Dorsal Hump Reduction Based on the New Ethmoidal Point Classification: A Clinical and Radiological Study of the Keystone Area in 138 Patients

Understanding Dorsal Preservation Rhinoplasty: Anatomy and Biomechanics

Application of dorsal preservation rhinoplasty techniques requires an in-depth understanding of the underlying nasal anatomy. A key tenant of dorsal preservation rhinoplasty is maintaining the relationship between the upper lateral cartilages and nasal bones. In this study, the authors discuss the pertinent nasal anatomy, surgical approaches to the nasal septum and bony pyramid, management of blocking points, and fixation of the lowered dorsum. They also introduce a new dorsal fixation method termed the "dorsal osseocartilaginous horizontal mattress" suture developed by the senior author for application in cases of combined structural and open dorsal preservation rhinoplasty.

Spare Roof Technique A and B - A Step-by-step Guide to Avoid Suboptimal Outcomes

Dorsal Preservation Rhinoplasty encompasses various techniques that share the common goal of achieving a straight and smooth dorsum without the need for middle-third reconstruction using flaps or grafts. The Spare Roof Technique, classified as a surface technique, has shown consistent and reliable results backed by rigorous scientific evaluation, with its variations thoroughly tested over time. The authors provide a detailed overview of the current state-of-the-art in this technique as practiced globally, incorporating insights from over a decade of experience and refinement.

Hybrid Dorsal Preservation Techniques

The term "Hybrid" has recently come to designate an specific intermediate entity between Preservation and Structural techniques, with the tip being done structural and the dorsum by preservation. This limits the indications to patients who present aesthetically pleasant dorsums, which can thus be fully preserved. In my "modified dorsal split" approach, the dorsum is split anatomically and reshaped appropriately. I preserve the Dorsal Keystone Area while the middle vault is reshaped and adjusted, followed by a cartilaginous push down or a full symmetric or asymmetric let down. Thus, patient indications are significantly expanded.

Subdorsal Flaps in Dorsal Preservation

In dorsal preservation rhinoplasty, resection of the septum is required to remove a hump. Modifications to the original immediate subdorsal strip excision of Goodale and Lothrop include the following sub-dorsal approaches: modified subdorsal strip method, Z-flap, intermediate septal strip, and Tetris concept. All of these subdorsal flap techniques are similar in using carefully designed septal cuts to excise and/or mobilize a dorsal cartilaginous segment for dorsal flexion and lowering. The growing body of outcomes data suggests satisfactory results and limitations of each of these septal approaches.

NOVA Spare Roof Technique and the Sail Maneuver-Vectorial Rhinoplasty Without Lateral Keystone Area Disarticulation

The authors propose a novel variation of the Spare Roof Technique for Preservation Rhinoplasty-"NOVA Spare Roof Technique." This modification involves a newly developed maneuver, the Sail Maneuver, which is a simple rhinoplasty technique for treating dorsal humps without lateral keystone area disarticulation. The authors find that this rhinoplasty strategy can be a precise surgery for a smooth and natural dorsum with a natural transition on the dorsal keystone area and, simultaneously, can improve the dorsal aesthetic lines (DALs). This approach is based on the new "dorsal vectorial concept" in rhinoplasty. A patient with a dorsal hump on a profile view can have a significant impact on the vector of the DALs. This rhinoplasty approach addresses that problem with a mathematical rationale.

Strategic Decision-Making in Preservation Rhinoplasty: Key Considerations for Optimal Outcomes

AIM AND BACKGROUND

 Candidacy for dorsal preservation rhinoplasty (DPR) techniques is determined by a combination of preoperative nasal analysis and intraoperative assessment of the bony vault and septum. Classic ideal candidates have a pleasing frontal aesthetic, shorter nasal bones, bony cap at or cephalic to the rhinion, straight and appropriately narrow dorsal aesthetic lines (DALs), and a small to medium-sized hump.

CURRENT AND FUTURE DEVELOPMENT

 Alongside the growing popularity of DPR in recent years there have been numerous new methods described for approaching the bony vault and septum that expand both the definition of dorsal preservation and its potential indications. These techniques expand DPR candidacy to the crooked nose, S-shaped hump, wide or irregular DALs, and deviated caudal septum.

CONCLUSION AND CLINICAL RELEVANCE

 The decision toward choosing a dorsal preservation approach is nuanced, surgeon-dependent, and may be less obvious with these new modifications. Classical or modified DPR, when executed well in appropriate candidates, is an excellent method to achieve a natural reduction of the dorsal profile.

Dorsal Preservation Rhinoplasty-the Perspective of "Preservers" Versus "Structural" Surgeons

The objective of this study was to describe the surgeons who have incorporated dorsal preservation (DP) into their practice and their techniques. An anonymous form reviewed by the Evidence-Based Rhinoplasty Research Group board was shared on its Telegram group. The study population was divided into three groups based on their answers: "Preservers," "Mainly Structural," and "Structural exclusively." This study included the answers of 145 worldwide surgeons. DP was more common among plastic surgeons than otolaryngologists/facial plastic surgeons; DP techniques were mostly preferred by surgeons with 10-20 years of experience, while structural techniques were mostly preferred by surgeons with > 20 years of experience; 50.8% of the surgeons who prefer DP techniques use it in more than 90% of primaries; surface techniques (ST) have been more used, mainly by surgeons who prefer structural techniques (p < 0.001). ST were considered more stable (p < 0.001), more predictable (p < 0.001), and shorter learning curve (p < 0.001). Many surgeons using DP still perform structural rhinoplasty. The most cited concern was hump persistence/recurrence. DP rhinoplasty is gaining acceptance, and ST are favored for their perceived short learning curve, stability, and predictability. However, concerns about hump recurrence cause some to continue using structural methods alongside DP.

Dorsal Preservation Rhinoplasty Using a Ferreira-Nakamura Spare Roof Technique B Highlighting the Low Septal Cartilage Strip

Dorsal preservation rhinoplasty techniques can be surface or foundation techniques and respect the philosophy of preserving the osteocartilaginous nasal vault. A spare roof technique (SRT) aims to preserve the upper lateral cartilages through surface techniques. In tension noses with considerable caudal septum deviations, the septal can be repositioned after a low strip of septal cartilage is removed, and the SRT-B is used to reduce the osteocartilaginous hump. This inclusion of the low septal cartilage strip in the SRT-B rhinoplasty is termed as SRT-B3 and builds upon the previously reported philosophy advocated in SRT-A and SRT-B. Correction of moderate deviations of the nasal axis and/or the caudal septum can be addressed with this modification.

Nasal Dorsum Anatomy of Major Different Ethnicities-Surgical Implications: A Multicenter Radiologic Study

BACKGROUND

The heterogeneity of nasal features across different racial and ethnic groups is evident. This large-scale multicenter study was performed to evaluate the dorsal keystone area and its relation to superficial nasal anatomy through computed tomography (CT) scans.

METHODS

Six populations were included: South Caucasian, Middle Eastern, Black South African, Eastern Asian, Mestizo, and Eastern European. Each center obtained CT scans performed between January of 2020 and December of 2022 from patients presenting a nasal hump and from an age- and sex-matched control group. Osteocartilaginous measurements in relation to ethmoidal point and to rhinion, as well as their relation to superficial nasal anatomy, were collected from nasal CT scans in midsagittal view. These were compared between populations and, in each center, between patient groups (nasal hump versus no nasal hump).

RESULTS

The study population included 600 patients (254 with nasal hump) with a mean age of 33.98 years (range, 18 to 59 years); 55.6% were women. Average distances from the ethmoidal point were 10.1 ± 3.5 mm to the rhinion and 1.68 ± 0.23 mm to the beginning point of the nasal hump. In 96% of cases, the ethmoidal point was cranial or no more than 5 mm caudal to the beginning of the nasal hump. S-shaped nasal bones were associated with nasal hump, but angulation (kyphion angle) did not correlate with nasal hump height.

CONCLUSIONS

In most patients, the nasal hump has no ethmoid bone underneath it, and the apex is located over the septal cartilage. The ethmoidal point is a reliable landmark and should be considered when evaluating established and new preservation and structural rhinoplasty approaches.

Preservation Rhinoplasty by the Ones Who Do It: A Worldwide Survey

Dorsal preservation (DP) rhinoplasty techniques, including surface techniques (STs) and foundation techniques (FTs) have garnered significant attention internationally over the past few years. The practice patterns and opinions from 117 of these surgeons were surveyed from a cohort of these surgeons who participate in an online Evidence-Based Rhinoplasty Research Group. The findings of the survey are merely a snapshot of the international rhinoplasty community's practices, yet did capture data from surgeons from a diverse geographic, years of experience, and training background. STs were most used for the bone changes, and the high-strip technique was preferred for the cartilaginous septal surgery. STs are mostly performed by younger surgeons (<10 years of experience), whereas FTs were more common in older surgeons (10-30 years of experience). STs were considered more stable (p < 0.001), more predictable (p < 0.001), and associate with a shorter learning curve (p = 0.015). Revision surgery rates were not different. Regarding why many surgeons using DP still perform structural rhinoplasty, the most cited concern was hump persistence/recurrence. In summary, among surgeons using DP rhinoplasty techniques, the majority perform DP in over half of their primary rhinoplasty surgeries, highlighting the importance of updating educational programs in medical training, conferences, and courses.

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

SUMMARY

Preservation rhinoplasty is a growing area of interest among rhinoplasty surgeons. Dorsal preservation-a tenet of preservation rhinoplasty-is predicated on maintaining the integrity of the nasal midvault and effecting aesthetic change through alterations to the bony nasal pyramid and underlying septum. A challenge that is unique to dorsal preservation is the phenomenon of hump recurrence, because of the existence of anatomical blocking points. Blocking points are resistant tensile forces that either impede dorsal lowering intraoperatively or push the dorsum back to its native convexity over time. Five anatomical blocking points have previously been described, which the authors expand on and include an additional two. The seven anatomical blocking points are as follows: the cartilaginous septum, the perpendicular plate of the ethmoid, the lateral osteotomy site, the Webster triangle, the internal mucoperiosteum of the maxillary bone, the medial canthal ligament, and the lateral keystone area. It is critical that the surgeon be aware of the particular blocking points relevant to his or her chosen technique, and to appropriately and methodically address them to ensure consistent long-term results.

Advanced Preservation Rhinoplasty in the Era of Osteoplasty and Chondroplasty: How Have We Moved Beyond the Cottle Technique?

BACKGROUND

Over the last 10 years, many new papers on innovative strategies from different surgeons worldwide have elevated the philosophy of preservation rhinoplasty (PR) to a different level: advanced preservation rhinoplasty.

OBJECTIVES

The goal of this article was to illustrate how 4 experienced surgeons approach important anatomical and functional issues related to PR.

METHODS

M.G.F., A.M.K., B.S., and D.M.T. were asked about how they approach classical problems and relative contraindications for dorsal PR with different modern advanced preservation rhinoplasty techniques.

RESULTS

The answers of each surgeon make clear a new reality in dorsal PR that did not exist in the recent past. These advances in dorsal PR techniques are due to many surgeons' contributions, leading this practice to a different level: advanced preservation rhinoplasty.

CONCLUSIONS

Dorsal preservation is making a dramatic resurgence and is fueled by the many very talented surgeons who are demonstrating outstanding outcomes with preservation techniques. The authors believe that this trend will continue, and a mutual collaboration between structuralists and preservationists going forward will continue to advance rhinoplasty as a specialty.

Modified Dorsal Split Preservation Hybrid Rhinoplasty for Cartilaginous Pushdown and Full Letdown Applications: A PROM-Based Review of 100 Consecutive Cases

Splitting the middle vault on an anatomical plane along the "Septal T" allows a new hybrid perspective on the many modifications of "surface" preservation techniques. The "dorsal split preservation" concept can be applied both to cartilaginous pushdown as well as to full letdown techniques. The dorsal keystone area is maintained, while the middle vault is reshaped. The septum is addressed by conventional L strut septoplasty. Precise direct suture fixation of the high-middle strip is easily accomplished after flexing the osseous-chondral junction at the K area. Specific technical points are described to allow exact and stable configuration of the dorsum.A retrospective analysis on 100 consecutive patients demonstrated aesthetic and functional improvement.

Septal Advancement Flap: Preserving, Restructuring, and Reshaping the Nasal Tip Contour with a Novel Flap

Tip support and the tip's exact final position-rotation and projection-remain a main concern among rhinoplasty surgeons. The available options can be classified into two groups: septal extension graft (variations including tongue-in-groove) and columellar strut (with all its variations). There is still the possibility of nasal tip ligament(s) preservation-namely the interdomal ligament, when anchoraged cephalically to the anterior septal angle preserving the tip support. Including this panoply of solutions, the author has identified some challenges with insufficient outcome. Based on engineering concepts, a novel septal flap was developed to facilitate a preferred tip position and shape. The septal advancement flap (SAF) is a rotational-advancement flap of the superior and caudal aspects of the cartilaginous septum that enables the surgeon to create stable and accurate tip shape and position. This flap was designed following the spare roof technique B sequence, although it can be completed along with any technique of structure or preservation rhinoplasty.

The RhinoCEROS Guidelines: A Practical Tool for Reporting Nasal Anatomy on Computed Tomography Pertaining to Rhinoplasty

Cone-beam computed tomography (CT) is gaining popularity worldwide due to an increasingly diffuse and affordable in-office availability. It is becoming more commonplace for rhinoplasty surgeons to utilize this imaging as tool for preoperative assessment; however, there is inconsistency among radiologists commenting on specific structures of the nose or nasal cavity as there is currently no standardized reporting protocol. The goal of this article is to present clear guidelines for radiologists to report relevant nasal anatomy in the context of preoperative rhinoplasty evaluation. We have proposed the RhinoCEROS Guidelines, which stands for: Rhinoplasty Cephalometric Evaluation for Radiologic pre-Operative Systematization. This guideline highlights the primary aspects of nasal anatomy on CT that affect rhinoplasty outcomes and will provide radiologists with a straightforward template for reporting this increasingly popular use for CT scan.

Ferreira-Ishida Technique: Spare Roof Technique B. Step-by-Step Guide to Preserving the Bony Cap While Dehumping

SUMMARY

For V-shaped nasal bones, the authors consider that ostectomy of the dorsal keystone area can be avoided, and this has led to the development of a new preservation technique: the spare roof technique B (or Ferreira-Ishida technique), where the bony cap is preserved. It includes six main steps, as follows. Step 1, draw on the surface of the skin the desired dorsal brow-tip aesthetic lines, the pyriform aperture, the rhinion, and the amount of triangular bone that has to be taken out to allow pushing-down the bony cap, and the transversal line in the beginning of the nasal hump. Step 2, release the upper lateral cartilages from the dorsal septum ("high septal strip"). Step 3, take out the amount of dorsal septum necessary to dehump. Step 4, perform the paramedian high parallel osteotomies exactly below the marked brow-tip dorsal aesthetic lines. Then, perform the second group of lower osteotomies, until the E-point, to achieve a triangular shape of bone in each side of the bony cap. Perform the ostectomy of the mentioned triangular areas. Release the lateral keystone area. Perform partial ultrasonic ostectomy endonasally, below the nasal bones, to promote the weakening of the transverse fracture line, in the sagittal plane just above the E-point. Push-down gently the rectangular bony cap with a Luc nasal forceps (19 cm) in a greenstick fashion. Perform lateral traditional osteotomies from high to low to high to narrow the bony bridge as much as is needed. Step 5, perform a regular L-shape Cottle septoplasty (if necessary). Step 6, suture the cartilaginous middle vault (upper lateral cartilages) to the dorsal aspect of the remaining septum.

Computed Tomography Analysis of Nasal Anatomy in Dorsal Preservation Rhinoplasty

BACKGROUND

Subdorsal septal resection and radix osteotomy are distinctive surgical steps in preservation rhinoplasty.

OBJECTIVES

The aim of this study was to evaluate the nasal bone thickness, the level of the septal bony-cartilaginous junction (K area), and the distances of the frontal sinus and skull base from the transverse osteotomy line in the Turkish population by means of conventional computed tomography (CT).

METHODS

A retrospective evaluation was made of 203 consecutive preoperative paranasal CT scans of patients (classified in terms of age and gender) who had undergone rhinoplasty surgery between January 2020 and June 2021. The nasal bone thickness at the medial canthus level, and the distances between the transverse osteotomy line and the K area, the frontal sinus, and the cribriform plate were measured.

RESULTS

The mean measurements were similar in terms of age groups (P = 0.402, P = 0.542, P = 0.134 and P = 0.276 for ages 18-30, 30-40, 40-50, and >50 years, respectively). The mean nasal bone thickness and the distance between the transverse osteotomy line and the K area showed statistical significance (P = 0.001 and P = 0.001, respectively). In both genders, the mean distances between the transverse osteotomy line and the frontal sinus and the cribriform plate were similar (P = 0.921 and P = 0.280, respectively). The nasal bone was thinner and the K area position more cephalic in females.

CONCLUSIONS

CT plays an important role in preoperative planning. The need for resection of the ethmoid perpendicular bone may be greater in males when lowering the dorsal hump, and hence they may be more prone to skull base complications. It is therefore necessary to be more careful in the surgical stage of subdorsal septal excision in males.

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

BACKGROUND

Preservation rhinoplasty (PR) techniques are continuously evolving and many variations of established techniques have been proposed since Daniel coined this term in 2018.

OBJECTIVES

The aim of this study was to describe indications for a new "3-level impaction" technique, allowing, in selected cases, a complete profile correction and dorsal reduction without dissection of the dorsal soft tissue envelope (STE).

METHODS

Three hundred and fifty primary closed rhinoplasty cases were retrospectively studied from January 2018 and October 2019. Age, sex, race, technical details, surgical time, and complications were registered. Ninety-five dorsa were reduced and shaped without dissecting the dorsal STE by combining: (1) a swinging-door septoplasty with low septal strip resection, (2) endonasal bony cap mosaic osteotomies, and (3) let-down or push-down operation.

RESULTS

All patients showed a dramatic change in profile height and shape without either dorsal STE dissection or bony cartilage dorsal tissue resection. Mosaic osteotomies converted the dorsal keystone area from S- to V-shaped dorsum, let-down-operation and low septal strip resection enabled impaction, and profile setting was achieved by quadrangular cartilage flap rotation. The average follow-up time was 14 months (range, 12-16 months).

CONCLUSIONS

In selected patients, dorsum can be preserved without STE dissection. By combining multiple endonasal maneuvers it is possible to obtain a dramatic change without dissecting the STE, while simultaneously avoiding any dorsal tissue resection. This method offers a versatile technique in selected patients, which leads to fast recovery and natural results.

LEVEL OF EVIDENCE: 4

The Caucasian Hump: Radiologic Study of the Osteocartilaginous Vault versus Surface Anatomy. Clinical Implications in Structured and Preservation Rhinoplasty

BACKGROUND

The relation between the osteocartilaginous nasal vault and nasal hump characteristics has not been fully investigated.

METHODS

Measurements were collected from computed tomographic nasal scans in the midsagittal plane in adult Caucasian patients seeking rhinoplasty because of nasal hump from January of 2015 to December of 2018. Measurements were compared to those of sex- and age-matched patients not seeking rhinoplasty (control group). Patients with other significant nasal deformities were excluded. The correlations between nasal hump length, height, and osteocartilaginous nasal vault measurements were assessed. Distances from the beginning of the nasal hump to the kyphion and ethmoidal points were measured as well. The location of the nasal hump apex in relation to the keystone area structures was detailed.

RESULTS

The study included 134 Caucasian patients, with 67 presenting nasal hump. The mean patient age was 32.9 years and 69.6 percent were female patients. Nasal hump measured a mean 17 ± 2.7 mm in length and 1.8 mm (range, 1.1 to 3.8 mm) in height. Nasal hump length correlated with nose length and nasal bone length. Nasal hump height correlated with nose length and the angle over the kyphion. In 97 percent of patients, the nasal hump began caudal to the ethmoidal point, and in all patients, the kyphion was underneath the nasal hump. The nasal hump is not a symmetric structure and, in all patients, its apex was situated above the septal cartilage.

CONCLUSIONS

The nasal hump characteristics are mainly attributable to the septal cartilage, and this should be the cornerstone of any dorsal hump reduction strategy. The caudal aspect of the nasal bones contributes to the nasal hump, whereas the posterior ethmoidal plate rarely does.

Preservation Rhinoplasty: Assessment of Anatomical Safe Boundaries on Computed Tomography

BACKGROUND

Nasal dorsum reconstruction is a crucial step of the rhinoplasty. For avoiding complications, techniques that preserve natural dorsal anatomy becomes popular recently. In preservation techniques, ethmoidal bone surgery may take part in the vast majority of defined techniques. Therefore, detailed anatomical knowledge is essential to avoid severe complications, especially cerebrospinal fluid leakage. Based on these, this study aimed to investigate anatomical safe boundaries of preservation techniques based on the measurements on computed tomography.

METHODS

A total of 100 patients who underwent paranasal computed tomography were enrolled in this retrospective study. Five groups were selected based on the age distribution. The distance of the dorsal osteotomy line to cranial base, amount of cartilaginous/bony septum overlaps under nasal bones, cartilaginous/bony septum length anterior and posterior to the nasal hump starting point, and anteroposterior distance of perpendicular plate was measured.

RESULTS

The mean distance between the starting point of the nasal hump and the cribriform plate was 29.5 mm. The amount of bony overlap above the cartilaginous septum was 10.9 mm in females and 10.5 mm in males. The length of septal cartilage posterior to nasal hump was 0 mm in 39 of 100 patients (39%) and the mean value was 2.38 mm in all populations. The mean distance from the starting point of the perpendicular plate to the cribriform plate was 28.17 mm.

CONCLUSIONS

Perpendicular plate may take part in the constitution of the nasal hump. Therefore, delicate surgery with appropriate tools needed for avoiding the risk of skull base injury.

LEVEL OF EVIDENCE

Level of Evidence: 3 (Therapeutic).

A Practical Classification System for Dorsal Preservation Rhinoplasty Techniques

Preservation rhinoplasty in general and dorsal preservation in particular are for sure one of the most attractive topics in modern rhinoplasty and probably the most puzzling concept in this field. Recent major meetings and many other publications have led to an increased interest in these old/new techniques. New strategies for preservation have been developed in recent years, with a broader range of indications than the older push/let down. A simple classification urges to clarify this puzzled semantic concept of "preservation". Is it possible to systematize all new preservation variations in a simple classification? Yes, in this viewpoint, we propose a simple classification that systematizes all kinds of preservation techniques-the old and the new techniques. Classifying preservation will clarify the relative position of all techniques. It will allow comparing procedures from similar families there so to compare outcomes and indications from each technique.

Middle Vault Changes After Humpectomy by Spare Roof Technique Versus Component Dorsal Hump Reduction

Objectives: To compare the effect of two different humpectomy techniques in the internal nasal valve (INV) angle in human anatomic specimens. Methods: Seven human anatomic specimens (14 heminoses) were included. A strip of subdorsal septal cartilage was removed and, in each nose, the right side of the middle roof lied intact over and was sutured to the septal cartilage (spare roof technique [SRT]), whereas in the left side the upper lateral cartilage was folded and sutured to the septal cartilage (component dorsal hump reduction [CDHR]). The INV angle was measured pre- and postoperatively. Results: Mean age of the specimens was 69.86 (60-80) years. Five were female. CDHR resulted in a mean change of +1.71 ± 3.12° (p = 0.197), +0.62 ± 6.89° (p = 0.817) and +6.97 ± 6.84° (p = 0.036) after resection of 2, 4, and 6 mm of septal cartilage, respectively. SRT resulted in a mean change of +1.27 ± 2.37° (p = 0.207), +6.89 ± 1.19° (p < 0.001), and +12.55 ± 1.79° (p < 0.001) after resection of 2, 4, and 6 mm of septal cartilage, respectively. In SRT, the amount of septal cartilage resection presented a significant correlation with change in INV angle (r = 0.813, p < 0.001). Conclusions: In this human anatomic study, SRT significantly increased INV angle.

120 Years of Dorsal Preservation in Rhinoplasty

Dorsal preservation techniques in rhinoplasty are experiencing a renaissance in recent years. New techniques and modifications to existing techniques are being described at an intensifying pace. Dorsal preservation, however, is not a new concept and was first described over 120 years ago. It is timely that we conduct a review of the key techniques and concepts of dorsal preservation in rhinoplasty that had been published over the past 120 years, at a moment in which we consider as a revival of this school of thought.