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Preservation rhinoplasty

Instead of cutting the hump off the top of the nose and rebuilding the roof underneath it, preservation rhinoplasty takes cartilage and bone out from below and lets the intact dorsum settle down into the new position. The profile that results is the patient's own bridge, lowered, rather than a reconstructed one. It was named in 2018, spread worldwide within five years, and its distinctive failure is the hump coming back.

What it is, and what it changes

Four things the evidence shows about this operation.

The dorsum is lowered, not removed

The osseocartilaginous roof (nasal bones, upper lateral cartilages and the septum where they meet) is left joined. A strip of septal cartilage is taken from beneath it, the bony pyramid is mobilised with osteotomies, and the whole structure drops. Push-down slides the pyramid down into the opening in the face; let-down removes a wedge of bone first so it settles lower. The alternative, structural rhinoplasty, removes the hump in layers and rebuilds the middle vault with spreader grafts, the technique published by Rohrich in 2004 and taught for two decades.

Rests on: Saban and Sachanandani, 1,191 cases · Rohrich et al., component dorsal hump reduction.

Against the structural operation, it finishes level and looks less operated

Four randomised trials and 419 patients favour preservation on appearance and breathing scores. Larger reviews qualify that: the cosmetic advantage is present at six months and gone by twelve, and the largest functional meta-analysis (22 studies, 2,058 patients) finds no difference at all. What does separate them is subtler: shown photographs, crowdworkers could tell a structural patient had had surgery and could not tell for a preservation patient, with equal improvement in both.

Rests on: Shim et al., four randomised trials · Chan et al., functional meta-analysis · Alford et al., crowdsourced assessment · and preservation in the literature.

Its own complication is the hump coming back

Pooled across 22 studies and 5,660 patients: hump recurrence 4.18%, revision 3.48%, postoperative deviation 1.13%, infection 1.89%. Recurrence happens because seven anatomical points resist the dorsum coming down or push it back up: the cartilaginous septum, the perpendicular plate of the ethmoid, the lateral osteotomy site, Webster's triangle, the maxillary mucoperiosteum, the medial canthal ligament and the lateral keystone area. Most of the technical literature since 2023 is about defeating them, and the measures work: a modified septal fixation cut recurrence significantly across 231 patients, and thermal rather than scalpel contouring of the upper lateral cartilage shoulders cut it from 13.6% to 2.5% in 205.

Rests on: Tham et al., meta-analysis of 5,660 patients · Goksel et al., the blocking points · Çelik and Tuluy, fixation modification · Şibar et al., electrocautery against scalpel.

Patient selection decides the result more than the technique does

The largest single-surgeon series shows the learning curve as a number: 3.4% revisions in the first cautious years, 9.9% when the indications were expanded without a framework, 3.3% once a classification was in place. Anatomy predicts it too, shorter nasal bones and a lower kyphion angle track with better outcomes on CT scoring. A preservation operation on the wrong nose destabilises a framework that did not need destabilising.

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

The named techniques

What surgeons mean by each term, and what the evidence says about it.

Push-down and let-down

The foundation techniques: the mobilised pyramid drops straight down, or drops after a wedge of bone is removed at the base for a larger hump. Pooled across 30 studies and 5,967 patients, satisfaction rose from 62.13 to 91.14, with push-down showing less residual or recurrent hump (1.3% against 4.6%) and fewer revisions (0% against 5.0%). Though push-down is chosen for smaller humps, which explains most of that gap.

Rests on: Wells et al., systematic review.

Surface techniques: spare roof, subdorsal strip, Z-flap

Instead of moving the pyramid, the roof itself is reshaped and cartilage removed from beneath the dorsum. Two named variants produced no measurable difference across 71 patients at twelve months, and in a randomised trial the modified subdorsal strip method matched conventional hump resection with spreader flaps on every measure.

Rests on: Barrera, subdorsal strip methods · Zarei et al., randomised · Ferreira et al., the NOVA spare roof technique.

The septal work, which is where the operation actually happens

Dorsal preservation is a septal operation with a bony finish. High strip or low strip describes where the cartilage is taken from; fixation afterwards is what holds the dorsum down. A four-type septal classification maps crooked noses (C, reverse-C, straight-axis, S) onto preservation-specific techniques, and the swinging-door technique keeps the quadrangular cartilage available for grafting later.

Rests on: Tremp et al., septal classification · Çelik and Tuluy · and the septum and the airway.

Soft-tissue preservation, the other half of the word

"Preservation" covers the ligaments and the skin envelope as well as the dorsum: subperichondrial dissection, keeping the scroll and Pitanguy ligaments, and avoiding dead space. This half can be done in an otherwise structural operation, which is why the categories blur.

Rests on: Çakır and Coşkun, two decades of evolution · Lisiecki et al., the Pitanguy ligament.

Open or closed

Both. In 100 consecutive primaries, a closed preservation approach was favoured for thin skin, minimal dorsal modification, foundation techniques, simpler tip work and an overprojected nose; open for extensive dorsal modification, S-shaped nasal bones, complex tip deformity and tip augmentation; structural dorsal work was always open. Piezoelectric and powered instruments are what made closed preservation practical.

Rests on: Kosins, preservation rhinoplasty open or closed · Guilarte and Malzone, 734 closed piezo cases.

Frequently asked questions

The questions people search, answered from the comparative trials.

What is preservation rhinoplasty?

The hump is lowered rather than removed. The roof of the nose is left joined, a strip of septal cartilage is taken from underneath it, the bony pyramid is mobilised with osteotomies, and the whole structure drops. The profile that results is the patient's own bridge, lowered.

Rests on: Saban and Sachanandani, 1,191 cases.

Is preservation better than the structural operation?

It finishes level with it. Four randomised trials and 419 patients favour preservation on appearance and breathing scores, but the cosmetic advantage is present at six months and gone by twelve, and the largest functional meta-analysis, 22 studies and 2,058 patients, finds no difference. One thing does separate them: shown photographs, crowdworkers could tell a structural patient had had surgery and could not tell for a preservation patient, with equal improvement in both.

Rests on: Shim et al. · Chan et al. · Alford et al..

Can the hump come back?

It is this operation's own complication. Pooled across 22 studies and 5,660 patients, hump recurrence runs 4.18%, revision 3.48%, deviation 1.13% and infection 1.89%. Seven anatomical points resist the dorsum coming down or push it back up, and most of the technical literature since 2023 is about defeating them.

Rests on: the pooled complication data.

How new is it?

The name is from 2018 and it spread worldwide within five years, but the push-down was described in the nineteenth and early twentieth centuries, disappeared, and returned. Three separate papers published between 2021 and 2025 go looking for its historical godfathers.

Rests on: history and education.

The terms, defined

The vocabulary of this operation.

  • Preservation rhinoplasty: a philosophy: keep the dorsum, the ligaments and the alar cartilages where possible, and change shape by working underneath and around them. Named in 2018. [29319790, 42455864]
  • Dorsal preservation (DP): the part of it that applies to the hump: the roof stays intact and is lowered. [42467617]
  • Push-down and let-down: the two foundation moves: the pyramid drops, with or without a wedge of bone removed first. [37130993]
  • Surface and foundation techniques: reshaping the cartilaginous roof itself, against moving the whole pyramid. [35443047]
  • High strip and low strip: where the strip of septal cartilage is taken from, just under the dorsum or along the floor. The choice drives fixation and recurrence. [39023572]
  • Blocking points: the seven anatomical structures that resist the dorsum coming down or push it back up. [37337323]
  • Hump recurrence: the convexity returning as the dorsum settles; the complication specific to this operation. [35172105]
  • Keystone area: where nasal bones, upper lateral cartilages and septum meet. Preservation is defined by leaving it joined. [42467617]
  • Spare roof technique: a surface technique that reshapes the roof rather than removing it. [40277124]
  • Component reduction: the structural alternative: the hump taken apart in layers and the midvault rebuilt. [15457053]
  • Piezoelectric osteotomy: cutting bone with an ultrasonic tip that does not cut soft tissue; less bruising and swelling, and what makes closed preservation practical. [42013314, 39812015]

Who it suits, and who it does not

  • Favourable: a straight nose with a modest hump, minimal deviation, intact anatomy, shorter nasal bones. [42154257, 40179243]
  • Less favourable: a large hump needing extensive dorsal modification, S-shaped nasal bones, severe septal deviation, complex tip deformity, where the published selection algorithms send the surgeon to a structural or hybrid operation. [35443047, 40327836]
  • Either way, the operation being avoided is not dangerous: structural rhinoplasty is the technique this whole literature is measured against, and it finishes level.

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should assess and document, whichever way the hump is lowered.

Rests on: the clinical practice guideline · the plain language summary.

The reference summary

Rhinoplasty in StatPearls, on the National Library of Medicine's Bookshelf, sets out the dorsal anatomy, the indications and the complication list in free full text.

What is not settled

  • 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. [40227917, 42532128, 42053436]
  • Push-down looks better than let-down on recurrence and revision, but is chosen for smaller humps and no study matches them on hump size. [37130993]
  • The evidence is short: most follow-up is under two years, in a technique whose distinctive complication appears late. [42154257]
  • Almost every technical refinement is one surgeon's consecutive series without a control arm. [39023572, 40972537]
  • Non-Caucasian data are thin: 17 Asian patients in the longest series and one 417-patient mestizo cohort. [39056121, 39876773]

Written by rhinoplasty.cc from the sources linked above, 2026-09-09.

Who publishes on preservation rhinoplasty

Ranked surgeons with papers under this topic in the archive, most first.

Sam P. Most (30) · Dean M. Toriumi (12) · Aaron Kosins (7) · Rod J. Rohrich (6) · Jose Barrera (4) · Bahman Guyuron (3) · Alan Matarasso (2) · Jason Roostaeian (2) · Robert Gilman (2) · Samuel Lin (2)

The literature: Preservation rhinoplasty, 193 papers. Video: Preservation, 166 videos. Every technique.