I recently attended the first American Preservation Rhinoplasty meeting held on Saturday November 16, 2019 in beautiful Newport Beach, California. It was an intensive one day teaching course and live cadaver dissection session to demonstrate to only 50 surgeons from around the world the rhinoplasty technique known as Preservation Rhinoplasty. Our wonderful hosts were Drs. Aaron Kosins, Rollin Daniels, Abdulkadir Goksel (from Turkey), and Dino Elyassnia. It was easily one of the best high-level technical meetings I’ve ever attended. It impressed upon me the need to bring the benefits of Preservation Rhinoplasty to Denver, Colorado.
What is Preservation Rhinoplasty? I think the best way to answer the question is to describe what it is not. It is a technique for nasal reshaping that doesn’t rely on the traditional destructive rhinoplasty techniques normally used in cosmetic nasal surgery. These techniques typically include removal of the nasal hump by excision and multiple floating nasal bone fractures that can create complications later on during healing. The technique was originally used in the late 1800’s, but it has been enjoying a resurgence in popularity over the last several years. There is a big fan base for the procedure amongst surgeons in Europe. Expert rhinoplasty surgeons looking to create a safer operation brought Preservation Rhinoplasty back into the spotlight.
In the graphic above, from a paper by Yves Saban and Rollin Daniels, et al. from 2018 in the Aesthetic Surgery Journal (ASJ), you can see that there are two types of procedures that can be performed with Preservation Rhinoplasty. In a “Push Down” type procedure, the nasal bones are disconnected from the facial skeleton in one single piece, and a strip of cartilage is removed from the septum underneath the nasal bone complex. Removing the strip of cartilage makes a space that the surgeon can push the nasal bones down into, hiding the bony hump without removing it. The nasal bones settle onto a solid surface and there aren’t multiple mobile pieces to shift out of place. In a “Let Down” type procedure, not only is a strip of cartilage removed from the septum, but a triangular sliver of bone is removed from the right and left nasal bones, creating a gap that the nasal bone complex falls down into. With either procedure, the beauty lies in the fact that the nasal bones, while disconnected, are in a single piece and more stable. The photos below from the same ASJ article show the anatomy more clearly.
Who is a good candidate for Preservation Rhinoplasty? Several criteria are evaluated when trying to choose the right candidate for this procedure, as listed below:
- The dorsal nasal lines are already quite good
- The caudal septum in between the nostrils is straight
- The patient has a small to medium sized hump
- There is no need to modify the radix
- The dorsal hump is mostly cartilaginous
- The nasal bones are V-shaped, not S-shaped
Many patients in my rhinoplasty present with this type of anatomy. This makes them good candidates for Preservation Rhinoplasty.
What are the advantages of performing Preservation Rhinoplasty? Because the technique is designed to avoid radical alterations in the nasal anatomy, the nose ends up having a more natural dorsum and intact keystone area. This enhances long-term stability. Using subperichondrial dissection techniques to perform the procedure leads to less long-term thinning of the soft tissue envelope. After the procedure, there is much less bruising and less swelling because it is less destructive. Finally, even if a revision procedure is necessary, it tends to be mild and easier to accomplish.
I am looking forward to providing this procedure to my patients and will be critically evaluating Preservation Rhinoplasty in my rhinoplasty practice. I have recently acquired a textbook by Dr. Baris Cakir from Turkey on using closed techniques to perform Preservation Rhinoplasty. He is a huge proponent of the procedure and I’ve heard him speak several times. His results are outstanding! I look forward to furthering my education…