Preservation Rhinoplasty

Preservation rhinoplasty is a surgical technique aimed at reshaping the nose while preserving as much of the patient’s original nasal structures as possible. This approach focuses on maintaining the natural anatomy and function of the nose, reducing the extent of tissue removal and disruption compared to traditional rhinoplasty. Here are the key aspects and benefits of preservation rhinoplasty:

1. Minimal Tissue Removal: Instead of removing large amounts of bone and cartilage, preservation rhinoplasty aims to reshape and reposition these structures. This often involves techniques such as pushing down or modifying the existing nasal dorsum (the bridge of the nose) rather than removing it entirely.
2. Natural Results: By preserving more of the original anatomy, this technique can lead to more natural-looking outcomes, avoiding the over-operated appearance that sometimes results from traditional methods.
3. Less Invasive: The preservation approach tends to be less invasive, which can lead to shorter recovery times, reduced swelling and bruising, and potentially fewer complications.
4. Improved Nasal Function: Since the structural integrity of the nose is maintained, there is often a better chance of preserving or improving nasal function, particularly breathing, which can be compromised in more aggressive surgeries.
5. Reduced Need for Grafts: Traditional rhinoplasty often requires the use of grafts to rebuild or support the nose after significant tissue removal. Preservation rhinoplasty reduces the need for such grafts, as the existing tissues are manipulated rather than replaced

Dorsal Preservation Techniques

General principles

• Dorsal Preservation: This involves conserving the bridge of the nose and adjusting it by lowering or modifying the underlying structures without complete removal.
• Cartilage Preservation: Instead of removing and reshaping cartilage, techniques are used to reposition and reshape the existing cartilage.
• Subperichondrial and Subperiosteal Dissection: These approaches involve precise dissection techniques that preserve the soft tissue attachments to the cartilage and bone, maintaining blood supply and structural integrity.

Specific Techniques

1. Let Down and Push Down Techniques:
   • Let Down Technique: Involves lowering the nasal dorsum by making controlled osteotomies (bone cuts) at the nasal sidewalls and base of the bony pyramid. This allows the dorsal segment to settle down without resecting the dorsal hump.
   • Push Down Technique: Similar to the let down technique but involves pushing the entire nasal dorsum downward, usually after performing subdorsal resections (removal of bone and cartilage beneath the dorsum) to make space for the downward movement.
2. Spreader Grafts and Spreader Flaps:
   • Spreader Grafts: Placing cartilage grafts between the septum and upper lateral cartilages to maintain the internal nasal valve and smooth the nasal dorsum.
   • Spreader Flaps: Creating flaps from the upper lateral cartilages, which are then folded and sutured to the septum, achieving a similar effect as spreader grafts but preserving the native cartilage.
3. High Strip and Low Strip Techniques:
   • High Strip Technique: Retains the upper strip of the septum intact while making a resection beneath it, preserving the dorsal aesthetic lines and ensuring a smooth contour.
   • Low Strip Technique: Involves resecting a strip of cartilage from the lower part of the septum to allow for repositioning without disrupting the dorsal aesthetic lines.

Tip Preservation Techniques

1. Cephalic Fold-in Technique:
   • Folding the cephalic (upper) portion of the lower lateral cartilages inward rather than trimming it. This maintains the structural integrity and natural shape of the nasal tip.
2. Pitanguy Ligament Preservation:
   • Maintaining the integrity of the Pitanguy ligament, a key ligament that supports the nasal tip, helps in preserving the tip’s position and projection.
3. Tip Grafting with Preserved Cartilage:
   • Using the patient’s own preserved cartilage to support and shape the nasal tip, providing a natural contour and avoiding synthetic materials.

Alar Base Preservation Techniques

1. Alar Base Suture Techniques:
   • Utilising sutures to modify the shape and position of the alar base without making extensive cuts or resections. Techniques like cinch sutures can narrow the nostrils and adjust the alar base width.
2. Alar Batten Grafts:
   • Placing cartilage grafts on the lateral side of the alar cartilage to support the nasal sidewalls and prevent collapse, while preserving the natural tissue.

Septal Preservation Techniques

1. Swinging Door Technique:
   • A method where the septum is mobilized by creating a controlled hinge at its base, allowing for repositioning without extensive resection.
2. Extracorporeal Septoplasty:
   • Temporarily removing the septum to reshape it outside the body, then reinserting it. This technique preserves the external nasal structures while correcting significant deviations.

Osteotomy Techniques

1. Piezoelectric Surgery:
   • Using ultrasonic instruments (piezoelectric devices) to perform precise osteotomies with minimal trauma to the surrounding soft tissues. This technique results in less bleeding and swelling.
2. Micro-osteotomies:
   • Performing smaller, controlled bone cuts to reposition the nasal bones, preserving as much of the original bone structure as possible.

Functional Preservation Techniques

1. Preserving the Internal Nasal Valve:
   • Techniques such as spreader grafts and flaps are used to maintain or enhance the internal nasal valve area, ensuring optimal airflow and preventing postoperative breathing difficulties.
2. Submucosal Inferior Turbinoplasty:
   • Reducing the size of the inferior turbinates while preserving the mucosal lining, which helps in maintaining nasal function and reducing the risk of crusting or dryness.

Postoperative Care and Minimising Trauma

1. Minimal Dissection and Elevation:
   • Limiting the extent of tissue dissection and elevation to preserve blood supply, reduce swelling, and speed up recovery.
2. Use of Absorbable Sutures:
   • Utilising absorbable sutures to minimise the need for suture removal and reduce patient discomfort.
3. Nasal Splints and Tapes:
   • Applying external splints and tapes to support the nasal structure during healing while minimising internal packing to enhance comfort and breathing post-surgery.

Preservation rhinoplasty represents a shift towards more conservative, anatomically respectful approaches in nasal surgery, aimed at achieving functional and aesthetic results while minimising trauma to the nose.