Guidelines for Dorsum Preservation in Primary Rhinoplasty

The multiplication of scientific articles related to the fast-growing interest in preservation rhinoplasty (PR) may lead to confusion in the decision-making process, thus requiring a need for guidelines through a focus on benefit-risk ratio and revisions. This study analyzes a 352 consecutive primary rhinoplasties series during a 3 year (2016 to 2019) period with 1-year follow-up. The evaluation of the most appropriate procedure to the patient's nasal anatomy and expectations requires to correlate (1) a convenient classification of nasal profile lines; (2) a review of the dorsum preservation techniques (DP) classified as: full DP, DP+resurfacing, bony cartilaginous disarticulation, and finally traditional rhinoplasty; (3) the role of septoplasties, subdividing this series in two main groups; (4) analyzing the revisions in the different subgroups and to the literature. Thirty-five revisions (9.94%) were done. Correlations between profile lines, surgical procedures, and revisions show (1) 129 straight noses underwent full DP in 88 cases with 5.68% revisions; however, DP+ hump resurfacing in 32 patients with no revision. (2) Among 71 tension noses, 33 underwent full DP with 6 revisions (18.18%), while 32 patients had bony cap resurfacing, 1 revision (3.13%). (3) Among 109 kyphotic noses, 64 patients underwent DP+resurfacing with 10 revisions (15.63%); 27 patients had cartilage-only DP with two revisions (7.41%). (4) In the 43 difficult noses group, revisions were done equally in DP+resurfacing and cartilage-only subgroups. Septum stability modifies the correlations, introducing Cottle's septorhinoplasty in the paradigm. The revision rate is jumping x2.50% when a septoplasty is associated with the rhinoplasty. Correlated to the benefit-risk ratio and the revisions, the following guidelines may be suggested in primary rhinoplasty: (1) Straight noses: full DP, (2) tension noses: DP+dorsum resurfacing and/or Cottle's variations, (3) kyphotic noses: cartilage-only DP, and (4) difficult noses: traditional rhinoplasties.