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Dorsal preservation involves eliminating the dorsal hump by performing reduction while preserving the patient's natural dorsal anatomy. This can involve surface manipulation or foundational techniques or a combination of both. When surgeons begin performing dorsal preservation, there are important factors to consider to avoid complications. In an effort to inform surgeons on how to avoid unfavorable outcomes, I will discuss my first 20 cases where I performed dorsal preservation. I review less than ideal outcomes and how these issues can be prevented.

Augmentation of the nasal dorsum is frequently required in the ethnic rhinoplasty patient to create a narrowing effect and to balance the upper two thirds of the nose with the desired increase in tip projection. The subdorsal cantilever graft (SDCG) provides a method to elevate the nasal dorsum to complement the increase in nasal tip projection. SDCG type A is situated below the bony dorsum and acts to raise the dorsum with limited elevation of the radix. The SDCG type B extends through a radix osteotomy site and raises the radix down to the supratip after complete release of the bony dorsum and middle nasal vault. Placement of the SDCG below the dorsum has many advantages, including preserving the features of the natural dorsum (dorsal aesthetic lines), controlled narrowing, and camouflage of the subdorsal graft. This is a complex procedure that requires a good understanding of dorsal preservation techniques. Use of the SDCG to raise the nasal dorsum in ethnic patients combines structure rhinoplasty with the principles of dorsal preservation for augmentation of the profile in patients with a low dorsum.

The subdorsal cantilever graft (SDCG) is a costal cartilage graft that is positioned below the nasal dorsum to control the position of the nasal bones and middle nasal vault. SDCG type A is used to raise the middle nasal vault and caudal nasal bones to correct the saddle nose deformity. SDCG type B can be used to raise the entire dorsum of the nose (radix, bony vault, and middle vault) in the ethnic augmentation rhinoplasty patient. This article will discuss the indications and technique of the SDCG in dorsal preservation rhinoplasty.

Background: Postoperative infections after rhinoplasties are rare, yet devastating on patient outcomes. The literature reports an overall incidence of

The saddle nose deformity typically occurs after the loss of underlying septal support with loss of projection of the middle nasal vault. This creates a saddling effect as the upper lateral cartilages contract and forms a dip in the profile. The saddle nose deformity can occur from many different etiologies, including septal hematoma, fracture of the septum after trauma, disruption of the dorsal L-strut support after septoplasty, and metabolic disorders resulting in the loss of septal support. In most cases, the nasal bones remain in their native position creating a discrepancy in dorsal height and deformity. Correction of the saddle nose deformity can be performed using one of the two primary approaches. The most basic option is to simply fill the defect with a cartilage onlay graft (solid graft, diced cartilage and fascia, and so on) to create a normal dorsal line. This approach can be effective in many cases. Over time, the onlay graft may descend and create deformity or become visible. The other approach involves opening the middle nasal vault, placing spreader grafts, and reconstituting the dorsal L-strut, performing septal reconstruction or extracorporeal septoplasty. In this paper, we present our technique of repairing the saddle nose deformity using a “push up” method that preserves the middle vault anatomy and reconstitutes the proper projection of the middle-third of the nose.

Structural preservation rhinoplasty merges two popular philosophies of rhinoplasty-structure rhinoplasty and preservation rhinoplasty-in an effort to maximize patient outcomes, aesthetics, and function. This allows the surgeon to both preserve the favorable attributes of the nose, and also to structure the nasal tip and dorsum with grafts to maximize contour and support. The concept of dorsal preservation is to preserve favorable dorsal aesthetic lines without the creation of an "open roof." However, the addition of some structure concepts can expand the utility of dorsal preservation in primary rhinoplasty patients. The authors discuss these structure concepts and their applicability to dorsal preservation.