Dorsal preservation rhinoplasty

Dorsal preservation rhinoplasty is a surgical approach to reshaping the nasal bridge that prioritises maintaining the original anatomical structures of the nasal dorsum — including the continuity of the osseocartilaginous vault, the nasal skin soft tissue envelope, and the soft tissue attachments to cartilage and bone — rather than removing the dorsal hump and reconstructing the bridge from excised remnants. The technique has been in development since the 1990s but underwent a significant resurgence from around 2015 onward, following renewed interest from surgeons in Europe, the United States, and Turkey who codified and refined its principles for a contemporary audience.

Dr Roth attended the inaugural Preservation Rhinoplasty Conference in Nice in 2019 and the Structure and Preservation Rhinoplasty Conference in Istanbul in 2024. He incorporates dorsal preservation techniques into his rhinoplasty practice where they are appropriate to a patient’s specific anatomy and goals, and is happy to discuss these approaches in detail at consultation.

All surgery carries risks — read the full rhinoplasty risks page →

Background — Why Dorsal Preservation Emerged

For most of the twentieth century, the standard approach to a dorsal hump was direct excision: the cartilaginous component was removed with a scalpel, the bony component with a rasp or osteotome, and the resulting “open roof” — a flat, separated gap between the nasal bones — was closed by performing lateral osteotomies to infracture the nasal bones toward the midline. The technique is reliable and well understood, but it carries inherent trade-offs that preservation rhinoplasty was developed to address.

When the dorsal hump is directly excised, the structural and aesthetic continuity of the nasal bridge is disrupted. The osseocartilaginous vault — which functions as the roof of the nasal airway — is opened, requiring deliberate reconstruction. The natural dorsal aesthetic lines, which reflect the three-dimensional curvature of the native nasal skeleton, must be recreated rather than preserved. Spreader grafts are frequently required to maintain the internal nasal valve and prevent middle vault collapse. And the skin soft tissue envelope, once elevated to allow excision, must re-drape over a reconstructed rather than native framework.

Dorsal preservation approaches the same problem differently: rather than removing the hump, the surgeon lowers it — by mobilising the intact dorsal unit and allowing it to settle into a new, lower position. The osseocartilaginous continuity is maintained. The native dorsal aesthetic lines are preserved. The internal nasal valve, supported by intact upper lateral cartilages, does not require graft reconstruction. And the skin re-drapes over the original structures in their new position rather than over a rebuilt skeleton.

Anatomy Relevant to Dorsal Preservation

Understanding dorsal preservation requires familiarity with the anatomical structures of the nasal bridge and their relationships.

The Osseocartilaginous Vault

The nasal dorsum is composed of two distinct structural zones that meet at the keystone area. The upper third of the nose consists of the paired nasal bones, which extend from the nasal root downward and overlap with the upper lateral cartilages below. The middle third is formed by the upper lateral cartilages, which are paired, flat cartilages that spread laterally from the septum and articulate with the nasal bones above and the alar cartilages below. The keystone area — the region where nasal bone overlaps upper lateral cartilage — is a zone of structural importance: it provides stability to the middle vault and is the fulcrum around which dorsal preservation manoeuvres rotate.

The Septum and Its Role

The nasal septum runs centrally through the nose from the nasal spine at the base to the dorsum above. The dorsal septum — the uppermost part of the septal cartilage — is the central pillar of the nasal bridge and is contiguous with both the upper lateral cartilages laterally and the nasal bones above. In conventional hump reduction, the cartilaginous septum is partially resected as part of the dorsal excision. In dorsal preservation, the septum is either left intact or modified subdorsally — beneath the dorsal profile line — so that the continuity of the dorsal septum with the upper lateral cartilages and nasal bones is maintained.

The Dorsal Aesthetic Lines

The dorsal aesthetic lines are the paired curved lines visible on frontal view that run from the medial brow, along the nasal bones, and down through the middle vault to the nasal tip. They reflect the three-dimensional curvature of the nasal skeleton beneath the skin and are a primary aesthetic reference point in rhinoplasty planning. Disruption of these lines — for example through uneven osteotomies, excessive removal of the nasal bones, or middle vault collapse — is one of the more difficult complications to correct in revision rhinoplasty. Dorsal preservation maintains these lines by keeping the native osseocartilaginous structure intact.

The Internal Nasal Valve

The internal nasal valve is the narrowest segment of the upper airway, located at the junction between the upper lateral cartilage and the dorsal septum. The angle between these two structures — normally approximately 10–15 degrees — is critical for unobstructed nasal breathing. In conventional rhinoplasty, the upper lateral cartilages are detached from the septum as part of the dorsal resection. If the internal nasal valve is not reconstructed with spreader grafts, valve collapse and airflow obstruction can result. Dorsal preservation maintains the upper lateral cartilages in their relationship with the septum, potentially reducing the need for valve reconstruction.

The Skin Soft Tissue Envelope

The soft tissue overlying the nasal skeleton — encompassing skin, subcutaneous fat, and the SMAS equivalent of the nose — must be elevated to allow access to the skeleton during rhinoplasty. In conventional rhinoplasty this elevation is typically performed above the perichondrium and periosteum (supraperiosteal dissection). In dorsal preservation, dissection is performed immediately beneath these coverings (subperichondrial and subperiosteal dissection), leaving the perichondrium and periosteum attached to the cartilage and bone. This plane preserves more of the vascular supply to the skeletal structures, maintains better attachment between the skin and the underlying framework, and may reduce post-operative oedema.

The Dorsal Preservation Techniques

Dorsal preservation is not a single operation but a family of techniques sharing the core principle of lowering the dorsum by mobilising rather than resecting it. The principal techniques are the let-down and the push-down, with numerous variations, refinements, and combinations depending on the patient’s anatomy, the location and configuration of the dorsal convexity, and the surgeon’s training.

The Let-Down Technique

In the let-down technique, the dorsal unit is mobilised by performing controlled osteotomies that free the bony pyramid from its lateral attachments — typically including lateral osteotomies along the nasal sidewalls and a transverse osteotomy at the bony base. Once the bony pyramid is mobile, it can be allowed to settle (or “let down”) into a lower position without resection of any dorsal tissue. A controlled amount of subdorsal septal cartilage may be removed beneath the dorsal profile line to create space for the settling motion. The technique preserves the surface of the dorsum completely intact.

The let-down is particularly well suited to patients with a predominantly bony dorsal hump, a strong keystone area, and a dorsal convexity that can be adequately corrected by movement of the intact bony pyramid into a lower position. It generally requires a larger amount of movement potential than the push-down and may be limited by the mobility achievable through osteotomy alone.

The Push-Down Technique

The push-down technique lowers the dorsum by removing a precisely measured strip of cartilage and bone from beneath the dorsal profile line — the so-called subdorsal resection — to create a space into which the dorsum can be pressed downward. Unlike the let-down, the push-down does not require full mobilisation of the bony pyramid; the dorsal unit is pushed into position against the subdorsal space created. The technique is applicable across a wider range of dorsal configurations and can address both cartilaginous and mixed humps.

The push-down can be performed via a high, intermediate, or low septal strip depending on where the subdorsal resection is made relative to the keystone area. Each variation affects how the dorsal unit moves and how much of the original dorsal line is preserved at the keystone zone. The choice between these approaches is determined by the anatomy of the individual patient’s hump at consultation and at the time of surgery.

The Subperichondrial and Subperiosteal Dissection Plane

Both the let-down and push-down techniques require elevation of the skin soft tissue envelope off the nasal skeleton. In dorsal preservation, this elevation is performed beneath the perichondrium (the connective tissue sheath surrounding cartilage) and the periosteum (the equivalent sheath surrounding bone). Working in this plane has several implications:

• Blood supply preservation. The perichondrium and periosteum carry the principal blood supply to the underlying cartilage and bone. Maintaining these layers attached to the skeleton preserves this vascularity, which is important both for healing and for graft integration if grafts are used.
• Soft tissue attachment. The subperichondrial/subperiosteal plane maintains a more substantial tissue layer attached to the skeleton, providing better re-draping of the skin envelope over the repositioned structures.
• Reduced dead space. The dissection plane minimises the dead space between the skeleton and the skin, which may reduce post-operative fluid accumulation and swelling.
• Tissue preservation for reconstructive use. Perichondrial and periosteal flaps can be used as reconstructive tissue for reinforcing osteotomy sites, closing dead space, or supporting graft placement if required.

Working in this plane requires precise dissection technique and a detailed understanding of the anatomical layers. It is a more demanding approach than supraperiosteal dissection and requires appropriate training and experience.

Spreader Flaps Rather Than Spreader Grafts

In conventional rhinoplasty following dorsal excision, the upper lateral cartilages are detached from the septum during resection. Reconstruction of the middle vault — to maintain the internal nasal valve and smooth the dorsal line — typically requires spreader grafts: pieces of cartilage placed between the septum and upper lateral cartilage on each side and sutured into position. This requires harvesting additional cartilage and adds to the complexity of the reconstruction.

In dorsal preservation, the upper lateral cartilages remain attached to the dorsal septum throughout the procedure. If the dorsal unit is lowered by even a modest amount, the upper lateral cartilages may become slightly redundant — a small excess of cartilage that is no longer under tension against the septum. This excess can be used as a spreader flap: the lateral edge of the upper lateral cartilage is folded under and sutured to the septum, creating a spreader-like effect without the need to harvest a separate cartilage graft. This is both a functional benefit — maintaining the internal valve — and a structural one, in that the native cartilage is repurposed rather than excised.

Management of the Cartilaginous Hump

A pure dorsal preservation approach does not remove any dorsal tissue. However, in patients with a significant cartilaginous component to the hump — and particularly when the cartilaginous excess is localised to the septal angle or the scroll region between the upper and lower lateral cartilages — a modest subdorsal resection may be necessary to create enough space for the push-down movement. This subdorsal resection is performed beneath the dorsal profile line and does not disrupt the surface of the dorsum visible from the outside.

In patients with a mixed osseocartilaginous hump, the cartilaginous and bony components are addressed together as part of the mobilisation manoeuvre rather than separately.

Osteotomies in Dorsal Preservation

Lateral osteotomies — controlled cuts along the sidewalls of the nasal bones — are performed in most dorsal preservation cases, as they are in conventional rhinoplasty. Their primary purpose is to allow the nasal bones to be repositioned medially to close any open roof, and in the let-down technique, to mobilise the bony pyramid for inferior displacement. The osteotomies in dorsal preservation are planned to allow controlled movement of the nasal bones while maintaining their relationship with the dorsal unit above.

Some surgeons performing dorsal preservation also use a percutaneous (through-skin) approach to the osteotomies, using a small-diameter osteotome inserted through tiny skin puncture sites rather than through an intranasal incision. This approach limits the intranasal soft tissue elevation required for osteotomy access and may further reduce tissue disruption.

Dorsal Preservation vs Conventional Structure Rhinoplasty

It is important to understand that dorsal preservation and conventional structure rhinoplasty are not competing techniques in the sense that one is right and the other is wrong. They are different approaches suited to different anatomical situations and patient presentations. The choice between them is a clinical decision based on individual patient anatomy — not a preference for one philosophy over another.

The comparison above reflects general tendencies, not absolute rules. Many rhinoplasty procedures use elements of both approaches. For example, a surgeon might perform a push-down to address the dorsal hump but still use an open approach, place a tip graft, or perform conventional tip work — all elements of structure rhinoplasty — to address the nasal tip or other concerns. The techniques are not mutually exclusive, and the most appropriate combination for each patient is determined by their individual anatomy.

Patient Selection for Dorsal Preservation

Not every patient with a dorsal hump is a candidate for preservation rhinoplasty. Several anatomical and clinical factors influence whether the technique is appropriate.

Anatomy of the Hump

Dorsal preservation techniques work most predictably when the dorsal convexity involves the osseocartilaginous vault as a relatively continuous structure that can be mobilised as a unit. A smooth, regular convexity — whether bony, cartilaginous, or mixed — is generally more amenable to preservation than an irregular, deviated, or structurally compromised hump. Very large humps may require greater displacement than osteotomies can safely provide. Very small, localised humps may be more simply addressed with conventional techniques.

The Septal Anatomy

The position, curvature, and dimensions of the nasal septum are critical to the feasibility of dorsal preservation. The push-down technique requires a sufficient height of septal cartilage beneath the dorsal profile line to permit subdorsal resection without compromising the L-strut — the structural framework of cartilage that provides support to the dorsum and tip. If the L-strut is already narrow, or if the septum is significantly deviated in the region where subdorsal resection would be performed, preservation rhinoplasty may not be safely achievable. Patients in whom the septum must be substantially straightened as part of the procedure may be better suited to conventional approaches where septal work is more readily combined with dorsal reshaping.

Skin Thickness

Skin thickness influences the outcome of any rhinoplasty technique, but it has particular relevance to dorsal preservation. Patients with thin skin are at higher risk for visible surface irregularities, as thin skin does not conceal minor contour variations beneath it. In conventional rhinoplasty, thin skin demands very precise osteotomies and dorsal refinement to avoid visible step-offs or asymmetries. In dorsal preservation, the risk of surface irregularity from the mobilisation itself must be weighed — though the preservation of the native dorsal surface arguably provides a smoother interface than a reconstructed one in thin-skinned patients. Patients with very thick skin may have less visible surface irregularity from either approach, but thick skin also limits how much change in dorsal contour will be externally apparent regardless of technique.

Nasal Deviation

A significantly deviated nose presents specific challenges for dorsal preservation. The mobilisation manoeuvres used in the let-down and push-down techniques assume a relatively symmetric bony pyramid that can be moved as a unit. Where asymmetric osteotomies are required to correct a deviated bony pyramid, the mechanics of the dorsal preservation movement become more complex and unpredictable. Many surgeons consider a significantly deviated nose — particularly one with a deviated septum requiring extensive septoplasty — to be a relative contraindication to pure preservation technique, or at minimum a situation requiring careful individual assessment.

Primary vs Revision Rhinoplasty

Dorsal preservation is primarily a technique for primary (first-time) rhinoplasty. In revision rhinoplasty, the native structures that preservation techniques rely upon — the intact dorsal septum, the upper lateral cartilage attachments, the native bone surface — have typically been partially or fully removed. Once the dorsal hump has been excised, the conditions for preservation rhinoplasty no longer exist. Revision rhinoplasty generally requires structure rhinoplasty techniques, often with cartilage grafting from the ear or rib.

Goals and Degree of Change

Dorsal preservation is well suited to patients seeking reduction of a dorsal hump, with or without other modifications, where the structural anatomy permits. It is not a technique designed for patients who require augmentation of the dorsum, significant narrowing of the nasal bones beyond what routine osteotomies provide, or complex reconstruction following trauma or previous surgery.

The Consultation for Dorsal Preservation Rhinoplasty

A consultation for rhinoplasty involving dorsal preservation is conducted in the same way as any rhinoplasty consultation — with a thorough history, examination of the nose externally and internally, and a detailed discussion of goals, concerns, and realistic expectations. The specific assessment for dorsal preservation includes evaluation of the following:

• The nature and location of the dorsal convexity — its height, width, extent into the bony vs cartilaginous dorsum, regularity, and relationship to the keystone area
• Septal anatomy — height of the dorsal L-strut, presence and degree of septal deviation, the feasibility of subdorsal resection
• Skin thickness and quality — assessment of how skin characteristics will interact with the technique being considered
• The nasal tip — whether tip modifications are required and which approach (open or closed) is best suited to achieve them alongside the dorsal work
• Nasal breathing — assessment of the internal nasal valve, the septum, and the turbinates; whether functional concerns need to be addressed concurrently
• Previous nasal surgery — whether any prior procedures have altered the structures required for preservation technique

Computer imaging may be used to explore different possible outcomes visually and to facilitate discussion about goals. Any images produced are for discussion purposes only and do not represent a predicted or guaranteed outcome. Rhinoplasty outcomes are determined by individual anatomy, healing, and the technical realities encountered at the time of surgery.

A minimum of two consultations is required before any cosmetic surgical procedure proceeds. Patients are encouraged to take the time they need, to ask detailed questions, and to seek a second opinion if they wish.

Surgical Approach — Open vs Closed

Dorsal preservation techniques can be performed through either an open (external) or a closed (endonasal) rhinoplasty approach, and surgeons experienced in these techniques have described both.

The closed approach — in which all incisions are made inside the nostrils with no external scar — has historically been more commonly used with preservation techniques, partly because the preservation philosophy aligns with the closed approach’s emphasis on minimising tissue disruption. The closed approach also avoids the external columellar scar of open rhinoplasty, which some patients and surgeons prefer to avoid. However, the closed approach provides more limited visibility and requires a high degree of manual dexterity to work through intranasal incisions.

The open approach — in which a small step-shaped incision is made across the columella (the strip of tissue between the nostrils), providing direct visualisation of the nasal tip cartilages — provides greater surgical exposure, which is particularly useful when tip modifications are also planned alongside the dorsal preservation work. Dr Roth uses both approaches depending on the requirements of each individual case.

Recovery After Dorsal Preservation Rhinoplasty

The overall structure of recovery from dorsal preservation rhinoplasty is similar to that from conventional rhinoplasty. The specific timeline varies between individuals depending on the extent of surgery, skin characteristics, and individual healing response. The following provides a general framework.

Post-Operative Care Instructions

• Keep the external splint dry at all times until it is removed at the one-week visit
• Do not blow the nose for at least one week — if you need to sneeze, open your mouth to release pressure
• Sleep with the head elevated on two to three pillows for the first two weeks
• Avoid strenuous exercise, heavy lifting, and bending over for at least two weeks
• Avoid contact sport and activities risking a knock to the nose for at least six to eight weeks
• Avoid wearing glasses resting on the nose bridge for four to six weeks if osteotomies were performed — tape or suspended glasses frames are an alternative during this period
• Attend all scheduled post-operative appointments — early and late review is important for monitoring healing and identifying any concerns
• Use saline nasal spray as directed to keep the intranasal environment moist and assist with healing

Smoking and Nicotine

Smoking and nicotine use significantly impair wound healing, reduce blood supply to healing tissues, and increase the risk of infection and poor scarring. Patients should cease all smoking and nicotine use — including patches, vaping, and e-cigarettes — for a minimum of four to six weeks before surgery and throughout the recovery period. This is not negotiable and will be discussed at consultation.

Risks of Dorsal Preservation Rhinoplasty

All rhinoplasty — including dorsal preservation — carries surgical risks. The specific risks relevant to preservation techniques include those common to all rhinoplasty plus some that are particular to the mobilisation manoeuvres involved.

• Insufficient correction. The dorsum may not descend to the planned position if the mobilisation is constrained by anatomical factors not fully apparent pre-operatively. In this case, additional procedures may be required.
• Asymmetry. Asymmetric settling of the dorsal unit following osteotomies can produce a lateral deviation or visible step in the dorsal profile.
• Keystone area irregularity. The junction between the bony and cartilaginous dorsum is a technically demanding area in preservation rhinoplasty. Irregularity at the keystone can produce a visible step or divot in the dorsal profile.
• Open roof deformity. If the lateral osteotomies do not allow adequate closure of the nasal bones over the new dorsal position, a widened or flattened appearance of the nasal bridge can result.
• Middle vault narrowing. If the upper lateral cartilages lose their tension against the septum after the push-down, the middle vault may narrow and the internal nasal valve may be compromised, affecting breathing. Spreader flaps are used to minimise this risk.
• Incomplete hump correction. Some residual convexity may remain, which can be difficult to fully address without converting to a conventional technique.
• Revision rhinoplasty. As with all rhinoplasty, revision procedures are sometimes required. The revision rate in rhinoplasty is generally quoted as approximately one in ten.

A full discussion of all applicable risks will be provided at consultation. Further information is available on the rhinoplasty risks page.

Frequently Asked Questions

Dr Roth’s Approach to Dorsal Preservation

Dr Roth has been incorporating preservation rhinoplasty techniques into his practice since attending the inaugural preservation rhinoplasty course in Nice in 2019, and he continued his training at the Structure and Preservation Rhinoplasty Conference in Istanbul in 2024. He does not apply a single fixed technique to all patients presenting with a dorsal hump. Instead, he assesses each patient’s anatomy individually and selects the approach — preservation, structure, or a combination — that is most appropriate for what that patient’s nose requires and what they are hoping to achieve.

Patients asking about dorsal preservation are welcome to raise it at consultation. Dr Roth is happy to discuss in detail whether their anatomy is suitable, what specific technique would be used, and how that compares to the alternative approaches. There is no obligation to proceed with any technique discussed at consultation.

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About Dr Jason Roth, MBBS, FRACS

Dr Jason Roth is a Sydney-based Specialist Otolaryngologist and Head & Neck Surgeon with fellowship training in rhinology and facial plastic surgery from Australia, the United States, and Europe. He performs more than 150 rhinoplasty procedures per year, including primary and revision cases, and has specific training and experience in preservation rhinoplasty techniques.

He attended the inaugural Preservation Rhinoplasty Conference in Nice (2019) and the Structure and Preservation Rhinoplasty Conference in Istanbul (2024). View his full profile here →