Preservation rhinoplasty

Preservation rhinoplasty lowers the hump by taking cartilage and bone out from underneath and letting the roof of the nose settle, instead of cutting the roof off and rebuilding it. After a decade of adoption the comparative evidence says the two approaches end up in about the same place, with preservation ahead on early appearance and on looking unoperated. Its one distinctive failure is the hump coming back, which is why most of the technical literature of the past three years is about the seven anatomical points that push it back up and how to defeat them.

193papers on file 38this page is written from 9journals, 2018–2026 42open access, full text 152with a plain-language summary

Where these 193 papers were published

44Aesthetic Plastic SurgeryAesthetic Plast Surg
34Facial Plastic SurgeryFacial Plast Surg
34Plastic and Reconstructive SurgeryPlast Reconstr Surg
26Facial Plastic Surgery Clinics of North AmericaFacial Plast Surg Clin North Am
23Aesthetic Surgery JournalAesthet Surg J
22Facial Plastic Surgery and Aesthetic MedicineFacial Plast Surg Aesthet Med
8Plastic and Reconstructive Surgery Global OpenPlast Reconstr Surg Glob Open
1Clinics in Plastic SurgeryClin Plast Surg
1JAMA Facial Plastic SurgeryJAMA Facial Plast Surg

12018 62019 122020 312021 172022 332023 142024 512025 282026

15 further papers on this topic came in through the history rather than the archive query: Skoog T 1966, Rudderman RH 1994, Guyuron B 1994, Gruber RP 2010 and 11 more. They are counted on the landmark papers, not here.

What repeats

Six findings reported by independent groups in different countries. Each card carries the papers it rests on.

Head to head, the two approaches finish level

Four randomised trials and 419 patients pooled favour preservation on both functional and cosmetic patient-reported scores. But the larger reviews qualify that hard: a meta-analysis of six studies and 753 patients found the cosmetic advantage present at six months and gone after; a seven-year cohort of 377 patients found an adjusted advantage at six months and none at twelve or twenty-four; a systematic review of 22 studies and 2,058 patients found no functional difference at all between the two. The honest summary is that preservation is faster to look right and no better a year out.

Rests on: Shim et al., four randomised trials · Kim et al., meta-analysis of 753 patients · Wei et al., seven-year cohort · Chan et al., functional meta-analysis.

A preserved dorsum reads as an unoperated nose

Shown before-and-after photographs, crowdworkers could tell that a structural rhinoplasty patient had had surgery (correlation 0.74) and could not tell for a preservation patient (−0.055), while both groups improved by about the same amount. A separate panel study reached the same place from the other direction: raters (the public, plastic surgeons and rhinoplasty surgeons) identified the approach correctly 52.9% of the time, which is chance. The dorsal aesthetic lines widen after both operations by the same amount on AI measurement. What preservation changes is not how good the nose looks but how operated it looks.

Rests on: Alford et al., crowdsourced assessment · McCleary et al., can raters tell the difference · Xu et al., dorsal aesthetic lines measured.

Hump recurrence is the complication that belongs to this operation

Every review names it and every technical paper is aimed at it. The reason is mechanical: seven anatomical blocking points: the cartilaginous septum, the perpendicular plate of the ethmoid, the lateral osteotomy site, Webster's triangle, the internal mucoperiosteum of the maxilla, the medial canthal ligament and the lateral keystone area. Resist the dorsum coming down or push it back up afterwards. Published countermeasures are specific: five tenets of prevention, a modified low-septal-strip fixation that cut recurrence significantly across 231 patients, and thermal rather than scalpel contouring of the upper lateral cartilage shoulders, which cut recurrence from 13.6% to 2.5% in 205 patients.

Rests on: Goksel et al., the seven blocking points · Cason et al., five tenets · Çelik and Tuluy, modified low-strip fixation in 231 · Şibar et al., electrocautery against scalpel in 205.

The technique is only as good as the patient selected for it

The largest single-surgeon series on file (1,191 consecutive primaries over fourteen years) shows the shape of the learning curve exactly: 3.4% revisions in the first cautious period, 9.9% when indications were expanded without a framework, 3.3% once a classification was in place, a difference that is highly significant. Anatomy predicts success measurably: shorter nasal bones and a lower kyphion angle track with better outcomes, longer radix-to-tip distance with worse. Selection algorithms have been published for hybrid use alongside open structural tip work.

Rests on: Saban and Sachanandani, 1,191 cases · Kemal et al., radiological predictors · Ganesh Kumar et al., hybrid selection algorithm.

The field has settled into hybrids rather than camps

The techniques now in use mix preservation with structure: dorsal preservation with open structural tip work; a split of the middle vault along the septal T; external strip and internal spreader grafts placed under a preserved dorsum; a percutaneous suture to narrow a middle third that preservation has widened; ligament preservation inside an otherwise structural operation. Surveys of the surgeons doing it say the same: many who use dorsal preservation still perform structural rhinoplasty, and the reason they give is hump recurrence.

Rests on: Nissan and Kosins, a decade of refinement · Robotti et al., dorsal split hybrid in 100 cases · Öztürk, external strip and internal spreader · Levy et al., the J-suture · Çakır and Coşkun, two decades of evolution.

Who is doing it, and who is not, is generational

Two surveys of the same international group, 117 and 145 surgeons: dorsal preservation is more common among plastic surgeons than facial plastic surgeons, most used by surgeons with ten to twenty years of experience, while surgeons with more than twenty years stay structural. Half of those who prefer it use it in more than 90% of primaries. Surface techniques, reshaping the cartilaginous roof rather than moving the whole pyramid, are rated more stable, more predictable and quicker to learn, and are the entry point for younger surgeons. Revision rates between the two families were not different in either survey.

Rests on: Santos et al., a worldwide survey · Santos et al., preservers against structured surgeons · Sergesketter et al., four senior surgeons in discussion.

By technique

The named operations inside "preservation", and what each one is for.

Push-down and let-down

The foundation techniques: the bony pyramid is mobilised and lowered, either dropped straight down (push-down) or dropped after removing a wedge of bone (let-down). Pooling 30 studies and 5,967 patients, satisfaction scores rose from 62.1 to 91.1, with push-down showing less residual or recurrent hump (1.3% against 4.6%) and fewer revisions (0% against 5.0%). But push-down is chosen for smaller humps, which is most of that difference.

Key paper: Wells et al., systematic review of 5,967 patients.

Surface and subdorsal strip techniques

Instead of moving the pyramid, the roof is reshaped and a strip of septum is removed beneath it. Two named variants, the modified subdorsal strip method and the Z-flap, produced no measurable difference across 71 patients at twelve months on any instrument. In a randomised trial of 84 patients, the modified subdorsal strip method matched conventional hump resection with spreader flaps on every measure: residual hump, width, projection, rotation, appearance and function.

Key papers: Barrera, subdorsal strip methods compared · Zarei et al., randomised against spreader flaps.

The septum, which is where the operation is actually done

Dorsal preservation is a septal operation with a bony finish, so septal handling decides the result. A four-type septoplasty classification maps the crooked nose (C-shaped, reverse-C, straight-axis and S-shaped) onto preservation-specific techniques, and the swinging-door technique keeps the quadrangular cartilage intact for later grafting instead of discarding it. The 1,191-case framework pairs its pyramidal classification with a named W-point septoplasty.

Key papers: Tremp et al., septal classification for crooked noses · Saban and Sachanandani.

Powered and ultrasonic instruments

Piezoelectric and powered tools are the reason closed preservation is practical: 734 closed piezo-assisted primaries with a 6% revision rate, mostly dorsal contour adjustments, and 97 power-assisted cases with an 8.5% complication rate and bruising lasting 5.6 days under 30 and 6.8 days over.

Key papers: Guilarte and Malzone, 734 closed piezo cases · Taglialatela Scafati et al., 97 power-assisted cases.

Preservation outside the standard hump nose

Asian hump noses: 17 patients at a median of 37 months with no recurrence and no saddling, and an earlier nine-patient series needing bony step-off camouflage in three. The mestizo nose: 417 closed preservation primaries with four tip-support types and 1.7% revision at six to twelve months. Simultaneous with jaw surgery: 118 patients having preservation rhinoplasty during bimaxillary orthognathic surgery, 12.7% complications. Cleft infants: ligament release and repositioning borrowed from preservation in six primary repairs. Septal perforation: pedicled flaps repairing the perforation under a preserved dorsum, previously considered a contraindication.

Key papers: Jin and Jeon, Asian hump noses · Jin et al., nine cases · Valdivia et al., 417 mestizo primaries · Raffaini and Arcuri, with orthognathic surgery · Tanikawa et al., cleft infants · Mariño-Sanchez et al., septal perforation.

The terms, defined

Every term the papers above use to mean something specific, in plain language.

Preservation rhinoplasty: a philosophy rather than one operation: keep the dorsum, the alar cartilages and the soft-tissue envelope where possible, and change shape by working underneath and around them. Named as a movement in 2018. [42455864, 42154257]
Dorsal preservation (DP, DPR): the part of it that applies to the hump: the osseocartilaginous roof is kept intact and lowered, rather than removed and rebuilt. [42418006]
Push-down and let-down: the two foundation moves. Push-down drops the mobilised pyramid; let-down removes a wedge of bone at the base first, for larger humps. [37130993]
Surface techniques and foundation techniques: surface techniques reshape the cartilaginous roof itself (spare roof, Z-flap, subdorsal strip); foundation techniques move the whole pyramid. Surveyed surgeons rate surface techniques more predictable and quicker to learn. [38635957, 39505713]
High strip and low strip: where the strip of septal cartilage is removed from: just under the dorsum (high) or along the floor (low). The choice drives fixation and recurrence. [39023572, 40972537]
Blocking points: the seven anatomical structures that resist dorsal lowering or push the dorsum back up: cartilaginous septum, perpendicular plate of the ethmoid, lateral osteotomy site, Webster's triangle, maxillary internal mucoperiosteum, medial canthal ligament, lateral keystone area. [37337323]
Hump recurrence: the convexity coming back after a preserved dorsum settles. The complication specific to this operation and the commonest reason surgeons keep a structural technique. [38722588, 39505713]
Keystone area: where the nasal bones, the upper lateral cartilages and the septum meet. Preservation is defined by leaving it articulated; some newer techniques avoid disarticulating even the lateral keystone. [36988641, 40277124]
Dorsal aesthetic lines (DALs): the paired highlight lines running from the brows to the tip. Both approaches widen them by the same measured amount. [41369038]
Spare roof technique: a surface technique that reshapes the roof rather than removing it; the NOVA variant adds a manoeuvre that avoids lateral keystone disarticulation. [40277124]
Spreader graft and spreader flap: the structural answers to an open roof: a graft placed between septum and upper lateral cartilage, or the cartilage folded in on itself. The comparator in the randomised trials. [38366551, 40327831]
W-point and the W-ASA segment: the junction area between the W-point and the anterior septal angle; where the middle vault collapses if it is not supported under a preserved dorsum. [40327831, 42467617]
Swinging door septoplasty: mobilising the quadrangular cartilage instead of resecting an L-strut, so the cartilage stays available for grafting later. [36826521]
Pitanguy ligament: the fibrous band from the dorsum to the tip; released and reconstructed rather than discarded, in both structural precision work and cleft infants. [39026387, 40358520]
Piezoelectric and powered instruments: ultrasonic and rotary tools that cut bone without cutting soft tissue, which is what makes closed preservation practical. [39812015, 41211956]
Kyphion angle: a radiological measure of the bony hump's angle; larger angles predicted worse outcomes in the CT-based selection study. [40179243]
RHINO, ROE, SCHNOS, NOSE, SNOT-22: the outcome instruments used across these papers; the first two rate appearance, the last three breathing and sinonasal symptoms, and SCHNOS covers both. [42154257, 41211956]

The papers this rests on

The 38 papers everything above was written from. Every one links to its abstract, its authors and its DOI.

APS
Comparison of Dorsal Preservation Rhinoplasty and Dorsal Hump Reduction Rhinoplasty: A Systematic Review and Meta-Analysis of Postoperative Outcomes
Khatib M, Skorochod R, Wolf Y

2026PMID 42418006Summary
APS
Shaping the Future of Nasal Surgery: A Systematic Review of Preservation Rhinoplasty
Gucuk D, Knoedler L, Niederegger T et al.

2026PMID 42154257Summary
FPS
Functional Outcomes of Dorsal Preservation Rhinoplasty: A Systematic Review and Meta-analysis
Chan C, North AS, Khademi Mansour HR et al.

2026PMID 42532128Summary
PRS
Clarification and Classification of Dorsal Preservation Rhinoplasty: Lessons from a Continuous 1,191-Case Experience
Saban Y, Sachanandani NS

2026PMID 42467617Summary
PRS
Dorsal Preservation versus Conventional Hump Reduction Rhinoplasty: A Seven-Year Review of Patient Reported Outcomes and Concurrent Operative Techniques
Wei EX, Fu B, Huang H et al.

2026PMID 42053436Summary
APS
Comparison of Patient-Reported Outcomes Between Dorsal Preservation and Conventional Dorsal Hump Reduction Rhinoplasty: A Systematic Review and Meta-Analysis
Kim DH, Jang DW, Hwang SH

2025PMID 40195129Summary
APS
Preservation Rhinoplasty Performed Simultaneously with Bimaxillary Orthognathic Surgery: Last Evolution in Orthofacial Surgery
Raffaini M, Arcuri F

2025PMID 40481156Summary
FPS
Trial, Error, and Expertise: My Evolution Through Structural and Preservation Rhinoplasty Techniques
Çakır B, Coşkun E

2025PMID 40550487Summary
FPSAM
Preservation Rhinoplasty Versus Structural Rhinoplasty in Dorsal Hump Reduction: A Systematic Review and Meta-Analysis of Randomized Controlled Studies
Shim SR, Kim JY, Lee SM et al.

2025PMID 40227917Summary
PRS
Refining Patient Selection in Hybrid Dorsal Preservation Rhinoplasty: A Review of 50 Patients
Ganesh Kumar N, Sherif R, Rohrich RJ

2025PMID 40327836Summary
FPSAM
Comparison of Dorsal Preservation Rhinoplasty Techniques: Functional and Aesthetic Review of Subdorsal Septal Strip Methods
Barrera JE

2024PMID 38648529Summary
APS
A Systematic Analysis of the Nasal Septum in Crooked Noses and Suggested Treatment Algorithm According to Preservation Rhinoplasty (PR) Principles
Tremp M, Schneider J, Raghu RBN et al.

2023PMID 36826521Summary
APS
Exploring the Resurgence of the Preservation Rhinoplasty: A Systematic Literature Review
Wells MW, DeLeonibus A, Barzallo D et al.

2023PMID 37130993Summary
FPS
Modified Dorsal Split Preservation Hybrid Rhinoplasty for Cartilaginous Pushdown and Full Letdown Applications: A PROM-Based Review of 100 Consecutive Cases
Robotti E, Cottone G, Leone F

2023PMID 36787789Summary
ASJ
Comparison of Functional and Cosmetic Outcomes Between Dorsal Preservation and Spreader Flap Rhinoplasty: A Randomized Trial
Zarei R, Most SP, Amali A et al.

2024PMID 38366551Summary
ASJ
Postoperative Differences in Dorsal Aesthetic Lines in Patients Undergoing Dorsal Preservation Rhinoplasty and Conventional Hump Resection
Xu L, Huang H, Kandathil CK et al.

2026PMID 41369038Summary
PRS
Dorsal Preservation versus Open Structural Rhinoplasty: Can We Tell the Difference between Aesthetic and Functional Outcomes?
McCleary S, Khan A, Khetpal S et al.

2025PMID 40331571Summary
ASJ
Crowdsourced Assessment of Aesthetic Outcomes of Dorsal Preservation Rhinoplasty
Alford JA, McCleary S, Roostaeian J

2025PMID 39498873Summary
PRS
Preventing Hump Recurrence in Dorsal Preservation Rhinoplasty: The 5 Key Tenets
Cason RW, Goksel A, Sergesketter AR et al.

2025PMID 38722588Summary
PRS
The Blocking Points: The Keys to Consistent Success in Preservation Rhinoplasty
Goksel A, Cason RW, Tran KN et al.

2024PMID 37337323Summary
PRS
Modification of Low-Septal-Strip Septoplasty to Reduce Hump Recurrence in Dorsal Preservation Rhinoplasty
Çelik V, Tuluy Y

2025PMID 39023572Summary
ASJ
Scalpel vs Electrocautery for Upper Lateral Cartilage Contouring in Dorsal Preservation Rhinoplasty: A Retrospective Comparative Study
Şibar S, Erdal AI, Okutan MT

2025PMID 40972537Summary
ASJ
Radiological and Anatomical Parameters as Determinants of Success in Dorsal Preservation Rhinoplasty
Kemal Ö, Tahir E, Çolak O et al.

2025PMID 40179243Summary
ASJ
Optimizing Closed-Approach Preservation Rhinoplasty by Ultrasonic Piezo-assisted Techniques for Enhanced Precision
Guilarte R, Malzone G

2025PMID 39812015Summary
PRS
Power-Assisted Preservation Rhinoplasty: Experience in 97 Consecutive Cases
Taglialatela Scafati S, Russo R, D'Angelo D et al.

2026PMID 41211956Summary
ASJ
Closed Preservation Rhinoplasty in the Mestizo Patient: Challenges and Techniques for Nasal Tip Support
Valdivia C, Durand PD, Çakir B

2025PMID 39876773Summary
PRS
The External Strip and Internal Spreader Graft Combined with Dorsal Preservation Rhinoplasty
Öztürk G

2025PMID 40327831Summary
FPSAM
Feasibility of Dorsal Preservation Rhinoplasty for Hump Nose Reduction in Asian Population
Jin HR, Jeon YJ

2024PMID 39056121Summary
PRS
Dorsal Preservation Rhinoplasty in Asian Hump Noses
Jin HR, Kim Y, Jeon YJ

2024PMID 36988641Summary
FPSAM
Preservation Rhinoplasty by the Ones Who Do It: A Worldwide Survey
Santos M, Azevedo SR, Dias D et al.

2024PMID 38635957Summary
FPSAM
Dorsal Preservation Rhinoplasty: The Perspective of "Preservers" vs. "Structured" Surgeons
Santos M, Most SP, Wayne I et al.

2025PMID 39505713Summary
PRS
Aspects and Concepts of What I Preserve in Rhinoplasty: Proceedings of the 2025 American Society of Plastic Surgeons Spring Meeting
Sergesketter AR, Thomas C, Shariati K et al.

2026PMID 41025796Summary
ASJ
Preservation Rhinoplasty: A Decade of Progress and Technical Refinement
Nissan ME, Kosins A

2026PMID 42455864Summary
PRS
Advancing Preservation Rhinoplasty: The J-Suture Technique for Refining the Middle Third of the Nose
Levy J, Mathieu O, Cetrulo CL Jr et al.

2025PMID 39026386Summary
FPSAM
NOVA Spare Roof Technique and the Sail Maneuver-Vectorial Rhinoplasty Without Lateral Keystone Area Disarticulation
Ferreira MG, Lyrio TM, Tamanqueira P et al.

2025PMID 40277124Summary
PRS
Pitanguy Ligament Preservation in Structural Precision Rhinoplasty
Lisiecki J, Chiodo M, Novak M et al.

2025PMID 39026387Summary
PRS
Introducing Preservation Rhinoplasty Principles to Cleft Nasal Surgery: Unveiling the Role of Nasal Ligaments in Infant Anatomy
Tanikawa D, Sá Á, Figueroa Á et al.

2026PMID 40358520Summary
PRS
"Pedicled Flaps for Nasal Septal Perforation and Graft Framework: Enhancing Outcomes in Preservation and Structural Rhinoplasty"
Mariño-Sanchez F, Alobid I, Santamaría-Gadea A

2025PMID 41071182Summary

What is still contested

Whether preservation is better. Four randomised trials say yes on both axes; the largest functional meta-analysis says no difference; two cohorts say the advantage is real at six months and gone at twelve. Everyone agrees the safety profile is at least comparable. [40227917, 42532128, 40195129, 42053436]
Late complications are read in opposite directions: one meta-analysis reports significantly fewer late complications with preservation (odds ratio 0.21) while also reporting hump recurrence in 12.5% and revision in 21.1% of the pooled complication events. The denominators differ; the pooled figures should not be read as a revision rate. [42418006]
Push-down looks better than let-down on recurrence and revision, but is selected for smaller humps. No study on file matches them on hump size. [37130993]
The evidence base is observational and short: 13 studies at a mean Newcastle-Ottawa score of 5.8, most follow-up under two years, in a technique whose distinctive complication appears late. [42154257]
Almost every technical refinement (fixation modifications, electrocautery contouring, the J-suture, layered strips) is one surgeon's consecutive series without a control arm. [39023572, 40972537, 39026386]
Non-Caucasian data are thin: 17 Asian patients in the longest series, one 417-patient mestizo cohort, nothing else on file.
The teaching problem is stated in print but not solved: rhinoplasty remains one of the hardest operations to teach, and two competing philosophies make it harder. [41025796]