bone (NB), cartilaginous SLC Scroll ligament complex
septum (CS), bony septum (BS), SMASS Muscular aponeurotic subcutane-
and upper lateral cartilage (ULC). ous system
A portion of the nose where the SSTE Superficial soft tissue enveloppe
bony vault overlaps the cartilagi- STE Soft tissue envelope
nous vault both dorsally. ULC Upper lateral cartilage
LCS Lateral crural steal suture W Point Point of separation of the ULCs
LDO Let down from septum: upper cartilage meet
LKA Lateral keystone area the dorsal septum

xvii
 Nasal Biomechanical Anatomy
as a Fundamental Basis for Preservation 1
Rhinoplasty

Yves Saban and Mohammad Alomani

1.1 Background tion from a pure anatomical analysis of the patient’s nasal
morphology to the desired aesthetic result, following pre-
In the history of primary rhinoplasty, three different philoso- operative simulations (Fig. 1.1). How should biomechani-
phies are mentioned in the literature. The most common and cal analysis be correctly carried out? Instead of basically
most frequently practiced until recently is the rhinoplasty removing the hump, the idea is to create a space in which
described by Joseph [1], which is principally aimed at the surgeon will be able to move nasal structures and mod-
removing deformities, especially the osteo-cartilaginous ify their form.
hump. Often, this is carried out via an endonasal approach.
The second philosophy is the so-called structural rhinoplasty,
which became popular in the 1990s after the introduction of
the external transcolumellar approach by Toriumi and
Kovacevic [2]. The third philosophy, described first by
Goodale [3], and diffused widely by Saban and de Salvador
[4], consists in preserving the nasal vaults that form the nasal
dorsum and improving the nasal function and shape.

1.1.1 Biomechanical Anatomy

It is certainly important to understand the anatomy of the

nose; however, simple anatomy is not enough, as the bio-
mechanical aspects of nasal anatomy are a cornerstone of
the comprehension of preservation rhinoplasty. This analy-
sis allows the surgeon to adapt the surgical procedure,
ensuring not only the aesthetic results but preserving/cor-
recting the nasal function as well. Biomechanical anatomy
is thus to be understood as the method allowing the transla-

Supplementary Information The online version contains supplemen-

tary material available at https://doi.org/10.1007/978-­3-­031-­29977-­3_1.

Y. Saban (*)
Private Clinical Practice, Nice, France
M. Alomani
Facial Plastic and ENT Surgery, Kuwait Ministry of Health, Fig. 1.1 Algorithm of the logic behind biomechanical analysis
Kuwait City, Kuwait

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 1

S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_1
2 Y. Saban and M. Alomani
1.1.2 The Principle of Preservation
Rhinoplasty
The principle of preservation rhinoplasty is to modify the
form of the nose by remodeling most of its structures instead
of resecting them, especially the osteo-cartilaginous vault,
and protecting or, even better, improving nasal functions,
namely breathing. Dorsal reduction is performed instead of
resection, then the orienting of the cartilaginous vault, by
remodeling the junction between the bone and the septotri-
angular cartilage at the level of the K-area.
Preservation rhinoplasty is designed to be a reduction pri-
mary rhinoplasty. It is not limited to the nasal dorsum, as the
preservation of nasal ligaments and remodeling of alar carti-
lage via a sub-perichondral approach is also considered in
this philosophy (for French readers see also Gola [5, 6]).
A clinical case will illustrate the biomechanical anatomy
and further explanations are mentioned later in this chapter.
1.2 Clinical Case
1. Analysis: A 23-year-old woman seeking a primary rhino-
plasty. No history of functional problem or nasal trauma.
No psychological issues. The physical examination
focuses on facial harmony, skin quality and thickness,
type of nose from a profile view, shape of the nasal tip,
dorsal aesthetic lines, after which the endonasal and func-
tional assessment are performed.
The results of this physical examination of the patient’s
characteristics (Figs. 1.2–1.4) are: harmonious face but
asymmetric face, thin skin, tension nose or ‘type II nasal
profile’ (according to the Saban classification [4]), no
deformities of the tip; however, the tip drops upon smil-
ing. Slight nostril asymmetry due to caudal septal devia-
Figs. 1.2–1.4 Front view showing good DAL, 3/4 view showing a
long nose, profile view showing type 2 nose with a dorsal hump: the
following structures are marked in order: radix, rhinion, anterior septal
tion. Front view: dorsal aesthetic lines (DALs) are good.
The anterior septal angle is prominent on the lateral view.
­Deviated septum to the right side, narrow pyriform aper-
ture as can be seen in the radiological assessment, which
is best performed by cone beam CT (Figs. 1.5–1.7).
2. Patient’s expectations: a straight nose with a natural
appearance is desired.
3. Technical procedure: type II preservation let-down rhino-
plasty [4] in which the superficial soft-tissue envelope
(SSTE) was elevated and the dorsum was rasped as the
first stage, then the dorsum preservation procedure by let-­
down (LDO) was performed (Video 1.1).
4. Interpretation of the biomechanical anatomy: given the
preoperative analysis, the surgeon suggests lowering the
hump and achieving a straight dorsum, reducing the
length of the nose, and performing a cephalic rotation of
the tip.
(a) Which surgical approach? As the patient presents
thin skin with an harmonious tip shape, an endonasal
approach is chosen. An external open approach could
have been an option in the case of a problematic tip;
however, this open approach generally leads to over-
done procedures on the tip, which are not required in
such a case.
(b) Does the septoplasty destabilize the septum support?
The septum is slightly deviated yet stable. Thus, no
septum resection is necessary. This septal support
stability leads to a high septal strip resection proce-
dure. Septoplasty procedures can be classified into
quadrangular cartilage preservation (“swinging
door” procedure according to Cottle [7]) versus carti-
lage resection (“L-strut” according to Killian). As far
as possible, it is desirable to preserve as much carti-
lage as possible. The “L-strut” procedure would lead
to excessive resection and loss of support; moreover,
angle (ASA), and the tip. The radix and tip are in the correct position.
Normal nasolabial angle and globally long nose
1 Nasal Biomechanical Anatomy as a Fundamental Basis for Preservation Rhinoplasty
Figs. 1.5–1.7 Cone beam CT scan, coronal and sagittal planes, 3D
sagittal plane showing type 2 nose with caudal septal deviation, steno-
rhinia, and no adjacent pathological conditions. The blue dots represent
it does not allow a high strip resection during the
preservation rhinoplasty procedure.
(c) How should the dorsum be dealt with? The patient
shows a tension nose with nice DAL. In the preserva-
tion philosophy, keeping the K area intact is one of
the main concepts. To achieve this goal,
• Nice DAL should be kept intact; therefore, a dor-
sal preservation procedure is favored. Thus, the
procedure will lower the dorsum, without chang-
3
(from superior to inferior) the sellion, the rhinion, the anterior septal
angle, and the tip
ing the DAL. A space must be created below the
bony–cartilaginous vault allowing the drop of the
dorsum into this empty space: a strip of high sep-
tum must be resected.
• The tension nose convexity requires to be flat-
tened. Basically, the bony dorsum is rigid whereas
the cartilaginous vault is flexible. To straighten the
dorsal K-zone, the attachments of the underlying
septum must be released (“coat-hanger effect”).
4 Y. Saban and M. Alomani
Figs. 1.8–1.10 Six months postoperatively frontal, 3/4 and profile views. We can observe the stability of the result during the follow-up; a small
residual hump can be noticed at 6 months postoperatively, which does not bother the patient
So, two actions are required: lowering associated with
flattening of the dorsum; thus, a type II dorsal preserva-
tion rhinoplasty is planned.
(d) What about the lateral sidewalls in this dorsum pres-
ervation procedure?
Two matters are to be considered: first, do we have to
disarticulate the lateral K area (LKA)? Second, do we
have to remove the Webster triangle?
• Lateral sidewalls must be considered, as they may be a
source of resistance which does not permit lowering
and ‘stretching’ of the nasal pyramid. The more con-
vex is the nose, the more we need to release the LKA
to eliminate any resistance leading to residual hump
later.
• LKA partial disarticulation ballerina maneuver (see
Goksel et al. [8]) and manipulation of the pyriform
ligaments are excellent techniques to allow stretching
of the nasal dorsum.
• How should lateral osteotomies be managed? How do
we choose between push-down (PDO) and LDO? The
main difference between PDO and LDO is the bony
wedge resection of the frontal process of the maxilla.
If the dorsum needs a reduction of 5 mm or more, the
PDO technique will be limited by the presence of the
inferior turbinate, which will block the descent of the
bony side wall; therefore, LDO is mandatory.
• Moreover, the narrow pyriform aperture, named
‘stenorhinia,’ along with the inferior turbinate, plays
an important role in choosing between the PDO and
LDO techniques.
(e) As a consequence of the dorsum lowering, the upper
lateral cartilage (ULC) pushes against the spring of
the internal nasal valve, thus opening the septal–tri-
angular space and resulting in widening of the middle
vault as a side effect on the external front view
(Fig. 1.8). There was also a spontaneous cephalic
rotation of the lateral crura of the lower lateral carti-
lage (LLC) that followed the reduction movement of
the nasal dorsum. Widening of the nostrils and open-
ing of the nasolabial angle can be observed.
5. Biomechanics of residual humps: one can differentiate,
according to the post-operative delay, the cause of hump
recurrence:
(a) Immediate residual hump (even per-operatively)
is most probably due to a technical error in one of the
surgical steps. It should be corrected intra-operatively.
(b) Early postoperative residual hump is mainly a result of
the ‘spring effect.’ This is mostly due to the cartilagi-
nous memory or inadequate release of the lateral K
area. Simple postoperative edema (as seen in Figs. 1.8–
1.10) must be rolled out by simple physical examina-
tion. This sort of hump can resolve spontaneously up
to 1 year postoperatively (Figs. 1.11–1.13).
(c) Delayed: sub-dorsal fibrocartilaginous formation
could result in progressive hump formation. Diluted
steroids could be injected locally to resolve such a
problem.
(d) Late: fibro-osseous callus is responsible for tardive
hump recurrence, which needs correction by simple
rasping.
1 Nasal Biomechanical Anatomy as a Fundamental Basis for Preservation Rhinoplasty
Figs. 1.11–1.13 Twelve months postoperatively frontal, 3/4, and profile views. Notice the spontaneous resolution of the postoperative residual
hump that was seen 6 months postoperatively
During the previous clinical case, highlights of the biome-
chanical aspects were mentioned. Now, further and deeper
explanations of the biomechanical anatomy of preservation
rhinoplasty will be discussed in detail.
1.3 The Mobility of the Nose
The nose is a mobile structure composed of ductile, mallea-
ble, and flexible components; this superficial hollow organ is
accessible for external manipulation. Perfectly adapted to
movements of ventilation that correspond to its function, it
can be compared with a directional aerodynamic structure.
However, as the nose is solidly implanted on the face, its
position cannot be freely changed. The insertions of the nose
into the face divide the nose into three zones. The first zone
(upper vault) at the root of the nose is bony and completely
immobile. The second zone (middle vault) is semi-mobile
and corresponds to the cephalic portion of the ULC and the
adjacent fibrous triangles. The third zone (lower vault) cor-
responds to the alae and columella at the base of the nose.
This zone is mobile and directional. Two modalities of move-
ment are possible via the effect of:
–– Sliding of the SSTE over deep and rigid planes.
–– Folding or bending of cartilaginous and cutaneous
structures.
Movement of the nasal muscles will affect facial expres-
sion and breathing function. These muscles act on the alar
cartilage, either at the triangular–alar junction, or at the
nasal–labial junction.
• Respiration and the nose: the dynamics of the nasal mus-
cles permit adaptation of the airflow in the nasal cavities and
thus, participate in the perfection of olfaction and ventilation.
However, forced inspiration may produce in some anatomi-
cal conditions a nasal valve collapse due to the Venturi effect.
5
1.4 Biomechanics and Plasticity of Nasal
Structures
This plasticity is a characteristic of cartilaginous structures
and overlying covering planes. It allows movements of the
nose or the modeling action of surgical procedures. We can
distinguish covering tissues and zones of junction.
1.4.1 The Role of SSTE in Nose Biomechanics
Skin, subcutaneous tissues, nasal muscles, adjacent fibrous
connective tissues and nasal ligaments, the periosteum, and
the perichondrium all constitute the envelope of the nose.
These covering tissues drape and grab the osseocartilaginous
infrastructure. They also contribute to the stability of these
underlying structures by acting as a flexible splint, pulling
together the infrastructure and suspending it over the empty
nasal cavity.
Furthermore, the muscles strengthen and add thickness to
the covering planes. Finally, these muscles define a deep
plane of surgical dissection in contact with bone and carti-
lage, a truly natural plane of dissection. Thus, the nasal mus-
cles play a fundamental role, both in nasal static in opposition
with dynamic.
Certain ‘weak structures’ may cause aesthetic problems
owing to a specific risk of distortion:
–– The facet (converse soft triangle) has two strictly cutane-
ous surfaces.
–– The weak triangle: the definition of the tip or the occur-
rence of a “polly beak” deformity depends on the filling
of the weak triangle, which corresponds to the supratip
area.
–– The nasal alae, made of only skin and muscles, are the
caudal extension of the fibrocartilaginous continuity of
the fibrous triangles and participate in facial expression
and respiration.
6 Y. Saban and M. Alomani
1.4.2 The Zones of Junction
Other functional structures are true fastenings incorporating
the mobile nose within the face:
–– The membranous septum situated between the caudal
edge of the septum and columella, is a link between the
mobile nose, which is the columella, and the fixed nose,
which is the quadrangular septal cartilage.
–– The lateral fibrous triangle (Fig. 1.14) at the level of the
pyriform aperture is a zone of junction between the nose
and the cheek. This fibrous triangle corresponds to a lateral
extension of the ULC toward the pyriform aperture. The
lateral extensions of LLC septum extend the lateral crura
(cauda) toward the pyriform aperture. These two lateral
extensions of the upper and the LLC toward the pyriform
aperture are de facto authentic fibrocartilaginous fastenings
joining the mobile nose to the fixed structures of the pyri-
form aperture. They also directly participate in nasal
breathing by avoiding collapse of the lateral nasal wall.
They are in contact with the transverse nasalis muscle.
–– Last, the labial–columella complex, deeply anchored to
the anterior nasal spine by the premaxillary ligament,
includes the footplates of the medial crura, the superficial
orbicularis oris, and the depressor septi nasi muscles. This
complex binds the medial support of the nose to the mus-
cles of the mouth.
Fig. 1.14 Anatomical preparation illustrating the lateral fibrous trian-
gle of the nose. Note the caudal extension of the lateral crus of the lower
lateral cartilage and its relations with the free edge of the triangular
cartilage and the pyriform aperture
1.5 Biomechanics and Surgery
Surgeons have few surgical maneuvers on the SSTE-
covering planes where the risk of unsightly scarring is too
high. Surgical manipulation will essentially involve the
deeper osseocartilaginous framework. The success or fail-
ure of deep surgical corrections into improved nasal cos-
metics constitute the multiple difficulties of rhinoplasty.
Therefore, the results of the rhinoplasty will depend as
much on the surgeon’s capacity to evaluate and anticipate
the biomechanical reactions of tissues as on his capacity for
aesthetic abstraction.
1.5.1 Bony Vault
Frequently, the nasal bony vault requires a surgical proce-
dure to achieve lowering or reshaping of this upper segment
of the nose.
The upper nasal vault is built by nasal bones and the fron-
tal process of the maxilla. On the bony sidewalls, the medial
canthal ligaments are inserted. The bones are covered by the
periosteal membranous envelope, which gives stability. The
nasal bones have their own shape, showing great variability
according to individual anatomy.
A rhinoplasty procedure needs to reshape these bones.
This can be accomplished by sculpture and/or osteotomies
and/or fractures. On a lateral view Lazovic et al. [9] has
described V-shaped and S-shaped nasal bones that reflect the
radix depth and bony dorsum shape. It is important to
remember that the shape of the bone is not absolutely repre-
sentative of the dorsal convexity.
One can divide the bony vault into two segments: the
radix and the bony cap; the bony cap corresponds to the bony
part of the central K area that covers the underlying quadran-
gular cartilage and the central part of the triangular cartilage
(dorsal K area).
Medial canthal ligaments can interfere with manipulation
of the bony vault, mainly when the radix requires lowering or
in a deviated dorsum. Thus, surgical disinsertion might be
necessary to free this blocking point; as a reminder, the ante-
rior head of the medial canthal ligament is not involved in
eyelid stability, and undermining it is not risky.
The periosteum is firmly attached to the bones. It can be
preserved, cut, or undermined. The more the periosteum is
freed, the more the bones can be mobilized. Conversely, the
1 Nasal Biomechanical Anatomy as a Fundamental Basis for Preservation Rhinoplasty
Fig. 1.15 Surgical
manipulation of the septum in
Cottle’s technique
Fig. 1.16 High septal strip in
Saban’s technique, allowing
dorsal descent
less we need to move the bones, the less we should under-
mine the periosteum. For example, in deviated noses, we
need to tilt the nose to one side in order to straighten it. On
the long sidewall, important periosteal undermining will be
done in order to create a space, which the nose will drop into,
whereas on the opposite side (the short sidewall), minimum
undermining will be performed.
Which technique should be used for preservation rhino-
plasty? There are two main techniques for accomplishing
dorsal reduction: septal disarticulation by Cottle [7] and
7
high septal strip by Saban and de Salvador [4]. Different
technical variations have been described that follow the
same general philosophies. The principle of Cottle’s tech-
nique is hump reduction via septal disarticulation and rota-
tion (Fig. 1.15), whereas in Saban and de Salvador’s
technique, a simple high septal strip is removed underneath
the dorsum controlling the dorsal reduction (Fig. 1.16). Of
course, whatever the septal maneuvers, complete osteoto-
mies detaching the nasal pyramid are mandatory to achieve
the desired results.
8 Y. Saban and M. Alomani
1.5.2 Upper Lateral Cartilage (Triangular
Cartilage) and K Area
This intermediate cartilage forms a true semi-mobile zone of
transition between the fixed root and the directional base of
the nose. Because this cartilage forms approximately the
caudal half of a nasal hump, it must be dealt with during
reduction rhinoplasty.
The K area corresponds to the overlap between the ULC,
high septum, and nasal bones.
Two segments can be considered: the dorsal K area
(DKA) and the LKA.
The problem with traditional resection rhinoplasty, is that
the resected part of the hump corresponds to the DKA, which
is the only support of this ULC “semi-mobile flying wing,”
which then becomes a “floating wing.”
–– Indeed, the triangular cartilage must be considered as a
structure that is “suspended” over the nasal cavity like a
semi-mobile wing articulating with a midline axis.
–– In our opinion, this cartilage may be analyzed in three dif-
ferent parts. Each part will have a precise role to play on
an anatomofunctional, as well as a morpho-dynamic or
surgical level (Fig. 1.17).
–– The midline axis of support at the articulation of the ULC
with the septum is the only part of this cartilage with solid
support. At this articulation the ULC forms a true vault
over the median septal pillar. This function is confirmed
by the specific Y-shape of this zone of junction with a
superior convexity that mimics the wings of birds in
flight. This structure is maintained by both the septal pil-
lar, which determines the height, and the deep solid inser-
tion under the nasal bones at Cottle’s K area, which links
the ULC to the nasal bones.
–– Laterally, the wing of the ULC is mobile. This mobility is
induced by the weakness of the lateral insertion of the
Fig. 1.17 Anatomical detail of the osseocartilaginous framework of
the nose. Note the relations of the triangular cartilage with the nasal
bones and with the alar cartilage
ULC under the nasal bones, the paraseptal caudal end, the
lateral extension by the fibrous triangle, and the absence
of rigid support throughout this area.
–– Caudally, the triangular–alar junction helps to form the
spring of the nasal valve where the caudal edges of the
triangular cartilage articulate below the cephalic portion
of the LLC.
1.5.2.1 Weakened ULCs in Open Roof
Rhinoplasty
During conventional “open roof” rhinoplasty, the ULCs are
weakened after the resection of their central support. Indeed,
during resection of a hump, removal of the midline support
of the ULC is inevitably the origin of the “flying wing” phe-
nomenon and thus collapse of the ULC. This collapse is
often aggravated by a destabilization of the triangular–alar
junction during an intercartilaginous approach and/or resec-
tion of the cephalic part of the lateral crura (Fig. 1.18).
Here, Figs. 1.18–1.20 show a photographic sequence of
an anatomical preparation showing triangular collapse after
rhinoplasty using a conventional technique.
Finally, an authentic “stripping” of the ULC may occur
under two circumstances. The inappropriate use of a rasp
may pull out the deep attachments of the cartilage under the
nasal bones. However, this is a rather rare event. More fre-
quently, during an en bloc hump resection, the DKA is
removed, keeping only the LKA intact at the deep surface of
the nasal bones. As a consequence, the medial collapse of the
ULC will, as a functional consequence, result in the closure
of the triangular–septal angle and thus cause the nasal valve
to deteriorate. The aesthetic consequence will be uni or bilat-
eral depression in the form of an inverted V deformity that
will disrupt the aesthetic lines of the middle third of the nose
(Fig. 1.21).
However, this collapse of the ULC is limited by the
attachments of the superior surface of the cartilage with the
superficial soft tissues that partially contribute to the stabi-
lization of the middle third of the nose. During a rhino-
plasty requiring a significant reduction of the dorsum that
will interrupt midline support, the surgeon will have a
choice of several techniques if he wishes to avoid triangular
collapse:
–– The use of a preservation rhinoplasty technique is highly
indicated for nasal humps with short nasal bones.
However, this technique is not always possible.
–– Triangular collapse may be avoided by protecting the
medial (septal) edge of the ULC and reconstructing the
triangular–septal vault named spreader flaps. This is best
practiced through an external approach with triangular–
septal sutures.
–– A “spreader graft” may be harvested on the septum.
1 Nasal Biomechanical Anatomy as a Fundamental Basis for Preservation Rhinoplasty
Figs. 1.18–1.20 Demonstration of triangular collapse after rhinoplasty using a conventional technique
Fig. 1.21 Inverted V appearance related to bilateral triangular collapse
and open roof
–– Whichever technique is used, it is highly recommended to
limit dissection of the covering planes over the ULC to
conserve their role as a splint.
1.5.2.2 Preservation Rhinoplasty and Push-Down
Technique
Conversely, during preservation rhinoplasty and while per-
forming a “push-down” technique [10], (Figs. 1.22 and 1.23)
the nasal hump will decrease; the caudal edge of the ULC (1)
9
will push against the spring of the nasal valve opening the
valve angle and the lateral extension of the ULC (2) will
push against the pyriform aperture flattening the middle third
of the nose. In addition, this pressure will induce a cephalic
rotation of the lateral crura of the LLC and individualization
of the tip of the nose with opening of the nasolabial angle
and flattening of the nostrils.
However, this dorsal reduction may result in a saddle
deformity of the supratip, in particular, when the hump is
very convex. This saddle deformity is due to the sinking of
the soft triangle as it is pulled down by the sinking W-ASA
segment of the cartilaginous septum. This adverse effect
must be corrected, either by performing the septal first inci-
sion at the level of the W-point in the high strip procedure, or
by rotating the septum anteriorly according to Cottle’s
technique.
Another aesthetic inconvenience, flaring of the nostrils, is
related to the opening of the triangular–septal angle and the
nasal valve. A reduction of the nostril can be indicated.
1.5.2.3 Biomechanical Changes in “Let-Down”
Preservation Rhinoplasty
The biomechanical changes in “let-down” preservation rhi-
noplasty are quite similar to the “push-down” technique.
However, several limitations in the biomechanics of the
push-down technique might require a let-down instead. This
is particularly important in the case of a narrow nasal cavity,
in which pushing the nasal bones into the “already” narrow
cavity will affect nasal breathing. Moreover, there is a lim-
ited distance in which the bony pyramid could be pushed
down to the nasal cavity because of the inferior turbinate and
probably the middle turbinate. In fact, the attachments of the
head of the inferior turbinate and the head of the middle tur-
binate could block the descent of the nasal bones. Thus, if a
reduction of 5 mm or more of the nasal bone is required,
ostectomy of a triangular bony wedge is necessary to allow
such a large reduction, as shown in Figs. 1.24–1.26.
10
Figs. 1.22 and 1.23 Anatomical preparations: Basic steps of the “push-down” maneuver: complete osteotomies and impaction of the nose
Figs. 1.24–1.26 Anatomical dissection showing the let-down technique and removal of a bony wedge, allowing reduction and strecthing of the
dorsum
1.5.3 The Lower Lateral Cartilage (Alar
Cartilage)
Tip surgery is a difficult task. One of the major keys to suc-
cess is understanding the relationship between the cartilage
and skin of the nasal tip. All the surgeon’s flair will be
expressed in his ability to model these structures while
adapting to the constraints of each individual patient’s
anatomy.
The alar cartilage is the major component of the nasal tip
[11]. Therefore, together with the skin that covers it, it
defines the tip shape. The study of the biomechanical anat-
omy of this LLC imposes an understanding of a vectorial
symmetric anatomy consisting of directional forces and aes-
thetic consequences.
Therefore, the biomechanical anatomy of the alar carti-
lage takes into account a good anatomical knowledge of:
Y. Saban and M. Alomani
–– The “enantiomorphic” three-dimensional structure of this
cartilage,
–– Their morphological interrelations and ligaments,
–– Their caudal connections with the skin of the nares and
cephalic connections with the ULC.
The following section covers the various types of biome-
chanical action as a function of the movements affecting the
tip of the nose.
The surgical application to operative techniques results
directly from the comprehension of these biomechanical
parameters. Therefore, according to the direction of move-
ment given, one may distinguish the movements of ascension,
cephalic rotation, lateral deviation, and retrusion of the tip.
1.5.3.1 Cephalic Rotation of the Tip
As shown in Figs. 1.27 and 1.28, this rotation is made possible
(1) by the presence of the membranous septum that, in turn,
1 Nasal Biomechanical Anatomy as a Fundamental Basis for Preservation Rhinoplasty
Figs. 1.27 and 1.28 Anatomical specimen. Simulation of the biomechanical effects of a preservation rhinoplasty
permits the retraction or projection of the columella, (2) by
bending of the triangular–alar junction that, in turn, permits
the retraction or projection of the lobule, and (3) by shifting of
the covering planes over the framework (Figs. 1.27 and 1.28)
–– This ascension is limited by tightening of the soft-tissue
envelope and by the presence of the cartilaginous septum,
which blocks the retraction.
–– This movement may be simulated by placing the fingers
on the skin overlying the nasal bones and pulling up the
skin of the dorsum.
–– The aesthetic implications of this movement are essen-
tially to shorten the nose and to open the nasolabial angle.
–– The surgical implications (Fig. 1.29) correspond to a
shortening of the septal obstacle and/or the membranous
septum, a release of the dermal–cartilaginous ligaments
and a possible reduction of the triangular–alar zone of
junction. The tongue-in-groove technique allows the col-
umella to move upward and eases a tip cephalic rotation.
The prototype of this movement is represented by “nose
lifting” in elderly patients: resection of the covering
planes at the nose root is then possible.
1.5.3.2 The Cephalic Rotation of the Lobule
and the Tip
This cephalic rotation is made possible (Fig. 1.29) by the
conjugated action of (1) the shifting or gliding of the medial
crura over the nasal spine that, in turn, if too forceful, may
pull the superior lip upward, (2) the cephalic retraction of the
membranous septum prolonged by the soft triangle, (3) the
conjoint bending of the articulation of the triangular and alar
cartilage, and (4) the articulation of the caudal extremity
with the pyriform aperture.
11
This rotation movement is limited (1) by the labial–colu-
mellar complex, which is put under tension, (2) by the ante-
rior septal angle that blocks the retraction of the medial crura
and the membranous septum, (3) by the undertow of the tri-
angular–alar junction, and (4) by the “alar chain”: the
sequential transfer of force as the medial crura push down on
the intermediate crura, the intermediate crura push down on
the lateral crura, and finally the prolongation of the cauda
bear upon the pyriform aperture.
–– Simulation of this movement is possible by placing a fin-
ger on the infra-tip and pushing up to raise the tip of the
nose. In addition, at the same time, the domes may be
rolled up with two fingers hooking under the infra-lobular
region. This will slightly pull in the triangular–alar
junctions.
–– The aesthetic implications of this cephalic rotation are (1)
a slight shortening of the nose, (2) a cephalic shift of the
domes that may individualize the tip and make it rounder
or more projected, (3) an obvious opening of the nasola-
bial angle, (4) increased visibility of the nostrils related to
a widening of the columellar–alar angle, and (5) increased
soft-tissue thickness of the junction.
–– The surgical applications correspond to either the execu-
tion of a preservation rhinoplasty or during conventional
“open roof” rhinoplasty, elimination of obstacles, facilita-
tion of this rotation movement, and the fixation of the
result: reduction of the anterior septal angle, reduction of
the triangular–alar junction, release of the caudal exten-
sion of the alar, release of the premaxillary ligament and,
when necessary, of the frenulum of the superior lip, as
well as release of the dermal–cartilaginous ligaments. In
extreme cases, the interruption of the “alar chain” by a
controlled section of the continuity of this cartilage com-
12 Y. Saban and M. Alomani

Fig. 1.29 Tip rotation: Nasal bone Scroll area empty space
reduction of the triangular–
alar junction and the caudal
edge of the septum

ULC

C
LL
option ‘1’

Closing Tongue in
Nasal bone space groove

ULC
S.

option ‘2’

Cephalic resection of the tip provocates closure of the space left by the resection of the scrolls
And protruding of cartilagineous septum into the membranous septum or in the ontermesial space

Option 1 resection of caudal border of the septum allows move back of the columella
Option 2 : tongue in a groove

pletes the mastering of this surgery. Fixation of the result
is obtained by modeling sutures after careful resection of
the excess vestibular skin.
1.5.3.3 Lateral Deviation
–– This lateral deviation is made possible by (1) bending of
the lateral crura of the LLC, (2) bending of the medial
crura and thus of the columella with for effect (3) a defor-
mation of the nostrils by passive adaptation.
–– This deviation is limited by the presence of the septum
and tightening of the skin, which limits shifting.
Furthermore, the interdomal ligament binds together the
intermediate segments of the alar cartilage permitting uni-
fied movement of the tip elements with little shifting of
the position between them.
1.5.3.4 Deprojection of the Nasal Tip
• This deprojection of the tip is made possible by a lower-
ing of the “tripod” of the alar cartilage: (1) at the level of
the medial crura: the membranous septum allows shifting
on the caudal edge of the septum; (2) at the level of the
lateral crura: the caudal extremity folds over the pyriform
aperture; (3) at the level of the triangular–alar junction:
lateral cleavage or shifting.
• This deprojection is limited by the action of tip support
mechanisms (Figs. 1.30 and 1.31): (1) the pressure of the
medial crura on the labial–columellar complex; (2) the
lateral pressure of the cauda propped against the pyriform
aperture and the spring of the lateral crura; (3) the block-
ing of the soft tissues pushing against the anterior septum;
(4) the recoil of the triangular–alar junction (Figs. 1.30
and 1.31).
1 Nasal Biomechanical Anatomy as a Fundamental Basis for Preservation Rhinoplasty
Figs. 1.30 and 1.31 Anatomical preparation. Effects of retrusion of the tip of the nose: “the alar chain”, bending of the caudal extension of the
lateral crura and of the triangular–alar junction (“scroll-winding effect”)
• This movement may be simulated by placing a finger on
the tip of the nose and pressing perpendicularly to the
plane of the face until obtaining contact with the nasal
septum.
• The aesthetic consequences are retrusion of the tip, flar-
ing of the nostrils, and, sometimes, modifications of the
nasolabial angle.
• The surgical applications correspond critically to the
management of “Pinocchio” noses using one of two prin-
cipal methods:
–– Either modifying the feet of the tripod:
Correction (by reduction or burying) of the exces-
sive length of the footplates of the medial crura and
the caudal extensions of the lateral crura, as well as
reduction of the nostrils;
Removal of the blockade of the septum and labial–
columellar complex; release of the triangular–alar
junction;
–– Or by reduction of the apex of this tripod:
Section and reduction of the intermediate crura of
the LLC sometimes associated with the removal of
blocking points if a major reduction is necessary.
1.6 Conclusion
The knowledge of biomechanical anatomy is particularly
important in preservation rhinoplasty and allows the under-
standing of the surgical procedures that will help the surgeon
to adapt his maneuver to the correction desired, by associat-
ing the conservation of the function with the correction of the
aesthetic appearance. When this adaptation is not possible,
then grafts can reasonably be contemplated.
13
References
1. Joseph J. Nasenplastik und sonstige Gesichtsplastik, nebst einem
Anhang über Mammaplastik und einige weitere Operationen aus
dem Gebiete der ausseren Körperplastik. [Nasal plastic surgery and
other facial reconstructive procedures, with an appendix on recon-
structive breast surgery and some other procedures in the area of
external plastic surgery]. Br J Surg. 1931;19(74):341–2. https://doi.
org/10.1002/bjs.1800197416.
2. Toriumi DM, Kovacevic M. Dorsal preservation rhinoplasty: mea-
sures to prevent suboptimal outcomes. Facial Plast Surg Clin North
Am. 2021;29(1):141–53. https://doi.org/10.1016/j.fsc.2020.09.009.
3. Goodale JL. A new method for the operative correction of exagger-
ated Roman nose. Boston Med Surg J. 1899;140:112. https://doi.
org/10.1056/NEJM189902021400503.
4. Saban Y, de Salvador S. Guidelines for dorsum preservation in pri-
mary rhinoplasty. Facial Plast Surg. 2021;37(1):53–64. Epub 2021
Feb 25. https://doi.org/10.1055/s-­0041-­1723827.
5. Gola R. Rhinoplastie fonctionnelle et esthétique. Rappel anatomique
et technique. In: Chirurgie esthétique et fonctionnelle de la face.
Paris: Springer; 2005. https://doi.org/10.1007/2-­287-­26720-­4_14.
6. Gola R, Nerini A, Laurent-Fyon C, Waller PY. Rhinoplastie con-
servatrice de l’auvent nasal [conservative rhinoplasty of the nasal
canopy]. Ann Chir Plast Esthet. 1989;34(6):465–75. French.
7. Cottle MH. Nasal roof repair and hump removal. AMA Arch
Otolaryngol. 1954;60(4):408–14. https://doi.org/10.1001/archo
tol.1954.00720010420002.
8. Goksel A, Saban Y, Tran KN. Biomechanical nasal anatomy applied
to open preservation rhinoplasty. Facial Plast Surg. 2021;37(1):12–
21. Epub 2021 Jan 27. https://doi.org/10.1055/s-­0040-­1715622.
9. Lazovic GD, Daniel RK, Janosevic LB, Kosanovic RM, Colic MM,
Kosins AM. Rhinoplasty: the nasal bones—anatomy and analysis.
Aesthet Surg J. 2015;35(3):255–63. https://doi.org/10.1093/asj/
sju050.
10. Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P. Dorsal
preservation: the push down technique reassessed. Aesthet Surg J.
2018;38(2):117–31. https://doi.org/10.1093/asj/sjx180.
11. Erol O, Buyuklu F, Koycu A, Bas C, Erbek SS. Evaluation of
nasal tip support in Septorhinoplasty. Aesthetic Plast Surg.
2019;43(4):1021–7. Epub 2019 Mar 20. https://doi.org/10.1007/
s00266-­019-­01352-­2.
 How Histology Is Pertinent
for Surgical Approach 2
Vincent Patron

2.1 What Is the Structure of the Nasal

Cartilages?

We have to talk a little about the nasal cartilages: They are

made of hyalin cartilage, which is similar to costal and tra-
cheal cartilage (Fig. 2.1). Nasal cartilage is made of an extra-
cellular matrix and the chondrocytes that produce it. The
matrix is mainly composed of collagen—type II, IX, and
XI—which provide stiffness. The cartilage has no innerva-
tion and no vascularization in itself, which means that pain
and bleeding during surgery are not caused by the carti-
lage but rather by the dissection of the surrounding
tissues.
More important to us than the composition of hyalin car-
tilage is the structure of its perichondrium (Fig. 2.2). The
perichondrium is a connective tissue, mainly composed of
collagen I. It is innervated and vascularized, and it is respon-
sible for nourishing the cartilage and its healing. It is there-
fore of paramount importance when performing a Fig. 2.1 Histological section of an alar cartilage with Masson tri-
subperichondrial dissection. It is composed of two layers: an chrome staining. Note the arrangement parallel to the surface of the
outer one and an inner one. chondrocytes close to the surface, while those in the center are more
The outer one is called the “stratum fibrosum.” It is a perpendicular. The white arrow indicates the perichondrium
fibrous, vascularized, and innervated connective layer that
nourishes the inner layer called the “stratum cellulare.” responsible for cartilage growth. Certain authors
This latter layer is of utmost importance, as it is a chon- described a third, intermediate layer composed only of con-
drogenic layer, composed of chondroblasts, and is nective tissues [1].

V. Patron (*)
Department of ENT—Head and Neck Surgery, CHU de CAEN
Normandie, Caen, France
Normandie Université, UNICAEN, EA7451 BioConnecT—
Biology of Connective and Cutaneous Tissues, Caen, France

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 15

S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_2
16 V. Patron

Fig. 2.3 Anatomical dissection of lower lateral cartilage (LLC). Black

Fig. 2.2 Perichondrial layers. Histological section of an alar cartilage star: “Sub-SMAS” dissection. Notice the feeding vessels above the car-
with Masson trichrome staining and orcein. Orcein (purple) marks the tilage. White star: subperichondrial dissection. Notice the whitish flap
elastin fibers corresponding to the perichondrial flap between the forceps (white
arrow)

2.2 How to Reach the Subperichondrial

Plane in Preservation Rhinoplasty?

According to the concept of preservation rhinoplasty, dissec-

tion is performed in the subperichondrial plane. Figure 2.3
shows a dissection in the subperichondrial plane (white star)
and in the classical plane of rhinoplasty (black star). I think
you can easily see the difference between the two planes.
Figures 2.4 and 2.5 show a magnified view of a subperi-
chondrial dissection under microscopic examination. You
can see that the subperichondrial dissection is made right
under the perichondrium, as well as that the chondrogenic
and the fibrous perichondrium are elevated as a single flap.
This dissection separates the chondrogenic perichondrium
from the underlying cartilage, which explains the need to
scratch the cartilage firmly to find the correct plane. The
Fig. 2.4 Histological section of a superichondrial dissection with
presence of the chondrogenic perichondrium at the inner hematoxyline eosine coloration (HES) staining. The flap includes the
part of the flap explains the whitish and bloodless aspect fibrous and chondrogenic perichondrium (the cartilage and chondro-
of the flap once elevated during surgery (Fig. 2.6). Sharp genic perichondrium is outlined in purple, and the fibrous perichon-
drium in yellow for better understanding)
instruments are thus absolutely mandatory for entering this
plane. You can use various instruments for this purpose like
scissors or a scalpel, but always make sure that your instru- Remember that if you do not actively search for the
ments are really sharp. Also, you must have the aim to subperichondrial plane, you will have no chance to
“attack” the cartilage in order to enter the subperichondrial find it.
plane. If you do not do so, you will be on top of the perichon- Remember that if you have doubt about being in the
drium (Figs. 2.7 and 2.8). subperichondrial plane, then you are not!
2 How Histology Is Pertinent for Surgical Approach 17

Fig. 2.5 Histological section of a subperichondrial dissection with HES

staining in ×2.5 magnification. The red arrow shows the dissection plane.
The difference in size of the chondrocytes/chondroblasts between the car-
tilage (white star) and the chondrogenic perichondrium (black star) can be
seen clearly (the cartilage and chondrogenic perichondrium is outlined in
purple, and the fibrous perichondrium in yellow for better understanding)

Fig. 2.8 Subperichondrial dissection of a left LLC: notice the tear of

the perichondrium during the elevation (arrow and arrowhead, leading
to a true subperichondrial dissection on the left part of the picture
(white star) with the classical “whitish aspect” and an immediate supra-­
perichondrial dissection on the right side (asterisk)

2.3 Why Is Septal Subperichondrial

Dissection Easier Than
the Subperichondrial Dissection
of the ULC and LLC?
Fig. 2.6 Whitish aspect of the perichondrium during LLC subperi- The septal subperichondrial dissection is the classical plane
chondrial dissection
for surgery.
Why is it more difficult to be subperichondrial for the
upper lateral cartilage (ULC) and the lower lateral cartilage
(LLC) than in the septum?
There are three main reasons to explain this statement:

1. The septal perichondrium is thicker.

The thickness of the septal perichondrium is 150 to
200 μm, whereas the ULC and LLC perichondria are only
50 μm thick, and thus less resistant [2].
2. Septal soft tissues are dense, while the soft tissues
around the ULC and LLC are loose.
Periseptal tissues are mainly composed of connective
tissues and glands, whereas the soft tissues around the
ULC and LLC are mainly composed of fat and loose con-
nective tissues (Figs. 2.9 and 2.10).
3. Septal cartilage is stiff, whereas the ULC and LLC are
not.
The primary task of septal cartilage is to provide the
Fig. 2.7 Sharp instrument used to enter the subperichondrial plane.
One must “attack” the cartilage nose with stiffness. The only task of the LLC and ULC is
18 V. Patron

Fig. 2.9 Histological section of septal cartilage with Masson trichrome Fig. 2.10 Histological section of LLC with HES staining. The arrow
staining. The black arrow shows dense soft tissues and the perichon- shows the perichondrium. Just above it is loose, fatty tissue
drium around the septal cartilage

to open the internal and external valve. They are thinner

and more flexible.
Then, when we need to scratch the cartilage to find the
subperichondrial plane, it is easier on the septal cartilage
because the septum itself is more resistant and less mobile
than the ULC and LLC.
You can understand this concept by looking at the
painting “The Floor Scrapers” by Gustave Caillebotte
(Fig. 2.11): it is easier to scrape something hard and resis-
tant than something weak and mobile.

When searching for the subperichondrial plane on the

LLC or ULC, try to stretch the cartilage and make coun-
ter pressure so that it is easier to scratch. Fig. 2.11 “The Floor Scrapers,”, Gustave Caillebotte (1848–1894),
Musée d’Orsay, Paris (Public domain)
2 How Histology Is Pertinent for Surgical Approach 19

2.4 Why Dissect the Subperichondrial

Plane in the Midline of the Dorsum
Rather Than on the Caudal Part
of the ULC?

Once again, this decision is a matter of perichondrial thick-

ness, cartilage stiffness, and mobility.
On the dorsum, the septal perichondrium can be very
thick, up to 1000 μm as shown in Fig. 2.12. In addition, the
septal Y is resistant, and easy to scratch.
One particularity of the dorsum is the presence of the
transverse muscle just above the perichondrium. It can be
very thick and resistant as well, when under tension
(Fig. 2.13).
The perichondrium of the ULC is thin, and the ULC a
weak, mobile cartilage. It is therefore difficult to scratch
it, especially the caudal part, which is very mobile.
This is why, in order to dissect the ULC in the subperi-
chondrial plane, it is easier to begin from the midline on the
septum, then to go laterally to dissect the ULC perichon-
drium, rather than trying to find the plane from the caudal
part of the ULC (Figs. 2.14 and 2.15).
Fig. 2.13 Histological section of the septal dorsum with Masson tri-
chrome with orcein staining, showing a large, transverse muscle (TM)

Fig. 2.12 Histological section of the septal Y with Masson trichrome

staining. The two-way black arrows show the 1000 μm thickness of the
perichondrium
Fig. 2.14 Histological section of the septum and right ULC with HES
staining. The dotted line shows the path of the dissection
20 V. Patron

Fig. 2.15 Dorsal

subperichondrial dissection: a b
the subperichondrial
dissection begins in the
midline on the dorsum (a),
continues laterally over the
ULC (b, c). A sweeping
movement is made to dissect
the caudal part of the ULC (c,
d). Do: dorsum. White star:
dorsal perichondrium. Arrow:
sweeping movement

c d

2.5 Can I Perform a Continuous

Subperichondrial Dissection
from the LLC Up to the Nasal Bones?

When performing a subperichondrial dissection from the

caudal part of the LLC to the nasal bones, two areas are dif-
ficult to dissect: the scroll area and the ULC/bone junction
(Fig. 2.16). In both those transition areas, it is difficult to
follow the subperichondrial plane.
For some authors, the periosteal and perichondrial enve-
lope is continuous [3–5], especially in the UCL/bone junc-
tion where Popko et al. describe the blending of the periosteal
and perichondrial fibers, referring to it as the periosteal/peri-
chondrial covering. We will see more in detail the UCL/bone
junction in the next paragraph.
When examining the scroll area specifically, as in
Figs. 2.17 and 2.18, it appears that the scroll area is com-
posed of dense, connective tissue rather than a continuous Fig. 2.16 View of the scroll ligament and ULC/bone junction
two-layered perichondrium. This connective tissue may cor-
2 How Histology Is Pertinent for Surgical Approach 21

Fig. 2.17 Histological

section of a right scroll area
with Masson trichrome
staining. Scroll sesamoid
cartilages (Sc) are embedded
in a connective structure
which correspond to the scroll
ligament complex (SLC)

Fig. 2.18 Histological section of a right scroll area with HES staining
showing an image of the scroll similar to Fig. 2.17

respond to the so-called scroll ligament complex [6, 7]. The

ULC, LLC, and each scroll sesamoid exhibit their own peri-
chondrium. In some cases, the distinction is more difficult,
as in Fig. 2.19, where the scroll area shows a dense, collag-
enous bundle and continuity of the perichondrium into the
scroll area as also described by Karapinar et al. [4].
Regardless of the anatomical variations in the scroll area, a
dissection should preserve its integrity. To achieve this goal,
when you reach the cranial part of the LLC in a subperichon-
drial manner, the dissection should continue beneath the scroll
ligament just above the vestibular mucosa, then reach the cau-
dal part of the ULC (Fig. 2.20a). Opening the perichondrium
here is difficult. At this level, the dissection should join the Fig. 2.19 Histological section of a left scroll area with Masson tri-
subperichondrial dissection performed from the midline to the chrome staining and orcein. The asterisks indicate the collagenous
caudal part of the ULC (Figs. 2.20b–d and 2.21). bundles
22 V. Patron

Fig. 2.20 Dissection of a left

scroll area. (a) a b
subperichondrial dissection
over the LLC. (b) entering the
scroll area. (c) reaching ULC.
(d) dissection over the ULC
under the scroll area. Sc scroll
cartilages, black star LLC
perichondrium

c d

2.6 How Does the ULC Connect

to the Nasal Bones?

This question is of paramount importance if you intend to

Fig. 2.21 Histological section of a right scroll area with HES staining.
The black dotted lines indicate the dissection planes from below. The
green dotted line indicates the subperichondrial dissection plane from
above
perform any of the partial dorsal preservation techniques
such as Ferreira’s spare roof technique, Ishida’s technique, or
Jankowski’s disarticulation technique [8–10].
Two main features characterize the keystone area:
First, the ULC and septum form a cartilaginous arch under
the bony cap, with an overlap of 8 to 9 mm on average [3, 11, 12].
This overlap is more important on the dorsal keystone area
(DKA) than on the lateral keystone area (LKA) [12] (Fig. 2.22).
At this level, the septo-triangular cartilage has the same
Y-shaped beam as more caudally. For Jankowski, this Y is
due to the fusion/invagination of the embryological left and
right intermaxillary processes on the midline [13]. For Popko
et al., the Y-shaped beam has a supportive effect in the archi-
tecture (Fig. 2.23) [3]. It thus makes sense to preserve the
2 How Histology Is Pertinent for Surgical Approach
Fig. 2.22 Left ULC/bone junction. Asterisk: ULC extension under
nasal bone; black star: bone periost; dashed lines: site of section of the
periosteal/perichondrial covering on the distal part of the nasal bones
Fig. 2.23 Y-shaped beam pillar supporting a bridge. (Photo: Michael
Sander)
23
Fig. 2.24 Histological slice of the Y-shaped beam of the septo-­
triangular cartilage in the dorsal keystone area. Mallory staining. Black
arrow: artery. White arrow: vein. B: nasal bone. Double black arrow:
thick multilayered perichondrium. Double white arrow: loose
perichondrium
cartilaginous dorsum, not only for esthetic reasons, but
also for mechanical reasons. Another role of this Y-shaped
beam seems to be vascularization, via large arteries and veins
filling the groove between the cartilage and bone (Fig. 2.24).
This is another argument for preserving the dorsum, avoid-
ing both damage to those vessels and a bloody operating area
during surgery.
The second feature of the keystone is a perichondrial/
periosteal cover, joining the ULC and nasal bone: the pi
riform aperture ligament (PAL). It is this ligament that is
severed during Jankowski’s disarticulation or Goksel’s bal-
lerina maneuver [7, 14].
The ULC is firmly attached to the bone of the pyriform
aperture by a merging of the ULC fibrous perichondrium and
nasal bone (or frontal process of the maxilla) periosteum,
consistent with a real PAL [3, 5, 12, 15, 16] (Fig. 2.25). This
ligament can be as thick as 1 mm and has the particularity of
attaching directly to the bone at its distal edge, confirming its
anchor role (Fig. 2.26). On the remaining borders of the bone
and cartilage, the periosteum and perichondrium fibers
remain parallel. Vessels can be found within the ligament.
On the dorsal keystone area, the ligament is very thick
(more than 1 mm) and made of multiple layers of fibrous
periosteum and perichondrium oriented in different direc-
tions (Fig. 2.24). Small vessels can be found inside it and
larger ones in its inferior part, between two layers of peri-
chondrium (as described above). The perichondrium around
the vessels and at the bottom of the groove is looser than at
the top.
The overlap area between the bone and cartilage
shows fewer anchoring structures. Only occasionally is it
possible to find dense bundles of fibrous connective tissue
24
Fig. 2.25 Histological slice of a right lateral keystone area with
Masson trichrome staining and orcein showing the dense PAL between
the nasal bone (B) and the ULC. The PAL is a mixture of periosteal and
perichondrial fibers. Note the loose connective tissue between the over-
lap of the ULC and the nasal bone (white arrow). TM transversalis
muscle
Fig. 2.26 Histological slice of a left PAL with Masson trichrome stain-
ing and orcein. The black arrows show the orientation of the periosteal
and periosteal fibers of the PAL. Red arrowhead: vessel into the
PAL. The white arrow shows the loose connective tissue at the level of
the overlap
V. Patron
Fig. 2.27 Histological slice of a right lateral keystone area with
Mallory staining. The black arrows show the dense bundles of perios-
teal/perichondrial fibers stretched between the ULC and the bone (B) in
the overlap area
unifying the bone and cartilage as anchoring ligaments
(Figs. 2.27 and 2.28). Most of the time, the overlapping
space is filled with very loose connective tissue, vessels, and
nerve, surrounded by thin parallel periosteal and perichon-
drial fibers. The vessels are mostly veins (Fig. 2.29).
What to conclude from these observations? The answer is
that the PAL has no significant suspensory action. The forces
that push the ULC to the nasal bones or frontal process of the
maxilla come from the natural strength of the cartilaginous
vault. This explains why disarticulation or ballerina maneu-
vers do not create step/inverted V deformity.
2 How Histology Is Pertinent for Surgical Approach
Fig. 2.28 Histological slice of the dorsal keystone area with Mallory
staining. The asterisk shows dense bundles of periosteal/perichon-
drial fibers stretched between the ULC and the bone in the dorsal
keystone (B)
Fig. 2.29 Histological slice of a left overlap area with Masson tri-
chrome staining and orcein. The white asterisk shows the loose connec-
tive tissue filling the area. Red arrows indicate veins. Po periosteum, Pc
perichondrium, B bone, PAL beginning of the pyriform aperture liga-
ment (see Fig. 2.26)
25
2.7 How Does the LLC Connect
to the Pyriform Aperture?
The area between the most lateral part of the LLC and the
pyriform aperture is an area where rhinoplasty surgeons
rarely extend their dissection. It is thus not very familiar to
them.
However, it has a functional interest as it relates to the
nasal valve area.
This area has been called the pyriform ligament by
Rohrich et al. [17, 18]. Macroscopically, it is possible to
isolate a fascial network in that location (Fig. 2.30).
Histologically, this tissue is composed of very dense con-
nective tissue, c­ onnecting the bone to the adjacent cartilage
(accessory cartilages and LLC) (Fig. 2.31). Its particularity
Fig. 2.30 Anatomical dissection of the pyriform ligament
Fig. 2.31 Histological slice of a left pyriform ligament with Masson
trichrome staining and orcein (dotted lines) stretched between the bone
in the frontal process of the maxilla (B) and the LLC. Note the wave
form of the ligament with a purple center of elastin. Gl mucous glands,
Ad adipose tissue, TM transversalis muscle
26
is the presence of large layers of elastin fibers, producing
the wave form of the ligament, as seen on histological slices
(Figs. 2.31 and 2.32). When stretched between the bone
Fig. 2.32 Closer view of a histological slice of the pyriform ligament
with Masson trichrome staining and orcein showing the wave form of
the ligament with its purple center of elastin. Gl mucous glands, Ad
adipose tissue
Fig. 2.33 Case study 1
V. Patron
and cartilage, elastin fibers are likely to keep the ligament
taut against inhalation maneuvers. The ligament can be
crossed by vessels, and lies between glandular structures on
the mucosal side, and fat and fibers of the transverse muscle
on the skin side.
2.8 Case Study
Case Study 1 (Fig. 2.33)
This patient presented with a right homogeneous nasal pyra-
mid and septal deviation plus a dorsal hump and a boxy tip
which she wanted to have corrected.
A closed septorhinoplasty was performed by bilateral
marginal approach. Septoplasty was performed followed by
subperichondrial/periosteal dissection. 5 mm steal and 5 mm
crural overlap followed by classical Cakir tip plasty with a
2-cm strut graft. Let Down technique was performed with
resection of a 4 -mm left nasal bone resection. Low septal
strip and fixation of the septum to the nasal spine. Partial sec-
tion of the Pitanguy ligament. 1 year result.
2 How Histology Is Pertinent for Surgical Approach 27

Fig. 2.33 (continued)

28
Case Study 2 (Fig. 2.34)
This patient presented a nasal obstruction and a crocked nose
following multiple ancient traumas (Fig. 2.35).
Open septorhinoplasty with subperichondrial and sub-
periosteal dissection was performed. A septoplasty was per-
Fig. 2.34 Case study 2
V. Patron
formed followed by rhinosculpture of the left nasal bone
with Piezotome and lateralization of the right nasal bone.
Section with Piezotome of the bony dorsum following the
fracture lines and proper replacement of the bones preserv-
ing the bony dorsal integrity. Tip surgery with Cranial Dome
2 How Histology Is Pertinent for Surgical Approach
Fig. 2.34 (continued)
Fig. 2.35 Preoperative 3D volume rendering of the case study 2
patient’s CT scan
Sutures and stabilization of the tip with an ANSA banner.
1 year result.
Case Study 3 (Fig. 2.36)
This patient presented for a left nasal septal obstruction and
desired a nasal refinement, she disliked her nasal profile.
29
Closed septorhinoplasty via a bilateral intercartilaginous
approach. Subperichondrial and subperiosteal dissection
with rasping of the dorsal hump of 3 mm and nasal bones
laterally, septoplasty allowing septal relaxation on midline,
reduction of 3 mm of the height of the dorsal septum fol-
lowed by spreader flaps. 3 mm reduction of the caudal sep-
tum to correct a slight hanging columella. No tip surgery or
dissection. 1 year result.
In this patient, a cartilaginous preservation of the dorsum
could have been performed instead and would have surely
allowed to maintain an ideal dorsal cartilage width and
height.
Case Study 4 (Fig. 2.37)
This patient presented with a left septal deviation, dorsal
hump, plunging tip, and hanging columella.
A closed septorhinoplasty was performed by bilateral
marginal approach. Septoplasty was performed followed by
subperichondrial/periosteal dissection. 1 mm alar rim inci-
sions, 4 mm steal, and 2 mm crural overlap followed by clas-
sical Cakir tip plasty with a 2.5-cm strut. 3 mm high septal
strip with Push Down technique. 1.5 year result.
30 V. Patron

Fig. 2.36 Case study 3

2 How Histology Is Pertinent for Surgical Approach 31

Fig. 2.37 Case study 4

32
Fig. 2.37 (continued)
2.9 Conclusions
Subperichondrial dissection is truly a subperichondrial dis-
section below the inner chondrogenic layer of the perichon-
drium. If the perichondrium is respected during dissection, it
does not generate fibrosis or devascularization, but instead
activates the chondrogenic activity of chondroblasts, result-
ing in cartilage production. It is therefore of paramount
importance to take care of the perichondrium when you
dissect.
In addition, histology teaches us that to correctly enter the
subperichondrial plane requires three things: (1) sharp instru-
ments, (2) keeping the cartilages stretched during the scratch-
ing maneuver, and (3) performing appropriate counter
pressure if possible.
Starting the dissection at the point where the cartilage is
its stiffest and least mobile, and where the overlying tissues
are the densest, can make the maneuver easier.
In the dorsal and lateral keystone, the PAL anchors the
bony pyriform aperture to the ULC but does not seem to have
supportive effect. This is the role of the Y beam shape of the
septo-triangular cartilage to support the middle third.
In the lower part of the pyriform aperture, the pyriform
ligament spans the space between the pyriform aperture and
the LLC and seems to have a functional effect.
Both structures have their own role and should be pre-
served if possible.
Acknowledgments The author would like to thank Dr. Pauline
Géraldy, Pr Guénaëlle Levallet, and Maëlle Guyot for their technical
help.
V. Patron
References
1. Bairati A, Comazzi M, Gioria M. A comparative study of
perichondrial tissue in mammalian cartilages. Tissue Cell.
1996;28(4):455–68.
2. Bleys RLAW, Popko M, De Groot J-W, Huizing EH. Histological
structure of the nasal cartilages and their perichondrial envelope.
II. The perichondrial envelope of the septal and lobular cartilage.
Rhinology. 2007;45(2):153–7.
3. Popko M, Verlinde-Schellekens SAMW, Huizing EH, Bleys
RLAW. Functional anatomy of the nasal bones and adja-
cent structures. Consequences for nasal surgery. Rhinology.
2018;56(1):89–95.
4. Karapinar U, Kilic C, Develi S, Gamsizkan M, Yazar F. The ana-
tomical and histological features of the area between the upper
and lower lateral nasal cartilages: a pilot study. J Exp Integr Med.
2013;3(1):57–61.
5. Popko M, Huizing EH, Menger DJ, Verlinde-Schellekens
SAMW, Mackaaij S, Bleys RLAW. New insights into tip sup-
porting structures. Consequences for nasal surgery. Rhinology.
2020;58(5):506–15.
6. Daniel RK, Pálházi P. Rhinoplasty: an anatomical and clinical atlas.
Berlin: Springer; 2018. p. 349.
7. Daniel RK, Palhazi P, Saban Y, Çakir B. Preservation rhinoplasty.
3rd ed. Istanbul: Septum; 2021.
8. Gonçalves Ferreira M, Santos M, Rosa F, Sousa CA, Santos
J, Dourado N, et al. Spare roof technique: a new technique for
hump removal—the step-by-step guide. Plast Reconstr Surg.
2020;145(2):403–6.
9. Ishida J, Ishida LC, Ishida LH, Vieira JC, Ferreira MC. Treatment
of the nasal hump with preservation of the cartilaginous framework.
Plast Reconstr Surg. 1999;103(6):1729–33; discussion 1734–5.
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by disarticulation. Eur Ann Otorhinolaryngol Head Neck Dis.
2021;138(3):195–9.
11. Palhazi P, Daniel RK, Kosins AM. The osseocartilaginous vault
of the nose: anatomy and surgical observations. Aesthet Surg J.
2015;35(3):242–51.
2 How Histology Is Pertinent for Surgical Approach
12. Natvig P, Sether LA, Gingrass RP, Gardner WD. Anatomical details
of the osseous-cartilaginous framework of the nose. Plast Reconstr
Surg. 1971;48(6):528–32.
13. Jankowski R. The evo-devo origin of the nose, anterior skull base
and midface. Paris: Springer; 2013. 210 p.
14. Jankowski R. Septoplastie et rhinoplastie par désarticulation: his-
toire, anatomie, chirurgie et architecture naturelles du nez. Elsevier
Masson; 2016. 370 p.
15. Daniel RK, Palhazi P. The nasal ligaments and tip support in rhi-
noplasty: an anatomical study. Aesthet Surg J. 2018;38(4):357–68.
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16. Craig JR, Bied A, Landas S, Suryadevara A. Anatomy of the upper
lateral cartilage along the lateral pyriform aperture. Plast Reconstr
Surg. 2015;135(2):406–11.
17. Rohrich RJ, Hoxworth RE, Thornton JF, Pessa JE. The pyriform
ligament. Plast Reconstr Surg. 2008;121(1):277–81.
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tomical study of the nasal superficial musculoaponeurotic sys-
tem: surgical applications in rhinoplasty. Arch Facial Plast Surg.
2008;10(2):109–15.
 Photography Evaluation and Morphing
for Preservation Rhinoplasty
Garyfalia Lekakis
The more importance you give to patient photography, the more you will develop your own standards and
make your patients feel valued
—Baris Çakir
3.1 Background Information: Why This
Particular Subject Has
to Be Particularly Studied?
Many rhinoplasty surgeons have difficulties in recording
consistently standardized photographs in an office setting.
The ease and widespread use of the smartphones with
increased power cameras has demotivated them from devel-
oping those essential photographic skills. Still, perusal and
scrutiny of patients’ photographs in articles from the medical
literature and from presentations in congresses identifies a
number of deficiencies present. It is clear that the art and
technology of photography can be overwhelming at first for
rhinoplasty surgeons. However, understanding basic photog-
raphy equipment and principles is critical for developing a
successful practice. Rhinoplasty remains very much a visual
endeavor, and as such visual cues are the best way to com-
municate with the patients and build up rapport by providing
information that may be difficult to accurately convey with
words and measurements only. It is for this reason that the
communication process demands more time and effort than
any other procedure of the head and neck region [1], particu-
larly because rhinoplasty allows very little or no margin for
error. The surgeon unwilling or unable to devote sufficient
extra time to planning in the interest of an excellent result
G. Lekakis (*)
Department of Otorhinolaryngology Head and Neck Surgery,
Hôpitaux Iris Sud, Brussels, Belgium
Louise Medical Centre, Brussels, Belgium
Department of Otorhinolaryngology Head and Neck Surgery,
University Hospitals Leuven, Leuven, Belgium
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_3
3
usually finds mediocrity a frequent companion [1]. On the
contrary with some attention to detail and a small investment
in time and money professional quality standardized images
can be achieved, and subsequently computer enhanced in
order to simulate surgical goals.
3.2 Description of the Technique Photos/
Videos
The standard care in rhinoplasty for the last 50 years has
been the use of 2D (two-dimensional) photographs.
Guidelines for photography standards have been well docu-
mented in the literature by different authors [1–6] for decades
now. In the United Kingdom, the Institute of Medical
Illustrators (IMI) has published National Guidelines as a
guide to good practice (Institute of Medical Illustrators
National Guidelines) [7]. The essential aspects of preparing
the studio and equipment are presented in this section.
3.2.1 Equipment
3.2.1.1 Camera
The recommended camera to use is a digital single-lens
reflex (DSLR) camera with a CMOS (complementary metal-­
oxide-­semiconductors) sensor and manual controls [7]. This
is also known as a “full-frame” 35 mm sensor. However,
cameras with sensors smaller than 35 mm, also known as
APS-C (advanced photosystem type C) or “crop frame” can
also be used, but they capture a narrower field of view than
“full-frame” cameras. One of the advantages of using a
DSLR camera is the choice of a wide variety of lenses
35
36
Fig. 3.1 The author’s DSLR
camera and macro lens
105 mm
(Fig. 3.1). The sensor is composed of millions of capacitors,
each of which accounts for one pixel of the image [8]. Pixel
density is related to resolution, a factor in image quality. A
resolution of 1.5 megapixels was once considered acceptable
for medical photography [4]. At the present time and the
speed of improvement in digital technology for photography,
new models of DSLR cameras come with 24-megapixel
sensors.
3.2.1.2 Lens
In photo documentation of the patient undergoing rhino-
plasty, it is important to use a lens that produces the least
distortion and provides the largest depth of field (DOF) to
ensure that the whole face is in focus [6].
Therefore, proper lens selection is crucial in order to
enable facial features to appear natural and non-distorted.
The key word here is focal length which ideally should be
between 90 and 105 mm [2, 4]. The focal length of lens is
defined as the distance in millimeters from the optical center
of the lens to the focal point located on the image sensor.
These lenses are known as “macro” or “portrait” lenses and
are produced for near focusing. This very much allows the
option of close-up portrait photography while keeping a
comfortable camera to patient distance of 2 m. Lenses with
shorter focal lengths should be avoided because they have a
wider angle of view and produce a central bulging “fish-eye”
appearance when used to photograph the face [3, 4]. In fish-­
eyed photos, you can see less of the ears and the nose tip will
also look bulbous. The same effect is achieved if you get
close to the patient and zoom out with the lens or if you take
photos with a smartphone. Patient counseling regarding this
effect is essential especially if we consider the popularity of
selfies, the ease with which are taken and the distortion of the
nose, most notably an increase in nasal dimensions, due to
the short distance from the camera [9].
In addition to focal length of the lens, several other factors
influence image characteristics. DOF refers to the distance
between the nearest and the furthest points in focus. For the
G. Lekakis
purposes of rhinoplasty, the DOF should include the entire
face with the nose at the focal point and with the greatest
definition. DOF may be manipulated by altering three fac-
tors: focal length of lens, distance between photographer and
subject, and aperture size. The lens aperture is made up of an
adjustable diaphragm that controls the passage of light
through the lens. Aperture size is measured as f-stops and
have an inverse relationship to aperture size. Decreasing
aperture size will increase the DOF; f-stops values of f10 to
22 will typically ensure that the entire subject will be in
focus [2, 4, 10].
3.2.1.3 Lighting
Lighting is of immense importance in photography for
patients undergoing rhinoplasty. It is critical to extract the
fine anatomic details and contours of the nose for our evalu-
ation and facial analysis. Different light arrangements, light
sources or positions can influence the final photographic
quality. The most inexpensive form of lighting is to use a
single-mounted camera flash, but this will produce harsh
shadows and uneven lighting [11] (Fig. 3.2a, b).
Additionally single flashlight, although simple and eco-
nomic, it will exacerbate the deformity; and if used preopera-
tively only, in combination with good lighting conditions
postoperatively will result to what is known as “light cheat”
where half the surgery is done by light changes alone [10]
(Fig. 3.2c, d).
It is therefore recommended that all views are taken with
two studio grade electronic flash, which provide diffuse indi-
rect light to produce shadowless images and both positioned
at 45° to the patient–camera axis, slightly above head level,
in order to prevent facial shadows and get natural light reflec-
tions. Large diffuse reflectors, soft boxes, and shoot-through
umbrellas may also be used to reduce some of the harshness
and improve the quality of the photo-documentation
(Fig. 3.3). As a high level of detail must be obtained, a maxi-
mum DOF is required, therefore the overall light source must
be sufficient.
3 Photography Evaluation and Morphing for Preservation Rhinoplasty
Fig. 3.2 (a) The same patient photographed with one single flash pro-
ducing harsh shadows and two synchronized studio flashes on the fron-
tal view. Both photos are pre-operative. (b) The same patient
photographed with one single flash and two synchronized studio flashes
on the left profile view. Both photos are pre-operative. (c) The same
37
patient photographed with one single flash and two synchronized studio
flashes on the right oblique view. Both photos are pre-operative. (d) The
same patient photographed with one single flash and two synchronized
studio flashes on the basal view. Both photos are pre-operative
38 G. Lekakis

Fig. 3.2 (continued)

3 Photography Evaluation and Morphing for Preservation Rhinoplasty 39

Fig. 3.3 Light and soft box used for portrait photography in the clinic

3.2.1.4 Background
The studio background should be of a uniform color and
neutral in order to place focus on the patient and avoid dis-
tractions. It is important to choose well the background, as it
is difficult to change this part of your studio in the office
easily [10]. The best choices are black and blue. Black is
more artistic but when it comes to an individual with darker
complexion it blends into the hair color. Blue provides suf-
ficient contrast, it is complimentary to all skin types, and
remains pleasant to the eye without overwhelming the sub-
ject [4, 5] (Fig. 3.4).

3.2.1.5 The Lighting Setup

The author is using a modified version of the quarter light
system (two lights for the patient and two backlights for the
background) that demands large space. This modification
consists of two synchronized studio flashes of equal intensity
positioned at 45° from the subject–camera axis with the
patient placed 1 meter from the background to minimize
shadows and eliminates the need for backlights (Fig. 3.4).
The location of the lights and the position of the patient have
to be maintained at all times that photography is performed.
The angle of light presentation has to be respected because if
the angle is increased, the tip-defining points may seem
wider, and vice versa [2]. Maintaining the light sources at a
fixed angle for all photos over time ensures that changes in
the horizontal angle of incidence reflect the result of surgery
and not the result of “photographic tip rhinoplasty.”.
3.2.1.6 Patient Preparation and Positioning
Patients need to be aware of the purpose of photography as
part of the consultation and that all images will be part of
Fig. 3.4 Photographic studio setup in the clinic
their medical record for surgical planning [2]. Informed con-
sent should be taken for photography [7], especially when
the surgeon plans to use the images for education, scientific
presentations/publications, or marketing. All detailed intents
of the photographs should be incorporated in the consent
from [2, 12]. Written informed consent is the key to limiting
liability and addressing legal issues related to the use of pho-
tography in rhinoplasty practices [12].
Both the patient and surgeon/photographer should be
positioned correctly, in a standardized manner, to produce
consistent photographs. This can be achieved by
40
a b
Fig. 3.5 (a) Preoperative photography for a rhinoplasty patient. (b) Preoperative photography for a rhinoplasty patient
• Ensuring the patient has suitable supportive seating that
can be adjusted to account for the height of the patient.
Markers on the floor may be used to fix the position of the
stool and to guide the patient in obtaining repeatable
views (Fig. 3.4).
• Removing distracting facial jewelry or spectacles and
placing the hair back with discreet bands/clips allow a
clear facial outline as well as both ears and forehead to be
fully visible.
• Instructing the patient to sit upright with their head
straight and both feet placed firmly on the floor achieves
the correct head alignment using the Frankfort horizontal
plane (an imaginary line from the infra-orbital rim to the
upper margin of the auditory opening) as a reference,
which should be parallel to the floor. The camera lens axis
should be horizontal and the camera back vertical (por-
trait photography), positioned at the same height as the
nose of the patient (Fig. 3.5a, b).
3.2.1.7 Standard Photographic Views
Standardized, recommended views for rhinoplasty are dem-
onstrated in Fig. 3.6. These views include the anteroposte-
rior, right lateral, right oblique, left oblique, left lateral,
inferior, basal, and the superior view. Additional views that
might be beneficial for surgical planning are the smiling lat-
eral and smiling anteroposterior views as well as some close-
­up views. The superior view allows an assessment of subtle
deviations of the dorsum and the smiling lateral view depicts
the dynamic changes of the nasal tip due to tip ptosis or over-
active depressor septi muscle.
Standard anteroposterior view: both ears should be clearly
visible and the forehead should be aligned with the chin.
Standard lateral view: the contralateral eyebrow should
not be visible.
G. Lekakis
Standard oblique view: the nasal tip is aligned with the
contralateral cheek contour.
Standard basal view: the head should be tilted back so that
the nasal tip is aligned to the glabella.
Standard inferior view: this view requires less elevated
position to include more of the nasal bridge by aligning the
nasal tip to the medial canthi.
Superior view: ask the patient to lower their head forward
below the horizontal midplane, so that the entire nasal bridge
can be photographed.
3.2.1.8 Photography Archive
An important asset of digital photography is the ability to
store and organize images, and the photo archive of a rhino-
plasty surgeon is considered priceless [10]. Nevertheless,
photography and data management of a rhinoplasty practice
has undergone a rapid change in complexity over the last
20 years because of an evolution of mechanisms in data por-
tability combined with governmental focus on health infor-
mation privacy [13].
Photographs taken and archived in rhinoplasty practices
are protected health information and must be handled in a
way that is compliant with federal laws such as the Health
Insurance Portability and Accountability Act (HIPPA) in the
USA [2, 12]. Although digital revolution has made techni-
cally simple to take clinical photographs, safeguarding infor-
mation stored on devices and backup storage media is less
simple but of upmost importance [14]. Use of passwords and
other means of user authentication is an essential practice.
3.2.1.9 Computer Imaging
Another important advantage of digital photography is the
potential to use computer imaging to facilitate communica-
tion with the patient and education of junior surgeons.
Computer imaging, also called morphing, allows surgeons
3 Photography Evaluation and Morphing for Preservation Rhinoplasty
Fig. 3.6 Standard views for photography of the rhinoplasty patient: anteroposterior, right oblique, right lateral, left oblique, left lateral, inferior,
basal/worm’s eye, and superior/bird’s eye view
to manipulate digital photographs of the nose for patients
seeking rhinoplasty [15], allowing photographs to serve a
predictive than solely documentary role [16]. It is a process
that entails a discussion and a preview of the proposed sur-
gical changes that may be difficult to communicate without
visual cues. Consequently, patients can understand better
the surgical goals, surgeons can appreciate better patients’
expectations, and to a degree use the application for patient
selection [17]. It is after all the surgeon’s responsibility to
temper the patient’s desires to realistic goals [18]. Adobe
photoshop (Adobe Systems Inc.) is a commonly used imag-
ing editing program and a few articles in the literature serve
as step-by-­step tutorials demonstrating different Photoshop
tools [19, 20].
Over recent years, three-dimensional (3D) photography
and imaging are gaining popularity in rhinoplasty and used
routinely in academic practices and private clinics, but they
have yet to be universally accepted. The limitations of 2D
41
images to address facial depth and nasal shape drive the tech-
nological evolution of 3D surface-imaging systems which
offer additional valuable data, such as volumetric analyses
and surface topographic distance measurements [21].
Additionally, there are 3D surface-imaging systems, such
as the Canfield Vectra (Canfield Scientific Inc., Parsippany,
NJ) that have an integrated system for both image simulation
and storage. A number of publications in the literature extols
the numerous advantages of this technology for surgeons and
patients, making it the current state of the art in preoperative
counselling and planning during rhinoplasty [22–26].
3.3 Conclusion
Understanding the basic photography equipment and princi-
ples, lighting, as well as patient preparation and positioning
are crucial to producing consistent, high-quality, standard-
42
ized images. It is vital that these standards are maintained as
photography in rhinoplasty is the best instrument for facial
analysis, patient education, surgical planning, postoperative
follow-up, critical evaluation, and self-improvement. With
the continued technology innovation, the importance of 3D
surface imaging will only be increasing in the future, push-
ing rhinoplasty surgery, to even a higher surgical standard.
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and analysis. Otolaryngol Clin North Am. 2002;35(1):1–27. v.
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rhinoplasty patient. Clin Plast Surg. 2022;49(1):13–22.
3. Swamy RS, Sykes JM, Most SP. Principles of photography
in rhinoplasty for the digital photographer. Clin Plast Surg.
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noplasty. Plast Reconstr Surg. 2002;109(4):1421–34.
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North Am. 2010;18(2):245–52. Table of Contents.
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surgery: pearls and pitfalls. Facial Plast Surg. 1999;15(2):93–9.
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IMINatGuidelines_Rhinoplasty_V2x-­1.pdf
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care for rhinoplasty patients. Facial Plast Surg Clin North Am.
2009;17(1):7–13. v
19. Hamilton GS. Morphing images to demonstrate potential surgical
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 Cone-Beam CT or CT Scan Analysis
for Routine Pre-Operative Planning
Before Rhinoplasty
Nicolas Baldini and Yves Saban
Key Points
The main CBCT or CT sections for pre-operative planning
are:
–– The horizontal sections: with the width and the shape of
the pyriform aperture.
–– The median sagittal section: with the position of the
anterior angle of the perpendicular plate of the ethmoid
and the location of the frontal sinuses, which sometimes
extend into the radix.
–– The horizontal and frontal sections: with the septum, and
the turbinates.
Pre-operative CBCT or CT scan enables any abnormalities
involving the turbinates and paranasal sinuses to be detected,
and the need for any associated surgical procedure to be
planned.
3D reconstructions offer surgeons new applications,
enhancing the analysis of nasal bone characteristics or of
surface aesthetics.
4.1 Introduction
Medical imaging has been considerably improved and
currently enables new considerations in the field of facial
analysis and surgical planning. CBCT is a medical imaging
technique consisting of X-ray computed tomography where
the X-rays are divergent. Therefore, the main difference
between CT scan and CBCT is the shape of the beams: CT
scans use fan-shaped X-ray beams that rotate while the
patient advances to capture limited thickness slices, whereas
N. Baldini
University of Bordeaux College of Health Sciences,
Bordeaux, France
Y. Saban (*)
Private Clinical Practice, Nice, France
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_4
4
CBCT uses a cone-shaped area detector that does not require
patient movement. Thus, it offers a significantly higher
resolution for bone structures. On the other hand, because of
its lower dosimetry, it produces a low resolution in contrast,
and will be ineffective for the evaluation of the density, and
thus of the soft tissues. Digital Imaging and Communications
in Medicine (DICOM) is the standard for the communication
and management of medical imaging information and related
data. DICOM is most commonly used for storing and
transmitting medical images, enabling the integration of
medical imaging devices.
Cone beam CT causes the patient no inconvenience and
has very few, if any, drawbacks, with these being limited to
radiation exposure and limited cost. The radiation exposure
from CBCT is up to four times less than that incurred from a
conventional CT scan. Nevertheless, depending on the
countries, the cost can act as a brake to its routine use for
pre-­operative planning before rhinoplasty [1].
4.2 Clinical Case
A 29-year-old woman seeking a primary rhinoplasty. No
history of nasal trauma. No psychological issues. Functional
and aesthetic complaints.
The physical examination focuses on facial harmony, skin
quality and thickness, dorsal aesthetic lines, nasal base and
tip, type of nose from a profile view; then, the endonasal and
functional assessment.
The results of this physical examination of the patient’s
characteristics are: harmonious face but asymmetric face,
thin skin.
Front view: dorsal aesthetic lines are good. Significant
septal deviation to the right-hand side, narrow pyriform
aperture, and inferior turbinate hypertrophy. Squared tip
with no deformities, wide nostrils (Fig. 4.1).
Profile view: tension nose or “type II nasal profile”
(according to Saban’s classification) [2] (Fig. 4.2).
43
44 N. Baldini and Y. Saban

The patient complains of nasal obstruction; furthermore, This physical examination is then completed by the
she does not like the hump and the wide nostrils. CBCT or CT scan analysis:
Patient’s expectations: a more feminine look and
improved breathing. A straight nose with a natural appear-
ance is desired. 4.2.1 Pyriform Aperture

On the left, we can see the narrow pyriform aperture reducing

the nasal airway (white stars) (Fig. 4.3). On the right, this is
the relevant slice for analyzing the pyriform aperture. In the
axial plane, we use the slice passing through the inferior
turbinates and showing the frontal process of the maxilla.
This slice enables us to evaluate the “functional width”
(white stars) at the level of the inferior turbinates, which dif-
fers from “anthropometric measurements” referring to the
largest width of the pyriform aperture (leptorrhine, mesor-
rhine, platyrrhine) [3]. When the frontal process of the max-
illa narrows the pyriform aperture, we may observe that the
direction of the ascending process is not parallel to the infe-
rior turbinates but oblique inside the pyriform aperture.
Clinical relevance: Narrow pyriform aperture and
furthermore any push-down procedure is likely to
compromise a little bit more the nasal airflow. Therefore,
resection of the lower pyriform aperture (Webster’s triangle),
possibly associated with a let-down in the case of a lowering
of the dorsum greater than 5–6 mm, would be the preferred
Fig. 4.1 Pre-operative frontal view technique.

Fig. 4.2 Pre-operative profile view, and overlay of the 3D bony reconstruction of CBCT
4 Cone-Beam CT or CT Scan Analysis for Routine Pre-Operative Planning Before Rhinoplasty 45

Fig. 4.3 Narrow pyriform aperture (white stars)

Fig. 4.4 Cone beam CT in frontal view with the corresponding segmented structures in 3D images: septum in blue, right inferior turbinate in red,
and right middle turbinate in green

4.2.2 Turbinates, and Septum Clinical relevance: In the case of a deviated perpendicular
plate of the ethmoid (PPE), posterior disarticulation of the
Cone beam CT or CT scan provides improved visualization of septum from the PPE is advised in order to prevent recur-
septal deviations and turbinate abnormality compared with rence of a septal deviation [4].
physical examination alone (Figs. 4.4, 4.5, 4.6, 4.7 and 4.8).
This can also be advantageous in revision rhinoplasty, where
one cannot be sure how much septal cartilage is left.
46 N. Baldini and Y. Saban

Fig. 4.5 Cone beam CT in the axial plane: inferior turbinates in red, septal deviation to the right (arrow)

Fig. 4.6 Cone beam CT in the axial and frontal planes: middle turbinates in green, concha bullosa (arrow)
4 Cone-Beam CT or CT Scan Analysis for Routine Pre-Operative Planning Before Rhinoplasty 47

Fig. 4.7 Cone beam CT in the axial plane: septal deviation to the right (arrow), and segmented septum on a 3D image showing the vomerine spur

Fig. 4.8 Cone beam CT in the frontal and axial planes: deviated perpendicular plate of the ethmoid to the right (arrow), straight anterior nasal
spine

4.2.3 Nasal Vault, Septum, and Skull Base The following points are identified [5, 6] (Fig. 4.10):

The axial and coronal plane views of each slice is inspected –– Trans-Radix osteotomy point (TROP) line passing
to identify the midline using a vertical marker (Fig. 4.9) and through the trans-radix osteotomy point, which is consid-
to locate the corresponding sagittal slice passing through the ered the soft-tissue center point of transition from the gla-
midline of the PPE (Fig. 4.10). bella to the nasal bones.
48
Fig. 4.9 Cone beam CT in the axial and frontal planes: multiplanar reformation for locating the relevant slice in the sagittal plane passing through
the PPE
Fig. 4.10 Cone beam CT in the sagittal plane passing through the
midline of the PPE
–– Thickness of the nasal bone/frontal spine at the radix.
–– S-point: the most anterior and caudal point of the frontal
sinus.
–– O-point: the most anterior part of the cribriform plate.
–– E-point: the junction between the bony and cartilaginous
septum at its most cranial aspect.
In previous studies, it was shown that there is considerable
variation in the thickness of bone at the radix osteotomy point
(2.59 mm in mean) depending on the length of the spine of
N. Baldini and Y. Saban
the frontal bone [5]. The nasal bone seems to be thinner and
the K area position more cephalic in females [7, 8].
The mean distance from the TROP to the frontal sinus
(S-Point) may be 13.58 mm (7.7–21.2), which means that
the frontal sinus is on average more than 1 cm posterior to
the osteotomy plane. The mean distance from the TROP to
the O-point may be 28.67 mm (7.7–21.2) which means that
the cribriform plate is on average more than 2 cm posterior
to the transverse radix osteotomy plane [5, 7, 8]. The mean
distance from the TROP to the E-point is 7.25 mm (−19.2
to +5.22 mm). It means that the subdorsal junction between
quadrangular cartilage and PPE (E-point) is often located
posterior to the TROP, so the septum is most of the time
cartilaginous below where the radix osteotomy is per-
formed [5].
Thereby, the analysis of this slice enables the surgeon to
check the relationship between the area of the transverse
osteotomy and the surrounding structures such as the frontal
sinuses, PPE, and skull base.
4.2.4 Paranasal Sinuses, and Lacrimal Ducts
The fourth main interest of the pre-operative CBCT or CT
scan may be the exploration of the nasal surroundings such
as the paranasal sinuses, and the lacrimal ducts (Figs. 4.11
and 4.12).
4 Cone-Beam CT or CT Scan Analysis for Routine Pre-Operative Planning Before Rhinoplasty 49

Fig. 4.11 CBCT in the axial plane showing: the maxillary sinuses (blue), lacrimal ducts (yellow), sphenoid sinus (red), ethmoid sinuses (orange)
50
Fig. 4.12 Cone beam CT in the frontal plane showing: the maxillary sinuses (blue), ethmoid sinuses (orange), and frontal sinuses (green)
4.3 Comments
4.3.1 3D Analysis
The images were exported for analysis using a triplanar
DICOM reader software:
InVesalius 3.1.1 (Renato Archer Information Technology
Center, Brazil).
itk-SNAP 3.x (Penn Image Computing and Science
Laboratory, University of Pennsylvania and Scientific
Computing and Imaging Institute, University of Utah,
USA).
4.3.1.1 Multiplanar Reformation
Multiplanar reformation or reconstruction (MPR)
involves the process of converting data from an imaging
modality acquired in a certain plane, usually axial, into
another plane. The acquired data, for example, from the axial
plane, can then be converted to non-axial planes such as cor-
onal, sagittal, or oblique. It may be interesting to locate a
structure in 3D, for instance, the vomerine spur (Fig. 4.13).
4.3.2 3D Layered Volume Rendering
3D rendering uses multiple thin sections of images and
reconstructs them into 3D images, which can enhance visu-
alization of structures, shapes, axes. This technology may
N. Baldini and Y. Saban
also be referred to as 3D reconstruction or 3D reformation
(Figs. 4.14 and 4.15).
The thickness and shape of nasal bones may differ
considerably from one patient to another [9]. CBCT or CT
scan with 3D reconstruction may easily elucidate the
different kind of nasal bones (Fig. 4.16). This may be of
interest to surgeons in order to choose the better option for
the dorsum, especially if a bone reshaping with rasps or
rhinosculpting with piezo instruments is considered.
Furthermore, 3D reconstruction enables the nasal parentheses
(i.e., the width of the base of the bony pyramid) to be checked
and to confirm if a refinement of this part is needed.
Regarding the profile of the nasal dorsum, the nasal bones
comprise the radix and the bony dorsum, and are often quite
thin but fused on top of the spine of the frontal bone.
Underneath these, there is either a cranial extension of the car-
tilaginous septum or the thin perpendicular plate of the eth-
moid. The dorsal septum determines the support of a new
dorsum in preservation rhinoplasty. By lowering the septal
height, flexion occurs at the central keystone, producing a flat-
ter bridge from a previous convex shape. A CBCT or CT scan
can show the thickness and caudal extent of the bony cap and
therefore help to determine if the area will flex or if the bony
cap should be removed to create a cartilaginous dorsum (type
1 vs. type 2 in Saban’s classification). Furthermore, it is help-
ful to visualize the profile shape of the nasal bones: V-shaped
or S-shaped nasal bone configuration [10, 11]. By understand-
ing the different anatomical configurations of the nasal bones,
rhinoplasty surgeons can better plan their operations within
the radix and bony dorsum: preservation or not.
4 Cone-Beam CT or CT Scan Analysis for Routine Pre-Operative Planning Before Rhinoplasty 51

Fig. 4.13 Multiplanar reformation mode: location of the vomerine spur

Fig. 4.14 Pre-operative 3/4 view, 3D volume rendering: surface aesthetics, bones, and soft tissues

One thing may be confusing about the nasion point,
which corresponds to the suture between the nasal pro-
cess of the frontal bone and the nasal bones [12]. The
“nasion cutaneous point” actually corresponds to the
bony sellion point, which is the deepest bony depression
at the root of the nose [13, 14]. The nasion to the sellion
represents the radix whereas the caudal bone, the sellion
to the rhinion, represents the bony dorsum. Thus, the pro-
file shape configurations refer only to the bony land-
marks (Fig. 4.17).
52 N. Baldini and Y. Saban

Fig. 4.15 Pre-operative frontal view, surface aesthetics, and nasal parentheses (dotted lines)

Fig. 4.16 Nasal bone characteristics

4 Cone-Beam CT or CT Scan Analysis for Routine Pre-Operative Planning Before Rhinoplasty 53

Fig. 4.17 Nasal dorsum profile landmarks

4.4 Conclusion

Pyriform aperture dimensions, nasal sidewall anatomy,

dorsal anatomy, and septal anatomy are all readily
assessed, as well as any abnormalities involving the
turbinates and paranasal sinuses. Thus, CBCT or CT
scans may be helpful to the surgeon in planning the most
appropriate modification of modern rhinoplasty. The
diagnostic value of a CBCT or CT scan cannot be
underestimated, and it should reassure the surgeon,
particularly with respect to the skull base. The surface
images will also strengthen aesthetic analysis. The
passage from a two-dimensional analysis to a three-
dimensional analysis thanks to 3D reconstructions offers
to surgeons new applications (Fig. 4.18, 4.19 and 4.20).
Fig. 4.18 Frontal section of the nose
54 N. Baldini and Y. Saban

Fig. 4.19 Pre-operative frontal view, and 6 weeks post-operatively (right). The patient was operated on by Dr. Valerio Finocchi, at the Preservation
Rhinoplasty Meeting 2022 in Nice, France

Fig. 4.20 Pre-operative profile view, and 6 weeks post-operatively (right). The patient was operated on by Dr. Valerio Finocchi, at the Preservation
Rhinoplasty Meeting 2022 in Nice, France

References 4. Jankowski R. Septoplastie et Rhinoplastie Par Désarticulation.

Elsevier Masson; 2016.
5. Sadri A, East C, Badia L, Saban Y. Dorsal preservation rhinoplasty:
1. Durand PD. Discussion: cone-beam computed tomography:
cone beam computed tomography analysis of the nasal vault,
a user-friendly, practical roadmap to the planning and
septum, and skull base—its role in surgical planning. Facial Plast
execution of every rhinoplasty—a 5-year review. Plast
Surg. 2020;36(3):329–34. https://doi.org/10.1055/s-­0040-­1712538.
Reconstr Surg. 2021;147(5):763e–4e. https://doi.org/10.1097/
6. Patron V, Hitier M. Chirurgie Endoscopique Endonasale. Elsevier
PRS.0000000000007912.
Masson; 2021.
2. Saban Y, de Salvador S. Guidelines for dorsum preservation in
7. Eravci FC, Özer H, Arbağ H, Eryilmaz MA, Aricigil M, Dündar
primary rhinoplasty. Facial Plast Surg. 2021;37(1):53–64. https://
MA. Computed tomography analysis of nasal anatomy in dorsal
doi.org/10.1055/s-­0041-­1723827.
preservation rhinoplasty. Aesthet Surg J. 2022;42(3):249–56.
3. Saban Y, Polselli R. Atlas d’anatomie Chirurgicale de La Face et
https://doi.org/10.1093/asj/sjab326.
Du Cou, vol. 1. Acta Medica; 2009. (French, Italian).
4 Cone-Beam CT or CT Scan Analysis for Routine Pre-Operative Planning Before Rhinoplasty
8. Most SP. Commentary on: computed tomography analysis of
nasal anatomy in dorsal preservation rhinoplasty. Aesthet Surg J.
2022;42(3):257–60. https://doi.org/10.1093/asj/sjab346.
9. Daniel RK, Palhazi P. Rhinoplasty: an anatomical and clinical atlas.
Berlin: Springer; 2018.
10. Lazovic GD, Daniel RK, Janosevic LB, Kosanovic RM, Colic MM,
Kosins AM. Rhinoplasty: the nasal bones - anatomy and analysis.
Aesthet Surg J. 2015;35(3):255–63. https://doi.org/10.1093/asj/
sju050.
11. Gruber RP, Gupta D. Commentary on: rhinoplasty: the nasal
bones—anatomy and analysis. Aesthet Surg J. 2015;35(3):264.
https://doi.org/10.1093/asj/sju061.
55
12. Saban Y, Baldini N, Alomani M, Fonseca E. Commentary on:
Rhinoplasty: the nasal bones—anatomy and analysis. Aesthet Surg
J. 2022.
13. Saban Y. CBCT before rhinoplasty. Presented at Bergamo Open
Rhinoplasty Meeting; 2014.
14. Robotti E, Daniel RK, Leone F. Cone-beam computed
tomography: a user-friendly, practical roadmap to the planning
and execution of every rhinoplasty—a 5-year review. Plast
Reconstr Surg. 2021;147(5):749e–62e. https://doi.org/10.1097/
PRS.0000000000007900.
 Surgical Steps in Dorsal Preservation
Erhan Coşkun and Barış Çakir
Preservation rhinoplasty (PR) has been gaining popularity
among rhinoplasty surgeons since Dr. Daniel introduced this
term [1]. The technique is evolving and many variations have
been proposed. The term total dorsal preservation (TDP)
represents changing the nasal dorsal shape by preservation of
the nasal bones and upper lateral cartilages together as a
unite. Cartilage only dorsal preservation (CODP) on the
other hand is preservation of only the dorsal cartilages but
manipulating the nasal bones similar to structural rhinoplasty
[2]. Both of these techniques can be done by low septal strip,
high septal strip, or intermediate septal strip septoplasty
techniques [3–5].
Our purpose in writing this chapter is to guide surgeons
through the important steps of the most commonly used
dorsal preservation (DP) techniques with detailed
explanations.
5.1 Presurgical Assessment
5.1.1 How to Choose Between TDP and CODP
The indications of DP techniques are well described in
several publications yet they may change according to
surgeons’ personal experiences. Generally, indications
suggest nasal bones to be not too wide, not too thin from the
frontal view, from the side view straight or V shaped is
preferred instead of S shape, radix position would not be too
high or too low. Some surgeons may use tools like rasps,
E. Coşkun (*)
Private Practice, Şişli, İstanbul, Turkey
Plastic Reconstructive and Aesthetic Surgery, Florence Nightingale
Gayrettepe Hospital, Beşiktaş, Istanbul, Turkey
B. Çakir
Private Practice, Şişli, İstanbul, Turkey
Plastic Reconstructive and Aesthetic Surgery, American Hospital,
Şişli, Istanbul, Turkey
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_5
5
sharp needlelike osteotomes or electric-powered devices to
further shape the bones, also would use more grafts for the
supratip or radix area to extend the indications of TDP. We
are using special bone rasps to shape the nasal bones to some
extent while trying to keep the need of grafting to radix or
supratip area as low as possible in TDP. Below you will find
pictures of different nasal dorsal aesthetic lines of different
patients and we will try to explain why we have chosen that
technique for the case.
This patient’s dorsal aesthetic lines have good thickness
from the frontal and dorsal view, almost straight dorsum
from the side view (Figs. 5.1 and 5.2). She had a TDP with
low septal strip, closed polygon tipplasty. 20 days after
surgery (Figs. 5.1, 5.2, 5.3, and 5.4).
This patient on the other hand had a S-shaped dorsum
with a convex prominent bony cap and long nasal bones with
low radix (Figs. 5.5 and 5.6). She had a CODP with bony cap
rasp with low septal strip, closed polygon tipplasty. Her
preop and 3 months postop result (Figs. 5.5, 5.6, 5.7, and
5.8).
This patient has broad nasal dorsum on the roof also on
the base with thick bones from the frontal view (Figs. 5.9 and
5.10). She had CODP without bony cap, closed polygon
tipplasty. Nasal bones are rasped. Her before and 9 months
results (Figs. 5.9, 5.10, 5.11, and 5.12).
Tip: Physical examination and tissue characteristics give
us a clue on which DP method to choose, but our final
decision is made in the surgery which will be explained with
more details below.
5.1.2 How to Choose Dissection Plane
When we do physical examination of the nose, we categorize
patients according to skin, soft tissue, and cartilage features
such as, thin, medium, thick skin, loose connective tissue,
firm connective tissue, weak, medium, strong cartilage
strength. If a patient has thin skin and good cartilage strength,
subperichondiral dissection is preferred [6]. We usually
57
58 E. Coşkun and B. Çakir

Fig. 5.1 Frontal view before and 20 days after surgery

Fig. 5.2 Dorsal aesthetic lines

5 Surgical Steps in Dorsal Preservation 59

Fig. 5.3 Lateral view

Fig. 5.4 Lateral oblique view

60 E. Coşkun and B. Çakir

Fig. 5.5 Frontal view before and 3 months after the surgery

Fig. 5.6 Dorsal aesthetic lines

5 Surgical Steps in Dorsal Preservation 61

Fig. 5.7 Lateral view

Fig. 5.8 Lateral oblique view

62 E. Coşkun and B. Çakir

Fig. 5.9 Frontal view before and 9 months after the surgery

Fig. 5.10 Dorsal aesthetic lines

5 Surgical Steps in Dorsal Preservation 63

Fig. 5.11 Lateral view

Fig. 5.12 Lateral oblique view

64
Fig. 5.13 Frontal view of susceptible weak tip cartilages
prefer subsmass dissection for tip if a patient has weak tip
cartilages [7]. A weak tip cartilage can be suspected with
touching the nose and examining with eye. In this case, the
cephalic and caudal borders of the lateral crura is
imperceptible, middle crura is thin (Figs. 5.13, 5.14, and
5.15). Also, weak tip cartilages can be felt with palpation.
E. Coşkun and B. Çakir
Fig. 5.14 Lateral crura cephalic border is indistinct in the lateral
oblique view of the patient
In this case, we preferred subsmass dissection for tip.
Leaving the perichondrium on the weak tip cartilage
increases the resistance and makes the cartilages more
pliable to shaping with sutures.
Here is another case, the cephalic and caudal borders of
lower lateral cartilage are indistinctive despite being thin
skin (Figs. 5.16, 5.17, and 5.18).
5 Surgical Steps in Dorsal Preservation 65

Fig. 5.15 Lateral view of the patient shows mild alar retraction Fig. 5.16 Frontal view
probably due to weak lateral crura cartilages
66
Fig. 5.17 Lateral oblique view of the patient
The tip feels floppy when examined with fingers. So
we chose a supraperichondrial dissection. The final
decision of the tip dissection plane can be given right
after the infracartilagenous incision is made. The cartilage
thickness and strength may be felt more precisely at this
moment.
E. Coşkun and B. Çakir
Fig. 5.18 Lateral view of the patient shows mild alar retraction similar
to the previous case
5.2 Surgery
Here the steps in DP will be discussed briefly as in the
surgical order. Tricky points and safety issue in these surgical
steps will be mentioned as much as possible.
5.2.1 Transfixion Incision
Our first incision is transfixion with a small backcut through
intracartilagenous incision on both sides. The mucosa incision
is kept about 4 mm away from the caudal septal edge to
preserve enough blood supply to the mucosa flap between
infracartilagenous and transfixion incisions (Fig. 5.19).
The backcut is not more than 4–5 mm (Fig. 5.20).
5 Surgical Steps in Dorsal Preservation 67

5.2.2 Septum Dissection

Caudal septum is dissected using Daniel-Çakır elevator

subperichondrially (Fig. 5.21).
After 1 to 2 cm of caudal septum is dissected with sharp
tip, blunt-tipped Daniel-Çakır elevator is used for the rest of
the septal dissection.
In low septal strip wide dissection of septum is necessary.
Tip: In low septal strip, quadrangular cartilage and upper
lateral cartilages are in continuity with each other.
Subperichondrial septal dissection around the upper lateral-­
septum junction area should be done in a limited manner to
preserve this junction safely.

5.2.3 W Point and Upper Lateral Caudal

Dissection

Septal subperichondrial dissection should be completed all the Fig. 5.20 Transfixion incision is continued with a small backcut
way up the W point. Holding the nostril cephalically with
Crile retractor in one hand, sharp-tipped, curved scissors are
used to dissect soft tissue and find the subperichondrial plane
(Fig. 5.22).

Fig. 5.21 Caudal septum is dissected using Daniel-Çakır elevator

subperichondrially

Fig. 5.19 The transfixion incision starts about 4 mm posteriorly from

the caudal septal edge

Fig. 5.22 Finding the subperichondrial plane over the W point

68 E. Coşkun and B. Çakir

This maneuver should be done gently otherwise upper

laterals can separate from septum. After finding the
subperichondrial plane, an elevator is used to dissect 1–2 cm
caudal part of the upper lateral cartilages until the scroll area.

5.2.4 Infracartilagenous Incision, Lower

Lateral Cartilage Dissection

Right after reaching the scroll area, we stop dissection over

W point and pick up double hook and start infracartilagenous
incisions. First marking is done (Fig. 5.23).
Tip: We do not follow the cartilage border after passing
the lateral crura turning point. Instead, we continue incision
in a straight line about 5 to 7 mm more toward the alar base
(Fig. 5.24).
We find this incision useful for correcting lateral crura tail
problems such as inverted cartilage or cephalic malposition.
Also easier to dissect a pouch and suture lateral crura onlay Fig. 5.24 Marking for the incision does not follow the cartilage border.
graft to treat nasal valve collapse problem. If the patient has It continues in a straight line after passing the turning point
caudal excess, we usually leave auto-rim flap up to utmost
1.5 mm cephalic to the incisions.

5.2.4.1 Subperichondrial Dissection

Fine-tipped double hook is given to the nurse holding the
mucosa right under lateral crura turning point. Fifteen1
blades may be used gently to make a fine incision to the
perichondrium (Fig. 5.25).

Fig. 5.25 Lateral crura turning point would be the point of entry to the
subperichondrial layer

Fig. 5.23 First lower lateral cartilage lateral crura caudal border is
marked
5 Surgical Steps in Dorsal Preservation
With a fine-tipped instrument or with sharp scissors,
subperichondrial plane is reached (Fig. 5.26).
Daniel-Çakır sharp-tipped perichondrium elevator is used
to dissect lateral crura (Fig. 5.27).
Tip: Usually the hardest part of lower lateral
subperichondrial dissection is passing from lateral crura
to middle crura. If you feel a resistance here with your
perichondrium elevator, instead of forcing with the
perichondrium elevator to pass the resistance point,
Fig. 5.26 Sharp scissors is used to reach the subperichondrial plane
Fig. 5.27 Sharp-tipped Daniel-Çakır elevator is used to dissect lateral
crura
69
using the scissors is safer not to damage the cartilage or
mucosa (Fig. 5.28).
At this point, the double-hook position should be changed
from turning point mucosa to a closer point to the dissection
area (Fig. 5.29).
Feeling the cartilage with the tip of the scissors and doing
very tiny cuts for 2–3 mm frees the resistance and then it is
easier to go on with the dissector all the way down to the
footplates (Figs. 5.30, 5.31, and 5.32).
Fig. 5.28 The resistance can be felt with the perichondrium elevator
close to the domes
Fig. 5.29 The double hook is changed closer to the dissection and
pulled toward the lateral canthus
70
Figs. 5.30 and 5.31 Using the tip of sharp scissors to pass the resistance point while turning from lateral crura to medial crura
Fig. 5.32 After passing the resistance point, the elevator may be used
to complete the lower lateral crura dissection
5.2.4.2 Subareolar Dissection
If subareolar dissection is planed, the dissection is started
from the turning point of lateral crura. We use the back of the
scalpel to find the cartilage. The perichondrium is kept intact
on the cartilages. The sharp Daniel-Çakır perichondrium
elevator is used for the dissection. Subareolar dissection is
usually faster and easier compared to subperichondrial
dissection.
E. Coşkun and B. Çakir
5.2.5 Opening the Scroll Area to Unite Two
Dissection Zones
Crile retractor is hold pulling the rim with the aid of finger
behind the skin and with the other hand elevator is used to
push the cephalic part of the lateral crura downward
(Fig. 5.33). A window will open between upper lateral
cartilage and lower lateral cartilage dissection zones
(Fig. 5.34).
Tip: This maneuver works better if upper lateral caudal part
and lower lateral dissection planes are both subperichondrial. If
lower lateral cartilage dissection is subareolar, instead of forcing
to unite the two dissection planes by pushing the lateral crura
down, sharp-tipped scissors can be used. Otherwise subareolar
plane dissection will extend to the dorsum which will lead
unwanted two separate dissection planes such as subperichondrial
and subareolar. Instead, using the tip of the scissors faces the
caudal edge of the upper lateral cartilage and dissecting gently
by pushing the soft tissue will unite lower lateral subareolar and
upper lateral subperichondrial dissection planes easier.
5.2.6 Dorsum Dissection
5.2.6.1 Limited Dorsal Dissection
The indications would be good radix position, good dorsal
aesthetic lines without any need of nasal bone rasping or
dorsal reshaping. Otherwise we prefer wide dissection. For
Ishida cases we experienced widening of the nasal bones
with limited dissection in big dorsal humps probably due to
the soft tissue re-draping problems.
5 Surgical Steps in Dorsal Preservation 71

Figs. 5.33 and 5.34 Dissection of the scroll area

Fig. 5.35 The elevator is advanced medially until the pitanguy Fig. 5.36 Use sharp scissors to complete the infracartilagenous
ligament tension is felt incision

Then dissection is carried out all the way to the nasal bone
5.2.6.2 Wide Dorsal Dissection
upper lateral cartilage junction cranially.
Dorsal dissection starts with opening the vertical scroll
The lateral border of the dissection is completed all the
ligament. The elevator is advanced medially until the
way down to the piriform aperture.
pitanguy ligament tension is felt (Fig. 5.35). Medial
Tip: It is important to dissect the lateral crura tail and the
dissection is completed at this point.
dorsal soft tissue lateral to the upper lateral cartilage lateral
border especially in big dorsal humps (Fig. 5.36). Otherwise,
72 E. Coşkun and B. Çakir

Figs. 5.37 and 5.38 Using the scissor and the dissector to complete lateral dorsal dissection

Figs. 5.39 and 5.40 Bone edge is scratched by bone elevator, and subperiosteal plane is found

the soft tissue redrape would not be sufficient causing dorsal
widening. This wide dissection also allows to do the bony
work with a superior vision.
Figure: Use the tip of the scissor by opening it to dissect
the skin and soft tissue envelope over the lateral border of the
lateral crura (Fig. 5.37). Complete the lateral dorsal dissection
with the elevator (Fig. 5.38).
Start the bone dissection either by scratching the bone
edge with the bone elevator or by using the scalpel to incise
at the nasal bone border (Figs. 5.39 and 5.40).
The dissection is completed on both sides laterally until
passing the lateral osteotomy lines, cranially to the transverse
osteotomy lines. Thae the two dissection planes are joined by
dissection of the bony cap and dorsal nasal bone. Dorsal
nasal bone dissection is stopped passing the radix osteotomy
line.
Tip: If the radix position is in the right place, it is not
necessary to extend the dorsal dissection after the bony cap
dissection.
5.2.6.3 Taking Out the Low Septal Strip
First use a scalpel to start low septal strip and continue with
straight lateral osteotome to cut the quadrangular cartilage
(Figs. 5.41 and 5.42).
5 Surgical Steps in Dorsal Preservation 73

Figs. 5.41 and 5.42 A scalpel is used to start the low septal strip cut

Figs. 5.43 and 5.44 Straight 3 mm lateral osteotome is used to complete the low septal strip cut

Tip: Care should be taken not to take out too much
cartilage at once. The scalpel position may change according
to the desired supratip dorsal height. If it is low and needs to
be elevated, the scalpel should be placed lower than the
septum anterior nasal spine junction. In all cases, carefully
take less than planed but also make sure to secure enough
size for a strong columellar strut. You may take more low
strip if necessary at the end of the surgery.
After the first incision started with the scalpel, the straight
lateral osteotome is pushed obliquely cutting the low septal
strip until the vomer bone is felt with the tip of the osteotome
(Figs. 5.43 and 5.44).
74 E. Coşkun and B. Çakir

Fig. 5.45 A sharp elevator is used to separate the low septal strip from Fig. 5.46 Low septal strip is taken out after completing the separation
the maxillary crest from maxillary crest and vomer bone

Use the sharp edge of Daniel-Çakır elevator to dissect the

lower connection of the low strip from the maxillary crest
(Fig. 5.45). Dissect the attachment of low septal strip from
the vomer bone. Take the low strip out with a forceps
(Fig. 5.46).

5.2.7 Vertical Septal Cut

The vertical cut is started from the highest point of the dorsal
hump and follow a straight line perpendicular to the dorsum.
It is important to leave the septum as big as possible. A fine
needle can be inserted from the highest point to see the
correspondence on the septum or the elevator can be felt with
finger palpation from the dorsum to decide where to start the
cut (Fig. 5.47).
Tip: Do not try to cut the septum at once, instead start
with scoring all the way down and continue scoring maneuver
until it is actually cut full thickness. It is safer to start the full
thickness cut closer to the dorsum and complete the deep
part (Figs. 5.48, 5.49, and 5.50). If the full thickness cut is Fig. 5.47 The elevator can be felt with finger palpation from the
started deeper and the sharp elevator is pushed up to the dorsum to decide where to start the cut
dorsum to complete the cut, the elevator may shear the
septum caudally causing total detachment of the septum from down to the desired shape due to the intact septal piece. A
the upper lateral cartilages. sharp scissor can also be used facing the tip up.
Tip: Always check if the cut is completed all the way up In most of the cases, vertical cut leaves some part of the
(Fig. 5.51). If not, the dorsum might have resistance to go quadrangular cartilage attached to the perpendicular plate. This
5 Surgical Steps in Dorsal Preservation
Figs. 5.48 and 5.49 It is safer to score with a sharp elevator first, all the way down the quadrangular cartilage so the cut can be precise following
this scored area
Fig. 5.50 The full thickness cut is completed all the way down starting
closer to the dorsum
area can be used to take additional cartilage grafts. The vertical
cut may be done directly from the quadrangular cartilage
perpendicular plate junction to preserve the quadrangular
cartilage as big as possible. But in this case if you need extra
cartilage graft, it should be taken from the mobile quadrangular
cartilage. It is technically more challenging to take a piece from
a mobile cartilage.
75
Fig. 5.51 It is important to check if the vertical cut is completed all the
way up
Tip: There should be a gap in between quadrangular
cartilage and remaining septum. If they overlap each other,
dorsum may be pushed to one side. In order to prevent this,
another cut should be done cephalic to the vertical cut if that
part is still cartilage. If this area is cartilage, sharp
perichondrium elevator can be used to take a strip as done in
vertical cut (Figs. 5.52 and 5.53). This cartilage can be used
as additional graft material (Fig. 5.54).
76
Figs. 5.52 and 5.53 If the remaining septum behind the vertical cut is cartilage, a sharp elevator can be used to take another strip
Fig. 5.54 This cartilage strip can be used as additional graft material
If that part is perpendicular plate bone, we use a special
punch that can remove small pieces with each bite without
any torsion maneuver (Figs. 5.55 and 5.56). A strong punch
E. Coşkun and B. Çakir
is recommended here not to damage the perpendicular plate
cranial base junction.
5.2.8 High Septal Strip Cranial to Vertical Cut
As shown in Fig. 5.57, a high strip cephalic to the vertical cut
should be taken in order to do both TDP or CODP.
This area may be composed of the quadrangular cartilage
or perpendicular plate of the ethmoid bone. If it is cartilage,
sharp curved scissors can be used to make the first cut as
close as possible to the dorsal roof (Fig. 5.58). Second cut
can be done with a straight scissor as taking out the desired
amount of piece (Fig. 5.59). Then a bayonet forceps is used
to take out the cartilage piece (Fig. 5.60).
Tip: Attention should be paid here not to take a piece
which is more than necessary. This part is one of the limiting
points protecting against a dorsal collapse either for letdown
or cartilage only pushdown.
If this area is composed of bone, we prefer to use a small
punch to take small bites as desired amount (Fig. 5.61).
5.2.9 Bony Cap Rasp
Both in TDP or CODP, we usually start with bony cap rasp. We
use big-teeth steel rasps as shown below (Figs. 5.62 and 5.63).
5 Surgical Steps in Dorsal Preservation 77

Figs. 5.55 and 5.56 Ayhan punch from Medisoft company is used to remove the bony part behind the vertical cut without any torsion maneuver
to prevent perpendicular plate break close the cranial base

Fig. 5.57 A high strip cephalic to the vertical cut should be taken in order to do both TDP or CODP
78 E. Coşkun and B. Çakir

Fig. 5.58 A sharp, curved scissors can be used to make the first cut as Fig. 5.60 A bayonet forceps is used to take out the cartilage piece
close as possible to the dorsal roof

Fig. 5.61 A small punch (Medicone company 2.5 mm trucut punch) is

used to take small bites as desired amount

Tip: Rasping the bony cap before doing CODP enables to

Fig. 5.59 Second cut can be done with a straight scissor to take out the
desired amount of piece
have a smooth passage from bony hump resection side to
cartilage dorsum and decreases the need to use grafting for
camouflage for dorsal irregularities (Fig. 5.64).
Tip: The rasping materials can be collected to use as bone
dust graft at the fine-tuning step for dorsal irregularities
(Fig. 5.65).
5 Surgical Steps in Dorsal Preservation
Figs. 5.62 and 5.63 Big-teeth steel rasps (Medisoft company) is used to rasp the bony cap
Fig. 5.64 Rasping the bony cap with big-teeth steel rasp
5.2.10 Lateral Key Stone Area Dissection
(Ballerina Maneuver)
The upper lateral cartilages and the cartilage dorsum continue
and attache inside the bony roof and nasal bones usually 1 to
2 cm (Figs. 5.66 and 5.67).
Using a sharp-edged perichondrium elevator, upper lateral
cartilages are dissected from nasal bones all the way down to
piriform aperture.
Tip: Dissection should be done all the way down to
piriform aperture. The depth of the dissection may be 2–3 mm
deep as shown with red mark (Figs. 5.68 and 5.69). The
79
Fig. 5.65 Big-teeth steel rasp collects the bone dust which may be
used as graft material to camouflage dorsal irregularities
cartilage dorsum will start to mobilize after this dissection.
There are strong connections between upper lateral
cartilages and nasal bones 1 to 1.5 cm cephalically shown
above with blue mark (Fig. 5.67). If more rotation in letdown
or more cartilage pushdown needed in CODP, the depth of
the dissection is increased cranially. Unnecessary dissection
should be avoided especially in CODP to prevent saddling of
the cartilage dorsum.
80 E. Coşkun and B. Çakir

Figs. 5.66 and 5.67 The yellow line shows the borders of the upper lateral cartilage advancing inside the nasal bones. Blue mark shows the
attachments between the nasal bones and cartilage

Figs. 5.68 and 5.69 The depth of the dissection may be 2–3 mm deep as shown with red mark

5.2.11 TDP or CODP 5.2.12.1 Transverse Osteotomies

The first 11 steps explained in detail above are identical in
TDP and CODP. Now the surgeon should choose the DP
technique and proceed according to the choice.
5.2.12 Bony Work for Letdown
Ostectomies can be done by various instruments such as
Piezo electric instruments, bone rasps, straight lateral
osteotomes, rongers, hand saws, and external osteotomes.
We mark the skin first (Fig. 5.70).
We use external 1.5 mm osteotome, holding the osteotome
with one hand and using the hammer with the other hand
(Fig. 5.71). Marking depends on the patient’s needs. It starts
from the radix area where the dorsum needed to be narrowed.
We intend to create a banana-shaped transverse osteotomy
line in order to smooth the transition from the transverse
osteotomy line to the lateral ostectomy.
Tip: Banana-shaped transverse osteotomy helps to
prevent the step deformity on the medial canthal area and
ease downward motion of the nasal bones to the desired
position.
5 Surgical Steps in Dorsal Preservation
Fig. 5.70 Marking the skin for transverse osteotomies
Fig. 5.71 We use external 1.5 mm osteotome, holding the osteotome
with one hand and using the hammer with the other hand
Tip: Do not start transverse osteotomies too high
cephalically if the cephalic part of the radix is already in
desired thickness. Start from where you want to narrow the
dorsum.
5.2.12.2 Lateral Ostectomies
A convex rasp is used to thin the ostectomy sites before
taking out the bones (Fig. 5.72).
Then we use a 3-mm straight lateral osteotome to take out
bone segments as needed. First do the high osteotomy and
then the lower osteotomy uniting the end points at the lowest
point of the transverse osteotomy (Fig. 5.73).
The ostectomy fragments are removed by bayonet forceps
(Fig. 5.74).
Tip: Rasping the ostectomy sites thins the bones, so bones
can be taken out more precisely without causing unwanted
nasal bone fractures.
81
Fig. 5.72 A convex rasp is used to thin the ostectomy sites before
taking out the bones
Fig. 5.73 First do the high osteotomy and then the lower osteotomy
uniting the end points at the lowest point of the transverse osteotomy
If the dorsum is tilted to one side, asymmetric ostectomies
are done taking out more bone from the opposite site of the
deviation.
5.2.12.3 Radix Ostectomy
We prefer to use 1.5 mm osteotome to make the radix cut.
Transverse osteotome can be inserted through the external
transverse osteotomy skin incision to make the bone cut.
Inside out radix osteotomy is also used if necessary. The
osteotome is inserted through the transfixion incision,
82 E. Coşkun and B. Çakir

sites by leaving a 2–3 mm radix bone intact. Also limited

dorsal dissection sparing the radix osteotomy site helps to
create a smooth hinge movement.
Tip: A true radix ostectomy is only done if the radix drop
is necessary. Otherwise, a hinge should be created to prevent
radix drop.
Tip: High septal strip excision is also important for safety
if a radix drop is not desired. The correct amount of septum
or perpendicular plate left under the radix area after the
high strip excision will be supportive to prevent dorsal
saddling even the nasal bones mobilized totally.

5.2.13 Bony Work for CODP

After the bony cap rasping and ballerina maneuver, the

cartilage dorsum will go down to the desired position. The
nasal bones can be lowered with fine bone scissors precisely
(Fig. 5.75). Then an osteotome can be used to take bone
hump left on the radix area (Figs. 5.76 and 5.77).
Fig. 5.74 The ostectomy fragments are removed by bayonet forceps Tip: A 5-mm medicone osteotome is very useful to lower
the radix bone. This osteotome has a concave side (Fig. 5.76).
If the concave side is facing up it goes deep in the bone, if it
is turned upside down it goes up taking bone pieces as
desired amount. A straight bone rasp is used to soften the
edges of the nasal bones at the end of the bony work.

5.2.13.1 Transverse Osteotomy in CODP

We usually prefer to do external transverse osteotomy with
1.5 mm osteotome. First skin is marked. The planning
depends on the patient’s needs. We start from where we want
to narrow and go down until the planed lateral osteotomy
ending point.

5.2.13.2 Medial Oblique Osteotomy

and Ostectomy
We prefer to use 3 mm straight lateral osteotome to do medial
oblique osteotomy (Fig. 5.78).
Tip: It is important to take a bone piece in some cases to
aid open roof closure (Fig. 5.79). Otherwise after the lateral
and transverse osteotomies, the nasal bone will in-fracture
in the base but will open on the roof area causing rocker
deformity.
Fig. 5.75 The nasal bones can be lowered with fine bone scissors
precisely
5.2.13.3 Lateral Osteotomy in CODP
A 3-mm straight lateral osteotome is used to do either low to
carefully aiming the tip of the osteotome to the desired
low or high to low.
osteotomy point.
Tip: Rasping with convex bone rasp and thinning maxilla
Tip: A hinge can be created on the radix osteotomy line
nasal bone junction before lateral osteotomy helps to do
with the inside out fracture by holding the osteotome in a 45°
precise bone cut. Unlike letdown, we do not dissect internal
angle from footplate to forehead direction. Also, a hinge can
mucosa before lateral osteotomy. Intact mucosa helps for
be created easily with the external transverse osteotome
bone stability.
paying attention not to unite the two transverse osteotomy
5 Surgical Steps in Dorsal Preservation
Figs. 5.76 and 5.77 Medicone company 5 mm chisel is used to take bone hump left on the radix area. This chisel is concave on one side
Fig. 5.78 3 mm straight lateral osteotome from Medicone company
5.2.14 Suturing the Quadrangular Cartilage
to Anterior Nasal Spine Periosteum
4-0 or 5-0 PDS suture is used to fixate the quadrangular
cartilage to anterior nasal spine periosteum (Fig. 5.80). 2
or 3 sutures are enough. One suture passing from the
quadrangular cartilage should be inferior to the anterior
nasal spine and another one should be superior to anterior
83
Fig. 5.79 A bone fragment from medial oblique osteotomy side is
taken to prevent rocker deformity
nasal spine in axial horizon to fix the dorsum in the desired
position preventing going down or going up during the
healing period.
Tip: If suture is passed deep from the quadrangular cartilage,
dorsum can be elevated for several millimeters and the caudal
septum can be extended caudally. This affect can be used to fill
the supratip saddle or to support the retracted footplate.
84
Fig. 5.80 4-0 or 5-0 PDS suture is used to fixate the quadrangular
cartilage to anterior nasal spine periosteum
5.2.15 Fine-Tuning
After the tip surgery is finished, fine-tuning can be done. DP
techniques give the surgeon the ability to control the dorsal
height up or down in millimeters to fine-tune the tip and
dorsum transition at the end of surgery. Both in letdown and
CODP techniques, the quadrangular cartilage is totally
mobile, attached to the dorsal structures. The suture from
quadrangular cartilage to anterior nasal spine periosteum can
be repositioned to a lower or higher point in the quadrangular
cartilage, augmenting or saddling the dorsal structures.
Tip: We usually put one suture to the quadrangular
cartilage to fix the dorsum after the dorsal work is done.
Then tip surgery is finished. The advantage of DP over
structure ­dorsal surgery is the ability to fine-tune the dorsal
height with only one suture removal and resuturing.
E. Coşkun and B. Çakir
5.3 Conclusion
DP techniques are becoming more popular in the last several
years. The popularity of this techniques may misguide the
unexperienced young surgeons to think this is an easy
surgery with superior results aesthetically. We believe the
most important variable in rhinoplasty to achieve good
aesthetic results is the time and attention the surgeon spends
before, during, and after this challenging surgical procedure.
With correct application of these techniques mentioned in
this chapter are promising to correct septal deviations causing
functional problems, as well as correcting axial dorsal
deviations with minimal dorsal grafting to achieve predictable
results in the long term.
References
1. Daniel RK. The preservation rhinoplasty: a new rhinoplasty
revolution. Aesthet Surg J. 2018;38(2):228–9.
2. Ishida LC. Nasal hump treatment with cartilaginous push-down and
preservation of the bony cap. Aesthet Surg J. 2020;40(11):1168–78.
3. Finocchi V, Daniel RK, Palhazi P. Modified SPQR Cottle rhinoplasty.
In: Preservation rhinoplasty. 3rd ed; 2020. p. 256–81.
4. Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P. Dorsal
preservation: the push down technique reassessed. Aesthet Surg J.
2018;38(2):117–31.
5. Neves JC, Tagle DA, Dewes W, Ferraz M. A segmental approach in
dorsal preservation rhinoplasty: the Tetris concept. Facial Plast Surg
Clin North Am. 2021;29(1):85–99.
6. Cakir B, OreroğluAR, Doğan T,Akan M. A complete subperichondrial
dissection technique for rhinoplasty with management of the nasal
ligaments. Aesthet Surg J. 2012;32(5):564–74.
7. Neves JC, Zholtikov V, Cakir B, Coşkun E, Arancibia-Tagle
D. Rhinoplasty dissection planes (subcutaneous, sub-SMAS, supra-­
perichondral, and sub-perichondral) and soft tissues management.
Facial Plast Surg. 2021;37(1):2–11.
 Letdown and Piezo Techniques
in Preservation Rhinoplasty
Abdulkadir Goksel and Khanh Ngoc Tran
6.1 Background
Preservation rhinoplasty represents a growing shift in rhino-
plasty philosophy toward preserving structurally sound anat-
omy and reshaping existing nasal structures into aesthetic
and functional ideals. In rhinoplasty, the achievement of
straight and smooth dorsal aesthetic lines with results that
are both predictable and long lasting continues to be a chal-
lenge. The commonly used method of dorsal lowering via
conventional hump resection using osteotomies and rasping
causes nasal keystone area disruption, necessitating middle
vault reconstruction or surface camouflage to address any
ensuing irregularities. There is a growing recognition
amongst surgeons that even in the best of hands, reconstruc-
tion cannot bring back the natural anatomy. Therefore, the
question arises that if it is possible to achieve satisfactory
functional and aesthetic results whilst preserving the natural
dorsal anatomy, then why create a defect that would only
need to be later repaired? Instead, why not reshape the nose
by lowering the dorsal height whilst simultaneously preserv-
ing the dorsal line? This is the philosophy behind preserva-
tion rhinoplasty.
The expression “preservation rhinoplasty” was first
coined in a 2018 editorial by Daniel [1] to describe the three
pillars of preservation surgery: dorsal, alar cartilage and soft
tissue/ligamentous preservation. The most well known and
studied amongst these is dorsal preservation, which dates
back in the literature as far as 1899, when Goodale [2] first
described it in a closed approach for dorsal hump reduction,
followed by notable contributions by Lothrop [3] and Cottle
Supplementary Information The online version contains supplemen-
tary material available at https://doi.org/10.1007/978-­3-­031-­29977-­3_6.
The videos can be accessed individually by clicking the DOI link in the
accompanying figure caption or by scanning this link with the SN More
Media App.
A. Goksel (*) · K. N. Tran
RinoIstanbul Facial Plastic Surgery Clinic, Istanbul, Turkey
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_6
6
[4] in the first half of the twentieth century. The hallmarks of
dorsal preservation are (1) correction of the dorsal hump
with simultaneous preservation of dorsal nasal architecture,
including all or part of the dorsal osseocartilaginous vault,
and (2) avoidance of creating an open roof deformity. Despite
its century-long history, widespread adoption of dorsal pres-
ervation techniques in the past has unfortunately been slow
and oftentimes stagnated, particularly with the advent of
open structural rhinoplasty. Whilst it is unclear precisely
why this occurred, contributing factors may have included a
perception that the former technique was more difficult and
that the latter was easier to learn and teach, as well as afforded
greater visibility and control [5].
Recently, however, there has been a resurgence of interest
in preservation techniques, resulting in the development of
several new surgical methods and modifications to existing
manoeuvres along with landmark publications that served to
demystify, clarify and troubleshoot current preservation
techniques, making it more accessible and appealing to a
wider audience of surgeons [5, 6]. Furthermore, the intro-
duction of innovative powered surgical instruments such as
the piezoelectric device poses a welcome addition to the sur-
geon’s toolbox, particularly for lowering the bony vault in
dorsal preservation surgery, especially with regards to dorsal
reshaping and precise and accurate osteotomies for
“letdown” and “pushdown” procedures [7].
In this chapter, we describe the various preservation rhi-
noplasty techniques that enable dorsal modification and
preservation, via the open approach and with the assistance
of piezoelectric instruments (PEIs). We outline the various
indications and applications of preservation rhinoplasty
surgery, describing the various advantages as well as the
potential difficulties that may be encountered. Particular
emphasis is given to important technical points and valu-
able tips to avoid potential complications. We will also be
discussing limited soft tissue dissection techniques, with
preservation of the ligamentous attachments and the bene-
fits of doing so.
85
86
6.2 Discussion
6.2.1 Patient Selection
The main rhinoplasty indication in Caucasian patients, which
constitute the majority of our patients, is the nasal dorsal
hump. When deciding whether a patient is suitable for dorsal
preservation, the key question the surgeon must ask himself
or herself is whether they wish to preserve this dorsum?
The ideal candidates for dorsal preservation are primary
cases where there is a predominantly cartilaginous small
dorsal hump with short v-shaped nasal bones, high to normal
radix, and straight dorsal aesthetic lines with linear axis devi-
ation [6]. Narrow tension noses are also suited to this tech-
nique. Table 6.1 outlines the indications, according to the
various septal techniques. In our practice, we consider (rela-
tive) contraindications to dorsal preservation to be the fol-
lowing: (1) difficult septoplasties (multiple fractures septum,
large septal perforation, high septal or severe deviations), (2)
when total or partial nasal septal reconstruction is required,
(3) severe S-shaped axis deviations, (4) secondary cases, (5)
patients with prior open-roof reduction rhinoplasty, and (6)
patients whose angle between the nasal bone and the upper
lateral cartilages (ULCs) is less than 150°. Whilst it ulti-
mately depends on the expertise level of the surgeon and
their comfort with applying preservation techniques, often-
times the aforementioned cases may be better managed using
classical structure or hybrid techniques.
Having established patient suitability, the next step is to
evaluate the dorsal convexity, any deviated aspects of the
bony and cartilaginous dorsum and the presence of any sep-
tal pathology, before deciding upon the following key techni-
Table 6.1 Preservation rhinoplasty indications according to septal
technique
High septal strip (HSS) approach
• Dorsal hump ≤4 mm
• Hump is mostly cartilaginous
• High septal deviation
• Over-projected radix
• Caudal septum is in the midline
• Straight noses
• V-shaped nasal bones
Mid-septal strip/subdorsal flap approach
• Same as HSS
• Slight crooked nose
Low septal strip approach
• Same as HSS
• If there is pathology along the connection of the ANS and
maxillary crest with the septal cartilage
• Crooked nose with straight dorsal aesthetic lines
Bony dorsal preservation
• Same as HSS
• Crooked nose with straight dorsal aesthetic lines, where there is
no pathology at the septal base
A. Goksel and K. N. Tran
cal elements: (1) the surgical approach—open versus
closed—and whether ligamentous preservation is possible
and if so, the extent of dissection (2) management of the sep-
tum; (3) management of the dorsum; (4) whether adjunctive
procedures are needed to facilitate dorsal lowering, such as
dissection of the lateral keystone area (Goksel’s ballerina
manoeuvre) to prevent tissue resistance to dorsal descent and
hump recurrence and bony cap removal to convert an osseo-
cartilaginous hump into a purely cartilaginous one; (5) points
of fixation to secure the mobilized osseocartilaginous vault
to the underlying septum.
6.2.2 Ligamentous Preservation
In open preservation rhinoplasty, it is possible to keep the
ligaments partially or completely intact and where possi-
ble in our practice we endeavour to do so. Since the nasal
ligaments are the main connection between the skin and
the nasal skeleton, by preserving them we can reduce
postoperative swelling, enable faster and more effective
re­draping of the nasal skin envelope whilst oftentimes also
retain the nose’s natural elasticity [8, 9]. This is particu-
larly relevant in cases where the patient has thick skin and
it is difficult to reestablish contours. In our experience, in
such patients the preservation of ligamentous attachments
can help to create better contours in the postoperative
period [9].
The decision on whether or not ligamentous preservation
is suitable is made during the patient evaluation process
when we divide the patients into three groups, according to
their soft tissue and dorsal deformity.
6.2.3 Group #1
These patients have good dorsal aesthetics, V-shaped nasal
bones and only need reduction of the dorsal profile line. In
this group, it is possible for open preservation rhinoplasty to
be performed without any dorsal skin elevation, preserving
most if not virtually all the nasal ligaments (Fig. 6.1a–c).
6.2.4 Group #2
These patients have good dorsal aesthetic lines yet require
modifications due to the height of the bony hump. In this
group, it is necessary to elevate the dorsal skin and par-
tially dissect the ligaments Fig. 6.2a–c. We approach the
dorsum via tunnels created between the deep pitanguy
and vertical scroll ligament (VSL). With this manoeuvre,
we can refine dorsal aesthetic lines whilst still preserving
the ligaments.
6 Letdown and Piezo Techniques in Preservation Rhinoplasty
a b
Fig. 6.1 (a–c) Group 1 dissection. The red and orange zones represent
the areas dissected. The green zone is intact, with no skin elevation.
(Video 6.1) A case of open preservation rhinoplasty using the subdorsal
flap. We began with the open approach with inverted V-incision.
Because of the patient’s beautiful dorsal anatomy, did not need to
approach the dorsum and scroll ligaments and pitanguy’s ligaments
were kept intact (Group 1 dissection). Supraperichondrial dissection
over the lower lateral cartilages, continuing laterally to expose the pyri-
form aperture. We create the osteotomy tunnel for piezo osteotomy pos-
terior to the NMSL attachment. For approaching the septum we used a
hemitransfixion incision and a subdorsal tetris septal flap was utilized.
On the septum, an externally inserted fine needle marked the most
prominent portion of the hump and the subdorsal tetris flap was created.
Posterior to the flap, cartilage was resected using a baby Rongeur
immediately under the bony hump and a long piezo insert was used to
a b
Fig. 6.2 (a–c) Group 2 dissection. The red zone demonstrates the dissected area. The green zone is not dissected and the skin is not elevated
87
c
break the relationship between the ethmoid bone and the nasal bone.
Transverse osteotomies were performed using the handsaw, followed
by low-to-low lateral osteotomies using the long insert and the piezo
device. Webster’s triangles were resected bilaterally to prevent overlap-
ping of the bony fragment. The periosteum on the inner surface of the
maxillary bone is elevated, followed by the ballerina manoeuvre, disar-
ticulating the lateral keystone connection from the ULCs to facilitate
dorsal lowering. Radix osteotomy was performed percutaneously using
a 2-mm osteotome in an oblique direction. The subdorsal flap was then
secured with suture fixation once the dorsum was lowered to the desired
height and quilting sutures were performed to further secure the septum
and close dead space to prevent a haematoma. Following tip plasty,
plasma-rich fibrin liquid and gel was prepared by harvesting blood,
which was then used to stick the diced cartilage together and placed on
the supratip area) (▶ https://doi.org/10.1007/000-­9pm)
c
88
a b
Fig. 6.3 (a–c) Group 3 dissection. The red zone represents the area of dissection
Fig. 6.4 The dotted line shows the NMSL on the suture line between
the frontal process of the maxillary bone and the nasal bone. VPL verti-
cal pyriform ligament
6.2.5 Group #3
In these patients, there are significant dorsal deformities;
however, despite the presence of dorsal irregularities and
asymmetries, the dorsum is still deemed suitable for dorsal
preservation. In this group the dorsum is reshaped and pre-
served through total dissection of the nasal dorsum skin
without any ligamentous preservation (Fig. 6.3a–c). The
Pitanguy ligament and scroll ligament can be fixed at the end
of the procedure.
We can also preserve the nasomaxillary suture line liga-
ment (NMSL) [9], delineated in Fig. 6.4, which is located
along the suture line between the nasal bones and the frontal
A. Goksel and K. N. Tran
c
process of the maxilla, for the cases in Groups #1 and #2. It
is an important structure when it comes to osteotomies, nota-
bly because if this ligament can be kept intact during the
piezo osteotomies, in our experience skin redraping and
healing will be faster. Preservation of the NMS ligament can
be achieved by creating a tunnel posterior to this ligament for
the low-to-low osteotomies.
6.3 Surgical Technique
6.3.1 Skin and Soft Tissue Envelope Elevation
For the open approach, we prefer an inverted-V incision. For
dissection of the skin and superficial musculo-aponeurotic
system (SMAS), it is essential to clearly establish what is the
planned procedure for the nasal dorsum, as this will dictate
the extent of soft tissue dissection.
Group #1: If there are no intended nasal dorsum changes,
we continue with the ligament preservation method without
dorsal skin dissection.
Group #2: For patients who require reshaping of the nasal
dorsum by rasping or camouflage, we elevate the nasal skin
supraperichondrially and dissect between the preserved ver-
tical scroll ligament and Pitanguy’s ligaments. Some dor-
sums have S-shaped nasal bones [10], in which case we
dissect the bony dorsum in the subperiosteal plane in antici-
pation for requisite rasping of the bony cap.
It is important to note that for during skin/SMAS dissec-
tion for Groups #1 and #2, we create a subperiosteal tunnel
for lateral and transverse osteotomies by approaching the
6 Letdown and Piezo Techniques in Preservation Rhinoplasty
pyriform aperture via a rim incision just lateral to the VSL
and the Pitanguy’s ligament, without nasal skin elevation.
The lateral tunnel should be wide enough to allow for the use
of piezo instruments under direct visualization.
Group #3: If extensive reshaping of both the bony and
cartilaginous dorsum is deemed necessary, we cut through
the Pitanguy’s ligament and the VSL, dissecting the skin in
the supraperichondrial plane over the cartilaginous area and
in the subperiosteal plane over the bony area. With a widened
skin dissection, the extent of the dissection extends to the
radix area and pyriform aperture, including the superficial
portion of the medial canthal ligament, enabling sufficient
access for the use of piezo instruments.
6.4 Management of the Septum
6.4.1 Approaching the Septal Cartilage
In open preservation rhinoplasty cases where the intention is
to preserve all the ligaments, the septal cartilage is reached via
a hemitransfixion incision. On the other hand, if the plan is to
cut the Pitanguy’s ligament and make modifications on the
nasal dorsum, the septum is accessed through the caudal area
without an additional incision. With regards to the plane of
septal dissection, we recommend adopting the strategy
described by Neves [11], which involves dissecting the septal
cartilage in the supraperichondrial plane, which Neves refers
to as the sub-laminar plane since it lies below the lamina pro-
a b
e f
Fig. 6.5 Preservation septal manoeuvres. (a) Saban HSS; subdorsal flap variations include (b) most subdorsal flap, (c) Neves tetris flap, (d)
Kovacevic Z-flap; low septal techniques include (e) Cottle low septal strip and (f) Finocchi SPQR; (g) Goksel bony dorsal preservation
89
pria, in the regions where one intends to insert a suture to later
fixate the dorsum. The intact perichondrial attachment to the
septum affords additional strength to the septal cartilage and
reduces the risk of suture material tearing through the cartilage
upon dorsal fixation. For example, with low septal strip tech-
niques, we recommend that at least the most caudal 1 cm of
septal cartilage be elevated in the supraperichondrial plane,
before switching to the bloodless subperichondrial plane for
the remainder of the septal dissection. If the surgeon antici-
pates that they will likely use an adjacent septal graft (e.g. sep-
tal extension graft, bony or cartilaginous graft to splint the
caudal septum), we advise that on the side of intended grafting
the septum be elevated in a subperichondrial plane, whilst on
the non-graft side the perichondrium be kept intact in the
regions of intended future suture fixation.
6.4.2 Septal Strip Excision
Prior to mobilizing the osseocartilaginous pyramid, it is nec-
essary to first create space for the dorsal hump to be lowered,
by resecting a septal strip. The main determinant of nasal
dorsum lowering is not the amount of bone resected but the
amount of septal strip removed. There are several established
dorsal preservation septal manoeuvres for the surgeon to
select from, as illustrated in Fig. 6.5a–g. They can be grouped
into the following categories: (1) high septal strip/subdorsal
resection (as popularized by Saban [6]), (2) mid-septal strip/
subdorsal flaps of various configurations (as per Most [12],
c d
g
90
Neves [13] and Kovacevic [14]), (3) low septal strip (Cottle
[15] or Finocchi’s [16] “SPQR” simplified preservation
quick rhinoplasty/modified Cottle) and (4) bony dorsal pres-
ervation (Goksel) [17].
Several factors influencing the choice of septal procedure,
including (1) the surgeon’s experience and the technique that
he/she is best accustomed to; (2) presence of septal devia-
tion, its location and severity; (3) whether the bony pyramid
is deviated (crooked nose) and (4) other indications as previ-
ously outlined in Table 6.1.
6.5 Management of the Bony Vault
6.5.1 Piezo Osteotomy/Ostectomy
Piezoelectrical instruments have a well-established history
in maxillofacial surgery and dentistry. It has been shown to
be a precise and safe surgical instrument with good applica-
bility also in rhinoplasty [7]. Thanks to the new generation
of devices, procedures such as recontouring, rasping and
cutting through the bones can be carried out much faster and
with greater accuracy. Furthermore, PEI has been shown to
preserve the integrity of the surrounding soft tissues and
membranes and thus often prevents significant bleeding dur-
ing the bone-shaping process, therein drastically reducing
both postoperative bleeding and oedema [7, 18, 19]. This
technique also helps to avoid potential problems associated
with osteotomies using osteotomes, such as unwanted frac-
ture lines and irregularities resulting from palpable bony
spicules. Additionally, even after the bony vault has been
mobilized, it is possible for to sculpt the bone without caus-
ing destabilization when using PEI. Gerbault’s publication
on piezo surgery is an important resource for this subject
[7, 18].
a b
Fig. 6.6 Webster’s triangle. (a) In relation to lateral osteotomy, (b) following resection and push down
A. Goksel and K. N. Tran
6.5.2 Addressing the Bony Vault
In preservation surgery, the bony vault can be managed in two
main ways—the letdown and the pushdown procedure. In both
instances, the entire bony vault is mobilized and lowered using
lateral, transverse and radix osteotomies. The let­down procedure
involves resecting a strip of bone is resected laterally at the facial
groove so that the bony pyramid descends to sit on the ascending
frontal process of the maxilla. In contrast, in the pushdown pro-
cedure, following osteotomies the bony pyramid is impacted
down into the pyriform aperture with bony overlap.
In our practice, we use PEIs for all our lateral osteoto-
mies; they enable us to create delicate osteotomies at a more
precise level and change the direction of the bony cuts from
horizontal to sagittal, thus decreasing the bony resistance to
posterior displacement during ­push­down. In both letdown
and the pushdown cases, we conduct low-to-low lateral oste-
otomies placed as close as possible to the maxillary bone,
right above the nasofacial groove, as we wish to avoid creat-
ing a visible or palpable step deformity in our patients. In our
experience, straight, and angled long piezo inserts are the
easiest, fastest and most precise method to achieve this. We
also often prefer to use a hybrid of the pushdown/letdown
procedures in our dorsal preservation cases. At the cephalic
portion of the bony pyramid we perform an osteotomy (with-
out ostectomy), which is essentially a pushdown type of
manoeuvre. At the caudal portion of the nasal bony pyramid
at the pyriform aperture (Webster’s triangle) we perform a
triangular shaped ostectomy, thus creating a letdown
(Fig. 6.6a, b).
It is our preference to excise Webster’s triangle so as to
prevent any potential blockage that may arise when the bone
of the pyriform aperture is pushed down and overlaps with
the head of the inferior turbinate attachment, which is located
immediately posterior to the Webster’s triangle (Fig. 6.7).
6 Letdown and Piezo Techniques in Preservation Rhinoplasty
The bone fragment of the inferior turbinate could potentially
block the intended downward movement of the nasal bone,
and such an impediment to dorsal lowering could result in an
unwanted residual hump. To prevent this from occurring, we
recommend that the Webster’s triangle be resected when
Fig. 6.7 Relationship between Webster’s triangle and the adjacent
head of the inferior turbinate, which could be a potential blocking point
during pushdown unless the Webster’s triangle is resected
Fig. 6.8 Transverse osteotomy using the Tastan-Cakir hand saw
a b
Fig. 6.9 (a) Sagittal lateral osteotomies using PEI and (b) pushdown manoeuvre in the straight bony vault
91
using the preservation technique. The PEI is an excellent
way to accurately perform this specific bony resection. A
recent computed tomography study has demonstrated
improved patency of the nasal area with resection of this
region when compared with the traditional pushdown proce-
dure [20]. We hypothesize that the reason resection of the
Webster’s triangle does not lead to internal nasal valve col-
lapse and obstruction is likely owing to the bony support pro-
vided by the overlapped bone.
In dorsal preservation surgery we typically perform oste-
otomies and associated manoeuvres, in the following order:
1. Transverse osteotomies: with Group #1 and Group #2
patients, where we preserve the ligaments and do not dis-
sect the nasal dorsum, we use the combination of Tastan-­
Cakir (Microsaw Medisoft Medical) hand saws and a
2-mm external osteotome. With Group #3 patients, we
carry out all the osteotomies including the transverse
osteotomies with PEI (see Fig. 6.8). In our experience, in
order to prevent irregularities to the radix including step
deformities, it is critical that the transverse osteotomy is
made at the correct level, taking the intercanthal area as a
guide. If the transverse osteotomy is carried out from a
level lower than the radix, such as from the beginning of
the hump, the inferior radix portion might cause a step
deformity or a low projected radix.
2. Low-to-low lateral osteotomies: created with the assis-
tance of PEI with long inserts designed by the senior
author. In our practice there are two options for the lateral
osteotomies, depending on whether or not the bony vault
is deviated. If the bony pyramid is straight and simply
requires lowering, we perform bilateral osteotomies in
the sagittal plane. As the two borders of the cut bones are
parallel to the sagittal plane (see Fig. 6.9a, b), it makes it
easier to push down the dorsum without resistance and
reduces the risk of residual hump recurrence in the late
postoperative period. In contrast, in the case of the
crooked bony vault, asymmetrical osteotomies are per-
formed (Fig. 6.10a, b). On the short side of the nasal
bone, we make a horizontal-oblique osteotomy, to mini-
92 A. Goksel and K. N. Tran

a b

Fig. 6.10 (a) Asymmetrical lateral osteotomies using PEI, with (b) pyramid tilting to correct the deviated bony vault

mize posterior displacement. On the longer side, a sagit-

tal osteotomy is used to allow for posterior displacement
and pyramid tilting.
3. Webster’s triangle is excised bilaterally, for reasons previ-
ously mentioned, in cases where there is no bony vault
deviation. However, in crooked nose correction where
there is no significant hump reduction needed, Webster
triangle excision is asymmetrical. On the longer side of
the nasal bone, we excise Webster’s triangle completely
whereas on the shorter side of the nasal bone, either a
smaller wedge of Webster’s triangle is removed or it is
left intact and used as a stabilizing stopper/pivot point
when tilting the deviated bony pyramid.
4. The periosteum on the inner surface of the maxillary bone
is elevated on both sides for the straight nose and on the Fig. 6.11 Elevation of periosteum along the inner surface of the maxil-
lary bone
longer side for the deviated nose, to create space for bony
descent and to prevent tissue resistance to dorsal lowering
(Fig. 6.11). We typically begin elevation at the pyriform
aperture and continue cephalically.
5. Finally, radix osteotomy to connect both sides of the trans-
verse osteotomies is performed in an oblique direction and
percutaneously using a 2-mm osteotome (Fig. 6.12).
Subsequently, the whole dorsum becomes mobile.

In cases of an over-projected radix, following completing

transverse osteotomy and lowering of the dorsum, there may
be a step deformity caused by high projection of the frontal
process and nasal bones. In such cases, the piezo scraper
insert can be very useful for equalizing the bone level.
Furthermore, for patients with an over-projected radix, it
should be remembered that the sub-SMAS layer in that area
might be thicker and there is also the procerus muscle adding Fig. 6.12 Percutaneous radix osteotomy in an oblique direction
bulk to the radix. Therefore, in cases where radix lowering
requires the bone to be rasped, it would also be worthwhile help the skin to settle, allowing us to create a more defined
to consider excising the procerus muscle, as it would further nasal starting point.
6 Letdown and Piezo Techniques in Preservation Rhinoplasty 93

6.6 Adjunctive Measures: To Control 6.6.1 Ballerina Manoeuvre (Lateral K Stone

the New Shape of the Nasal Dorsum Dissection)

In order to achieve the desired dorsal lowering and prevent
dorsal hump recurrence, there are several adjunctive manoeu-
vres that can be employed, beyond the previously described
septal strip excision and bony base lowering. For example, to
change the shape of the dorsal keystone area (DKA) with the
high septal strip approach, the remnant dorsal cartilaginous
septum can be scored to further weaken their connection.
Releasing the longitudinal pyriform ligament can further
mobilize the keystone area to help achieve a more concave or
straighter appearance [21]. Removal of the bony cap and
shaving off any prominent ULC shoulders are other addi-
tional manoeuvres to help the nasal dorsum obtain its new
shape.
Apart from the release at the DKA it may also be necessary
to mobilize the lateral keystone area (LKA) by releasing the
LKA side wall connections (Fig. 6.13a). The ballerina
manoeuvre [22], which involves separating the ULCs from
the nasal bone, eliminates a potential blocking point causing
resistance to nasal dorsal lowering and therefore prevents
hump recurrence. The hump height and the desired shape
determine the extent of lateral K stone dissection for each
case. In Fig. 6.13b one can see that the blue line marks the
hump, which correlates with the end point for the lateral dis-
section. Dissection of the LKA, the extent of lateral dissec-
tion and effective dorsal lowering can be seen in Fig. 6.13a,
c, d, respectively.

a b

c d

Fig. 6.13 Ballerina manoeuvre. (a) Releasing the connection between the ULCs and the nasal bones. (b) Red line represents the lateral keystone
area. Blue line indicates the nasal hump and limit of lateral dissection. (c, d) Effective dorsal lowering following lateral keystone area dissection
94 A. Goksel and K. N. Tran

6.7 Fixing the New Position

of the Dorsum

The final step in dorsal preservation rhinoplasty is to fixate the

lowered dorsum into the new position to ensure stability. The
fixation method depends on the preservation septal technique
used. Fixation should always occur without any tension.
In mid-septal/subdorsal flap techniques fixation is with septal
sutures to suture the mid-septal cartilages either end ­to ­end or
overlapping, with additional transmucosal septal mattress sutures
to provide further reinforcement. In contrast, in low septal strip
techniques, there is a single point of fixation of the freed caudal
septum to the anterior nasal spine (ANS). Our preferred method
is to create a notch with a #15 blade on the middle portion of the
ANS and then carefully drill a hole from one side to the other
with the piezo drill insert through the body of the ANS, followed
by second and third holes on either side of the notch. As opposed
to standard high-speed spinning drills, the PEI drill device works
with vibration, so there is no risk of catching the soft tissue. A
4–0 polydiaxonone (PDS) suture can be used to fix the septum to
the ANS, passing through the three holes created (Fig. 6.14). In
our experience, this method of direct fixation to the ANS bone is
the most stable and reliable means of single suture fixation.
High septal strip techniques require fixation between the osseo-
cartilaginous dorsum and the underlying septum. The sutures can
be placed in many different ways but the key point is that they
should not be tied too tightly, in order to avoid creating middle vault
distortion. It is our preference to use the criss-cross suture method
for fixating the dorsum in open preservation high septal strip cases.
This involves drilling a hole on both sides of the nasal bones using
the piezo drill insert. The piezo drill insert can be used to perforate
the nasal bones, even when they are mobile, without causing desta-
bilization. Starting from one side a 5–0 PDS suture is passed
obliquely through the nasal bone and dorsal septal cartilage, exiting
at the opposite ULC. The suture then loops upwards passing
through the contralateral nasal bone drill hole, and courses obliquely
again through the septum to exits by passing through ULC on the
side of the starting point, and is thus secured. In Fig. 6.15a–c, an
open roof is created on a cadaver (for illustrative purposes only as
normally the dorsum is preserved) in order to demonstrate how the
criss-cross suture traverses through the septum and osseocartilagi-
nous vault. At the completion of the criss-cross suture, the nasal
dorsum is fixed to the stable septal cartilage underneath.
Fig. 6.14 ANS fixation for low septal strip single-point fixation
In the bony dorsal preservation technique, the septum is
separated from its attachment to the ULCs and at the end of
6 Letdown and Piezo Techniques in Preservation Rhinoplasty 95

a b c

Fig. 6.15 (a–c) Criss-cross suture for HSS, fixation. For illustrative purposes an open roof has been created on this cadaver model, in order to
better demonstrate how the criss-cross suture traverses through the septum and osseocartilaginous vault

the procedure delivers between the ULCs when the bony-­
cartilaginous dorsum drops down to its ideal height. After the
emerged dorsal septum is trimmed to the level of the
descended ULCs, the septum is reconnected to the ULCs
using 6.0 PDS, thus fixating the dorsum in the process.
The aforementioned techniques are demonstrated in
Video 6.1.
6.8 Conclusion
Preservation rhinoplasty represents a paradigm shift in rhi-
noplasty philosophy towards preserving and reshaping
existing nasal structures. The concepts are over a century
old but has experienced a recent resurgence of clinical and
academic interest, sparking improvements and refinements
of existing techniques and the development of new ones.
Preservation rhinoplasty is fast becoming a dynamic, com-
plex and ever-evolving field of rhinoplasty surgery.
Incorporating the open approach to preservation surgery
enables greater visualization of the nasal tip and dorsum and
provides greater ease of powered instrument access.
Furthermore, the addition of the piezoelectric device with
rhinoplasty-specific inserts serves to improve the precision
and accuracy of osseocartilaginous management and dorsal
fixation, thus reducing the risk of bony irregularities and
optimizing the surgical outcome.
96 A. Goksel and K. N. Tran

6.9 Clinical Cases
6.9.1 Case 1
29-year-old female who underwent open preservation rhino-
plasty with the assistance of the PEI. She underwent Group 2
dissection with partial ligamentous preservation, and a sub-
dorsal flap septal technique was used. Piezo-assisted lateral
osteotomies with the long insert were made in the sagittal
plane. Columella strut and suture tip plasty. Preoperative and
2 years postoperative photos.
6 Letdown and Piezo Techniques in Preservation Rhinoplasty 97
98
6.9.2 Case 2
24-year-old female who underwent open preservation rhino-
plasty using the PEI. She underwent Group 2 soft tissue dis-
section with partial ligamentous preservation and a low
A. Goksel and K. N. Tran
septal strip technique was used. Columella strut and suture
tip plasty. Clinical photographs are preoperative and 1 year
postoperative.
6 Letdown and Piezo Techniques in Preservation Rhinoplasty 99
100
6.9.3 Case 3
28-year-old female who underwent open preservation rhino-
plasty using the PEI. She had Group 1 soft tissue dissection
with ligamentous preservation and a subdorsal flap septal
A. Goksel and K. N. Tran
technique was used. Columella strut and suture tip plasty.
Clinical photographs are preoperative and 1 year
postoperative.
6 Letdown and Piezo Techniques in Preservation Rhinoplasty 101
102
6.9.4 Case 4
35-year-old female who underwent open preservation rhino-
plasty using the PEI. She had Group 2 soft tissue dissection
with partial ligamentous preservation and a subdorsal flap
A. Goksel and K. N. Tran
septal technique was used. Columella strut and suture tip
plasty. Clinical photographs are preoperative and 1 year
postoperative.
6 Letdown and Piezo Techniques in Preservation Rhinoplasty 103
104 A. Goksel and K. N. Tran

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plasty: method and outcomes of the modified subdorsal strip
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tion. Aesthet Surg J. 2018;38(2):228–9.
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Meet Am Laryngol Assoc. 1958;79:245–6.
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3. Lothrop OA. An operation for correcting the aquiline nasal defor-
ification of the Cottle technique in dorsal preservation rhinoplasty.
mity; the use of new instrument; report of a case. Boston Med Surg
Curr Opin Otolaryngol Head Neck Surg. 2021;29:244–51.
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pyramid and the nasal septum for restoration of normal physiology.
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 Combination of Structure
and Preservation: A Step-by-Step 7
Surgical Guide to French-Touch
Preservation Rhinoplasty

Sylvie Poignonec

Aim of the Chapter
Why combine the techniques of structural and preservation
rhinoplasty?
What is a French-touch preservation rhinoplasty?
How to select patients for this technique.
How is French-touch preservation rhinoplasty accom-
plished? How I do it step by step.
Surgical guide with clinical cases is given.
7.1 Introduction
Dorsal preservation rhinoplasty is not a new technique; the
first operation was done in 1898; Maurice Cottle popularized
the “push-down” [1–3]. Yves Jallut [4] related the history of
rhinoplasty.
Preservation rhinoplasty involves three points: subperi-
chondrial and subperiosteal dissection, cartilage conserva-
tion with plicature and suture instead of resection, and
osseocartilaginous dorsum preservation, respecting the mid-
dle nasal vault contour and ligaments at the time of surgery.
In recent years, many great surgeons such as Yves Saban
[5, 6] Rolin K. Daniel [7–9], Baris Cakir [10, 11], and others
have modified and improved the initial procedure.
Preservation of underlying nasal anatomy may be partial or
total. Complete preservation rhinoplasty with a single dis-
section of the soft-tissue envelope (STE) (Fig. 7.1) as a sin-
gle sheet of perichondrium and periosteum without resection
and with complete dorsum preservation has very specific
indications, which are not often fully realized.
Dissection is often limited to prevent a weak, floating
nose, to avoid external incisions, and to preserve cartilage,
obviating the need for grafts. Total preservation rhinoplasty
is a philosophical concept, but patient anatomical variations
often require surgeons to adapt to reality.
Most people are addicted to social media; we can see in
Fig. 7.2 patients taking daily selfies and they are connected
through all types of social networks, frequently comparing
their nose with that of their peers. In the setting of rhino-
plasty, patients show off their surgical results whether happy
or dissatisfied.
Like patients, many surgeons do the same, publishing
their own before and after results through social media.
Although this practice may be questionable because of the
medical confidentiality or different interpretations made by
on-lookers, social media provide both an audience and a
marketing platform for surgeons.

Special thanks to Matt Miller, Md University of Kansas School of

Medicine

Supplementary Information The online version contains supplemen-

tary material available at https://doi.org/10.1007/978-­3-­031-­29977-­3_7.
The videos can be accessed individually by clicking the DOI link in the
accompanying figure caption or by scanning this link with the SN More
Media App.

S. Poignonec (*) Fig. 7.1 Soft-tissue envelope, underlying superficial musculoaponeu-

Plastic Surgery and Head and Neck Surgery, Centre Esthétique rotic system, anatomical dissection
Paris - Eiffel, Paris, France

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 105
S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_7
106 S. Poignonec

Fig. 7.2 Selfie generation

In my opinion, the closer the surgeon is to their patient’s

aesthetic personality, the better they perform. That said, each
patient is unique; don’t do the same nose for every patient.
Preserving the existing anatomy is the best way to obtain
beautiful and long-lasting results for both real and digital
life.

7.2 Why Combine Structure

and Preservation

In specific indications, as we explain in the text below, dorsal

preservation protects the natural dorsum, avoids irregulari-
ties or open-roof deformities, and cartilage conservation pre-
vents the long-term retraction of the nostrils and the collapsed
lateral alar cartilage from pinching… But for the tip, this
technique is not always sufficient.
We know that anticipating the long-term results, espe-
cially regarding the tip, is important. For example, patients
who have a hypo-projected tip or thick skin need to have
very stable tip support: in Fig. 7.3 this young patient, 8
months after a preservation rhinoplasty, complained about a
slight modification of the tip with fullness of the supra-tip
and the start of a polly-beak deformity.
Thus, in some cases of heavy skin or dropping tip we need
to graft the tip to obtain a stable result. That is why we intro-
duced the notion of combined structural and preservation Fig. 7.3 Modification of tip with a polly-beak deformity
rhinoplasty.
7 Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty
Fig. 7.4 After 20 years. Closed approach rhinoplasty; the hump has been rasped; no graft was used on the nose refinement of the skin
Patients with thin skin can develop irregularity, which
appears after many years.
Results of rhinoplasty may sometimes seem random,
depending on the technique, patient scarring, and skin qual-
ity (Fig. 7.4).
French-touch nose: in France, most of our patients ask
their surgeons to keep a natural-looking nose without any
appearance of surgery. This means that the nasolabial angle
should be kept at around 100–110° for women, and 90° to
100° for men. Some of our patients, especially men, want to
keep a straight dorsum. Nordic and white color skin is most
often associated with thin or moderately thick skin; thus, the
structured tip refinement and onlay grafts could be visible
under the skin for months. Preservation of the STE and the
cartilaginous structure is important. Tensioning and reshap-
ing the alar cartilage are better than resecting. Roundness
and softness of the tip are often better in the long term than a
thin, pointy tip that is palpable under the skin.
107
7.3 Selection of the Patients for this
Technique
Dr. Rollin Daniel [7–9] said “selecting good cases will make
you a happy surgeon!” Following his advice could help you
throughout your surgical career.
1. First impression:
Take a complete look at your patient – size, weight, dress,
and attitude. Start the moment that they enter your office. Are
they introverted, confident, shy, talkative, or mute? The first
impression is often the best to help with patient selection.
Have confidence in your own feelings. If you are unsure, ask
for advice from a psychiatric colleague. At the beginning,
don’t accept exceptionally difficult cases. Try to select good
cases to build confidence. See patients twice or more before
their surgery date. You may have different impressions after
getting to know them better. You can also ask your staff nurse
108 S. Poignonec

Name:
Surname:
Date:
1)-Since how long have you been thinking about rhinoplasty or nasal surgery?
2)-Do you feel insecure about your physical appearance?
Minor insecurity about my nose (slight dorsal hump)
Great insecurity about my nose (too large, deviated, bothered daily)
Severe insecurity about my entire appearance (I can’t even look in the mirror)
3)-Have you told your family or friends about your plans for rhinoplasty?
4)-Do you want to change your nose because it represents a family legacy (similar nose as a
family member you dislike)?
5)-Do you to change because of your ethnicity
6)-Is rhinoplasty the only surgery plastic surgery you are considering?
7)-Is rhinoplasty going to improve your life?
8)-Do you have any known nasal functional disease/obstruction?
9)-Have you had any prior nasal trauma or injury?
10)-Do you have psychological troubles?
11)-have you had prior rhinoplasty?

Fig. 7.5 Rhinoplasty eligibility questionnaire

anesthesiologist about their own feelings concerning the
patient.
2. Medical Questionnaire: Fig. 7.5.
Completion of a medical questionnaire helps you to select
your patient and save time during the consultation.
Questionnaires must be filled out by patients after a
2-week minimum contemplation period. Questionnaires
include the Rhinoplasty Outcomes Evaluation [10, 12] and
the surgeon-specific one, which should be completed either
in the waiting room or at home. Typically, questionnaires
take half an hour to complete correctly; these can be adapted
to your own practice and can even help with future
publications.
Facial malar bone asymmetry: right flat face, asymmetri-
cal nostrils, and facial asymmetry are very common because
of many factors (facial, skeletal and muscular issues).
Helping patients to see their asymmetries can prevent further
frustration after the operation is finished (Figs. 7.6 and 7.7).
Mirror (Canfield) [14] helps you to stitch two right
sides and two left sides together (Fig. 7.8)
Be aware of different patterns of anatomy. Because anat-
omy is so variable from one patient to another, technical
procedures must be adapted. Every case is different. We
must account for our patient’s skin quality and capacity to
retract/scar on an individual basis. We all develop a base-
line surgical technique that we must customize to each
patient.
Analysis of multiple facial angles is normal in rhinoplasty
procedures. The forehead and chin must be examined for
proportions. Sometimes additional procedures may help to
improve the aesthetic result: chin augmentation, forehead
contouring by fat grafting (Figs. 7.9 and 7.10).

Severe insecurity about one’s entire appearance, espe-
cially in men who have undergone two or more
prior rhinoplasties
3. Analyze the entire face: facial asymmetry is very com-
mon; but most people never notice it before surgery; pho-
tography will help you to explain your to patient that
rhinoplasty will not correct this asymmetry, as mentioned
by Sozen et al. [13].
4. Nasal analysis: first, we must appreciate the quality of
the skin. Thick, seborrheic skin needs to be treated before
and after surgery (collaboration with dermatology col-
leagues is helpful) in the case of a thick tip supraperi-
chondrial dissection is advisable to partially de-fat the tip.
For patients with thin skin sub-perichondral dissection is
preferable. we must take care of post-operative skin scar-
ring; we have to pay attention to the use of tip grafts,
which could be visible and must be covered by some
camouflage procedures, as described in Chap. 8.
7 Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty 109

ASYMETRY PREOP MUST BE DETECTED PRIOR ASYMETRY PREOP MUST BE DETECTED PRIOR
SURGERY SURGERY

Fig. 7.6 Front view pre-operatively Fig. 7.7 Basal view pre-operatively
110 S. Poignonec

Fig. 7.8 Simulation of two

right sides and two left sides
stitched together by Mirror
(Canfield)

Fig. 7.9 Additional procedures: 2 years post-operatively, fat grafting of the chin (3 cc) and forehead (10 cc)
7 Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty
PRESERVATION RHINOPLASTY TECHNIQUES SAVE TIME
FOR ADDITIONNAL AESTHETIC PROCEDURES
Fig. 7.10 Fat grafting and procedures
Frontal analysis: generally, dorsal lines are not strictly
straight but wider in the K area than in the radix area. For
complete dorsal preservation, dorsal lines must be regular
and soft; if not, hybrid techniques could be used. The
keystone region is located higher in men than in women
[10, 11] (Figs. 7.11 and 7.12).
Nasal bones must be carefully palpated to find out
whether they are short or long; short nasal bones are easier
for beginning dorsal preservation; some bones could be
convex on one side and concave on the other [7–9]; this is
an indication for structural rhinoplasty; the K area (see
111
Fig. 7.11 Dorsal lines
Abbreviations) is one of the most important parts of the
nasal anatomical examination. Breathing and other func-
tions could be studied using the Cottle test [3]; nasal valve
dysfunction is studied in Chap. 9. The tip must be precisely
examined and palpated; the tip’s lateral crural width and
facet polygons [10, 11] can be drawn on the patient’s nose
to determine the amount of cartilage to be resected. The
resting angle is the angle the between upper cartilage and
the lower cartilage; tip modeling and sculpture with carti-
lage preservation without any excisions constitute the best
way to maintain function and have a beautiful aesthetic
result (Figs. 7.11 and 7.12).
112
IDEAL RESTING ANGLE :100°
Fig. 7.12 Resting angle
7.4 Profile Analysis
Facial angle analysis is explained in Fig. 7.13. The forehead
and chin should be in the same vertical line; the nasofrontal
angle could be deep or full; the nasolabial angle closed or
open. The nasal spine must be palpated. The dorsum could
be straight or convex: a kyphotic nose has an S shape or a V
shape, as described by Daniel and Palhazi [7]; straight nose
or V-shaped nose is ideal for preservation.
• In basal analysis we look for columellar deviation, hang-
ing columella, retracted columella, nostril asymmetry
• Examination when smiling detects tip drooping; exami-
nation when opening the mouth looks for good or bad
occlusion and dentition
• Deep breathing detects nasal valve alar collapse using the
Cottle test [11, 15]
• Endonasal speculum or fibroscopic examination fully
visualizes the septum, which could be straight, slightly
deviated, or complexly deviated. To begin with, a straight
or slightly deviated septum is easier
At the end, we must know if we have a good tip support
and a stable septum. If yes, the columellar strut will likely be
S. Poignonec
Fig. 7.13 Side view
enough to maintain tip projection, but in the case of poor
projection or a heavy ptotic tip, a septal extension graft as
described by Toriumi [15, 16] and Kosins and Daniel [17] or
an ANSA banner [18] or Teostrut by Dogan [19] is
advisable.
• CT scans (see Chap. 4) are mandatory with significant
deviation of the septum, prior nasal trauma, or full naso-
frontal angle.
• Photos and simulations have been explained in Chap. 3
Then, a decisional tree can be drawn (Fig. 7.14).
Steps-by-step surgical approach to a standard dorsal
preservation high strip primary rhinoplasty for a white
nose using a closed approach (could be opened at the end
of the procedure to check the tip).
Good indications:
• Straight narrow nose,
• V-shaped nose (only one curvature),
• Straight septum with deviated dorsum or slightly high
deviation of the septum,
• Normal radix,
• Straight over-projected dorsum.
7 Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty 113

Fig. 7.14 Decisional tree

First Impression
- Presentation
- Appearance
- Mental State
- Completed
questionnaire

Positive Negative
- Precise - Psychological Issue
Examinaon - Medical
- Photo Contraindicaon
Simulaon - Abnormal Request
- Radiographs
scanner

Good Intermediate Poor

- Non-Preservation
- Total - Partial Preservation Technique
Preservation - Dorsal Resection - Overly broad nose
- Straight Nose Bony cap - Prior big Trauma
- Small Dorsal - Middle Vault - Complex Deviaon
Hump Conservation
- ethnic noses
- High Strip or - Ishida (ref 22)
low strip Ferreira (ref 24)
- Saban(ref 5-6) -kosins (17)
- Kovacevic(ref 21)
- Cottle
- Neves (ref 18)
Goksel (ref 26)

Bad indications:
• Very deviated septum,
• Secondary rhinoplasty,
• Very wide dorsum,
• Low radix,
• Broad saddle noses.

Instrumentation (Fig. 7.15): it is advisable to have your

own surgical box. Specific tools are necessary: nasal double
hook, angled scissors, Daniel Cakir elevator, microsaw,
microrasp, cartilage cutting block with grooves, suction
­elevator, rotatable Heyman nasal scissors, Piezotome baby
rongeur (Marina Medical).
Positioning of the patient (Fig. 7.16) is very important:
surgery is performed under general anesthesia, in a supine
position with reverse Trendelenburg, eye protection with eye
drops, and adhesive tape. General anesthesia is mandatory.
Intubation must be positioned in the middle or laterally and Fig. 7.15 Instrumentation
the chin must be seen. Throat packing is mandatory.
Drawings are made prior to infiltration: cartilage incision, Infiltration: 10 cc saline solution, 5 cc xylocaine 1%, with
desired position of the tip, and osteotomies. Patient photo- 5 cc Naropeine 1/4 mg adrenaline; slow infiltration is advised
graphs are taped on the wall in front of the surgeon, as well with frequent blood pressure checks. In the case of tachycar-
as any computer simulations. dia, stop infiltration for few minutes. We use 5-cc syringes
114
Fig. 7.16 Positioning of the patient. (Video 7.1 Installation of the
patient) (▶ https://doi.org/10.1007/000-9pq)
with 25- and 30-gauge needles. It is advisable to add epineph-
rine a few minutes before injection and wait 15–20 min before
beginning surgery to optimize hemostasis.
Surgical steps for preservation:
1. Incision
2. Sub-perichondral dissection reaching the two domes
with resection of 2 mm of lower cartilage if necessary, to
help the tip sculpture (von Gruber points)
3. Pitanguy window
4. Septum works: high strip
5. Osteotomies: radix, transverse, and lateral
6. Impaction
7. Fixation of osseocartilaginous vault to the underlying
septum
8. Tip surgery
9. Ligament repair
10. Closures
11. Taping
1. Incision (Fig. 7.17 and Video 7.2)
Closed extended marginal approach: a frank incision with
a 25 blade is realized, straight intra-cartilaginous, then
infra-cartilaginous 3 mm short of the domes leaving
3 mm of the lateral crura as an auto-rim flap. Incision
travels low along the crura up to a few millimeters from
the base of the columella.
S. Poignonec
Fig. 7.17 Incision. (Video 7.2 Incision)
(▶ https://doi.org/10.1007/000-9pp)
2. Dissection: the tip of the blade will reach the perichon-
drium over the cartilage, which is white and bright; if the
cartilage is very thin and fragile it is better to stay over
the perichondrium. The Daniel Cakir elevator (Marina
Medical) is useful for this step (Figs. 7.18 and 7.19;
Video 7.3).
Then, we reach the subperichondral and subperiosteal
dissection with the Daniel Cakir elevator, which scratches
the perichondrium to reach the alar cartilage (Fig. 7.18).
Then, the dissection reaches the domes and lateral part of
the lower cartilage.
At this time, we can add a minimal resection of 3 mm of
the upper part of the lower cartilage to help the rotation of
the tip by sutures.
3. Then, we reach the dorsum with the Pitanguy window.
4. The high strip is done (Fig. 7.19)
7 Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty 115

Fig. 7.18 Subperichondral dissection

Fig. 7.20 Oblique radix osteotomy. (Video 7.3 Oblique radix osteot-
omy) (▶ https://doi.org/10.1007/000-­9pn)

upper lateral cartilage to 1 cm behind the anterior septal

5. Osteotomies (Fig. 7.20 and Video 7.3) to mobilize the
Fig. 7.19 Endoscopic view
Septal strip resection high under the dorsum is performed
to separate the dorsum from the septum and flatten the
dorsum. Next, submucosal septal dissection is performed.
With the cartilaginous scissors, we cut 3 mm under the
angle, preserving an appropriate L-strut to avoid any
saddle-­nose deformity.
If necessary, we use the baby-Bayer rongeur to resect a
few millimeters of perpendicular plate of ethmoid (PPE).
bony pyramid can be preceded by the use of a Tastan saw
[20]
Transverse percutaneous osteotomies of the radix to sepa-
rate the bony pyramid from the facial skeleton; we begin
by a median radix osteotomy with a 2-mm bone cut
osteotome. This is an oblique transverse percutaneous
osteotomy to permit the bone to slide instead of dropping
116
Fig. 7.21 Lateral osteotomies endonasal approach
vertically and avoid a radix step; next, a transverse lateral
osteotomy is performed bilaterally.
Then, lateral endonasal osteotomies are performed
(Fig. 7.21).
Carefully, we move the bones laterally before impac-
tion. Then, the push-down is performed, pinching the
bony lateral walls and pushing the nose down.
6. Impaction by push-down is done slowly and carefully
(Fig. 7.22 and Video 7.4); finger impaction with excessive
force may result in extended fracture on the skull base.
At this moment, if we cannot push down the entire
pyramid, we must perform two additional maneuvers:
verification of the resection of the septum and PPE and
the ballerina maneuver [25]. If it is not sufficient, we can
S. Poignonec
Fig. 7.22 Push-down. (Video 7.4 Push-down)
(▶ https://doi.org/10.1007/000-­9pr)
either add a septal strip or proceed to vertical striations of
the upper septum.
7. Fixations: then we have to fix the osseocartilaginous vault
to the underlying septum with resorbable monofilament
PDS 4/0 suture.
8. We proceed to the tip work: the Cakir tip [10, 11] with
columellar strut in white normally projected nose. In the
case of a heavy tip, hypo-projected nose, Latin, or Arabic
patient, we instead perform a septum extension graft,
ANSA banner [18] (Fig. 7.23), or Teostrut [19].
9. At the end of the procedure, all the dead spaces must be
closed: ligaments, scroll region and Pitanguy must be
sutured with Vicryl 5-0 (resorbable Vicryl suture).
Doyle splints are sutured to the septum with nonre-
sorbable 3-0 suture to be removed in 8 days
A metallic hand-made splint is placed over Steri-Strips
(Fig. 7.24 and Video 7.5).
7 Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty 117

Fig. 7.24 Metallic splint. (Video 7.5 Metallic splint)

(▶ https://doi.org/10.1007/000-­9ps)

• For the first few days, do not eat hard foods

• You may remove your compression stockings after a few
Fig. 7.23 Tip work: ANSA- banner days or the day after you start walking regularly
• Keep wearing Steri-Strips on your nasal tip during the
Rhinoplasty post-operative guidelines to give to your evening for 1 month
patient: • Protect your nose from heavy glasses
• You do not have gauze but instead have small tubes inside • Protect your nose from sun for 2 months
your nose that allow you to breath • Use sunscreen daily
• Sleep with two pillows the first night • Post-operative visits
• Use cold compresses or a cold mask to reduce swelling –– Day 8
• The first week, avoid bending over such as when lacing –– Day 15
shoes –– 3 months
• No sports or gym for 1 month –– 6 months
• No hammams or saunas for 10 days –– 1 year
• No baths –– 2 years…
• Shower without wetting your face
• No blowing your nose during the first week; instead use The post-operative check-up visit must be regular and
nasal rinses free of charge; it is important to follow your patients and to
• Use serum six times per day and apply antibiotic cream at learn from your mistakes; it is important to be able to man-
the base of your nose and inside your nostrils using a Q-tip age your own failures and do your own retouch(es)
118 S. Poignonec

7.5 Clinical Cases

7.5.1 Case 1

Miss F is a 37-year-old architect with traumatic nasal history

at 15 years of age
She complains of a dorsal hump and left nasal obstruction
in supine position only (Fig. 7.25).
Front view: shows an asymmetric face (Fig. 7.26)
The dorsal lines are broad with irregularities in the K area
The tip is bulbous with caudal and cephalic alar cartilage
excess
The skin is thick; endonasal examination shows a septal
deviation
Side view: we notice a high and full frontonasal angle
with a hypo-projected tip and a drooping tip when the patient
smiles; the nasolabial angle is about 95°
Basal view: shows a slight columellar deviation follow-
ing a deviated septum
A CT scan is mandatory (Fig. 7.27), in this case because
the nasofrontal angle is very high and we need to see the
distance from the skull base.
Surgery (Fig. 7.28): this patient underwent an open
approach with trans-columellar incision, dorsal preservation

Fig. 7.26 Clinical case 1 before surgery

Fig. 7.27 CT scan of clinical case 1

rhinoplasty with subperichondrial, subperiosteal dissection:

the high-strip size was 7 mm long by 4 mm in height. The
PPE resection was performed deeply with a rongeur because
Fig. 7.25 Clinical case 1 before surgery of the fullness of the radix. A push-down was realized, and
7 Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty 119

Fig. 7.29 ANSA banner (surgical photo)

the tip was projected with an ANSA banner graft (Fig. 7.29).
Tip refinement was obtained with 6-0 Prolene Gruber sutures
[21].
After 1 year from the front view (Figs. 7.30 and 7.31), the
patient shows a more refined nose with smooth nasal lines;
from the side view, a good projection of the tip and no more
hump (Figs. 7.32 and 7.33).

7.5.2 Case 2

Miss M is a 19-year-old woman with an Algerian father

Fig. 7.28 Surgical procedure
She complains of a large nose with a dorsal hump, a bul-
120 S. Poignonec

Fig. 7.30 Result after 1 year:

improvement of dorsal lines

Fig. 7.31 Basal view result

after 1 year: good projection
of the tip
7 Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty 121

Fig. 7.32 Post-operative

result after 1 year from the
side view, good projection of
the tip

Fig. 7.33 Post-operative

result after 1 year
122 S. Poignonec

Fig. 7.34 Pre-operative view

bous tip that droops when smiling, and a left nasal

obstruction.
Examination from the front view shows regular nasal
lines, thick skin, and a bulbous tip. From the side view the
nasofrontal angle is deep (Fig. 7.34), there is an S-shaped
nasal hump, and a ptotic hypo-projected tip.
A CT scan shows a slight septal deviation (Fig. 7.35).
Surgery: a partial preservation procedure is performed
(Fig. 7.36) via an open approach with a bony cap resection
with a bur (Bien-Air); a low septal strip and ANSA banner
septal extension graft are performed (Cakir tip).
The result after 1 year shows a great improvement of the
side view with opened nasolabial angle, with good projec-
tion of the tip (Figs. 7.37, 7.38, 7.39, and 7.40).
From the front view, a slight widening of the dorsum is
observed; improvement occurs after a few months with
edema resorption (Fig. 7.37 and 7.39).
Fig. 7.35 CT scan

7.5.3 Case 3
Mr D is a 22-year-old man who complains of nasal deviation
after a traumatic football accident; facial asymmetry and a
bulbous tip; from the front view we see a deviated nasal dor-
sum and nostril asymmetry (Fig. 7.41).
From a side view, the nasofrontal angle is deep, and an
S-shaped hump is visible (Fig. 7.42).
Surgery: a closed partial preservation rhinoplasty is per-
formed. Septoplasty is carried out with a low strip 4-mm
high-nasal spine fixation of the septum.
7 Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty 123

Fig. 7.36 Surgical procedure

Fig. 7.37 One year

post-operatively
124 S. Poignonec

Fig. 7.38 One year

post-operatively

Fig. 7.39 One year

post-operatively
7 Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty 125

Fig. 7.40 One year

post-operatively

Fig. 7.41 Front view Fig. 7.42 Side view

126
Hump is rasped with a tunsten rasp radix and tarnverse
osteotomies are performed transcutaneously then endonasal
lateral osteotomies are performed (Fig. 7.43).
On the tip we create a dome suture [21].
Result after 18 months shows a good symmetry of the
dorsum, best definition of the tip, despite his heavy skin
(Fig. 7.44). From a columellar view there is good projection
of the tip and nostril symmetrization owing to an ANSA ban-
ner graft (Fig. 7.45).
From the side view, there is no longer a hump and good
profile alignment (Fig. 7.46).
Fig. 7.43 Surgical procedure
Fig. 7.44 Result 18 months
post-operatively
S. Poignonec
7.5.4 Case 4
Miss C is a 31-year-old woman, who complains of a droop-
ing tip when smiling and a small dorsal hump.
Examination from a front view shows irregular nasal
lines, a square tip, and hanging columella; from a side view
a small V-shaped dorsal hump, good projection of the tip,
and a prominent chin are seen (Fig. 7.47). Endonasal exami-
nation shows a slight septal deviation.
7 Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty 127

Fig. 7.45 Columellar view: result after 18 months

Fig. 7.46 Side view 18

months post-operatively
128 S. Poignonec

Fig. 7.47 Photo before

surgery

Fig. 7.48 Surgical procedure

Surgery: partial preservation rhinoplasty (Fig. 7.48), K

area rasping with a Piezotome is performed via an open Result after 3 years shows regular nasal lines, there is
approach, high strip, let-down, Cakir tip (columellar strut). no longer a hanging columella, there is tip refinement,
and a dorsum reduction with an open nasolabial angle
(Figs. 7.49, 7.50, 7.51, 7.52, and 7.53).
7 Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty 129

Fig. 7.49 Front view result

after 3 years

Fig. 7.50 Basal view after 3

years
130 S. Poignonec

Fig. 7.51 Side view pre- and

post-operatively

Fig. 7.52 Side view

7 Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty 131

Fig. 7.53 Helicopter view

pre- and post-operatively

7.5.5 Case 5

A 31-year-old woman complains about a dorsal hump and

over-projected tip; from the front view the dorsum is straight
and narrow, but deviated from the helicopter view.
From the side view, deep nasofrontal angle, hump-shaped,
hyper-projected nose.
A push-down preservation rhinoplasty (Fig. 7.54) is per-
formed via an open approach with a high strip, radix osteot-
omy, and lateral endonasal osteotomies; Cakir tip overlapping
3 mm with the medial crus.
The result after 1 year is shown in Figs. 7.55, 7.56, 7.57,
7.58, and 7.59: dorsum is in a symmetric position, the tip
projection is decreased, and there is no longer a hump.
Failure: could have had a nasofrontal graft to fill the naso-
frontal angle.

Fig. 7.54 Surgical procedure

132 S. Poignonec

Fig. 7.55 Before and after

surgery

Fig. 7.56 Before and after

surgery
7 Combination of Structure and Preservation: A Step-by-Step Surgical Guide to French-Touch Preservation Rhinoplasty 133

Fig. 7.57 Before and after

surgery

Fig. 7.58 Before and after

surgery
134
Fig. 7.59 Before and after
surgery
7.6 Conclusion
Preservation rhinoplasty is a successful technique if the
surgeon chooses the right indications that allow the best
outcomes: selection of patients is based on the decisional
tree. The best indications are a straight or V-shaped dor-
sum, a normal radix, a cartilaginous hump only, short nasal
bones, and a deviated dorsum without complex septal
deviation.
The technique needs to be performed very precisely,
respecting the chronology of the procedure: the rhinoplasty
surgeon must be versatile and has to adapt this procedure to
his own patients; each patient is a specific case each time.
Much like a pilot before landing a plane under variable
weather conditions, surgeons must also adapt their technique
during the surgery. The rhinoplasty worksheet presented here
is very helpful both during surgery and for following your
results. This will help you to build a preoperative strategy
and understand the concepts of preservation rhinoplasty.
I use closed approach, as often as I can in primary cases,
but during the surgical procedure I have the option to transi-
tion to an open approach if the result is not as perfect as I
wish, especially on the tip. In my opinion, the assessment of
dorsal reduction is better using a closed approach because
the nose remains in anatomical alignment.
In the case of a hypo-projected nose or heavy skin, a cau-
dal septal extension graft could be useful, or at least columel-
lar strut, which is often not enough to obtain a long-lasting
result on the tip projection.
S. Poignonec
The combination of dorsal preservation and structural tip
rhinoplasty permits surgeons to obtain both a long-lasting
and natural French-touch result.
Our results are natural because we are very conservative
with the cartilage of the tip; we think that preserving the
roundness and softness of the tip is the best way to keep the
natural light reflection on the nose without looking like any
surgery has taken place.
Following our own patients is advisable in order to treat
our own failures; it helps us to learn more about our personal
technique and to keep our patients’ trust and allegiance.
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1. Cottle MH, Loring RM. Corrective surgery of external nasal pyra-
mid and the nasal septum for restoration of normal physiology. Ill
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2. Cottle MH. An introduction to conservative septum-­pyramid sur-
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3. Cottle MH. Nasal roof repair and hump removal. AMA Arch
Otolaryngol. 1954;60:408–14.
4. Jallut Y, Bardot J. Naissance de la rhinoplastie en occident
texte fondateurs et vrais précurseurs. Ann Chir Plast Esthet.
2021;66:107–14.
5. Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P. Dorsal
preservation: the Push-down technique reassessed. Aesthet Surg J.
2018;38:117–31.
6. Saban Y, de Salvador S. Guidelines for dorsum preservation in pri-
mary rhinoplasty. Facial Plast Surg. 2021;37(1):53–64. https://doi.
org/10.1055/s-­0041-­1723827.
7. Daniel RK, Palhazi P. The nasal ligaments and tip in rhinoplasty: an
anatomical study. Aesthet Surg J. 2018;38:357–68.
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8. Daniel RK. The preservation rhinoplasty: a new rhinoplasty revolu-
tion. Aesthet Surg J. 2018;38:228–9.
9. Daniel RK, Palhazi P. Rhinoplasty: an anatomical and clinical atlas.
Heidelberg: Springer; 2018.
10. Cakir B. Aesthetic septorhinoplasty. In: Di Rosa L, Cerulli G, De
Pasquale A, editors. Rhinoplasty outcomes evaluation (ROE) ques-
tionnaire. Heidelberg: Springer; 2016.
11. Cakir B, Kucuker I, Aksakal IA, Sagir HO. Auto-­ rim tech-
nique for lateral crura caudal excess treatment. Aesthet Surg J.
2017;37:24–32.
12. Di Rosa L, Cerulli G, De Pasquale A. Rhinoplasty outcomes evalu-
ation (ROE) questionnaire. Aesthet Plast Surg. 2020;44(1):131–8.
https://doi.org/10.1007/s00266-­019-­01538-­8. Epub 2019 Nov 25.
PMID: 31768580.
13. Sozen T, et al. Awareness of facial asymmetry and its impact on
postoperative satisfaction of rhinoplasty patient. Aesthetic Plast
Surg. 2021. PMID: 32974739.
14. Majawit LP, Wan Hassan WN, Wey MC, Mohd
RR. Anthropometric study of three-dimensional facial morphol-
ogy in Malay adults. PLoS One. 2016;11(10):e0164180. https://
doi.org/10.1371/journal.pone.0164180. eCollection 2016.
PMID: 27706220.
15. Toriumi DM. Discussion: septum-based nasal tip plasty: a compara-
tive study between septal extension graft and double-layered conchal
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https://doi.org/10.1097/PRS.0000000000004125.
16. Toriumi D, Kovasevic M. Dorsal preservation rhinoplasty: mea-
sures to prevent suboptimal outcomes: facial plasty surgery. Dent
Clin N Am. 2021;29:141–53.
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plasty: a 100-case series with one-year follow-up. Aesthet Surg J.
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18. Neves JC. Preservation rhinoplasty: an update. Facial Plast Surg.
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Apr 12. PMID: 338455495.
19. Dogan T. The Peruvian fisherman’s knot a new simple, and versatile
self-locking sliding knot. Ann Plast Surg. 2010;64(1):128. https://
doi.org/10.1097/SAP.0b013e3181a42d65. PMID: 20023462.
20. Tastan E, Sozen T. Oblique split technique in septal reconstruction.
Facial Plast Surg. 2013;29(6):487–91. https://doi.org/10.1055/s-­-
0033-­1360599. Epub 2013 Dec 10. PMID:24327247.
21. Kovacevic M, Buttler E, Haack S, Riedel F, Veit JA. Dorsal pres-
ervation septorhinoplasty. HNO. 2021;69(10):817–27. https://
doi.org/10.1007/s00106-­020-­00949-­3. Epub 2022 Sep 29. PMID:
32995897.
22. Ishida LC, Ishida J, Ishida LH, Tartare A, Fernandes RK, Gemperli
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23. Nakamura F, Luitgards BF, Ronche Ferreira JC. Combining
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GOX.0000000000003323. Collection 2021 Jan.
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Aesthet Surg J. 2015;35:255–63.
 Camouflage in Preservation
Rhinoplasty 8
Guillaume Carles

8.1 Background Information

As all the rhinoplasty techniques, preservation rhinoplasty

(PR) can be source of irregularities, pits, bumps, depres-
sions, that must be corrected to avoid suboptimal results with
subsequent unhappy patients and revision rhinoplasties.
Thus, camouflage techniques should be in the rhinoplasty
surgeon toolbox, beginning from the easiest technique as the
“free-diced cartilage” technique to a most complex as “diced
cartilage + PRF grafts.”

Frequent Etiologies of Dorsal Irregularities in

Preservation Rhinoplasty
Supratip saddling
Middle third: distortion/irregularities of the carti-
laginous vault
Fig. 8.1 Cephalic trimming. (Video 8.1 Diced cartilage creation)
Keystone: stair step between bony and cartilaginous (▶ https://doi.org/10.1007/000-­9px)
dorsum (cartilage push down)
Radix step: stair step in the bone section line

8.2 Solid Grafts

Solid graft can be used as camouflage material [1, 2].

The material must be very thin, ideally from cephalic alar
resection cartilage.
If the septum is used, it must be gently crushed with a
Brown Adson forceps and his edges smoothed (Figs. 8.1 and
8.2).

Supplementary Information The online version contains supplemen-

tary material available at https://doi.org/10.1007/978-­3-­031-­29977-­3_8.
The videos can be accessed individually by clicking the DOI link in the
accompanying figure caption or by scanning this link with the SN More
Media App.

G. Carles (*) Fig. 8.2 Graft from cephalic trimming. (▶ https://doi.org/10.1007/000-­9pv)

Clinique Clémentville, Montpellier, France

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 137
S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_8
138
The drawback of those grafts is a possible postoperative
displacement.
The author recommends to insert those grafts, if possible,
in a small pocket and/or to fix it (PDS 6/0) to avoid its
mobilization.
8.3 Free-Diced Cartilage
Free-diced cartilage (FDC) is made from residual cartilage,
collected at the end of the intervention (Fig. 8.3) [3–5].
The cartilage will be chopped as finely as possible with a
dermatome blade (Fig. 8.4, Video 8.1).
The best support for dicing is a PTFE plate (example: ref
I000013, Landanger, France). Using a metal or glass plate
will make thin dicing more difficult.
In order to avoid dispersing the material, it should be
slightly moistened.
Fig. 8.3 Residual cartilage. (Video 8.3 Cartilage paste creation)
(▶ https://doi.org/10.1007/000-­9pw)
Fig. 8.4 Dermatome blade. (Video 8.4 Diced cartilage + PRF large
grafts) (▶ https://doi.org/10.1007/000-­9pt)
G. Carles
Fig. 8.5 Diced cartilage. (Video 8.5 Diced cartilage + PRF full proce-
dure) (▶ https://doi.org/10.1007/000-­9py)
The procedure takes between 5 and 10 min, and is per-
formed by the operating assistant while the surgeon does
a step that does not require operating assistance (Fig. 8.5).
Once chopped like very fine semolina, the cartilage will
be passed through a 1-cc syringe via a #4 ear speculum
(Fig. 8.6).
The syringe should be pierced with a needle at its distal
end to remove excess fluid. If the cartilage does not pass
through the syringe, it means that it is not finely chopped
enough (Figs. 8.7 and 8.8, Video 8.2).
The “FDC trocar” device distributed by Medicon® is easy
to use and has the advantage of being thinner than the syringe
(Fig. 8.9).
If the cartilage is chopped for a long time and very finely,
it can be injected transcutaneously through an 18-gauge nee-
dle (Fig. 8.10).
Free-diced cartilage has the advantage of being “quick
and easy” to apply, with a volumizing effect that could be
compared to an injection of hyaluronic acid and with a low
resorption rate.
The FDC has to be used priorly on low skin pressure
areas: supratip, infralobule, on the side walls (Fig. 8.11).
It should be avoided on the keystone because it is fre-
quently visible on the long time unless it is very finely
chopped and used in very low volume.
The FDC has the disadvantage of being mobile. It should
therefore only be used in low volume on the tip.
8 Camouflage in Preservation Rhinoplasty 139

Fig. 8.6 Transferring the diced cartilage via an ear speculum. (Video 8.6
Diced cartilage + PRF graft insertion) (▶ https://doi.org/10.1007/000-­9pz)
Fig. 8.9 Medicon® FDC trocar

Fig. 8.7 Puncture of the seringue to purge excessive liquid

Fig. 8.10 Injection of ultrathin diced cartilage via an 18-gauge needle

Fig. 8.8 Injection of diced cartilage
140 G. Carles

Fig. 8.12 Creating cartilage paste with 15″ blade

Fig. 8.11 Before-after injection of 0.2 cc of diced cartilage in supratip

at the end of a preservation rhinoplasty

Fig. 8.13 Creating cartilage paste with 15″ blade

8.4 Cartilage Paste and Fluid Cartilage

Cartilage paste is made by rasping cartilage with the edge of

a 15″ blade [6, 7].
The blade must be new and must be frequently changed
(Figs. 8.12 and 8.13, Video 8.3).
The paste is very thin and can be injected transcutane-
ously via an 18-gauge needle trocar if mixed with saline
solution (Fig. 8.14).
Cartilage paste has the disadvantage of requiring large
fragments of cartilage (at least 10 mm). It therefore finds
little indication in preservation rhinoplasty.

Fig. 8.14 Transcutaneous injection via an 18-gauge needle trocar

8 Camouflage in Preservation Rhinoplasty 141

8.5 Diced Cartilage with PRF

Plateletrich fibrin (PRF) was initially developed for use in

maxillofacial surgery by Choukroun et al. This technique
creates fibrin membranes after centrifugation of patient’s
blood, which can be mixed with a bone substitute, called
“sticky bone” [7–10].
Kovacevic proposed to mix PRF with diced cartilage to
create soft grafts in rhinoplasty [11]. Those grafts have the
benefit to be easy to create without the need for a second
operating site, while promoting healing through growth fac-
tors (Video 8.4).
More recently, Gode demonstrated that benefits of using
injectable platelet-rich fibrin (iPRF) are a diminution of
postoperative edema and the reduced rate of resorption of the
material compared to free diced cartilage [12, 13].
Fig. 8.16 Choukroun’s centrifuge
In 2020, the author created a rhinoplasty template to cre-
ate thin, standardized grafts. This template is a steel plate
developed in collaboration with Landanger, France, contain-
ing 11 molds allowing for a wide variety of grafts from 1 to
2 mm thickness (Fig. 8.15) [14].

8.5.1 DC + PRF Protocol

After dicing the cartilage, the surgeon will fill the chosen
mold. The most frequent molds used by the author are the 9
× 29 × 1 mm for a whole dorsal lining, and a 10 × 15 × 1-mm
diamond-shaped shield graft.
The blood is collected in dry tubes during the surgical
procedure. In our protocol, two kinds of tubes, acquired from
PRF-process (PRF-process, Nice, France) are used: plastic
tubes (green) and glass tubes (red). Blood samples are taken
and all tubes are centrifuged at 1300 rpm for 14 min
(Figs. 8.16 and 8.17).
The two keys for success are a fast blood sampling (less
than 15 s/tube in our protocol) and blood refrigeration.
If the sampling is not performed quickly enough, the
fibrin will polymerize and the obtained product will not be Fig. 8.17 Blood sampling tubes
usable. Both tubes must be stored in a fridge before surgery
and in a refrigerating collector during the sampling
(Figs. 8.18 and 8.19).
If sampling is not done fast enough, the chance of success
is lower and the procedure might have to be repeated.
After centrifugation, the plastic tubes (green) will pro-
vide a fluid matrix with leukocytes, platelets, and growth
factors on the most superficial layer. This fluid is named
iPRF. After collection from the tube using a seringue, the
iPRF is injected directly on the diced cartilage to create a
scaffold (Fig. 8.20).
The glass tubes (red) allow a natural coagulation in the
tube. This process created a leucocyte- and platelet-rich
Fig. 8.15 Carles rhinoplasty templates (Landanger France) fibrin clot in the middle of the tube. This clot, called
142 G. Carles

Fig. 8.18 Pompack® refrigerating collector (reproduced with permis-

sion from [14])

Fig. 8.21 DC + iPRF graft ready (reproduced with permission from

[14])

Fig. 8.19 Blood sampling

Fig. 8.22 DC + iPRF shield graft

is crushed between 2 gauzes using a mallet in a way to cre-

ate a thin and strong membrane that can be used to rein-
force the diced cartilage with iPRF graft if added on top of
it. After adding the aPRF membrane on top of the graft, it
must be left alone for a minimum of 2 min to have the final
DC + PRF graft, ready to be manipulated (Figs. 8.21 and
8.22; Video 8.5).

Fig. 8.20 Injection of iPRF on diced cartilage (reproduced with per-
mission from [14])
“advanced PRF” (aPRF), is removed from the tube and
separated from the red blood cells using a scissor. The clot
Procedure
1. Chop the cartilage as finely as possible.
2. Optional: place the chopped cartilage in a mold.
3. Prepare 3 red tubes (glass) and one green tube
(plastic).
The tubes must be refrigerated before the sur-
gery and placed in a refrigerated container through-
out the maneuver (Pompack®).
4. Fast blood sampling: under 15 s/tube.
8 Camouflage in Preservation Rhinoplasty
If the blood flow is low, the vein must be
changed.
The author suggests to start with red tubes.
5. Centrifugation with Choukroun’s protocol: 1300
rpm, 14 min.
6. Green tube: after the assistant has removed the cap
from the tube, the operator will aspirate the liquid
part of the tube with a needle mounted on a syringe.
The liquid “iPRF” will be injected on the diced
cartilage.
7. Red tubes: after the assistant has poured the con-
tents of the tube into a cup, the operator will take
the membrane, place it on a compress, then crush it
with a metal plate. The crushed membrane will be
placed on the diced cartilage + iPRF graft.
8. After 2 min, the graft is ready and can be sutured to
the recipient site.
Fig. 8.23 DC + PRF dorsal graft in place
8.5.2 DC + PRF in Preservation Rhinoplasty
The best indications in preservation rhinoplasty are over-­
reduced noses, from a simple supratip saddling to a full dor-
sal defect.
Thereby, DC + PRF grafts can easily fill 1–2 mm defects,
covering the dorsal aesthetic unit (Fig. 8.23).
In closed rhinoplasty, the author suggests using a transcu-
taneous suture at the level of the radix to help positioning 14. Beaudoin PL, Carles G. Template for diced cartilage with Platelet
(Video 8.6).
DC + PRF grafts can also be stitched to the tip as cap or
shield grafts for a mild augmentation or camouflage.
143
Disclosure Dr. Carles has a conflict of interest with Landanger instru-
ments, France.
References
1. Duron JB, Aiach G. Greffes cartilagineuses en rhinoplas-
tie [Cartilaginous graft in rhinoplasty]. Ann Chir Plast Esthet.
2014;59(6):447–60. https://doi.org/10.1016/j.anplas.2014.07.008.
Epub 2014 Sep 8. PMID: 25213491.
2. Sheen JH. Tip graft: a 20-year retrospective. Plast Reconstr
Surg. 1993;91(1):48–63. https://doi.org/10.1097/00006534-­
199301000-­00007. PMID: 8416539.
3. Dong W, Han R, Fan F. Diced cartilage techniques in rhinoplasty.
Aesthetic Plast Surg. 2021. https://doi.org/10.1007/s00266-­021-­
02628-­2. Epub ahead of print. PMID: 34731262.
4. Tasman AJ. Advances in nasal dorsal augmentation with diced car-
tilage. Curr Opin Otolaryngol Head Neck Surg. 2013;21(4):365–
71. https://doi.org/10.1097/MOO.0b013e3283627600. PMID:
23842290.
5. Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplasty sur-
gery. Plast Reconstr Surg. 2004;113(7):2156–71. https://doi.
org/10.1097/01.prs.0000122544.87086.b9. PMID: 15253210.
6. Manafi A, Hamedi ZS, Manafi A, Rajabiani A, Rajaee AR, Manafi
F. Injectable Cartilage Shaving: An Autologous and Long Lasting
Filler Material for Correction of Minor Contour Deformities in
Rhinoplasty. World J Plast Surg. 2015;4(2):93–100.
7. Choukroun J, Adda F, Schoeffler C, Vervelle A. Une opportunité en
paro-implantologie: le PRF. Implantodontie. 2000;42:55–62.
8. Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi
J, Gogly B. Platelet-rich fibrin (PRF): a second-generation plate-
let concentrate. Part I: technological concepts and evolution. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(3):37–44.
https://doi.org/10.1016/j.tripleo.2005.07.008.
9. Miron RJ, Fujioka-Kobayashi M, Hernandez M, Kandalam U,
Zhang Y, Ghanaati S, Choukroun J. Injectable platelet rich fibrin
(i-PRF): opportunities in regenerative dentistry? Clin Oral Investig.
2017;21(8):2619–27. https://doi.org/10.1007/s00784-­017-­2063-­9.
Epub 2017 Feb 2. PMID: 28154995.
10. Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classification
of platelet concentrates: from pure platelet-rich plasma (P-PRP)
to leucocyte- and platelet-rich fibrin (L-PRF). Trends Biotechnol.
2009;27(3):158–67. https://doi.org/10.1016/j.tibtech.2008.11.009.
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11. Kovacevic M, Riedel F, Wurm J, Bran GM. Cartilage scales
embedded in fibrin gel. Facial Plast Surg. 2017;33(2):225–32.
https://doi.org/10.1055/s-­0037-­1598184. Epub 2017 Apr 7. PMID:
28388803.
12. Gode S, Ozturk A, Kısmalı E, Berber V, Turhal G. The
effect of platelet-rich fibrin on nasal skin thickness in rhi-
noplasty. Facial Plast Surg. 2019;35(4):400–3. https://doi.
org/10.1055/s-­0039-­1693436.
13. Gode S, Ozturk A, Berber V, Kısmalı E. Effect of injectable platelet-­
rich fibrin on diced cartilage’s viability in rhinoplasty. Facial Plast
Surg. 2019;35(4):393–6. https://doi.org/10.1055/s-­0039-­1693035.
Rich Fibrin (PRF) in rhinoplasty: an easy solution for millimetric
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 Functional Considerations
for Preservation Rhinoplasty,
Nasal Valve, and Clinical Cases
Emmanuel Racy, Amanda Fanous, Grégoire d’Andrea,
and Nadia Benmoussa
Key Points
1. Primary reduction rhinoplasty affects both the bony and
cartilaginous dorsum as well as the bulbous tip. The nasal
passage is narrowed at various points, resulting in an
overall decrease in nasal airflow in particular during the
inspiratory phase. It is crucial to preserve nasal valves
intrinsic stiffness.
2. Anatomical and functional considerations are mandatory
for all nose surgeons.
3. The modified SAC flap is a simple technique allowing tip
definition while maintaining nasal airway function by
preserving the crucial anatomic scroll area.
9.1 Background Information
Nasal valve anatomy is particularly complex as it involves
bony, cartilaginous, cutaneous, and mucosal structures.
Before discussing the anatomy, it is important to understand
Supplementary Information The online version contains supplemen-
tary material available at https://doi.org/10.1007/978-­3-­031-­29977-­3_9.
The videos can be accessed individually by clicking the DOI link in the
accompanying figure caption or by scanning this link with the SN More
Media App.
E. Racy (*)
Maxillo Facial Surgeon, Clinique Saint Jean de dieu, Paris, France
Department of Otolaryngology-Head and Neck Surgery, Adolphe-­
Rotschild Fondation, Paris, France
A. Fanous
Division of Facial Plastic Surgery, Department of Otolaryngology-­
Head and Neck Surgery, McGill University, Montreal, QC, Canada
G. d’Andrea
Department of ENT and Head and Neck Surgery, Institut
Universitaire de la Face et du Cou, GCS Nice University Hospital,
Antoine Lacassagne Centre, Côte d’Azur University, Nice, France
N. Benmoussa
Department of Head and Neck Oncology, Gustave Roussy Institut,
Villejuif, France
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_9
9
that nasal respiration is a very abstract and subjective con-
cept. It is quite surprising to realize during consultations that
some patients with major septal deviation or valve collapse
have no functional complaints. How can the absence of
symptoms in the presence of such asymmetrical nasal ana-
tomic findings be explained? In the majority of cases, these
nasal deformities are congenital and appear during growth
from childhood to adulthood. During this growth phase,
mechanical receptors will adapt to the differing influx of air
and these differences will also manifest themselves as vary-
ing sensory nerve conductions.
The article by Zhao and Jiang [1] describing 22 patients
denying respiratory obstruction symptoms demonstrates to
what extent respiratory influx can differ in a subgroup of the
population that claims to be breathing normally.
Rhinoplasty surgeons are often faced with multiple
requests where cosmesis seems to be center stage. However,
neglecting the functional component is no longer acceptable
in this day and age.
Different types of requests exist:
1. Augmentation rhinoplasty: in general, these surgeries do
not lead to functional impairment.
2. Post-traumatic rhinoplasty: regardless of the direction of
impact, the ensuing bony and cartilaginous disruptions
very often lead to functional obstructive impairment.
These patients will usually have both functional and
esthetic concerns.
3. Revision rhinoplasty: in this case, the patient’s request is
either esthetic, functional, or both. It is very important to
perform a proper nasal analysis in order to pick up on
potential anatomic disruptions that may have occurred
during prior surgeries, particularly in relation to the nasal
valves. Of course, the surgeon should refrain from accept-
ing the patient’s request to reduce the size of the nose
even further, which will likely aggravate any existing
respiratory impairments.
4. Revision rhinoplasty for cleft palate patients, in particular
patients presenting both a cleft lip and palate. These cases
145
146 E. Racy et al.

are very complex and require a separate and

well-thought-out treatment plan given the important
­
esthetic and functional concerns.
5. Primary reduction rhinoplasty (the essence of this chap-
ter): in this case, the reduction affects both the bony and
cartilaginous dorsum as well as the bulbous tip. The nasal
passage is narrowed at various points, resulting in an
overall decrease in nasal airflow in particular during the
inspiratory phase. This narrowing will need to be com-
pensated by other anatomical structures to avoid the
apparition of obstructive symptoms (straightening a pre-
viously asymptomatic deviated nasal septum, inferior or
middle turbinate reduction, etc.). Indeed, according to
Bernoulli’s principle, the quality of nasal airflow on
inspiration relies on both the available surface area and
the resistance of the nasal passages to collapse, in particu-
lar the internal and external nasal valves. If you take a soft
plastic straw and suck air through it while gradually
applying more force, the straw will collapse pretty rap-
idly. However, if the same is done with a stiffer straw, it
will take longer to achieve collapse. The same concept Fig. 9.1 The nasal valves. (Video 9.1 Inspiratory collapse of the left
can be applied to the nasal valves. It is crucial to preserve external nasal valve in a patient suffering from a right-sided, deviated
nasal septum. The external nasal valve is floppy (congenitally) and the
their intrinsic stiffness in order to overcome the
collapse logically occurs on the side presenting a greater inspiratory
intra­
­ thoracic negative pressure generated by the dia- force) (▶ https://doi.org/10.1007/000-­9q1)
phragm movements and prevent collapse.

9.2 Anatomical Considerations

9.2.1 The External Nasal Valve

There are two types of valves (Fig. 9.1). The external nasal
valve is formed by both cutaneous and cartilaginous compo-
nents. Resistance to inspiratory collapse depends on the skin
thickness and elasticity as well as the inferior border of the
lower lateral cartilage (LLC). This cartilage provides resis-
tance to collapse in two ways: its intrinsic stiffness and its
position. A malposition of the LLC (higher position) will
lead to a deficiency of the alar rim and an increased suscep-
tibility to collapse (Video 9.1).

9.2.2 The Internal Nasal Valve

The anatomy of the internal nasal valve is more complex and

involves various anatomical structures. Firstly, the bony
anatomy of the piriform aperture, which is often neglected,
must be analyzed with a preoperative computed tomography
scan. This is even more important in cases of cleft palate
patients since there is almost systematically a narrowing of
Fig. 9.2 Bony malformations and their impact on the vomer and turbi-
the piriform aperture on the side of the cleft. In Fig. 9.2, we nates. (Video 9.2 Simulation of the resistance of the scroll area against
can clearly see that the bony structure of the piriform aper- inspiratory movements) (▶ https://doi.org/10.1007/000-­9q0)
9 Functional Considerations for Preservation Rhinoplasty, Nasal Valve, and Clinical Cases 147

ture poses a problem, exacerbated by the shape of the bony
septum (vomer) and the inferior turbinate.
The second fundamental structure is cartilaginous in
nature and has been through a long history of surgical vio-
lation and destruction, due to a general ignorance of its
important functional role: the scroll zone. The scroll is the
transition zone between the upper lateral cartilage (ULC)
and LLC, represented internally by the plica nasi. The arti-
cle by Popko et al. [2] describes the anatomical continuity
between these two structures, creating a resiliency at the
level of the plica nasi (Fig. 9.3).
We can assimilate the scroll zone to the longitudinal scroll
ligament described by Daniel and Palhazi in their book [3].
They also described a vertical scroll ligament that can be pre-
served although no article in the literature has demonstrated
its functional interest.

Fig. 9.3 Anatomical drawing of the continuity between the two cartilaginous structures, which together form a real spring at the level of the plica
nasi. (Video 9.3 The modified SAC flap (simulation and surgery)) (▶ https://doi.org/10.1007/000-­9q2)
148
Of course, muscular structures (muscle dilators) play an
important role as well. Their importance becomes clearly
evident in cases of facial nerve paralysis. However, these
muscles are usually spared during rhinoplasty (a muscle that
has been detached by sub- or supra perichondrial dissection
should have no problem regaining full function).
However, reduction in the height of the alar cartilages was
considered mainstream for a prolonged period of time, at the
expense of creating a void at the cephalic portion of the lat-
eral crus and the functional compromise created by disarticu-
lating the scroll. The concept of preserving this zone is the
subject of many ongoing research projects, aiming at restor-
ing harmony between reduction rhinoplasty and preservation
of nasal inspiratory function.
A second important zone is the junction between the
septum and ULCs, forming a natural arched vault. A lack
of respect for this zone following a classical hump reduc-
tion result in an inverted V deformity, created by stenosis
of the junction of the septum with the ULCs. This not
only significantly impairs nasal function but also poorly
affects the cosmesis. Spreader grafts [4] and spreader
flaps [5, 6] were invented to counter this collapse of the
ULCs following hump reduction. Spreader grafts are
mainly used in revision rhinoplasty since they can be har-
vested from donor sites other than the dorsum (septum,
concha, and rib).
It should be noted that the preservation techniques (push
down and letdown) may not affect this septo-triangular junc-
tion zone, but some authors associate these preservation
techniques with width reduction by sectioning and suturing
the septo-triangular region. Currently, there exist no func-
tional studies of these new techniques in the literature.
The nasal resistance during breathing has been simulated
and published in a previous article: Video 9.2 [7].
9.3 Rhinoplasty and Nasal Valve
Conservation
It is very surprising to analyze the history of internal valve
preservation in primary rhinoplasty: surgeons first per-
formed state-of-the-art reductions (e.g., Goldman Tip) and
very aggressive LLC reductions before realizing the damage
these techniques entail, to then repair it during a revision
rhinoplasty.
The first articles in the literature on the subject were not
articles on the preservation of the internal valve but on the
repair of internal valves destroyed by aggressive surgeries on
the LLC and the scroll zone [8, 9].
Note that the scroll zone is not systematically destroyed
in all primary reduction rhinoplasty. The scroll zone is only
destroyed when the reduction of the LLC height for a ­bulbous
tip requires a resection of a high band along the entire length
E. Racy et al.
of the LLC and not only at the level of the dome. If the resec-
tion only involves the dome and does not reach the scroll
area, there is no reason for a functional consequence on the
internal valve.
In the case of a bulbous tip, where a major reduction is
required along the entire length of the lateral crus, there is a
risk of destroying the scroll zone and weakening the internal
valve. To avoid this, several techniques have been described
in the literature.
One of the first techniques described in the literature was
the turn-in flap which was first described by Tellioglu and
Cimen in 2007 [10].
This technique consists in turning the cephalic part of the
LLC under the caudal part after having cut the scroll area to
free the LLC from the ULC.
It allows both reduction of the height and reinforcement
of the LLC; however, cutting through the scroll and destroy-
ing the continuity between the ULC and the LLC predis-
poses to inspiratory collapse of the internal valve.
The physiological consequences of this technique have
unfortunately not been studied.
Murakami et al. also published this technique in 2009
without further physiological studies [11].
Finally, Apaydin in 2012 described this technique without
sectioning the scroll which keeps the continuum between the
LLC and the ULC [12]. Unfortunately, once more, no objec-
tive physiological studies (e.g., PNIF test) or subjective stud-
ies (e.g., NOSE score) exist to demonstrate the impact on the
internal valve.
Another technique used to preserve the internal valve at
the scroll zone to reduce a bulbous tip was the sliding alar
cartilage (SAC) flap described by Ozmen in 2009 which our
team has modified and studied functionally more recently [7,
13].
9.4 Description of the Technique
9.4.1 Modified SAC Flap [7]
In 2009, Ozmen et al. first described their “SAC flap” tech-
nique, consisting of sliding the upper portion of the alar car-
tilage under its remaining lower portion, to refine the nasal
tip while maintaining the scroll area [13]. Authors use a simi-
lar but modified technique, which he has named the modified
SAC flap [7]. Although the authors acknowledge that the
proper terminology for this flap is the “scroll-preserving alar
sliding flap,” the decision was made to refer to the flap as the
“SAC flap” in the remainder of this article for simplicity.
The spreader flap and the SAC flap do not act at the same
level of the internal valve. The spreader flap acts on the
septum-­ ULC junction, while the SAC flap preserves the
ULC-LLC zone (scroll area). Admittedly, both of these tech-
9 Functional Considerations for Preservation Rhinoplasty, Nasal Valve, and Clinical Cases
niques are involved in preserving and maintaining the integ-
rity of the internal nasal valve. The varying degrees of action
of these respective techniques is impossible to know but the
authors feel that the scroll area may be the more important of
the two techniques, judging from endoscopic viewing of the
anatomy and expert opinion.
There is a good functional outcome by the unchanged
means of the NOSE and PNIF scores between preoperative
and postoperative values.
The modified SAC flap is a simple technique allowing tip
definition while maintaining nasal airway function by pre-
serving the crucial anatomic scroll area. It can be a valuable
addition to any facial plastic surgeon’s armamentarium of
procedures.
9.4.2 Operative Technique (Fig. 9.4
and Video 9.3)
Infiltration using 1% xylocaine with 1:10,000 epinephrine
limited to the tip and septum is performed. A standard open
rhinoplasty approach is begun but this surgery can also be
done by a marginal endonasal approach. A subperichondral
Fig. 9.4 The SAC flap technique: marking of the incisions. The carti-
lage is then divided in its mid portion. Over 1 cm of alar cartilage is
preserved caudally. The excess portion of the old dome is severed. The
149
dissection of the LLC is done only if the cartilage is very
thick. The Pitanguy ligament is identified and cut, followed
by separation of the medial crura. Two forceps are placed to
spread apart the medial crura. A subperichondrial septal
plane is identified and dissected. Then a structural our pres-
ervation middle vault rhinoplasty is done.
After the middle vault surgery, the current dome is
marked followed by marking of the desired dome location
to be achieved by transposition (lateral crural steal). Marking
of the ideal dome height (6–8 mm depending on individual
patient characteristics) is done and measurements are taken
of the amount of lateral crus to be preserved (9–11 mm
depending on individual patient characteristics).
Subperichondrial infiltration of the deep surface of the lateral
crura is performed. The deep surface of the lateral crura is
then dissected with fine scissors, with careful attention not to
violate the scroll area. Although the scroll area remains
untouched, a sufficiently sized pocket needs to be dissected
caudally in order to receive the sliding alar cartilage flap.
Potz scissors (sharp and angled) or converse scissors are
used to section the LLC starting from the dome and heading
laterally in order to create the SAC flap. A cranial tip suture
according to the Kovacevic technique is then performed in
cephalic portion of the alar cartilage is then slid under its caudal por-
tion. The cartilage is fixed in place by sutures
150
order to plicate the domes [14]. A “U”-type 5/0 PDS stitch is
then used to approximate the posterior dome. A septal carti-
lage graft, which is usually harvested from the septum, is
inserted in between the medial crura, maintained in place by
two transfixing thin needles, and sutured using two or three
5/0 PDS stitches. The SAC flap is adjusted and sutured in
place with two “U”-type sutures using 5/0 PDS generally
after the cranial tip sutures, depending on the cases. Suturing
the SAC flap helps to fix the nasolabial angle. To fix the
nasolabial angle, there are different techniques including:
1. The Haubant technique using a 5/0-PDS or polypropylen
stitch placed between the columellar strut and the caudal
septum.
2. The Tebbetts stitch using a 5/0-PDS or polypropylen
between the septum and both part of the paradomal LLC.
The Pitanguy ligament is then sutured, occasionally
accompanied by skin defatting if needed. The cutaneous inci-
sion is closed using simple interrupted 6/0 prolene sutures.
Two Teflon sheets are placed on either side of the septum to
serve as a bolster. A thermoregulated cast in placed.
A variation of this technique was described by Cakir
Baris and Genç Bülent in the book Preservation Rhinoplasty
third edition [15].
Through an extended marginal approach and strict subp-
erichondral dissection, the vertical scroll ligament is freed
E. Racy et al.
from its deep mucosal aspect to allow access to the cartilagi-
nous and bony dorsum in the preservation technique.
The SAC flap is made and then the ligament is sutured in
its insertion zone at the end of the procedure.
There have been no functional studies of this modified
technique.
9.5 Conclusion
There are few objective functional studies that have been
able to demonstrate preservation of the internal valve func-
tion after primary reduction rhinoplasty.
It is certain that the systematic physiological study of the
respiratory consequences of rhinoplasty will allow better
preservation of respiratory function.
One of the only bulbous tip reduction techniques that has
benefited from a physiological study showing preservation
of the internal valve is the SAC flap.
9.6 Clinical Case
Case 1 Before (top) and after 1 year (bottom) result using the
modified SAC flap technique.
9 Functional Considerations for Preservation Rhinoplasty, Nasal Valve, and Clinical Cases 151
152 E. Racy et al.

Case 2 Before (top) and after 1 year (bottom) result using Case 3 Before (top) and after 1 year (bottom) result using
the modified SAC flap technique. Endoscopic view of both the modified SAC flap technique.
nasal valves: they are patent with no collapse during inspira-
tion with this technique.
9 Functional Considerations for Preservation Rhinoplasty, Nasal Valve, and Clinical Cases 153

Case 4 Before (top) and after 1 year (bottom) result using right nasal valve: remains patent with no collapse during
the modified SAC flap technique. Endoscopic view of the inspiration with this technique.
154 E. Racy et al.

References 8. Gunter JP, Friedman RM. Lateral crural strut graft: technique
and clinical applications in rhinoplasty. Plast Reconstr Surg.
1997;99(4):943–52; discussion 953–55.
1. Zhao K, Jiang J. What is normal nasal airflow? A computa-
9. Toriumi DM, Josen J, Weinberger M, Tardy ME. Use of alar bat-
tional study of 22 healthy adults. Int Forum Allergy Rhinol.
ten grafts for correction of nasal valve collapse. Arch Otolaryngol
2014;4(6):435–46.
Head Neck Surg. 1997;123(8):802–8.
2. Popko M, Verlinde-Schellekens SA, Huizing EH, Bleys
10. Tellioglu AT, Cimen K. Turn-in folding of the cephalic portion of
RL. Functional anatomy of the nasal bones and adjacent structures.
the lateral crus to support the alar rim in rhinoplasty. Aesthet Plast
Consequences for nasal surgery. Rhinology. 2018;56(1):89–95.
Surg. 2007;31(3):306–10.
3. Daniel RK, Palhazi P. Rhinoplasty: an anatomical and clinical atlas.
11. Murakami CS, Barrera JE, Most SP. Preserving structural integrity
Berlin: Springer; 2018.
of the alar cartilage in aesthetic rhinoplasty using a cephalic turn-in
4. Sheen JH. Spreader graft: a method of reconstructing the roof of
flap. Arch Facial Plast Surg. 2009;11(2):126–8.
the middle nasal vault following rhinoplasty. Plast Reconstr Surg.
12. Apaydin F. Lateral crural turn-in flap in functional rhinoplasty.
1984;73(2):230–9.
Arch Facial Plast Surg. 2012;14(2):93–6.
5. Gruber RP, Park E, Newman J, Berkowitz L, Oneal R. The
13. Ozmen S, Eryilmaz T, Sencan A, Cukurluoglu O, Uygur S, Ayhan
spreader flap in primary rhinoplasty. Plast Reconstr Surg.
S, et al. Sliding alar cartilage (SAC) flap: a new technique for nasal
2007;119(6):1903–10.
tip surgery. Ann Plast Surg. 2009;63(5):480–5.
6. Oneal RM, Berkowitz RL. Upper lateral cartilage spreader flaps in
14. Kovacevic M, Wurm J. Cranial tip suture in nasal tip contouring.
rhinoplasty. Aesthet Surg J. 1998;18(5):370–1.
Facial Plast Surg. 2014;30(6):681–7.
7. Racy E, Fanous A, Pressat-Laffouilhere T, Benmoussa N. The mod-
15. Daniel RK, Palhazi P, Saban Y, Baris C. Preservation rhinoplasty,
ified sliding alar cartilage flap: a novel way to preserve the inter-
3rd ed. Plast Reconstr Surg. 2021;147(5):1256–8.
nal nasal valve as illustrated by three-dimensional modeling. Plast
Reconstr Surg. 2019;144(3):593–9.
 Dorsal Precision Segmental
Preservation and How to Avoid 10
Aesthetic Drawbacks

J. Carlos Neves and Diego Arancibia-Tagle

10.1 Introduction 10.2 Dorsum Conservative Techniques

Conservative dorsal rhinoplasty, until recently called the
push-down rhinoplasty [1–22], has been written about exten-
sively, and over the last decade, dorsal preservation rhino-
plasty (PR) has regained an impressive popularity and has
seen considerable advances in just a few years, since many
doctors have improved and developed new ideas on the sub-
ject [1].
Since the end of the nineteenth century, some works have
shown how to reduce a projected dorsum without impairing
the surface anatomy of the nasal pyramid. By many, it was
seen as an uninteresting and perhaps mistaken concept but
by a few it was seen as the logical approach for preserving
structures and avoiding massive complications. Recently, as
we already said, we have observed the rebirth of dorsal con-
servative concepts [6]. In some cases, the technique is incor-
rectly assumed to be new, and in others they are philosophies
and details that really represent a step forward to achieving
the best results in an accurate and predictable fashion.
Like any other surgical technique, dorsal conservative rhi-
noplasty has its indications and limitations. In this chapter,
we focus on our personal strategies to obtain the best result
possible and how to avoid some of the drawbacks and stig-
mata of the dorsal line PR.
Even though the concept of dorsal preservation was already
more than one half of a century old, it was Cottle [2, 3] who
popularized the “push-down technique” in 1946, combining
several steps described by other surgeons. The principle of
the technique was to preserve the continuity of the nasal dor-
sum by impacting the bony and cartilaginous hump around
the keystone point. His technique consisted of a basal strip
resection of the septal cartilage, one or two paramedian oste-
otomies, the preservation of the keystone area, and lateral
osteotomies allowing him to move the nasal pyramid down-
ward and inward (or outward) into the frontal process of the
maxilla (Fig. 10.1, push down). After the pushdown (PDO)
technique became popular, there were other surgeons who
also described variations of the technique [11]. The “letdown
technique” (LDO) was afterward popularized, even though
authors like Lothrop in 1914 had already described the resec-
tion of a triangular bony wedge of the lateral nasal wall. This
considerably facilitates the downward movement of the nasal
bones and avoids the narrowing of the nasal cavity (see
Fig. 10.1, let down).

Supplementary Information The online version contains supplemen-

tary material available at https://doi.org/10.1007/978-­3-­031-­
29977-­3_10. The videos can be accessed individually by clicking the
DOI link in the accompanying figure caption or by scanning this link
with the SN More Media App.

J. C. Neves (*)
Private Practice MyFace Clinic, Lisbon, Portugal
e-mail: jcneves@myface.pt
D. Arancibia-Tagle
Private Practice, Mallorca, Spain

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 155
S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_10
156 J. C. Neves and D. Arancibia-Tagle

Fig. 10.1 Artist’s sketch of PDO technique and the letdown (LDO) technique. (Courtesy of Fernando Vilhena de Mendonça, 2022, All rights
retained) (Video 10.1 Tetris 2.0) (▶ https://doi.org/10.1007/000-­9q3)

10.3 The Segmental Preservation
Approach
Whenever there are a considerable number of techniques
describing how to achieve the same final surgical purpose, it
means that the ideal technique has not yet been found. We can
also apply this rule to rhinoplasty techniques, and specifically to
dorsal preservation concepts. Some disadvantages can be attrib-
uted to the PDO technique/LDO technique family.
Bringing the nasal semirigid pyramidal unit down as a
whole structure without addressing each segment for refine-
ment can be the main disadvantage.
The main disadvantages are a low radix and radix step,
residual dorsal hump (being caused by a global hump relapse
or by the inability to correct the residual bony hump),
­supratip saddle, wide dorsum, and eventual impairment of
the nasal airway. Based on that factor, the pyramid must be
addressed by segments and not as a single block.
10 Dorsal Precision Segmental Preservation and How to Avoid Aesthetic Drawbacks 157

a b

Fig. 10.2 The intermediate septal approach. (a) The intermediate split, omy. (b) The segmental Tetris concept, where three segments are cre-
where a fragment of septum is removed from the caudal border of the ated with the key player being the Tetris block. The common gray area
septum till the perpendicular plate at the level of the transverse osteot- in both images is exactly at the same position

The Tetris concept in combination with the LDO technique

aims to control each of them, regarding position and shape.
The main author has been doing preservation techniques
for more than 10 years, with his preference being the inter-
mediate approach. He has developed one modification of the
LDO technique with a septal intermediate resection, the split
PR (Fig. 10.2a) that showed the real advantage of the inter-
mediate resection in stabilizing the rhinion position by put-
ting a suture from our free anterior dorsal septal cartilaginous
flap to the basal posterior stabile septum. In fact, this is a
critical stitch for predictably keeping the rhinion in the
desired position with great accuracy.
The Tetris concept (Fig. 10.2b) is an evolution of the split
Fig. 10.3 The lateral wall. We prefer the L technique. The blue seg-
preservation technique, with some advantages, which include ment represents the bone to be removed. Note that next to the medial
suturing the free anterior septum (the Tetris block) in two vec- canthal tendon, we create some space where both osteotomies meet to
tors, craniocaudal and posteroanterior, conferring more stability facilitate the pushdown maneuver. The amount of bone removed will
to the pyramid in two axes and preserving a natural caudal sep- not influence the final dorsal profile position. The gray shadow repre-
sents the dissection area to perform the lateral splits movement
tal strut, which allows us to control the supratip area and keep
the caudal border and its relationship with the anterior nasal
spine stable. As a general concept, these two techniques share
the most relevant factor, the design of an intermediate fragment
of cartilage below the rhinion to be anchored and consequently First, a transverse osteotomy is performed using a
creating stability to the final dorsal profile. h­ andsaw or an ultrasonic device under direct vision or
For more details of the surgical technique, we invite you to alternatively a 2-mm osteotome that can be used percuta-
read the original articles “The Split Preservation Rhinoplasty, neously. The cut is made from the level of the medial can-
The Vitruvian Man Split Maneuver” and “The Segmental thal ligament up to the level of the lateral dorsum
Preservation Rhinoplasty, The Split Tetris concept.” (Fig. 10.4a). We prefer to keep the dorsal portion of the
nasal bones untouched so we can do a green type of frac-
ture when connecting this fracture line with the septal
10.4 Surgical Technique: Osteotomies wedge resection beneath the nasal bones.
and Pyramid Mobilization The lateral osteotomy is part of the LDO technique. It
consists of two osteotomies followed by the removal of the
The LDO technique is our preference for approaching the intervening triangular bony wedge from the frontal process
lateral nasal wall because it gives us better mobilization of of the maxilla (Fig. 10.4b–d). The excision must be done
the pyramid and avoids bone impaction into the nasal cavity very low laterally, in the nasofacial groove, to avoid any pal-
(Fig. 10.3). pable or visible step.
158 J. C. Neves and D. Arancibia-Tagle

a b

c d

Fig. 10.4 The LDO technique. Intraoperative pictures. (a) Upper left:
a transverse osteotomy was performed with a Tastan-Cakir’s saw,
closed approach. (b) Upper right: The anterior osteotomy of the osseous
wedge to be resected is being performed with a 3-mm osteotome,
closed approach. (c) Lower left: the posterior osteotomy of the osseous
wedge to be resected is being performed with an ultrasonic device, open
approach. (d) Lower right: after the bony wedge resection with an
osteotome in close approach; note the periosteum and its vessels were
preserved

10.5 The Lateral Wall Split Maneuver
To create the flattening of the dorsal profile, the lateral walls
must show some plasticity. To achieve that goal, the lateral
articulation between the upper lateral cartilage (ULC) and
the nasal bones in its posterior cephalic border can be
released so that the lateral wall split maneuver movement is
facilitated.
Goksel and Saban [20] also described this maneuver as
the ballerina maneuver.
After the lateral bony wedge is removed, we dissect the
inner surface of the lateral in a subperiosteal plane, to protect
ULC and soft tissues. The pyriform ligaments are also liber-
ated. This dissection will allow for an anterior and caudal
sliding movement of the middle third of the lateral wall (see
Figs. 10.3 and 10.5).
10 Dorsal Precision Segmental Preservation and How to Avoid Aesthetic Drawbacks
a b
Fig. 10.5 The lateral wall split. Intraoperative pictures. (a) (left) Dissecting the ULC from the nasal bone with a delicate dissector. (b) (right) The
triangular space created in between the ULC and the nasal bones after the anterior and caudal sliding movement
10.6 Septal Resection
Conceptually, in preservation techniques the septum can be
addressed lower in its base, by keeping the attachment with
the cartilaginous vault intact and bringing all the structure
down as a unit, and it can be addressed higher at the junction
with the ULCs, exclusively pushing down the cartilaginous
vault. It can also be addressed by splitting the septum in a
strategic medial position, bringing the ULCs and the remain-
ing attached septum down. Each one of these approaches has
its pros and cons.
10.6.1 The Intermediate Split Preservation
Rhinoplasty
The intermediate split PR consists of the following essential
steps: (1) A tapered intermediate resection (that represents
the amount of hump deprojection) begins at the caudal bor-
der of the septum and extending to the perpendicular plate
of ethmoid, with its highest point in the most prominent
aspect of the hump, at the rhinion level. (2) A vertical chon-
drotomy just toward this prominent point of the hump is per-
formed, at the K point or, most often, caudal to it. (3) A
suture is placed for fixation from the free anterior dorsal
septal cartilaginous flap to the basal posterior stabile septum
(Fig. 10.6).
10.6.2 The Medial Wall Split Maneuver
A perpendicular chondrotomy below the most prominent
point of the hump is performed to flatten the profile during
the push down maneuver. Generally, this point is exclusively
159
represented by cartilage, 1–3 mm caudally to the rhinion.
This vertical section allows us to mobilize these two new
septal segments, like the splits maneuver, allowing the sur-
geon to obtain the desired nasal dorsum esthetic line.
We keep a 5- to 8-mm cartilage strip under the ULCs so
we can suture it to the stable basal septum. A suture between
these two septal pieces is mandatory and is always performed
after mobilizing the bony pyramid. The posterior fixation
will define the rhinion height and will stop it from popping
up and creating a new hump, providing stabilization. This
step is the main goal of this intermediate septal approach;
that is, to create a stabilization point that guarantees the final
position, and without any upward movement in the postop-
erative period because of relapsing forces, as seen in other
approaches. In the last decade, this approach has been our
workhorse, and attempts to be accurate with respect to the
final position of the dorsum, by precisely stabilizing the
point where more tension that leads to relapses is felt.
Additional sutures are placed until the caudal septal bor-
der, using figure-of-8 stitches, 5–0 PDS. If more stability is
needed, a strut side to side with the caudal septum can be
used, which is sometimes useful as an extended septal graft.
10.6.3 The Segmental Preservation
Rhinoplasty: The Split Tetris Concept
The Tetris concept is a modified intermediate septal resec-
tion consisting of the following steps (Fig. 10.7). A 5- to
8-mm rectangular piece of septal cartilage will be designed
below the cartilaginous hump in between the most prominent
point of the hump (at or slightly caudal to the rhinion) and
the caudal border of the ULC (the W point). The block is
defined by two lines perpendicular and one horizontal to the
160
Fig. 10.6 Artist’s sketch of the intermediate septal strip resection plus the perpendicular chondrotomy and the figure-of-8 sutures creating a very
firm and stable cartilaginous septum. (Courtesy of Fernando Vilhena de Mendonça, 2022, All rights retained)
Fig. 10.7 The Tetris concept. A 5- to 8-mm height block is designed in
between the WASA and the dorsal hump most prominent point (red
line); a trapezoid figure is drawn below the block, which represents the
amount of the hump to be reduced (gray trapezoid); a triangular figure
is drawn below the bone pyramid, from the block till the lateral wall
transverse osteotomy level to facilitate the pushdown movement (blue
triangle); to avoid overlapping the caudal aspect of the Tetris block with
the natural caudal septal strut we trim a triangular portion of the block
cartilage (purple triangle); to adjust the new dorsal profile level a trim-
ming of the anterior border of the caudal septal strut must be performed
(blue dots)
dorsum (see Figs. 10.5 and 10.8a). We prefer the block
(quadrangular or rectangular) figure compared with a trian-
gular shape, for instance. This is because it is designed to
achieve a more stable structure, and once we have stabilized
a vertical and a horizontal vector, we can avoid tilting of the
free pyramid in the coronal and sagittal planes.
Two new shapes will be designed: one below the rectan-
gular block and another below the bony hump. The shape
below the block must have the height that we intend to
decrease the dorsal projection. The shape of the excised area
will usually be trapezoidal because the reduction will be big-
ger under the most projected point of the hump and less in
the more caudal region. Below the bony hump, we draw a
triangular excision area (triangular wedge) with its vertex at
the level of the transverse osteotomies. The marked areas
will be excised, which creates the space for the descending
dorsum (Fig. 10.8b).
J. C. Neves and D. Arancibia-Tagle
Using a 15 blade, the caudal, posterior, and cephalic bor-
ders of the rectangular block are cut. It is essential to free the
cartilaginous hump. When pushed down, the block overlaps
with the stable septal cartilage and we create a saddle nose
below the UCL caudal border. Next, the triangular segment
below the bony hump is removed using scissors. The cut
always starts at a tangent to the undersurface of the bony
vault to avoid an excess resection that can lead to a radix
step. We initially remove a small triangular piece, and then
perform the pushdown maneuver and analyze how much we
have deprojected. If not enough, we go in again and remove
another triangular slice until reaching the desired level. In
some cases, we only remove cartilage, whereas in other cases
we have to remove a small piece of bone, for which scissors
are often necessary as well. Rarely, we use a baby rongeur,
which we try to avoid, because it can create a bigger space
than is needed and the radix step will appear as a conse-
quence (Fig. 10.8c).
Now, the hump can be reduced and the cartilage block
overlaps the stable basal septal cartilage; and because we
have isolated the Tetris block we press it down, and by a
rotational movement, posterior and caudal, we can create the
side splits effect, thereby eliminating any residual dorsal
hump. We are ready to remove the trapezoid slot, and thus
create the space for our Tetris block.
The rotational movement of the block, downward and
caudal, creates an overlap of a small portion of cartilage of
its caudal border with the caudal septum strut we have left
intact. Thus, we trim the caudal border of the block so that it
fits the slot created perfectly (Fig. 10.8d). This movement
brings the pieces down into their spaces in a perfect match
resembling the Tetris game, so we have called it the Tetris
preservation concept. At this point in the operation, the sur-
geon decides how satisfied they are with the dorsal profile
line. Sometimes, if the dorsum is too convex or a more con-
cave shape is desired then a Tetris split is done at this time (as
described elsewhere in this article).
The first suture of 5–0 PDS is placed between the poste-
rior aspect of the caudal border of the Tetris block to the
caudal septal strut, which stretches and helps to flatten the
10 Dorsal Precision Segmental Preservation and How to Avoid Aesthetic Drawbacks 161

a b

c d

Fig. 10.8 The Tetris block designing (fresh specimen). (a) Designing and can be repositioned. (d) A triangle to be resected was marked in the
the Tetris block. (b) Designing the space slots. The trapezoid below the caudal border of the Tetris block to avoid overlapping with the natural
Tetris block, that determines the hump reduction, and the triangular caudal strut
below the bony pyramid. (c) The Tetris block and the pyramid are free

dorsum. This movement resembles what we performed in the
Cottle PDO technique [2, 3], and because of this here we can
see a mini-Cottle, using an intermediate approach, with the
advantage of preserving the stability of the rest of the sep-
tum. After performing this suture, the hump is reduced.
Nevertheless, immediately we observe a small relapse of the
hump that will slightly increase with time, the so-called
spring effect (Fig. 10.9c). This phenomenon is responsible
for the residual hump seen in a considerable number of cases,
being a major problem of the dorsal preservation techniques.
To prevent recurrent humps, we use a rhinion suture. At the
level of the rhinion, we suture the cephalic border of the
Tetris block to the underlying stable septal cartilage to guar-
antee precision and predictability (Fig. 10.9d). This suture
can be performed as a simple interrupted one (Fig. 10.10) or
as a figure-of-8 stitch, which is our preference. Additional
sutures must be added between the caudal and the posterior
borders of the Tetris block to the surrounding stable septal
cartilage. To increase stability, we include the contralateral
perichondrium and mucosa. With this approach, our inci-
dence of recurrent cartilaginous humps has been negligible.
At this point, the dorsum has been brought down to its
ideal position, except at the level of the caudal septal strut,
which was previously pre-served. In fact, one can often end
up with a slight pollybeak appearance. The anterior border of
this natural strut must be addressed, and most often it is
162 J. C. Neves and D. Arancibia-Tagle

a b

c d

Fig. 10.9 The Tetris concept (fresh specimen). (a) The space slots are
prepared to allow the PDO movement. (b) Adjusting the Tetris block,
the profile is checked. (c) Two PDS 5–0 sutures have stabilized the cau-
dal border of the block; the stabilization of this border of the block is
paramount to avoid pyramid lateralization. Note the spring effect below
the rhinion, a gap is created in the cephalic aspect of the space slot
below the rhinion. (d) The 5–0 PDS suture was placed below the rhin-
ion. The stabilization of the dorsum in a predictable final nasal dorsum
position is probably the greatest achievement of this technique
10 Dorsal Precision Segmental Preservation and How to Avoid Aesthetic Drawbacks
Fig. 10.10 The Tetris block. Intraoperative picture showing the two
most important block sutures. Additional sutures will be added to com-
plete stabilization. (Note that the stabilization of the two borders that
are perpendicular promotes an affective stability to the pyramid, even-
tually like no other dorsal preservation technique)
a b
c d
Fig. 10.11 The caudal septal strut. Intraoperative pictures showing the
natural caudal septal strut. (a) The natural caudal septal strut before
being addressed. (b) The septal profile after equalization of the caudal
septal segment. Note the slight concave curve that the profile shows; it
163
trimmed to achieve the desired dorsal height (Fig. 10.11b).
Alternatively, it can be left partially at its maximum height to
act like a strut to the tip or to support the stabilization of a
septal extension graft (Fig. 10.11d).
In deviated noses, one can suture the overlapped carti-
lages side by side without resecting the trapezoid piece (gray
trapezoid in Fig. 10.5). The rectangular block is sutured on
the opposite side to the deviation so it can compensate
(Figs. 10.11c, d, 10.12, and 10.13).
In a nasal dorsal hump, the cartilaginous component
tends to be convex. Even after hump reduction, a curved
line can persist that creates a small hump in between the
rhinion and the supratip region; in some cases, it is essen-
tial to flatten this cartilaginous curve. One or two additional
vertical cuts are made into the septal block converting it
from a single entity into two or three new blocks that will
be brought caudally into rotational movement (see
Figs. 10.13 and 10.14). The creation of multiple pieces
allows the dorsum to flex, which resembles the spreading of
fingers. This movement brings the pieces down into their
spaces in a perfect match resembling the popular game and
avoids the supratip saddling phenomena of some dorsal preservation
techniques. (c) The caudal septal strut lateral to the Tetris back in a
deviated pyramid. (d) The caudal septal strut supporting a septal exten-
sion graft (the anterior nasal septal angle banner)
164
Fig. 10.12 The Tetris concept in deviated pyramids. When there is
indication to perform the procedure in deviated pyramids there will be
no slot creation below the Tetris block (red line) and consequently no
trapezoid resection as seen in previous demonstrations; the block will
suture to the stable septum in the opposite site of the deviation for com-
pensation. The gray grid represents the septal harvesting leaving a sta-
ble L-shaped septum after suturing the Tetris block
Fig. 10.13 The split Tetris concept. Splitting the Tetris block (red
lines) allows the cartilaginous segment to flatten or eventually to
become concave. The wider the gray triangle the more concave this seg-
ment will be
thus the name—the split Tetris PR. The more the block
pieces are moved apart, the more concave the profile
becomes.
10.6.3.1 Tetris 2.0
We have introduced a variation at the caudal cut of the
Tetris flap. Instead of considering the W point (the caudal
board of the ULC) as the starting point, we are preserving
now below the ULC 3–5 mm of septum (meaning the cau-
dal limit of the flap is 3–5 mm cephalic to ULC caudal bor-
der) that works as an additional stability pillar at the
supratip area (Video 10.1).
J. C. Neves and D. Arancibia-Tagle
10.6.3.2 How to Avoid Aesthetic Drawbacks
Dorsal Segments and Strategies to Avoid Stigma
The split Tetris is an evolution of the intermediate split
approach [1], whose fundamental goal is to stabilize and pre-
dict the nasal dorsum final position. It was designed to
improve nasal pyramid stability, regarding the coronal and
sagittal axis, and to treat each segment of the dorsum more
independently. At first, this technique may seem demanding,
but once it has been learned it is relatively simple to perform.
For many years, the preservation techniques have been criti-
cized for their lack of precision and the stigma of the out-
come. With the segmental approach we aim to reduce its
weaker aspects.
Profile Drawbacks
Residual Hump or Hump Recurrence
The ideal scenario for a pyramid PDO/LDO maneuver is a
high flat tension nose. When we face a convex dorsal profile
that needs to be flattened, several considerations need to be
taken into account to avoid a residual hump or other stigmata
postoperatively.
To some extent, the definition of residual hump depends
on the eye of the beholder. Sometimes results are shown and
described as having no hump where it is possible to see a
residual convexity and based on that some surgeons admit to
<5% of residual hump while others 15% [6–24].
Though one may regard a small hump as natural, it is
important to achieve a result planned at preoperative consul-
tation, flat or slightly convex.
In smaller convexities, pushing the pyramid down and
hiding a possible radix step below the thick-soft tissues may
be a good strategy for producing a flattened profile. We pre-
fer to avoid radix steps, except when the radix is high and
bringing it down is part of the surgical strategy. So, routinely
we employ additional maneuvers that philosophically ques-
tion whether we are actually performing real preservation
surgery, once we disrupt structures in the foundation of the
nasal pyramid.
We consider three aspects to obtain an ideal profile: (1)
accurate and predictable deprojection, (2) dorsal line flatten-
ing movement, (3) stability of the final position avoiding
relapses (Fig. 10.15).
Let-Down Technique
While the lateral wall can be approached using the PDO
technique or the LDO technique [25, 26] (Fig. 10.1), we pre-
10 Dorsal Precision Segmental Preservation and How to Avoid Aesthetic Drawbacks 165

a b

c d

Fig. 10.14 The split Tetris concept (fresh specimen). (a) Upper left: anterior position. (c) lower left: two splits of the block; note the power-
one split of the block and defining the desired profile curvature. (b) ful effect of the craving effect. (d) Lower right: stabilization of the three
Upper right: one split of the block, we can see the eventual distortion of small blocks to the underlying stable septum using 5–0 PDS
the caudal aspect of the UCL when bringing its caudal portion to a more

fer the LDO since it allows a good pyramid mobilization
avoiding bone impaction into the nasal cavity and conse-
quently the benefits of not impinging on nasal airway.
The precision of the wedge resection in LDO has no
impact on pyramid stabilization or the final profile posi-
tion, as the septal wall is the guiding structure dictating
the final result. Even if we excise a wedge of bone match-
ing the exact amount of dorsal height deprojection, the
two borders of bone are not in contact as the remaining
bony pyramid is narrower than the basal bony structure,
with the possible contact happening exclusively in the
cephalic end. Any gap in the bony continuity left after the
pyramid is adjusted to the new position will be filled by
neoosteogenesis, because of the periosteal preservation
(Fig. 10.16).
Splitting the Three Walls
In low and intermediate strip approaches, the septal wall
ideally must be split at the level of the most prominent
point of the hump, generally caudal to the rhinion (almost
always is septal cartilage that we have to resect), in order to
create the necessary movement to correct the convex pro-
file. To be effective when stretching the dorsal convexity,
the midwall should have two pillars (at caudal and a
166 J. C. Neves and D. Arancibia-Tagle

Fig. 10.15 (a, b) A low strip

PDO approach was a b
performed. A residual hump
and a minor supratip saddling

Fig. 10.16 One-year

postoperative revision case;
a b
an LDO technique was
performed. (a) New bone in
the gap created is seen,
thinner and whiter. (b) An
LKA disarticulation was
performed in the previous
surgery. Note the normal
continuity and stability in
between the ULC and the
bony wall. LKA lateral
Keystone area
10 Dorsal Precision Segmental Preservation and How to Avoid Aesthetic Drawbacks
Fig. 10.17 Two stable pillars must be preserved: one cephalic at the
radix area and the other one caudal at the supratip region. A force that
counteracts the spring effect responsible for hump recurrency is para-
mount to predict accuracy and stability
cephalic end of the curve) supporting the forces imposed in
between them, over the splitting point. It works like the
splits (Fig. 10.17).
The lateral wall should follow the same concept. In most
of our cases, we perform the LKA disarticulation (Fig. 10.3),
which creates a lateral split and allows for a sliding move-
ment of the cartilaginous structure in an anterior and caudal
vector [1–29]. The more the distance from the dorsal line the
more the limitation in the movements that the pyriform liga-
ment and ULC lateral bony wall cause. The lateral wall will
work as a facilitator for defining the final dorsal profile that
follows the septal work.
Subrhinion Stabilization
The spring effect has its maximum force vector at the highest
point of the hump. To counter this phenomenon, we preserve
a piece of cartilage attached to the pyramid below the most
prominent point of the hump that will be anchored with PDS
sutures to a stable basal segment of the septum. That means
we are performing an intermediate approach or eventually a
partial intermediate approach, as in the Tetris concept [21,
22] (Fig. 10.7).
In the low approach, the probability of relapsing and hav-
ing a residual hump is greater. All the mobile pyramid is sta-
bilized to the anterior nasal spine region. A stretching effect
of the hump is produced by the caudal and anterior rotational
167
Fig. 10.18 In a low approach, two or three oblique sutures to the
spring effect vector are placed to achieve stabilization of the final pro-
file line avoiding recurrences of the hump
movement that flattens the hump. However, the spring effect
is not directly counterbalanced. Even if it is not possible to
be as effective as the parallel opposite sutures previously
described, we use two or three oblique sutures to the spring
effect vector to achieve stabilization of the cartilaginous
vault (Fig. 10.18).
In the high approach a transdorsal suture can be placed,
passing over the cartilaginous pyramid and stabilizing it to
the basal septum.
Reshaping the Residual Bony Hump
In dorsal PR, the analysis of the osseous upper third is para-
mount. The concept of S-shaped and V-shaped nasal bones
introduced by Lazovic et al. [30] is being discussed as a
guide for the best indications for full dorsal preservation
techniques, with the V shape being the best scenario since it
will produce a smooth transition to the dorsal cartilaginous
surface.
The S-shaped nasal bones can promote the appearance of
an osseous residual hump that represents a potential stigma
of the dorsal conservative procedures. After the deprojection
maneuver is performed the appearance of this residual hump
may be unnoticed during surgery, therefore refinement
maneuvers may have to be considered.
Depending on the approach rasps, burs, or piezotome may
be used. We prefer cylindric burrs to create smooth surfaces
and transitions (Fig. 10.19). The bony cap will be reshaped
to the desired level obtaining the ideal profile line, as well as
the lateral walls and the nasofacial groove.
168
a b
c d
Fig. 10.19 Refinements in dorsal PR. (a) A step at the right nasofacial
groove can be seen; a cylindrical burr will be used. (b) Smooth transi-
tion at the left nasofacial groove after it has been corrected. (c) Sculpting
Reshaping the Residual Cartilaginous Hump
The cartilaginous hump can show an intrinsic convexity
exhibiting: (1) a residual localized cartilaginous hump (cau-
dal hump greater than the original) and (2) depression at the
caudal end of the cartilaginous profile (Fig. 10.20).
Controlling the convex arch of the cartilaginous line fol-
lows the same principles as used on the septum to control the
nasal hump. The cartilaginous septum is split midway of the
arch to achieve flatness. This can be done by splitting the
quadrangular cartilage into a strategic line. The segmental
preservation concept considers the possibility of splitting the
Tetris block (Fig. 10.13) and so designing a flattened or
eventual concave curve. Moreover, by preserving a natural
caudal septal strut (in between the anterior nasal septal angle
and W point), it allows us to precisely design the supratip
area and avoid eventual saddling.
J. C. Neves and D. Arancibia-Tagle
S-shaped nasal bones. (d) Paramedian osteotomies with an ultrasound
device to narrow the bony vault
Radix Position Control
Periosteum Dissection
Subperiosteal dissection is the best way to address the upper
third of the nose. However, in dorsal PR the soft tissues over
the radix may be left untouched, completely or partially thus
acting as a tent to support an eventual descent of the pyramid
at the level of the transverse osteotomies.
Transverse Osteotomies
Location of transverse osteotomies is crucial. From the level
of the medial canthal tendon a line is marked that goes supe-
riorly in an oblique fashion reaching the radix in amore
cephalic position, where the radix is deepest from skin sur-
face. This serves to camouflage step deformity should it
occur (Fig. 10.21).
10 Dorsal Precision Segmental Preservation and How to Avoid Aesthetic Drawbacks 169

Fig. 10.20 (a, b) A residual

cartilaginous convexity can be a b
seen postoperatively. A full
intermediate approach was
used with subrhinion
stabilization. A cartilaginous
split would have helped
flattening the cartilaginous
profile

obtain two oblique line fractures that support the free pyra-
mid and protect it from collapse.

Septal Wall Work

Fig. 10.21 Anterior and cephalic line to perform a transcutaneous
transverse osteotomy
Routinely, two lateral percutaneous osteotomies follow
the drawn line and leave a fragment of bone in the midpoint
to facilitate the greenstick fracture and spare a periosteal
stripe. If a midline osteotomy is needed (best avoided in
most cases), the osteotome must be placed obliquely to
With the pyramid free, the support for the bony pyramid
entirely comes from the septum. The lateral wall in LDO acts
as a facilitator. At this point, the convex pyramidal arch is
supported by at least two stable pillars, one at the radix, cau-
dal to the transverse osteotomies (cephalic pillar), the other
at septal angle (Fig. 10.17).
Depending on how the septal segment below the bony
vault is addressed the radix keeps its original position, goes
up or down. It has both cartilaginous element (the quadran-
gular cartilage) and osseous one (the perpendicular eth-
moidal plate). In most cases, the cartilaginous component is
predominant.
Preserving a piece of perpendicular plate below the bony
dorsum (extending caudal to the transverse osteotomies)
gives the necessary nasal pyramid support and avoids col-
lapse and radix step.
In most cases, cartilaginous septum is trimmed precisely
with sharp, slightly curved scissors to avoid cartilage
shearing.
Large instruments like rongeurs are best avoided.
Technically, the scissors are inserted convex side up, tangen-
tially to the inner surface of the nasal vault from the splitting
point to the transverse osteotomy point. This will free the
nasal pyramid from the septum. Then, small triangles are
170
Fig. 10.22 LDO technique
with perpendicular ethmoidal a b
plate control bringing the
radix down to a pleasant level
excised using the scissors with concavity looking up and
adjusting the ideal profile. At this point, different options
include
1. Keeping the radix at the same level: The exact amount of
septal excess is resected and the pyramid rests completely
on the septum or only a cephalic stable portion of PEP is
preserved working as a true pillar for the pyramid stabil-
ity, allowing extensive septoplasty.
2. Creating a step-down: As already mentioned, the trans-
verse osteotomies can be performed strategically where
an eventual step-down is camouflaged by the overlying
thick-soft tissues, promoting a bony step-down not visi-
ble in profile.
When the radix is high and the nose appears to start at
eyebrow level, it is possible to create a lower starting
point by bringing the radix area down. The septal sup-
portive point of the pyramid is resected incrementally
until the profile reaches the desired level (Fig. 10.22).
This is a delicate maneuver that requires an accurate cut
of the septum, especially at perpendicular ethmoidal
plate. If resected excessively free pyramid can collapse
with disastrous results that must be compensated with
grafts (Fig. 10.23).
3. Creating a step-up: Preservation technique is not suited
for low radix patients. However, when radix position is
controlled as already explained, one can achieve to lift the
radix using step-up technique: when approaching the sep-
J. C. Neves and D. Arancibia-Tagle
tum, we define a pivotal point where the pyramid remains
at the same position. Caudal to it the pyramid is pushed
down and cephalic to it the pyramid goes up, creating the
desired radix step-up. After defining the pivotal point, a
predefined triangular piece of septum is trimmed caudal
to the pivot. This triangular space allows for the deprojec-
tion maneuver, and the free pyramid cephalic to the pivot
goes up (Figs. 10.24 and 10.25).
Supratip Position Control
The supratip saddling is a common drawback and stigma
especially in low approach PR. The main reasons for this
are (1) inability to correct the dorsal convexity, leading to a
profile that curves to a low supratip area; (2) poor control of
the septal height when resecting septal cartilage excess;
and (3) poor fixation of the new position of the septum to
the anterior nasal spine. Based on the above factors, supra-
tip position should be defined carefully.
Supratip over resection is avoided in the high strip [6] and
the partial intermediate approach by sparing a natural caudal
strut that can be trimmed as desired. This also aids in design-
ing precise profile of this segment.
In the low approach, an excess of septal resection at the
supratip line must be avoided to prevent saddling. Height
measurements are taken with septal rotational movement
and sutured securely. If anchorage of the septum to the
anterior nasal spine is deficient, some posterior and cephalic
10 Dorsal Precision Segmental Preservation and How to Avoid Aesthetic Drawbacks 171

a b c

Fig. 10.23 (a, b). LDO technique with loss of perpendicular ethmoidal plate control creating a low radix of the nose, which were partially com-
pensated with grafts. (c) The Rx image shows the loss of control of the patient’s pyramid

a b

Fig. 10.24 (a) A pivotal point where the pyramid remains at the same position is designed. (b) Caudal to the pivotal point the pyramid is pushed
down; cephalic to it the pyramid goes up, creating the desired radix step-up

movement may lead to a supratip depression and hump
recurrence.
In septum pyramidal adjustment and repositioning
(SPAR) concept and when possible, Dewes developed a
strategy to retain a stripe of basal septum, especially at the
anterior nasal spine, to stabilize more easily and effectively
[15, 16].
Pyramid Lateralization
Apart from hump recurrence, pyramid lateralization is prob-
ably the most common reason for revision. With good septal
stabilization, in deviated noses, the longer wall is approached
by LDO and the shorter with PDO. Alternative is LDO tech-
nique allowing pyramid movement on both sides facilitating
repositioning.
The low approach techniques (Cottle or SPAR) are the
best indications for the treatment of deviated noses that need
a complete septoplasty and a septal repositioning. The “lat-
eral Tetris” [21, 22], which is a partial intermediate approach,
overlaps the free septal cartilage at the opposite side of the
deviation and compensates for smaller pyramid lateraliza-
tion (Fig. 10.12).
The worst scenario is converting a straight nose to a
deviated pyramid. To avoid this, lateral wall should be free
to move but the septum should be fixed firmly. Even in a
straight structure conflict at the inner concavity of the vault
can be seen at the septal wall. When the triangular piece of
172 J. C. Neves and D. Arancibia-Tagle

Fig. 10.25 (a) The bony

elevation created by the a b
step-up technique. (b)
Postoperative X-ray showing
the step-up

the septal wall is removed below the bony vault, it is com-

mon to see a residual septum coming from the concave
roof, which is sometimes difficult to remove completely,
and especially at the perpendicular ethmoidal plate. During
the deprojection maneuver, this residual septum may
assume a side-to-side position with the basal septum and
deviates the nasal axis, especially at the radix level. For
this reason, accurate reduction and fixation is important. A
definite advantage of designing the Tetris block is the two-
axis stabilization in straight septum, by blocking cephalic–
caudal and anterior–posterior vector movements
(Fig. 10.26).
Fig. 10.26 Two-axis stabilization. The posterior border of the block
(yellow) avoids oblique axial-coronal tilting (mainly axial). The caudal
border of the block (orange) avoids oblique coronal-axial tilting (mainly
10.6.4 Broad Bony Pyramids and Mid-Third coronal)
Broadening
posterior to the ULC posterior border. The widening of the
Broad nasal pyramids and irregular dorsum surfaces are ULCs would not happen if their posterior and caudal borders
generally contraindications for dorsal PR. However, we were completely free. In that case, they could move freely
will propose tools that can reverse contraindications. with the bony movement. So, it is important to understand
the dissection posterior to the UCL posterior border and the
10.6.4.1 Cartilaginous Pyramid role of the scroll by blocking the movement.
During the deprojection maneuver, the cartilaginous
­mid-third tends to widen. This can be advantageous as it Suturing the Middle Third Roof
opens the internal valve but has aesthetic drawback. It can be The middle third roof suturing goal is to narrow a wide mid-
avoided if we understand the cartilaginous blocking points: dle third roof and get a precision dorsal line by preserving
(1) deficient control of the septal cartilage caudal to the split, nasal functions in rhinoplasty. After the nasal dorsum projec-
(2) by the scroll complex, and the (3) soft tissues mass effect tion is reduced and stabilization is achieved, the dorsal line
10 Dorsal Precision Segmental Preservation and How to Avoid Aesthetic Drawbacks 173

a b

c d

Fig. 10.27 (a) Broad nasal dorsum, (b, c) continuous mattress sutures Note the continuity of bony and cartilaginous aesthetic lines. Compare
with reduction of the ULC flaring, and (d) new dorsal aesthetic line the width in (a) and (d), before and after
(DAL) was designed narrowing the bony vault with a cylindrical burr.

harmony should be checked. If there is broadening or asym-
metry on the middle third roof despite all the maneuvers, the
suturing option should be considered.
Continuous or intermittent 5.0 PDS sutures can be used
starting a few millimeters cephalically from the W point run-
ning cephalically. When a continuous horizontal mattress
suture is performed, we turn caudally again and tie the suture
at the starting point (Fig. 10.27).
For the patients who have broader cartilages, we need to
excise a triangular piece of cartilage at the dorsal T platform
starting at the rhinion (the base of the triangle), in between
the septum and the thickest aspect of the ULC, going cau-
dally till necessary (the apex of the triangle). The three com-
ponents, the two ULC and septum, are brought together
achieving the ideal width. The suture described above can be
applied now if necessary. In other cases, trimming the edge
174
a b
Fig. 10.28 (a) Wide and irregular middle third, (b) Continuous mattress sutures; note the trimming of the ULC edges next to the rhinion area:
also new DAL were created with piezo (note the greenstick osteotomy in both sides) and shaved with a cylindrical burr
of the ULC close to the rhinion may prevent cartilage irregu-
larities (Fig. 10.28). The use of monopolar cautery can also
be an interesting option to control these edges.
There are a few critical points to help avoiding drawbacks
of the technique. The suture should be placed as more ante-
rior as possible, close to the T platform (Fig. 10.5c), where
the ULC are thicker in order to avoid collapse of the middle
third lateral wall and eventual consequent breathing prob-
lems, what can happen if the suture is performed in a more
posterior position.
Also, the suture should save a free segment next to the
nasal bones in order to avoid excessive narrowing of the mid-
dle third next to the rhinion which can lead to an apparent
pyriform aperture and a consequent inverted V aspect.
Additionally, the suture should be tightened according to the
desired dorsal lines. Too tight or too loose may produce
nonideal aesthetic lines. Based on that, in some cases it is
preferable to use single sutures.
In some cases, only one ULC is bulging, specifically if we
are dealing with a crooked nose. A single unilateral suture
can be placed using the same concept. The knot can be bur-
ied in the depression found in between the septum and upper
lateral, it is interestingly well disguised in this area.
10.6.4.2 Bony Pyramid
The wide bony pyramid can be an aesthetic limitation when
performing DPR. Sometimes the pyramid is already wide,
sometimes it looks wider after impaction. We usually
address the lateral wall for reshaping, the nasofacial groove
J. C. Neves and D. Arancibia-Tagle
for smoothing and dorsal platform width by creating new
DALs.
Sculpting the Lateral Wall
The lateral wall can be also sculpted. It is common to see
some bulging of the lateral wall at the nasofacial groove.
This bulging may be completely or partially corrected by the
letdown wedge resection; when some building remains, the
burr can be used to smooth its convexity. In deviated noses,
PR can be real powerful bringing the pyramid to the mid-­
line. However, in many cases the lateral walls remain asym-
metric, with convexities or concavities, that can be corrected
with use of power instruments [20, 21]. Both walls can be
shaved till the inner cortical of the lateral is observed as a
gray granite look. This paper-thin bone can be remodeled by
digital compression, a powerful tool to control bony convexi-
ties (Fig. 10.29).
The naso facial groove is also addressed. In many
occasions, after the basal osteotomies some step can be
felt at this point. The use of the burr smooths the basal
edge of the osteotomy creating a gentle transition to the
face and helping in reducing the width of the nasal base
(Fig. 10.30).
The width is defined, and a new DAL is designed. Its con-
tinuity with the cartilaginous vault may be also shaved. In
some cases, the shaving limit is reached, leaving only an
eggshell thickness of lateral bone but still with some unde-
sired dorsal width. In these cases, we may consider DAL
osteotomies.
10 Dorsal Precision Segmental Preservation and How to Avoid Aesthetic Drawbacks 175

a b

Fig. 10.29 (a, b) In this case the lateral bony wall was shaved till a creating a new DAL; the piezo helped creating a greenstick fracture; a
gray granite look is observed; the bone is paper-thin in some regions. continuous mattress sutures was placed at the cartilaginous vault. (c)
The width of the dorsal platform was reduced to the ideal measurement Pre-­op dorsal width. (d) Immediate postop width

a b

Fig. 10.30 (a) Left lateral nasal wall, where it is visible the gap left eventually be palpated. (b) After smoothing the transition with the
by the LDO technique—the edge of the basal osteotomy border is cylindrical burr
sharp. Even if the osteotomy in very low at the nasofacial groove it can

Defining Dorsal Aesthetic Lines Osteotomies
In wider bony vaults the reshape of the DALs can also be
achieved with power instruments, performing DAL oste-
otomies that should be placed immediately lateral to where
we would like to see the new DAL, so the dorsal platform
has the adequate width and continues smoothly with the
cartilaginous vault. This is the main goal of our approach
in dorsal PR, to preserve the dorsum in between the DAL
leaving the main trauma (that necessarily exists) to the lat-
eral wall where really few complications must be seen and
176
a b
Fig. 10.31 (a) Reshaping the DAL with a drill and (b) defining the new DAL with a piezo
almost never irregularities are palpated. These fractures
should not ideally not cut the bone on all its width, creat-
ing a greenstick in-fracture to help in the lateral wall stabi-
lization. Because of some instability that the LDO
maneuverer must create to the pyramid, here the use of
piezo is for sure of a high value by creating a precise cut.
Sometimes by fragilizing this area with the burr, the bone
becomes paper-thin as already mentioned and the lateral
wall fractures in at the defined DAL (Figs. 10.29 and
10.31). Thus, we defined precisely the width of the dorsal
platform control the surface of the lateral wall and fracture
it in to narrow the bony nasal base. With these technical
possibilities, the contraindication for PR is at least only a
partial contraindication if any.
10.7 Discussion
In coronal straight noses, the segmental approach and other
preservation approaches are indicated. In fact, the best candi-
date is the one with a straight narrow delicate nose with a
dorsal hump. The greatest advantages of this approach are
the stability of the rhinion area owing to the central suture,
the rigidity of the caudal septal border with its attachment to
the anterior nasal septum, the ability to achieve a flat or even
concave profile of the cartilaginous segment, by splitting the
Tetris block, and the avoidance of supratip depressions.
The suturing of the two perpendicular borders of the
block promotes a unique stabilization of the nasal pyramid in
two axes. If the nose has a slight deviation, we can take
J. C. Neves and D. Arancibia-Tagle
advantage of the block over-lap with the basal septum and
suture it in an overlapping fashion with the block opposite to
the deviation. If the septal deviation is mainly basal, we can
perform a split Tetris PR and then the septoplasty. In fact, it
works exactly as the L-structure preservation in direct hump
resection procedures. Because our Tetris block is around
5–7 mm high, if we stabilize it to a 5 bar of the stable septum
it means that we end up with 10–12 mm of septum we cannot
harvest. Below it we can proceed with a traditional septal
harvesting (see Fig. 10.7).
The primary contraindications of this technique are
crooked pyramids, severe septal trauma, and a wide cartilagi-
nous dorsum. One prerequisite is that there must be suffi-
ciently stable and relatively straight septum without major
intrinsic high anterior septal deviations. In severe bigger
deviations, we prefer a classical Cottle/septum and pyramid
adjustment and reposition technique because it permits a
more aggressive approach to the septal deviation or an open
book technique.
10.8 Clinical Cases
10.8.1 Case Study 1
Dorsal PR work: LDO technique and LKA disarticulation;
right side overlap lateral Tetris flap; lateral wall sculpted
with 5 mm cylindrical burr; DAL refined by piezo, green-
stick osteotomy; continuous mattress suture at the cartilagi-
nous platform, 5.0 PDS.
10 Dorsal Precision Segmental Preservation and How to Avoid Aesthetic Drawbacks 177
178 J. C. Neves and D. Arancibia-Tagle
10 Dorsal Precision Segmental Preservation and How to Avoid Aesthetic Drawbacks 179

10.8.2 Case Study 2 sculpted with 5 mm cylindrical burr; cartilaginous continu-

ous mattress suture, 5.0 PDS.
Dorsal PR work: LDO technique and LKA disarticulation;
septal subdorsal Tetris flap; lateral wall and bony dorsum
180
10.9 Conclusion
The dorsal preservation surgery, which has been popular in
recent years, is increasing its magic. Despite its reputation,
the drawbacks of this technique should not be ignored. To
avoid the nasal pyramid widening and irregularities and
achieve precise DAL in PR, we need to consider additional
maneuvers apart from impacting and splaying. Following
this principle in a considerable number of our patients we
end up performing surface procedures, additional osteoto-
J. C. Neves and D. Arancibia-Tagle
mies as DAL osteotomies, sutures and grafts to the mid-­
third. It leads to the question: what are we really preserving?
The answer guided the logic of this article: the nasal dorsal
platform continuity with precisely defined DAL.
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 Prevention and Correction of the Most
Common Problems in Preservation
Rhinoplasty
Bart M. Stubenitsky
Preservation rhinoplasty (PR) has transformed our way of
approaching primary rhinoplasty surgery by shifting from
the standard teaching of reduce and rebuild to the concept of
preserve and reshape.
Preservation rhinoplasty comprises the following three ele-
ments: (1) elevating the skin sleeve in the subperichondrial–
subperiosteal plane, (2) preserving the osseocartilaginous
dorsum, and (3) maintaining the alar cartilages with minimal
excision while achieving the desired shape using sutures.
A growing repertoire of PR techniques is evolving, and
many variations of established techniques have been pro-
posed since Daniel introduced this term in 2018 [1].
It is therefore essential to have a clear understanding of
which preservation technique to use for which nose and to
realize when not to use PR.
This chapter will give an overview of the different tech-
niques addressing both the osseocartilaginous and the tip. It
focuses on the prevention and correction of the most com-
mon problems by using the following algorithm:
1. analyzing of the nose
2. visual planning of the desired aesthetic outcome
3. choosing the optimal technique.
11.1 Analyzing the Nose
Systematic analysis by touching the whole nose and evaluat-
ing the internal anatomy will give an idea of the tissue you
are going to work with. The first assessment in choice of
technique or possible limitations is made here. An additional
3D cone beam can be of use for the deeper bony and carti-
laginous anatomy.
B. M. Stubenitsky (*)
Dr BartClinic, Amsterdam, Netherlands
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. Poignonec (ed.), Clinical Atlas of Preservation Rhinoplasty, https://doi.org/10.1007/978-3-031-29977-3_11
11
Soft-tissue envelope (STE): thickness and elasticity of the
skin on the dorsum and in the tip area.
Cartilaginous vault: K area, high point, strength, vault
deviation, septal deviation, height caudal septum, broadness,
irregularities and asymmetries.
Bony pyramid: height of radix, length of nasal bones,
shape of hump (S or V shaped), pyramid deviation, broad-
ness, irregularities and asymmetries.
Tip: strength and length of cartilages, support, broadness,
irregularities and asymmetries.
Function: breathing issues, septal deviation, concha
hypertrophy, allergies, valve collapse.
Findings should be recorded.
11.2 Visual Planning of the Desired
Aesthetic Outcome
Preoperative visual planning of the desired aesthetic result is
essential. This should be done together with the patient,
thereby giving them a visual tool to express their wishes. The
morphing gives the best insight into what is being requested,
what is possible, and how to achieve that result. It gives the
surgeon a clear idea what must happen to the osseocartilagi-
nous dorsum and the tip.
The preoperative design of the nose is therefore an aes-
thetic or artistic process, based on the preferences of both the
patient and the surgeon (Figs. 11.1 and 11.2). The surgery on
the other hand is the technical effectuation of that design. It
should be made clear to the patient that the design is the goal
toward which we will be working, rather than an absolute
commitment to a particular result.
183
184
a b
Fig. 11.1 From left to right—actual preoperative sideview, planned preoperative sideview, overlay of (a, b)
Fig. 11.2 Actual and planned
preoperative frontal view
11.3 Choosing the Optimal Technique
Many factors such as experience and preferences of the sur-
geon, anatomy of the nose, and the desired outcome influ-
ence this process. And although the goal is to preserve as
much as possible, one must realize that sometimes it is better
not to. There is an increasing tendency toward a marriage or
B. M. Stubenitsky
a+b
mosaic of preservation techniques with a touch of structural,
all aimed at creating the most optimal result.
Choice of technique is done in the same systematic order
(STE, bony pyramid, cartilaginous vault, and tip), taking in
account the experience and preferences of the surgeon, anat-
omy of the nose and the desired outcome.
11 Prevention and Correction of the Most Common Problems in Preservation Rhinoplasty 185

11.4 STE

Undoubtedly, more than one approach to the nasal STE can

produce beautiful and safe results in both open or closed rhi-
noplasty, if the Pitanguy and scroll ligaments are preserved
or repaired. The dissection of the cartilage can be done
supraperichondrial or subperichondreal depending on the
thickness of the soft tissue and the strength of the cartilage.
For a thin, soft-tissue patient, regardless of the cartilage
characteristics a total subperichondral and subperiosteal dis-
section plane is advised.
Patients with loose connective tissue, thick-soft tissue,
and weak cartilage are most challenging. In theses cases it is
better to do a supraperichondrial dissection il may be favored
as fibrosis is produced which leads to soft-tissue adherence
to the. Weak cartilages are easier to manipulate, reshape with
sutures when dissected with its perichondrium covering it.

11.5 Cartilaginous Vault

Currently, two forms of traditional dorsal preservation are

being performed with either a high septal strip [2] or a low
septal strip [3], being removed from the septum followed by
mobilization of the bony pyramid via osteotomies and either
a pushdown or letdown procedure. If the cartilaginous dor-
sal aesthetic lines are not good, they should not be
preserved.

11.5.1 High Septal Strip Resection (Fig. 11.3)

The high septal strip resection starts approximately 10 mm

cephalic to the ASA at the W point. The cut in made just
below the dorsum while following its contour. Thereafter,
based on the preoperative planning, a lower, second cut is
made, and the intervening cartilaginous strip is removed.
This should be done incrementally in order to avoid over
resection, paying special attention to the WASA-segment.
If needed, limited elevation of the radix mucosa is per-
formed prior to carefully removing a small, subdorsal seg-
ment of perpendicular plate of the ethmoid under the bony
cap, using a small rongeur or bonecutter. Excision is contin-
ued just below the dorsum toward the level of the future
radix osteotomy.
Fig. 11.3 High septal strip removal
11.5.2 Low Septal Strip Resection (Fig. 11.4)
Indications for the low septal strip resection are either mod-
erate to severe septal deviation or tension noses. Slightly
more challenging, but extremely powerful, low strip septal
surgery consists of the following steps:
• A basal, triangular strip resection along the inferior bor-
der of the quadrangular cartilage, starting 1cm posterior
186
Fig. 11.4 Low septal strip removal
to the anterior nasal spine and broadening as one moves
posteriorly.
• A complete vertical septal cut at the bony-cartilaginous
junction of the dorsum.
• If needed, an excision of cartilage or perpendicular plate
under the bony cap area.
• Final resections of quadrangular cartilage after the bony
pyramid lowering, to obtain the desired dorsal height.
• Fixation of the septum to the anterior spine.
In contrast to the high septal strip, a wide septal dissection
and a more significant resection of septum are required.
The movement of the dorsum in a low strip is rotational,
moving down at the midvault and forward and upward more
caudally, thereby straightening the septum and dorsum in
one of the most efficient ways. The rotational movement pre-
vents potential midvault widening as seen in the high strip
B. M. Stubenitsky
Table 11.1 Relative indications for high- and low septal strip
resection
High septal strip resection Low septal strip resection
Straight and slightly deviated septum Deviated septum
1–3 mm lowering >1 mm lowering
Narrow midvault Broad midvault
Small noses Big noses
Tension noses
and raises the supratip area thereby creating tip support
(Table 11.1).
11.6 Bony Pyramid
Wide bony vaults are unsuitable for preservation techniques.
While the cartilaginous vault is preserved, the bony pyramid
can be treated with rhinosculpture techniques using either
rasp, burs, or a piezoelectric device, in combination with
classic osteotomies.
Previous work by Kosins [4] has shown there to be two
types of nasal bony humps: either V- or S-shaped. The
V-shaped bones have a straight-line configuration starting at
the sellion, through the kyphion, toward the rhinion. S-shaped
nasal bones have a triangular configuration with the kyphion
as the high point. It is preferable to convert S-shaped humps,
as much as possible, into V-shaped humps by rasping or by
careful removal of bone at the high point.
There are currently three types of BP lowering described.
11.6.1 BP Type 1—Cap Reduction (Fig. 11.5)
The bone is removed incrementally by rasp or bur, exposing
the underlying cartilaginous vault. This can be combined
with classic osteotomies. It effectively changes the propor-
tions of the dorsum by increasing the amount of exposed car-
tilage while removing excess bone. This maneuver helps to
decrease the convexity/kyphosis of the nasal profile, to create
a more flexible osseocartilaginous joint.
11.6.2 BP Type 2—Cap Lowering (Fig. 11.6)
In this technique described by Ishida [5], the bony cap is
freed from the rest of the bony vault using an osteotome or
saw, but left attached to underlying cartilaginous cap of the
upper lateral cartilage (ULC). Following pushdown of the
released cap, the protruding edges of the nasal bones are then
rasped down to the desired height and width. If needed, clas-
sic osteotomies to narrow the nasal bones can be performed.
11 Prevention and Correction of the Most Common Problems in Preservation Rhinoplasty
Fig. 11.5 BP type 1
11.6.3 BP Type 3—Bony Pyramid Lowering
(Fig. 11.7)
In complete bony pyramid lowering by letdown, pushdown
[2]—or a hybrid technique (in which only the Webster’s tri-
angle is removed), the bony pyramid is lowered, and the lat-
eral walls are inside the pyriform aperture to a variable
degree.
It amounts to transverse osteotomies, a radix osteotomy,
and low-to-low osteotomies. These can be performed by
osteotome, handsaws, or powered microsaws.
Once effectuated, there must be separation of the bony
pyramid from the skull. This is confirmed by gentle horizon-
187
Fig. 11.6 BP type 2
tal mobilization of the pyramid from right to left. Then, the
pyramid is pinched and pushed down to achieve the desired
lowering.
The radix osteotomy in BP type 3 can either function as a
hinge or as the site of a downward displacement of the nasion
area (Table 11.2).
Additional dorsal modifications to optimize the shape of
the dorsum can be applied. These include bony pyramid
remodeling by rasp, ULC shoulder shaves with the scalpel,
hidden spreader grafts (below ULCs), and radix or supratip
onlay grafts.
188 B. M. Stubenitsky

11.7 Tip

Preservation rhinoplasty advances tip surgery even further by

preserving virtually the entire alar cartilage, which enhances
function and reduces potential long-term problems.
Preserving the alar cartilages, and in particular the lateral
crus, is a relatively recent development. The critical steps are
to shape the domal cartilage with sutures, to control the lat-
eral crus with tensioning techniques, and to achieve tip sup-
port with the use of a strut.

11.7.1 Shaping the Dome

The foundation for aesthetic tip surgery with ligament preser-

vation was introduced by Cakir using the polygon concept [6].
Within this concept, the desired domal shape can be obtained
using sutures with or without lateral crural steal. Based on the
preference of the surgeon, either a cranial tip suture [7] or a
more aggressive cephalic dome suture [8] can be used. Both
sutures create domal definition, stiffen and tension the lateral
crura, and evert the caudal border of the lateral crura (Fig. 11.8).

11.7.2 Lateral Crus Control

An attempt should made to preserve the maximal amount of

lateral crural volume, as transection and excision weaken the
alar shape and projection, often leading to long-term prob-
lems. If lateral crural volume needs adjusting, one can choose
a technique that decreases volume while also strengthening
or straightening the lateral crus. The sliding alar cartilage
Fig. 11.7 BP type 3 flap as described by Ozmen [9] and Racy [10] strengthens
the lateral crus by incising the cephalic lateral crus and then
sliding the cephalic portion underneath the remaining strip.
Table 11.2 Relative indications for BP type 1–3
The turn-in flap as modified by Apaydin [11] strengthens and
BP type 1 cap BP type 3 pyramid
straightens the lateral crus by performing a 180° plication of
reduction BP type 2 cap lowering lowering
Bony pyramid Bony pyramid lowering Bony pyramid the cephalic portion underneath the remaining strip.
lowering <2 mm >2 mm lowering >2 mm
Kyphotic hump Kyphotic hump Large nose
Short nasal bones Broad bony cap (with Moderate hump 11.7.3 Supporting the Tip
osteotomies)
Narrow bony cap Deviated bony
(without osteotomies) pyramid
In all cases, either a columellar strut or septal extension graft
Hinge at nasion Lowering at nasion is used. Systematic analysis of the nose and visual planning
of the desired aesthetic outcome guide the decision.
11 Prevention and Correction of the Most Common Problems in Preservation Rhinoplasty 189

a b

New dome
New dome

Postoperative
Postoperative

Fig. 11.8 (a) Cranial tip suture (by Kovacevich) and (b) cephalic dome suture (by Cakir). Courtesey of A Kosins

Table 11.3 Relative indications for tip support 11.9 Early Postoperative Concerns (<3
Columellar strut SEG Month)
Normal STE Thick STE
Strong cartilage Weak cartilage 11.9.1 Dorsal Hump Appearance
Normal projection Underprojection

In the early postoperative period, periosteal or perichondral

A columellar strut is advised in a tip with a thin to normal
skin, adequate strength of the cartilage, and a normal projec-
tion. If a columellar strut is chosen, preservation of ligaments
is crucial to maintain tip support.
A septal extension graft (SEG) is preferred for a thick
STE, weak cartilages, and an underprojected tip. Many varia-
tions on SEG exist and can be used according to preference
(Teostrut, F-Strut, Tacostrut, ANSA banner graft) (Table 11.3).
fibrotic reaction may lead to a pseudohump. Often this can
be treated by taping and/or triamcinolone injections.
11.9.2 Axis Deviation
Early postoperative taping, massage, and pressure may solve
the problem.

11.8 Solving Common Problems 11.10 Late Postoperative Concerns (>3

month)
Despite the best preoperative preparation and planning,
problems will occur. It goes without saying that choosing the Osseocartilaginous vault Tip
correct procedure for the individual case is paramount. In Dorsal hump Loss of tip support
Supratip saddling Tip deviation and asymmetries
order to prevent complications, it is essential to have a clear
Middle third widening Scroll-winding effect
understanding of when to use PR techniques and when to Axis deviation
realize not to use them. Radix step
Luckily, most problems seen in can be easily prevented
and more importantly, easily corrected postoperatively.
190
11.10.1 Osseocartilaginous Vault
11.10.1.1 Dorsal Hump Recurrence (Fig. 11.9)
A recurrence of the hump is the most common problem
encountered in PR. It is due to either insufficient release of
the septal tension at the K area, the LKA and piriform liga-
ments (spring effect), and/or inadequate fixation (spring
effect in high strip or backward rotation in low strip resec-
tion). It can also be caused by ULC asymmetry where one
paraseptal cleft is higher as compared to the other.
In high septal strip resection, rasping of the K area, scor-
ing of subdorsal septum, release of the LKA and piriform
ligaments, and fixation of the mobile osseocartilaginous
vault dorsum to the septum (Teodor stitch) can prevent a
recurrence of the hump. Sometimes, a partial or unilateral
release and excision of the ULC from the septum is neces-
sary to equalize the cartilaginous vault.
In low septal strip resection, a “swinging-door” septo-
plasty with total mobilization of the quadrangular cartilage
from its bony attachments is of the essence. The subdorsal
dissection must release the junction of the quadrangular car-
tilage with the perpendicular plate of the ethmoid and should
be caudally extended to the rhinion.
Once there is no tension left, the quadrangular cartilage
(QC) flap is securely fixed to the anterior nasal spine (ANS)
periosteum in order to prevent relapse. Here too, sometimes
a partial or unilateral release and excision of the ULC from
the septum is necessary to equalize the cartilaginous vault.
a b
Fig. 11.9 From left to right. (a) Preoperative sideview, (b) postoperative sideview with residual hump, and (c) postoperative sideview after rasping
K area and scoring of cartilage
B. M. Stubenitsky
Solving the dorsal hump recurrence
Rasp K area
Release LKA and piriform ligaments (ballerina move)
Release tension cartilaginous vault by scoring, releasing, resecting,
or slicing the ULC (Teoslice)
11.10.1.2 Supratip Saddling (Fig. 11.10)
Supratip saddling can occur in both high- and low septal strip
resection. The incremental resection of distal septum is
essential. In high septal strip resection, saddling can happen
due to over aggressive lowering of WASA segment. In low
strip resection, it is seen due to aggressive resection of the
septum at the anterior nasal spine.
Solving supratip saddling
In high septal strip resection—release of the mobile vault and
suturing the septal mucosa together in the space between the
mobile vault and the septum under the W point to elevate the
supratip area
In low septal strip resection—release of the QC, osteotomies,
additional rotation QC to raise supratip, resecuring in the correct
midline position
Placement of cartilage graft
Filler
11.10.1.3 Middle Third Widening (Fig. 11.11)
The widening of the midvault is a problem that can occur in
both high- and low septal strip resections, at different loca-
tions and due to different mechanisms. In high septal strip
c
11 Prevention and Correction of the Most Common Problems in Preservation Rhinoplasty 191

a b c

Fig. 11.10 From left to right. (a) Preoperative sideview, (b) postoperative sideview with supratip saddling, and (c) postoperative sideview after
placement of filler

a b c

Fig. 11.11 From left to right. (a) Preoperative frontal view, (b) postoperative frontal view with midvault widening, and (c) postoperative frontal
view after release of LKA and partial division of the ULCs from the septum with resection of the excess ULC

resection, widening seen at the junction between septum and
ULC is purely mechanical due to the downward movement
of the dorsum. In low septal strip resection, widening of the
ULC is seen at the caudal border near the piriform aperture
due to the rotational movement of the quadrangular septal
cartilage.
Solving middle third widening
Incomplete incision on one or both sides of the dorsum at the
junction of septum and ULC
Partial division of the ULCs from the septum, with resection of the
excess ULC (if needed)
Excision of the caudal and/or basal edge of the ULC
Release of LKA and piriform ligaments
11.10.1.4 Axis Deviation
Axis deviation is encountered in both high- and low strip sep-
tal resection and is mainly due to inadequate fixation of dor-
sum and septum or residual tension in the cartilaginous vault.
In high septal strip resection, the dorsum must be fixed to
the septum at the K area (Teodor stitch) and more caudally to
prevent lateralization. The latter is done by suturing the sep-
tal mucosa together in the space between the mobile vault
and the septum under the W point (after Cakir).
In low septal strip resection, the septum must be posi-
tioned tensionless, without bowing. Thereafter, it must be
fixed to the ANS in a secure fashion to prevent dislodgement
and deviation of the axis.
192
Solving axis deviation
In high septal strip resection—release of the mobile vault and
resecuring in the correct midline position
In low septal strip resection—release of the QC, if needed inferior
strip resection to alleviate bowing, and resecuring in the correct
midline position
Camouflage by use of hidden spreadergrafts, minced cartilage grafts,
or filler
11.10.2 Radix Step
In BP type 1, complete removal of the bony cap can occa-
sionally lead to an unwanted depression or irregularity at the
nasion, creating the need for camouflage grafts. If seen in DP
type 2 and 3, the cause is more likely due to removal of the
PPE. During surgery, be conservative with the amount of
bony cap or PPE removed. Best is to perform the removal in
small steps, each time checking if the desired result has been
accomplished.
Solving a radix step
Rasping of the step
Microfractures with osteotome above the step to fill the gap
Placement of cartilage graft
Filler
11.10.3 Tip
Unfortunately, the tip often is more susceptible to change
through scaring in the postoperative period than the dorsum.
To minimize change, cartilage resection to be diminished as
much as possible. The use of the sliding alar cartilage flap
and the turn-in flap are great tools in accomplishing this. Tip
support also must be adequate to prevent loss of projection.
Therefore, perhaps indications for the use of SEG should be
increased. Additionally, the relation between the ULC and
LLC has to be evaluated. As a consequence of lowering of
the dorsum by high or low strip resection, a conflict can
occur at the level of the scroll causing internal nasal valve
problems and fullness. Often, resection of ULC, release and
reconstruction of scroll are essential is creating a desirable
result.
11.10.3.1 Loss of Tip Support
Thick skin, weak cartilages, short medial crura, and under-
projection of the tip will all predispose to a postoperative tip
drop. The only adequate solution to this complication is tip
B. M. Stubenitsky
revision with a SEG support with or without the addition of
a projecting tip graft.
11.10.3.2 Tip Deviations and Asymmetries
More frequently seen in the closed approach rhinoplasty.
Prevention of asymmetries can be obtained by minimal car-
tilage excision, carefully and equally placed dome markings
and sutures, control of ULC/LLC relation, and tip support. If
a deviation or asymmetry occurs, the only solution is to redo
the whole tip.
11.10.3.3 Scroll-Winding Effect (After Saban)
Middle third fullness due to excess of cartilaginous scroll
is caused by the overlap of the caudal scroll at the ULC/
LLC junction. It can be prevented or corrected postopera-
tively by direct resection of the proximal scroll area after
lowering of the dorsum. The same effect can be obtained
by caudal ULC excision or by a sliding alar cartilage
flap.
11.11 Conclusions
Preservation rhinoplasty truly has created a paradigm shift
in rhinoplasty. In most patients, the STE as well as the
nasal ligaments can be preserved. Overall, dorsal preserva-
tion is an excellent technique if patients are chosen prop-
erly. No dorsum looks as good as a natural dorsum, and
long-term issues with the middle vault and keystone area
can be avoided. As for the tip, the lateral crura should be
preserved and tensioning techniques should be chosen
over excision.
True mastery comes to those with a clear understanding
of which preservation technique to use for which nose, and
to realize when not to use PR.
11.12 Case 1
11.12.1 Analysis of the Nose
STE: Normal thickness skin
Cartilaginous vault: Strong cartilage, high caudal septum
Bony pyramid: Normal height of radix, V-shaped bony
hump
Tip: Strong cartilages
Function: No breathing issues
11 Prevention and Correction of the Most Common Problems in Preservation Rhinoplasty 193

11.12.2 Visual Planning of the Desired

Aesthetic Outcome

11.12.3 Surgical Technique Used

Low strip septal resection, BP type 3 (bony pyramid lower-

ing), polygon tipplasty (4-mm lateral crural steal, 3-mm
medial crural overlay)
194 B. M. Stubenitsky
11 Prevention and Correction of the Most Common Problems in Preservation Rhinoplasty 195
196 B. M. Stubenitsky

11.13 Case 2 Bony pyramid: Normal height of radix, S-shaped bony

hump
11.13.1 Analysis of the Nose Tip: Medium cartilage strength
Function: No breathing issues
STE: Normal thickness skin
Cartilaginous vault: Strong cartilage, low caudal septum

11.13.2 Visual Planning of the Desired

Aesthetic Outcome

11.13.3 Surgical Technique Used steal, 2-mm medial crural overlay), tip graft (boomerang
graft)
Low strip septal resection, BP type 2 (bony cap lowering
with osteotomies), polygon tipplasty (2-mm lateral crural
11 Prevention and Correction of the Most Common Problems in Preservation Rhinoplasty 197
198 B. M. Stubenitsky
11 Prevention and Correction of the Most Common Problems in Preservation Rhinoplasty 199

11.14 Case 3 Tip: Medium cartilage strength

Function: No breathing issues
11.14.1 Analysis of the Nose

STE: Normal thickness skin 11.14.2 Visual Planning of the Desired

Cartilaginous vault: Strong cartilage, low caudal septum Aesthetic Outcome
Bony pyramid: Normal height of radix, V-shaped short
bony hump
200 B. M. Stubenitsky

11.14.3 Surgical Technique Used

Low strip septal resection, BP type 1 (cap rasping with oste-

otomies), polygon tipplasty (2-mm lateral crural steal, 2-mm
medial crural overlay), minced cartilage on K area
11 Prevention and Correction of the Most Common Problems in Preservation Rhinoplasty 201
202 B. M. Stubenitsky
11 Prevention and Correction of the Most Common Problems in Preservation Rhinoplasty 203

11.15 Case 4 Cartilaginous vault: Weak cartilage, high caudal septum

Bony pyramid: Normal height of radix, V-shaped short
11.15.1 Analysis of the Nose bony hump
Tip: Medium cartilage strength
STE: Thick skin Function: No breathing issues

11.15.2 Visual Planning of the Desired

Aesthetic Outcome

11.15.3 Surgical Technique Used

High strip septal resection, BP type 1 (cap rasping with oste-

otomies), polygon tipplasty (2-mm lateral crural steal, 2-mm
medial crural overlay)
204 B. M. Stubenitsky
11 Prevention and Correction of the Most Common Problems in Preservation Rhinoplasty 205
206 B. M. Stubenitsky

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plasty: a step-by-step guide. Aesthet Surg J. 2014;34(6):941–55.
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Plast Surg. 2014;30(6):681–7.
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