The Probable Reasons for Dorsal Hump Problems following Let-Down/Push-Down Rhinoplasty and Solution Proposals

Overview

Dorsal preservation rhinoplasty lowers the bridge by dropping the whole nasal roof rather than shaving it off, keeping the natural surface intact. A recognized failure is that the hump comes back. This study reviews the authors' series to identify why and to propose preventive steps.

Sections of note

• 520 patients who had primary rhinoplasty between 2016 and 2018: 448 straight noses and 72 deviated.
• The push-down method was used for humps under 4 mm; the let-down procedure for larger humps.
• Hump height was measured from profile photographs; mean follow-up 13 months, range 9 to 16.
• Visible hump recurrence occurred in 63 patients, appearing at 1 to 4 months after surgery; 41 of these had a preoperative hump over 4 mm.
• Recurrence under 2 mm in 34 patients, none of whom wanted revision because they were satisfied.
• Recurrence of 2 to 3 mm in 11 patients, treated with minimal rasping only.
• Recurrence of 3 to 4 mm in 18 patients, who underwent secondary let-down surgery.
• Preventive recommendations: subperichondrial and subperiosteal dissection, subdorsal excision of cartilaginous and bony septum, scoring the remaining upper septum just below the keystone, lateral keystone dissection, and preferring let-down for kyphotic noses. Level of evidence IV.

What it means for a patient

• Hump return after dorsal preservation happened in roughly 12 percent of patients, and appeared within the first four months.
• Most of those recurrences were small enough that patients did not want anything done.
• Larger preoperative humps carried the higher risk of recurrence.
• Limits: single center, retrospective, no comparison against conventional hump removal, and mean follow-up of 13 months.

Why this paper matters

Dorsal preservation has grown quickly because it keeps the natural bridge line, and hump relapse is its characteristic failure. Reporting its rate and grading the recurrences by size is unusually specific. The preventive recommendations are derived from experience rather than tested in a comparison.

Terms

• Dorsal preservation rhinoplasty: Lowering the bridge by dropping the whole nasal roof rather than shaving it off.
• Push-down: Dropping the nasal roof straight down into the face.
• Let-down: Removing a wedge of bone so the roof settles lower.
• Keystone: The junction where the nasal bones meet the cartilage of the middle nose.
• Rasping: Filing down a small bony or cartilage irregularity.
• Kyphotic nose: A nose with a marked convex curve in the bridge.