Dorsal Preservation in Rhinoplasty: A Deviated Nose

The Background

Most patients requesting rhinoplasty will focus on the position and shape of the bridge first, and the form and shape of their nasal tip second. “I don’t like the bump” is a familiar request for rhinoplasty and traditionally a convex profile or a high bridge has been removed by direct excision using rasps, osteotomes, or a scalpel. This type of reduction was popularized by Joseph and has been the mainstay of modern modification of the dorsum.

Reduction of a hump by direct excision creates what is known as an “open roof” that interrupts the dorsal aesthetic lines as well as the intimate relations of the keystone area. These will require a form of reconstruction, either by medializing the nasal bones and remaining upper lateral cartilage, upper lateral turn-in flaps, or spreader grafts, necessitating harvest of cartilage from the nasal septum. This approach creates a problem particularly where the nasal dorsum is originally attractive, as it often results in widening of the aesthetic lines, or disruption with an inverted “V” and a dysfunctional nose due to compromise of the nasal valve. Resection of septal cartilage means that if revision is required, rib grafting is frequently needed to restore the nasal framework. An alternative approach to managing the dorsum is to preserve the existing aesthetic lines by dropping the whole dorsum downwards as a composite structure–dorsal preservation rhinoplasty.

The Indications

• A high dorsum with preexisting pleasing dorsal aesthetic lines (overprojected nose)

• A straight nose but with axis deviation

• Moderate to small dorsal humps

• Cartilaginous dorsal excess with short nasal bones