Published online: 2021-03-14

Original Article 45

Indications for Preservation Rhinoplasty:

Avoiding Complications
Mario Bazanelli Junqueira Ferraz, MD1 Guilherme Constante Preis Sella, MD, PhD2

1 Department of Facial Plastic Surgery, Clinica Mario Ferraz, Campinas, Address for correspondence Guilherme Constante Preis Sella, MD,
Brazil PhD, Curso de Medicina, UniCesumar Curso de Medicina, Av Guedner
2 Curso de Medicina, UniCesumar Curso de Medicina, Maringa, 1610, Maringa, PR 87050-390, Brazil
Paraná, Brazil (e-mail: guilherme_sella@yahoo.com.br).

Facial Plast Surg 2021;37:45–52.

Abstract Nasal dorsal preservation surgery was described more than 100 years ago, but recently
has gained prominence. Our objective is to show the surgical technique, the main
indications and counterindications, and the complications. It is a technique that does
not cause the detachment of the upper lateral cartilage (ULC) from the nasal septum,

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and has the main following sequence: preparation of the septum and its resection can
be at different levels (high or low, i.e., SPAR [septum pyramidal adjustment and
repositioning] A or B); preparation of the pyramid; transversal osteotomy; lateral
osteotomy(s); and septopyramidal adjustment. The result is a nose with a lower radix
than the original, a deprojection of the nasal dorsum tending to maintain its original
shape; an increase in the interalar distance (IAD) and enlargement of the nasal middle
⅓; and loss of projection of the nasal tip and roundness of the nostrils. Thus, the ideal
candidate is the one who benefits from such side effects, that is: tension nose, that is,
high radix with projected dorsum, projected anterior nasal septal angle (ANSA), narrow
middle ⅓, narrow IAD, thin nostrils and straight perpendicular plate of the ethmoid
(PPE), and, depending on the characteristics, the deviated nose. The counterindica-
tions are low radix, irregularities in the nasal dorsum, ANSA lower than rhinion, and a
Keywords wide middle ⅓. And the main stigmas are: a nose with a very low radix, middle ⅓
► rhinoplasty enlarged, residual hump, and saddling of the supratip area. Other issues of this
► preservation technique are: the shape of the radix; the need or not to remove PPE; wide dorsum;
rhinoplasty irregular dorsum; ANSA lower than rhinion; weak cartilages; long nasal bone; deviated
► push-down PPE; and obsessive patient. We conclude that this is a great technique for noses with
► SPAR characteristics suitable to it; care must be taken with the stigmas it can cause.

The first description of nasal dorsal reduction using a preser- The traditional nasal dorsal resection technique described
vation technique was performed through endonasal approach by Jacques Joseph9,10 is today the most accomplished one.
in 1899 by Joseph Goodale.1 At the beginning of the twentieth However, to avoid complications such as changes in the
century, other surgeons also contributed to preservation internal nasal valve (INV), open roof, and irregularities in
rhinoplasty (PR) such as Oliver Lothrop2 and Maurice Cottle the dorsum, reconstruction of the middle third is usually
—the latter coined the classic term “push-down.”3,4 Over time, necessary using spreader grafts or flaps.11,12
this work was forgotten in most major American and European The nasal dorsal preservation surgery is an alternative to
centers, with few contemporary surgeons around the world this technique, which recently gained prominence and has
performing it routinely, such as Wilson Dewes,5 Raymond been the topic of many discussions in the main congresses and
Gola,6 Yves Saban,7 and Fausto Úlloa.8 scientific articles.13,14 This technique, if properly indicated,

published online Issue Theme Preservation Rhinoplasty: © 2021. Thieme. All rights reserved. DOI https://doi.org/
March 14, 2021 An Update; Guest Editor: Jose Carlos Thieme Medical Publishers, Inc., 10.1055/s-0041-1725154.
Neves, MD 333 Seventh Avenue, 18th Floor, ISSN 0736-6825.
New York, NY 10001, USA
46 Indications for Preservation Rhinoplasty Ferraz, Sella

keeps the keystone area and nasal valve intact and the aesthetic
line of the nasal dorsum in its natural aspect. On the other hand,
if misindicated may also cause complications such as radix step
or its overdeprojection, hump recurrence, widening of the
middle third, saddle deformity, and functional problems.15,16
Thus, our objective is to show, in a practical way, the surgical
technique, the main indications and counterindications for this
type of surgery, and the complications encountered by the
surgeon to perform or not the preservation of the nasal dorsum.

Surgical Technique
Preservation of the nasal dorsum is a technique that does not
cause the detachment of the upper lateral cartilage (ULC) from
the nasal septum. Authors use the SPAR variants and technique/
philosophy detailed in 2013.5 It can be performed through both
open and closed approach; we follow the principles described
by Cottle3 that initially consist of septal incision and subper-
ichondrial detachment. Afterward, the septum is prepared, and

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its resection can be at different levels in the septum itself (high
or low—SPAR A or B);5,7 the level or septum resection is one
of many differences among types of dorsal preservation
techniques. Fig. 1 Preservation of the nasal dorsum resecting a low strip of septum:
In the first subtype of septal preparation (low-septum SPAR B. SPAR, septum pyramidal adjustment and repositioning.
resection—SPAR B), which is equivalent to the classic descrip-
tion by Cottle,3 the cartilaginous septum (CS) is detached from
both the maxilla corridor and the perpendicular plate of the
ethmoid (PPE); a small triangle is then resected in the highest
portion of the PPE; and the CS is only attached to the ULCs and
is resected in its lower portion (preserving if possible a small
segment below the highest point of the dorsum for fixation),
with the amount of septal excision directly correlating with
the amount of dorsal reduction desired (►Fig. 1).
Another way of preparing quadrangular cartilage is in its
highest (subdorsal) portion, similar as described by several
authors as Gola,6 Ribeiro,17 Saban,7,18,19 Neves,20 and Öztürk.21
A more cartilaginous bone septum strip is resected, and the Fig. 2 Highest septum strip removal, or SPAR A. SPAR, septum
two portions of the septum are fixed together after the nasal pyramidal adjustment and repositioning.
pyramid is lowered (►Fig. 2).
After preparing the septum, the pyramid is then prepared and/or lowering of the nasal pyramid) is performed. Finally,
—adjustment of bone and cartilage irregularities without the septum must be fixed on the anterior nasal spine or
separating the septum from the ULC. Transversal osteotomy periosteum anterior to it (if using a low-septum resection
must be performed at the point where our new radix will be technique). If a high-resection technique is chosen, it must be
created. Saw can be used for this purpose (►Fig. 3A) and the fixed in itself or through transdorsal suture.
fracture is done using 2 or 4 mm osteotome (►Fig. 3B); Tip treatment is done after these steps, as needed. As the
another option is to use drill or piezoelectric instruments, new position of the dorsum changes the conformation and
so it is not necessary to do a skin incision—on the other hand, rotation of the tip, it is always better to start the surgery with
an extended approach must be necessary. modification of the nasal dorsum—performing the cranio-
Lateral osteotomy(s) can be performed after subperiosteal caudal direction. If columellar strut25 or septal extension
detachment by restricted or extended access (full-open), and graft26,27 is chosen for structuring the nasal tip, both can be
they are also performed by osteotome or piezoelectric instru- made from the septum portion removed in preparation, or, if
ment. It is well described in the literature that if the hump is less insufficient, can be harvested as a part of the posterior CS
than 4 mm, the push-down technique is preferred; in cases with that will not harm the shape of the nasal dorsum.
a hump height greater than 4 mm or when a long nasal bone is
identified, the let-down procedure is regarded as more
Preservation Dynamics
suitable.7,8,16,22–24
After these steps, there is complete release of the nasal In general, whenever we preserve the nasal dorsum associated
pyramid from the face, and then the SPAR (lateralization with septum work (PPE and CS), lateral and transverse

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 Indications for Preservation Rhinoplasty Ferraz, Sella 47

Fig. 3 Use of a saw to mark the new radix (A), and the osteotome to perform the transverse fracture (B).

osteotomies, we have a natural and passive behavior of the They are: a nose with a very low radix (►Fig. 5), middle ⅓
nasal dorsum and the nose. It results in a lower radix than the enlarged, residual hump, and saddling of the supratip area.
original, a deprojection of the nasal dorsum tending to main-
tain its original shape (►Fig. 4A and B); an increase in the
Avoiding Complications
interalar distance (IAD) and enlargement of the nasal middle ⅓
(►Fig. 4C and D); and loss of projection of the nasal tip and The best way to avoid stigma is a proper indication (►Fig. 6).

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roundness of the nostrils (►Fig. 4E and F)—we call these the In addition to the ones indicated above, we will address some
side effects of the technique. more issues present in the literature.
When fixing the septum to the corridor or the upper
segment (in the case of high PR), the dorsum has a rectifica- S-Shape versus V-Shape Radix
tion limit but maintains its elasticity and the tendency to The S-shape radix shows nothing more than a large irregularity,
return to its original position. Thus, the most important a significant and abrupt gap between the radix and the nasal
aspect of PR is the original shape of the dorsum, since it dorsum. The more abrupt and the greater the gap, the greater
will remain, but in a different position from the initial one. the chance of having a step between the dorsum and the radix
and the greater the probability of having resulting irregularities
and the need to fill this radix with grafts as a rescue. We avoid
Indications
PR on every nose with S-shape radix.
As the side effects of the technique are a lower radix, a less Hidden S-shape: Often the soft tissue under tension on
projected dorsum, a wider middle ⅓, an increased IAD, and a the nasal dorsum hides an S-shape radix and we only notice
less projected anterior nasal septal angle (ANSA), the ideal this after the detachment of the nasal dorsum. By decreasing
candidate is the one who benefits from such side effects, that the tension in soft tissues, the radix S-shape reveals itself.
is: tension nose, that is, high radix with projected dorsum,
projected ANSA, narrow middle ⅓, narrow IAD, thin nostrils, The Radix
and straight PPE (the latter is one of the most important and Most of the time transverse osteotomy is performed in the
least discussed topics).7,28,29 It is also important to empha- region of the radix; and, in any PR, the radix height is
size that this technique can only be applied to noses that have maintained by the PPE. In cases where surgery is needed
never been operated before. at the PPE, it is weakened or partially removed; as a conse-
quence, the radix loses its greatest support. In this way, PR is
not indicated in patients who need surgery in PPE. In patients
Counterindications
with PPE deviations, a correction of the deviated PPE may
The most important and almost absolute counterindications lead to a loss of control of the radix height (►Fig. 7).
are low radix, irregularities in the nasal dorsum, ANSA lower Although there may be tricks and techniques to keep the
than rhinion, and a wide middle ⅓. We call it almost absolute radix stable, such as not detaching the radix periosteum or
because any nose can be converted to a preservation surgery making perforated fractures, we do not consider it safe enough
depending on the effort and the risk put into this action. to depend on parts of the periosteum to keep the radix in
Being possible to do it does not mean that it is the most position. Loss of control of the radix height can be desperate
suitable, plausible, or direct way to do. Ending a preservation during a PR; if this occurs, there will be a need for grafting in
surgery with radix and supratip grafts is not the best this region with its possible complications.
example of “preserving.”
Wide Dorsum
A dorsum that is already wide in its middle ⅓ will not
PR Complications
become narrower with PR. On the other hand, when lowering
As with resective surgery, preservation of the nasal dorsum its projection, the tendency is to widen or at least remain
can lead to stigmas characteristic of the technique when not with the same width. For this reason, we indicate PR in
indicated or performed correctly or with due care in details. patients in whom an enlargement is desirable.

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48 Indications for Preservation Rhinoplasty Ferraz, Sella

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Fig. 4 Pre- (left) and postoperative (right) photos after dorsal preservation rhinoplasty: the dorsum keeps its shape but in a lower position (A, B). Increase in
the interalar distance and enlargement of the nasal middle ⅓ (C, D). Loss of projection of the nasal tip and roundness of the nostrils (E, F).

Irregular Dorsum (►Fig. 8). If after these maneuvers we do not get a regular
There are some irregularities that can be corrected with rasp, dorsum, it is advisable not to progress to PR.
drill, and/or piezoelectric instruments by osteoplasty in its
bone component. In cases of irregularities in cartilaginous ANSA Lower Than Rhinion
component, we often use the monopolar cautery in the “cut This is a very frequent situation. Most of the low PR (e.g.,
mode” and are able to model the cartilaginous dorsum Cottle or SPAR B) reduce projection of the ANSA region or at

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 Indications for Preservation Rhinoplasty Ferraz, Sella 49

Fig. 5 Pre- and postoperative dorsal preservation surgery (SPAR B) photos showing a very low radix. SPAR, septum pyramidal adjustment and
repositioning.

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Fig. 7 A profile photo showing low radix and under-projected nose;
this is a situation when preservation rhinoplasty should be avoided.

Fig. 6 Decision flowchart in a rhinoplasty. ANSA, anterior nasal septal ⅓ enlarged, retropositioning of the maxilla, and thick skin.
angle; INV, internal nasal valve; PPE, perpendicular plate of the ethmoid; These are poor candidates for PR.
SPAR, septum pyramidal adjustment and repositioning.

Long Nasal Bone

During PR we can have two well-known situations: Push-
least leave it in the same projection. The probability that a Down and Let-Down. In the push-down, the pyramid is
nose with ANSA lower than rhinion will remain with pushed into the nasal cavity; there is an infracture in the
residual hump is high. Another possibility in this patient region of the lateral osteotomy and the nasal bone (and part
is grafting supratip region, with a consequent chance of of the ascending maxillary branch) is medialized. As the ULCs
irregularity in the long term. For this reason, we avoid PR in are connected to the bony part of the nasal pyramid, they are
these patients (►Fig. 9). medialized resulting in a decrease in the angle between
the septum and ULC, impacting the intrinsic component of
Weak Cartilage the INV. The longer the bone part of the pyramid, the greater
It is characteristic of many ethnicities that nasal cartilages the impact. Consequently, we indicate push-down on short-
are more fragile and offer less support to the nose, such as bone noses and let-down on medium or long bones.
Latin (mixed race), Mulatto, Negroid, and Asian noses. A
structurally weak septal cartilage can lead to loss of support Deviated PPE
causing saddle nose or deviations. Generally, patients with Almost nothing has been written or said about PPE in PR. The
these noses have concomitantly, usually, a low radix, middle junction of PPE with the CS and vomer is one of the places

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50 Indications for Preservation Rhinoplasty Ferraz, Sella

most affected by deviations and, consequently, must be

worked to avoid or correct nasal obstruction. During the
process of correction of deviations in this area, the PPE is
partially or totally removed to release the nasal cavity. PPE is
the main support for the dorsum of the bone and the radix;
failure to observe these situations can lead to a loss of control
of the height of the radix. Patients who have deviations in PPE
and require treatment of these deviations are not suitable
candidates for PR.

Obsessive Patient
This kind of patients does not accept small humps or convex-
ity in the dorsum and can be annoyed by minimal changes,
making them not good candidates for this technique. A very
common complication that can occur in PR is the residual
hump (►Fig. 10); there are authors who show a rate that
varies from 3.4,7 to 12,30 to 15%.16 If a small residual hump
occurs, it can be easily removed with local anesthesia and a
simple rasp by a closed approach; if it is a large hump, the

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most appropriate option is a surgical revision.

Fig. 8 Use of monopolar cautery during surgery to correct small

Expanding PR Indications
irregularities in the cartilaginous dorsum. In a large number of patients, it is possible to perform
maneuvers to prepare the nose so that it has a lower chance
of PR stigmas. These maneuvers can range from small adjust-
ments such as restricted osteoplasty in the osteocartilaginous
transition to large maneuvers for complete remodeling of the
nasal pyramid before and after PR.

• Full-open approach and complete remodeling of the nasal

pyramid with drills or piezoelectric instruments from
pyriform aperture to wear of the bone pyramid.
• Lateral split and ballerina (►Fig. 11): Detachment of the
lateral portion of keystone area leaving only the central
portion connected to the nasal bone, as already described
in the literature.19–21
• Onlay graft in radix or supratip area.
Fig. 9 This is another situation when preservation rhinoplasty should
be avoided: anterior nasal septal angle lower than the rhinion.

Fig. 10 Pre- and postoperative photos of a preservation rhinoplasty showing residual hump.

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 Indications for Preservation Rhinoplasty Ferraz, Sella 51

We do not recommend these more aggressive maneuvers

for the following reasons:

• If they are really necessary, perhaps the patient is not the

best candidate for PR and can benefit from a structured
technique that in these conditions seems to be less
aggressive since it will have less detachment and less
instability.
• In case of revision surgery, where there is a need for
opening the nasal roof, we will find a complete separation
between bone and cartilaginous pyramid and between
PPE and CS. In this way, we will have, unlike what is
propagated (that revision in PR is easier), a highly complex
surgery with an unstable dorsum.

Deviated Nose
According to a line that runs from the midpoint between the
eyes to the summit of Cupid’s bow, we classify the deviated
nose in two groups:

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1. K area deviated from the central axis.
2. K area not deviated from the central axis.

No technique is as effective and straightforward in moving

the K area laterally as the PR and can be applied in both
Fig. 11 Detaching upper lateral cartilage from the nasal bone in the
situations, being obviously more powerful in the case of the
keystone area. deviated K area from the central axis.

Fig. 12 Decision-making in the deviated nose. SPAR, septum pyramidal adjustment and repositioning.

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52 Indications for Preservation Rhinoplasty Ferraz, Sella

We must remember that as the shape of the dorsum will 8 Úlloa F. Let Down Technique. 2011. https://www.rhinoplastyarch-
remain, a severe deviation of the nasal axis as “C” or “S” form ive.com/articles/bony-vault-nasal-dorsum/let-down-technique.
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14 Lee J, Abdul-Hamed S, Kazei D, Toriumi D, Lin SJ. The first
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Conclusion early- to mid-20th centuries and relevance today. Ear Nose Throat
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Tuncel U, Aydogdu O. The probable reasons for dorsal hump

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16
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