Article published online: 2022-09-23 THIEME Cosmetic: Idea and Innovation 563 Rhinoplasty with Recycled Dorsum Preservation: Technique and Outcomes Carlos A. Rodriguez, MD1 Ali M. Al-Sakkaf, MD2 Mauricio Verbauvede, MD3 1 Department of Plastic Surgery, Hospital Universitari Sant Joan de Address for correspondence Mauricio Verbauvede, MD, Clínica Reus, Tarragona, Spain Verbauvede, Gaztambide 46, Madrid 28015, Spain 2 Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, (e-mail: mauricioverbauvede@gmail.com). Universitat Autònoma Barcelona, Barcelona, Spain 3 Clínica Verbauvede, Madrid, Spain Carlos A. Rodriguez, Department of Plastic Surgery, Hospital Universitari Sant Joan de Reus, Avinguda del Doctor Josep Laporte, 2, Arch Plast Surg 2022;49:563–568. 43204 Reus, Tarragona, Spain (e-mail: carlosrodriguezpacci@gmail.com). Abstract Rhinoplasty is one of the first surgical procedures described with evidence in the history of medicine. At first, these were performed for the reconstruction of traumatic defects caused by punishments, sequels of war, and then it had been reused after suffering from diseases such as syphilis. Many techniques have been developed from the need of aesthetics outcomes in this field. The objective of our work is to describe a modified approach of recycled dorsum Keywords preservation procedure that we have proposed as a safe and reliable technique. ► rhinoplasty In this work, we have showed that this technique has a marked advantage of preserving ► nose the natural tissue with satisfactory postoperative result. We had no functional ► hypertrophy complications up to date. We recommend that every specialist in the field of ► nasal septum rhinoplasty should be able to use it as a reproducible and feasible alternative. Introduction surgical techniques with the instruments used.2 With the advancement of these aesthetic techniques begin The treatment of the nasal dorsum is a subject of continuous the expansion of rhinoplasty around the world debate from the beginning of rhinoplasty until the current performed by many prestigious surgeons. At that period, days, due to the different treatment alternatives. Jakob Levin Joseph introduce the concept of close rhino- The concept of aesthetic rhinoplasty was born at the end plasty, and his technique was based on nonpreservation of the 19th century, introduced by John Roe in 1891 who not approach. only made a meticulous classification according to different In 1934, Aurel Rethi proposed an open approach that ethnic groups, but also described the technique used with allowed a wide anatomical exposure and was considered local anesthesia without the need for general anesthesia in to treat hyperprojected noses through a columellar incision. five patients.1 Without achieving good aesthetic results at that moment, In 1931 Jakob Levin Joseph, published a book that set the technique was forgotten for a few years,3 till then, all the the beginning of cosmetic surgery of the face, classifying procedure were under the concept of nonpreservation until the diverse types of deformities, and describing the the idea of preservation was born. received DOI https://doi.org/ © 2022. The Korean Society of Plastic and Reconstructive Surgeons. December 11, 2021 10.1055/s-0042-1756314. All rights reserved. accepted after revision ISSN 2234-6163. This is an open access article published by Thieme under the terms of the April 18, 2022 Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/ licenses/by-nc-nd/4.0/) Thieme Medical Publishers, Inc., 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA 564 Rhinoplasty with Dorsum Preservation Rodriguez et al. The concept of preserving the nasal dorsum was intro- sequences. During this stage, facial asymmetries and the duced by Goodale, who describes removing the subdorsal effect of the smile on the nose are recorded, where we can cartilage followed by lateral osteotomies.4 Lothrop added plan the surgery precisely even though we use the same bone resections and transverse osteotomies to this tech- technique. The preoperative planning is very important, nique.5 Many authors in France began reporting successful especially in patients with nasal deviations or when we cases with similar techniques and Maurice Cottle in 1946, realize the drop of the nasal tip during smiling, our technique reintroduced the Goodale approach under the concept of could solve these kinds of problems, actually it become the “Push Down.”6 Drumheller and Huizing reestablished Loth- precise indications for those cases. Finally, the simulation rop’s idea of bone resection under the concept of “Let software add more values specially to detect the aforemen- Down.”7,8 Different alternatives were reported by cartilagi- tioned structural problems, the images are recreated to nous resection combined with bone resections but step by evaluate the postoperative changes, and to explain compli- step the concept of the dorsum preservation of the nose was cations, based on real expectations of the results that we can more familiar. offer to patients.10,11 In 1966, Tord Skoog, combined preservation and reduc- tion concepts in a revolutionary idea, thinking to solve the Surgery excessive resections that were made by the Joseph’s original The procedure is performed under general anesthesia. The technique, as well as the asymmetries due to calculation surgery begins with an open rhinoplasty approach. Infiltra- failures.9 tion is performed using lidocaine with epinephrine, which The importance of this reviewed history is to demonstrate allows not only the control of bleeding, but also the hydro- the diversity of the techniques that have been described and dissection of tissues. An open rhinoplasty is performed the importance to know each of them, to include their through a Z-plasty transverse columellar incision.12 Once concepts in our surgical practice. the incision is completed, all planes are selectively dissected. We described in this article a dorsal recycled preservation The dermocartilaginous ligament of Pitanguy is identified, technique based on a modified approach of the original completely dissected, and cut, then left to be repaired for Skoog’s technique, our approach includes four main points: later plasty13 (►Fig. 1). the open access, preparation of the recipient site with Dissection is continued through the inter-wing cartilages preservation of the caudal part of the septal cartilage, fixa- and the soft tissues to have a complete view of the septal tion of the recycled hump like a piece of puzzle to the cartilage. In this way, we can perform an easy, controlled, and recipient site, and the use of modern technologies which is fast dissection of the mucosa through a subperichondral the piezoelectric device. plane. We believe that recycling the hump in rhinoplasty achieves Once the different anatomical elements have been ex- better outcomes especially after surgery when patients touch posed, we proceed to cut the upper part of the septal their dorsum of the nose and do not feel any irregularities, cartilage, preserving the caudal portion which will be useful comparing with nonreplaced hump techniques. as self-support to the tip of the nose as a natural strut.14 Although the definitions of preservation and reduction Considering the needs of reduction, the upper lateral sound opposite we are going to demonstrate that these two cartilages are sectioned in their internal portion and concepts are complementary, transforming rhinoplasty into a safe and reproducible procedure to achieve a natural aesthetic result. Ideas Our approach is based on trying not to remove natural tissues if those could be preserved and recycled, and to maintain a sustainable result over the time. We perform an open approach with dorsal preservation technique which is different from the typical preservation approach like push down or let down, that was done for all patients with or without nasal deviations and for those with nasal drop during smiling effect. Planning After conducting a complete functional and aesthetic evalu- ation, including the preoperative risks, and assessing patients’ expectations and wishes, the informed consent of the patient was completed. Fig. 1 Meticulous dissection of Pitanguy ligament. Dissection and The process continued with photographs which is per- cutting at the distal part of the Pitanguy ligament in open approach formed with a digital camera, with static and dynamic rhinoplasty. Archives of Plastic Surgery Vol. 49 No. 5/2022 © 2022. The Korean Society of Plastic and Reconstructive Surgeons. All rights reserved. Rhinoplasty with Dorsum Preservation Rodriguez et al. 565 Fig. 2 Nose hump remodeling with open approach rhinoplasty. Remodeling the hump to recreate the new dorsum of the nose by Fig. 3 Final osteocartilaginous dorsum insertion and fixation. Fixation of cutting the excess of the nose hump but conserving the periosteum. the reshaped dorsum with polydioxanone (PDS) suture in rhinoplasty. Visualizing all the anatomical elements in open approach to facilitate the insertion of the recycled dorsum. Video 1 continued along the same line, drawing an inverted V, with perpendicular osteotomies along the nasal bones. Once this Recycled dorsal preservation approach. Step by step step is completed, the hump is removed and redesigned for description of the surgical procedure. Online content later use as a “recycling approach” (►Fig. 2). Lateral osteot- including video sequences viewable at: https://www. omies are added to allow an adaptable and stable reduction thieme-connect.com/products/ejournals/html/ to suit the new designed size. 10.1055/s-0042-1756314. Once the different anatomical elements have been ex- posed and the hump is removed, we proceed to cut the upper part of the septal cartilage, preserving the caudal portion which will be useful as self-support to the tip of the nose as a Postoperative Care and Follow-Up natural strut.14 In this way, we prepare the bed to be attached The nose is immobilized with an articulated nasal splint, to the recycled hump in a way resembling a piece of puzzle. which is left for 7 days. This permits us to minimize the future complication like The patients were recommended to return to their daily radix steps or abnormalities on palpations, also conceals any activities as soon as possible without making positive pres- deviation of the upper part of the septum. sure on the nose for at least 40 days. All osteotomies were performed with prior marking and A regular follow-up was done at 1, 2, and 6 months and subsequent section with a piezoelectric device, to have an then yearly followed up. adequate precision and better damage control.15 A quality questionnaire (Likert scale) was given to all At final stage, once the new dorsum is recreated, we make patients at their 6 months postoperative follow-up to assess the fixation with absorbable suture (polydioxanone) to the the sensation, to evaluate the regularity of the dorsum, patient caudal portion of the septal cartilage (strut) and through expectation, and overall satisfaction. We believe that the post- holes that was performed by the piezoelectric device, it is operative sensation is very important to be preserved specially also fixed to the nasal bones and the lateral cartilages. This in open approach rhinoplasty to achieve a natural result and fixation allows stability of the new hump and to avoid the should be included as an essential goal in all rhinoplasties. possibility of any displacement (►Fig. 3). Once the expected result has been achieved, the dermo- Results cartilaginous ligament is reinserted and repositioned in the correct position after treatment of the dorsum, this guaran- From January 2018 to April 2021, we performed a series of tees a true plasty of this anatomical element and conserving 300 dorsal preservation rhinoplasties with the previously the dynamic harmony of the nose. described technique. The intervention was performed more The procedure ends with nasal tip treatment and subse- in women than in men with a ratio of 7:3, the range of quent closure of the skin. We clarify that it is not the purpose patients’ age was between 24 and 28 years. of this article to describe this part of the surgery (the nasal With a period of follow-up of minimally 6 months to tip), although we consider it as an integrative part of any 4 years, there was no reported bone or cartilage resorption or rhinoplasty, because it needs a meticulous description and mobilization of the recycled hump. There were only two exceeds the objective of this work (Supplementary Material patients who reported dissatisfaction with the scar of the ►Video 1, available online only). open approach, three patients had some fibrosis and Archives of Plastic Surgery Vol. 49 No. 5/2022 © 2022. The Korean Society of Plastic and Reconstructive Surgeons. All rights reserved. 566 Rhinoplasty with Dorsum Preservation Rodriguez et al. Table 1 Reported complications after 300 rhinoplasties with ologists, or maxillofacial surgeons. Our modified dorsum preservation rhinoplasty’s main indication is primary reduction rhino- plasties, although it can be used for any degree of hump Complications Total patients no: 300 (%) hypertrophy especially in patients with nasal deviation. Orbital ecchymosis 15 (5) Furthermore, it can be also combined with different techni- Fibrosis 3 (1) ques for nasal tip treatment. Comparing to Skoog technique, who was the first to Scar in satisfaction 2 (0.66) mentioned the preservation of the hump aiming to avoid Nasal obstruction 0 any dorsal irregularities, we have described a modification to Nose deviation 0 his technique by changing and adding other steps that could Radix step 0 give a better end result.9 CSF leakage 0 Hump recurrence 0 Abbreviation: CSF, cerebrospinal fluid. Note: Values are presented as number (%). resolved completely with the infiltration of local corticoid like triamcinolone, and 5% of patients had mild ecchymosis, we consider that these complications were expected for this kind of procedure. We did not have any report of complications such as cerebrospinal fluid leak, radix step, or hump recurrence at long-term follow-up (►Table 1). Additionally, there was no reported lose or severe alter- ation regarding the dorsal skin sensation and around 80% had mild or no alterations at all. In regard to patient’s satisfaction we had the following: extremely satisfied 50%, highly satis- fied 40%, and moderately satisfied only 10% (►Figs. 4 and 5). Example of preoperative photos and the final results of our technique are shown in ►Figs. 6–8. Fig. 5 Patients’ satisfactions postrhinoplasty. Patient results with Discussion this modified technique. Rhinoplasty is currently one of the most frequently per- formed surgical procedures by plastic surgeons, otolaryng- Fig. 6 Patient 1: Before and after rhinoplasty with recycled dorsum Fig. 4 Dorsal skin sensation after rhinoplasty. Patients reported preservation. (A) Frontal view before surgery. (B) Frontal view after result 6 months after surgery. surgery. (C) Lateral view before surgery. (D) Lateral view after surgery. Archives of Plastic Surgery Vol. 49 No. 5/2022 © 2022. The Korean Society of Plastic and Reconstructive Surgeons. All rights reserved. Rhinoplasty with Dorsum Preservation Rodriguez et al. 567 Fig. 7 Patient 2: Before and after rhinoplasty with recycled dorsum Fig. 8 Patient 3: Before and after rhinoplasty with recycled dorsum preservation. (A) Frontal view before surgery. (B) Frontal view after preservation. (A) Frontal view before surgery. (B) Frontal view after surgery. (C) Lateral view before surgery. (D) Lateral view after surgery. surgery. (C) Lateral view before surgery. (D) Lateral view after surgery. The open approach of this modified technique not only We consider that although many rhinoplasty techniques allows us to have a wide anatomical exposure, but also gives were described years ago, the advancement of recent tech- us the additional advantages like comfort in handling of nasal nologies allow us to readapt the old concepts and adjusting tip, reducing skin when is necessary, and to avoid any them to the current days. The described modified technique respiratory complications. is reproducible, offering aesthetic, natural, and functional We consider that the Pitanguy dermocartilaginous liga- results that satisfy patients’ needs. ment is an essential functional element to be preserved. Many authors suggest the simple dissection of this structure Ethical Approval is to improve the drooping of the nasal tip.16 Our concept in This study was performed in accordance with the princi- this point is like any other anatomical structure in our body, ples of the Declaration of Helsinki. the fore mentioned ligament has a function in facial gestures that gives naturalness, its removal leads to lack of nasolabial Patient Consent dynamics, ends with nose without significant mobility, thus The patients provided a written informed consent for the we usually fix it in the correct place. article publication and the use of their images. We cut the osteocartilaginous hump except the caudal part to reduce the hypertrophy and to avoid the drop of the Authors’ Contributions nose, then we recycled this hump as described to recreate a Conceptualization: M.V. Data curation: C.A.R., M.V. For- new dorsum providing a good aesthetic and natural outcome mal analysis: C.A.R., M.V. Methodology: C.A.R., A.M.A.-S., without losing sensitivity, combined with a regular and M.V. Project administration: C.A.R., M.V. Visualization: C. smooth dorsum. The fixation of the recycled hump to the A.R., M.V. Writing - original draft: C.A.R., A.M.A.-S., M.V. specific insertion bed was done to ensure further stability. Writing - review and editing: C.A.R., A.M.A.-S., M.V. Ap- The preservation of the caudal portion of the septal proval of final manuscript: C.A.R., A.M.A.-S., M.V. cartilage offers support not only to the tip of the nose, but also for the fixation of different elements, keeping a solid Conflict of Interest structure that gives the nose sustainability over time. None declared. This technique showed good results without evidence of significant pain, probably because of two main factors: first, due to the damage control steps of the intervention by doing References a meticulous anatomical dissection (the open approach), 1 Roe JO. 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