Preservation rhinoplasty is not just a series of surgical techniques, but rather a fundamental approach and philosophy for the entire rhinoplasty operation.
The three basic principles of preservation rhinoplasty are preservation of the skin sleeve, dorsum and alar cartilages. The goal is to replace resection with preservation, excision with manipulation. This new approach marks a distinct change from both “resecting rhinoplasty” and “structural rhinoplasty”, thus leading to new terminology “preservation rhinoplasty”.
Lothrop first introduced the concept of dorsal preservation in nasal surgery in 1914. He demonstrated a good aesthetic and functional result in one case of tension nose. His technique consisted of nasal impaction using basic steps, resection of high strip of septal cartilage and perpendicular plate of ethmoid bone, a triangular bony resection of the frontal process of maxilla, and direct percutaneous osteotomy of the radix.
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Cottle et al. described the push down technique later in 1946, in which the nasal dorsum continuity was preserved by impaction of the bony cartilaginous hump around the keystone area. This technique helped to prevent collapse of upper lateral cartilages and closure of the internal nasal valve. In addition, the rotation of the quadrangular septal cartilage was essential, but a difficult step.
Drumheller in his review of Cottle’s technique reassessed the basic push down technique (PDO) by adding a bony wedge resection from the frontal process of maxillary bone, thus allowing the nasal pyramid to desend freely. This modification became known as the let down operation (LDO).
In 1989, Gola refind the concept of lowering the bony- cartilaginous dorsum simply by removing a strip of nasal septum below the nasal dorsum.
While the results were generally good to excellent, dorsal preservation techniques were gradually abandoned foe three reasons. First, the classic Cottle PDO involved complex septal surgery, especially in the pre-endoscopic era. Secondly, the techniques were not versatile enough to be used in wide range of cases. Thirdly, the open approach offered greater visibility, more accurate control of structures, and facilitated teaching.
It is fundamental to understand the difference between resection, destruction and reduction. Destruction involves the need to rebuild anatomy, while reducing means to modify the structure without destroying the anatomy. As said by Rollin Daniel in his editorial entitled “the preservation rhinoplasty-the next rhinoplasty revolution” (Daniel 2018)
We must have clear concepts which progress from anatomy to the understanding of three-dimensional structure, the comprehension of healing process, the concept of dissection based on high level of manual dexterity and a clear understanding of artistic/aesthetic concepts.
There are five commandments for preservation rhinoplasty, subperichondrial-subperiosteal dissection, maximal soft tissue preservation, wide dissection, bloodless field, and restoring what has been damaged and close dead space.
It is essential to have a good understanding of the macro and micro- anatomy of the nose. Without this knowledge, it is impossible to achieve a good result. The nose is a complex structure with numerous anatomical variations in each single tissue of which it is composed, bone, cartilages, muscles, fatty tissue, skin, ligaments, mucosa, etc. understanding the relationships between these structures and how they are articulated among themselves in a static and dynamic way is of fundamental importance.
Much in the same way, the micro-details make a difference. For example, if we take into consideration the cartilaginous vault one will notice how it has a supraseptal groove (Daniel, Palhazi2018) usually filled with SMAS. In the classic dorsum reconstruction techniques such as spreader grafts or flaps this detail is not considered. In PDO or LDO we directly skip the dorsal reconstructive phase, as the dorsum will be intact, and therefore all the anatomical details necessary to obtain a good result are already there.
To obtain a stable and lasting result, it is essential that the operated nose is well structured and that the dead spaces have been closed. The more the dead space is left, the more you will stimulate fibroblast activity and therefore the risk of fibrosis and post-operative deformities will increase. In fact, the scarring processes are able to change the nose over time if these two aspects are not considered.
Those who employ destructive techniques are forced to reconstruct the nasal structure with grafts to avoid the classic stigmata of rhinoplasty surgery (deviations, inverted V deformity, bone callus, supratip deformity, tip collapse, …). This kind of approach produces good aesthetic results, but sacrifices the elasticity of the nose. The philosophy of preservation minimizes the destruction of the anatomy, and therefore also the scarring processes are reduced to a minimum. This means offering our patients a more predictive result with a reduced complication rate.
The philosophy of preservation also includes maximum respect for the soft tissues of the nose and not only of the osteocartilaginous tissues. It is necessary to become an expert of dissection in the subperichondrial-subperiosteal plane. There are two ingredients without which it is impossible to perform this technique correctly; good-manual skills and microsurgical instrumentation.
Once a push- or let-down procedure has been performed, what happens to the dorsum and nasal bones as described by Saban et al. is that a chondro-osseous joint if formed (Saban et al. 2018). Essentially, the osteocartilaginous vault flattens at the keystone junction, and the hump disappears.
