Dorsal Preservation Shows Early Aesthetic Gains Over Conventional Rhinoplasty

Evolution of the Nasal Dorsum in Primary Rhinoplasty

Rhinoplasty remains one of the most frequently performed aesthetic procedures, yet the risk of functional impairment or secondary deformity necessitates precise surgical planning to minimize postoperative harms [1]. Traditional techniques involving the resection of the osseocartilaginous vault (the structural framework of the upper two-thirds of the nose) often require complex midvault reconstruction using spreader grafts or flaps to maintain the patency of the internal nasal valve, which is the narrowest segment of the airway regulating nasal resistance [2, 3]. While autologous cartilage remains the preferred material for these reconstructions, a meta-analysis of 1,233 patients demonstrated that autologous grafts significantly reduce complication rates (RR 0.34; 95% CI: 0.22, 0.52) compared to synthetic silicone prostheses [4]. The search for techniques that minimize structural disruption has led to a resurgence of interest in dorsal preservation, an approach that aims to maintain the integrity of the nasal keystone (the critical junction of the nasal bones and upper lateral cartilages) by repositioning rather than resecting the dorsal anatomy [5, 6]. Recent systematic data indicate that specific preservation methods, such as the spare roof and let-down techniques, provide a mean internal nasal valve angle improvement of 1.43 degrees (p = 0.02), suggesting these methods are functionally viable alternatives to traditional resection [7]. Building on this foundation, a new longitudinal analysis compares the patient-reported outcomes of these two distinct surgical philosophies over a multi-year period to guide clinical decision-making.

Comparing Preservation and Resection in a Seven-Year Cohort

To evaluate the comparative efficacy of two primary surgical strategies for nasal dorsal reduction, researchers conducted a retrospective cohort study yielding Level of Evidence 3 data. The analysis included 377 patients treated between 2017 and 2024. Within this cohort, 178 patients underwent dorsal preservation rhinoplasty (DPR), a technique that maintains the integrity of the nasal bridge by repositioning the existing anatomy. These individuals were compared against 199 patients who received conventional hump reduction (CHR), the traditional method involving the resection of bone and cartilage to achieve the desired profile. To quantify patient-reported outcomes, the study utilized two validated instruments: the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS), a questionnaire used to measure both functional and aesthetic nasal concerns, and visual analog scale (VAS) scores, which allow patients to rate their satisfaction on a continuous spectrum. These assessments were performed at baseline and at 3, 6, 12, and 24 months postoperatively, providing a longitudinal view of the recovery trajectory. By tracking these metrics over a two-year period, the investigators aimed to identify whether the structural preservation inherent in DPR translated into superior long-term aesthetic or functional benefits compared to the more invasive CHR approach, directly informing how surgeons counsel patients on expected recovery timelines.

Early Cosmetic Advantages and Long-Term Convergence

To isolate the specific impact of the surgical technique on patient outcomes, the researchers utilized multivariate linear regression, a statistical method that controls for confounding variables to ensure observed effects are truly attributable to the procedure itself. This analysis adjusted for age, sex, and baseline symptom severity, providing a rigorous comparison between the two cohorts. In the initial unadjusted analyses, DPR demonstrated a measurable advantage in patient satisfaction during the early postoperative phase. Specifically, DPR was associated with lower SCHNOS-C (cosmetic) scores and higher VAS-C (cosmetic) scores at 3 and 6 months postoperatively compared with CHR. While these metrics indicated superior aesthetic perception among DPR patients, the researchers noted that the absolute differences in unadjusted aesthetic scores at 3 and 6 months were modest, suggesting a narrow clinical margin between the two techniques. The statistical significance of these findings shifted when the researchers applied the multivariable adjustment. Under this more stringent model, DPR was independently associated with improved SCHNOS-C scores at 6 months, yet it was not independently associated with improved SCHNOS-C scores at 3 months. This pattern suggests that the aesthetic benefits of preservation may take several months to fully manifest as postoperative edema subsides. However, these early advantages did not persist into the late recovery period. The study found that no significant differences in aesthetic outcomes were observed at 12 or 24 months, indicating a convergence in cosmetic results between DPR and CHR by the one-year mark. Furthermore, the choice of technique did not appear to influence respiratory ease or other physical metrics, as functional outcomes were similar between groups across all time points. For the practicing surgeon, these data suggest that while dorsal preservation may offer slightly accelerated aesthetic refinement, the two-year cosmetic and functional endpoints remain comparable to traditional resection methods.

Divergent Operative Strategies and Clinical Implications

The technical execution of each procedure required distinct secondary maneuvers to address the structural changes inherent to the primary technique. In the cohort of 199 patients receiving CHR, surgeons more frequently utilized techniques to stabilize the middle third of the nose following the resection of the osseocartilaginous vault. Specifically, patients who underwent CHR more frequently underwent midvault reconstruction with spreader grafts or autospreaders, which are longitudinal cartilaginous grafts used to maintain the internal nasal valve and prevent midvault collapse. Additionally, these patients more frequently underwent anterior septal reconstruction (ASR), a procedure to straighten or reinforce the front portion of the nasal septum, and more frequently underwent clocking sutures, specialized stitches used to orient and secure the upper lateral cartilages to the septum. These adjuncts are often necessary in CHR to restore the structural integrity compromised when the nasal roof is removed. In contrast, the 178 patients in the DPR group required a different set of adjunctive procedures to refine the nasal contour while maintaining the original dorsal bridge. The researchers noted that DPR patients frequently underwent supratip, radix, and underlay articulated rim grafting. These techniques involve placing cartilage grafts in the area just above the nasal tip (supratip), the root of the nose (radix), or along the nostril margins (underlay articulated rim grafting) to optimize the transition between the preserved dorsum and the surrounding nasal structures. While these procedural differences highlight the varied technical demands of each approach, the authors emphasize that the findings are associative rather than causal. This distinction is critical for the practicing physician, as it underscores that the choice between preservation and resection should not be based on a perceived universal superiority of one method. Instead, the researchers conclude that patient selection and underlying nasal anatomy must remain the primary guides for surgical technique, ensuring that the chosen maneuver aligns with the specific structural requirements and aesthetic goals of the individual patient.

References

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2. Garefis K, Konstantinidis I, Tsetsos N, Garefis M, Nikolaidis V, Markou K. Role of spreader flaps in primary rhinoplasty, functional and aesthetic outcomes: a systematic review. Rhinology Journal. 2022. doi:10.4193/rhin21.235

3. Migliavacca RDO, Lavinsky‐Wolff M, Friedrich EP, Toledo S, Azeredo AMD, Silva DR. The Role of Spreader Grafts in Reduction Septorhinoplasty: A Randomized Clinical Trial With Quality of Life Assessment. The Laryngoscope. 2025. doi:10.1002/lary.32131

4. Wu C, Yang S, Zheng G, Huang C, Tu J. A systematic review and meta-analysis of the efficacy and complication rates of augmentation rhinoplasty with autologous cartilage and silicone prosthesis. Annals of Palliative Medicine. 2022. doi:10.21037/apm-22-111

5. DeSisto NG, Okland TS, Patel PN, Most SP. State of the Evidence for Preservation Rhinoplasty: A Systematic Review. Facial Plastic Surgery. 2023. doi:10.1055/s-0043-1768654

6. Patel PN, Abdelwahab M, Most SP. A Review and Modification of Dorsal Preservation Rhinoplasty Techniques. Facial Plastic Surgery & Aesthetic Medicine. 2020. doi:10.1089/fpsam.2020.0017

7. Alharthi RS, Alshahrani MA, Rajab RH, et al. Impact of Dorsal Preservation Rhinoplasty on the Internal Nasal Valve. Plastic & Reconstructive Surgery Global Open. 2026. doi:10.1097/gox.0000000000007577