Preservation rhinoplasty is the practice of maximizing the axis of tissue mobilization over resection. Modern preservation rhinoplasty includes (1) lateral crural preservation with an emphasis on suture modification, (2) subperichondrial dissection to preserve the soft-tissue envelope and nasal ligaments, and (3) dorsal preservation by treating the bony-cartilaginous midvault as a single unit during hump reduction (dorsal preservation rhinoplasty [DPR]).[1] Each of these techniques may be deployed in combination or independently. The anatomic and functional considerations of these methods have been previously described.[2]
[3]
[4]
These techniques are distinct from structural techniques, which are relatively more destructive in nature, and more prevalent.[5] While preservation rhinoplasty is not a new concept, there has been a resurgence of interest in both clinical and academic settings. Numerous studies report positive outcomes using preservation techniques; however, evidence-based outcomes for preservation rhinoplasty are lacking.
In the present study, we aim to systematically review and analyze the current body of preservation rhinoplasty literature, to better understand the strongest evidence for or against preservation techniques, and where additional research is required. To our knowledge, a study with this scope has never been published.
Methods
A comprehensive literature review was conducted on October 31, 2022, using the PubMed database. Three groups were established. The first group included variations of the search term “lateral crural preservation.” The second group included variations of the search term “soft-tissue preservation.” The final group included variations of the search term “dorsal preservation.” A complete accounting of the search criteria may be found in [Appendix 1]. Each search was run separately, and all references were uploaded to Endnote reference management software where duplicates were removed.
Article abstracts and titles were independently screened by two reviewers (T.S.O. and P.N.P.) The full text was included for review if the abstract clearly discussed one of the three preservation techniques noted earlier. If there was question about content of the reference, it was also included for full-text review. Disagreements were resolved via discussion between the two reviewers. The inclusion criteria were (1) quantifiable data for one of three preservation rhinoplasty categories (dorsal preservation, lateral crural preservation, soft-tissue preservation); (2) English language article; (3) full-text publication; (4) clinical trial, cohort study, case–control study, systematic review, or meta-analysis. Exclusion criteria included (1) cadaveric studies; (2) articles published as conference abstracts or posters; (3) no quantifiable data; (4) case report, letters, commentaries, or “How I Do It” articles.
We defined dorsal preservation as any technique that reduces the bony-cartilaginous complex in the process of hump reduction without disruption of the upper lateral cartilage attachments to the dorsal septum. References focused on techniques of dorsal preservation were included in the “dorsal preservation” group (Group 1). We defined soft-tissue preservation as any technique including subperichondrial dissection for the preservation of ligaments and other soft tissue. References focused on this technique were included in the “Soft Tissue Preservation” group (Group 2). Finally, we defined lateral crural preservation as any technique aimed at nasal tip refinement with minimal lateral crural resection. This included both grafting and suture techniques (e.g., lateral crural struts, turn-in flaps). All references focused on these techniques were included in the “Lateral Crural Preservation” group (Group 3). In this final group, emphasis was placed on tip refinement techniques without the need for complete lateral crural repositioning (to better compare it to lateral crural excisional techniques) and modifications made for functional reasons only were excluded. Each reference was assigned a level of evidence according to those established by the Oxford Centre for Evidence-Based Medicine ([Table 1]).
Table 1
Oxford Centre for evidence-based medicine: level of evidence
|
Level of evidence
|
Study description
|
|
1a
|
Systematic review (with homogeneity) of randomized controlled trials
|
|
1b
|
Individual randomized controlled trial (with narrow confidence interval)
|
|
1c
|
All or none
|
|
2a
|
Systematic review (with homogeneity) of cohort studies
|
|
2b
|
Individual cohort study (including low-quality randomized controlled trial)
|
|
2c
|
Outcomes research; ecological studies
|
|
3a
|
Systematic review (with homogeneity) of case–control studies
|
|
3b
|
Individual case–control study
|
|
4
|
Case-series (and poor quality cohort and case–control studies)
|
Results
A total of 6,272 studies initially resulted using this search strategy. All 6,272 were uploaded into Endnote software and 1,524 duplicates were removed. The remaining 4,748 articles were title/abstract screened by two independent reviewers (T.S.O. and P.N.P.). A total of 107 articles were included for full-text review. A final reviewer (N.G.D.) performed full-text review according to our established inclusion/exclusion criteria. Seventy articles were included for data extraction. Data collected included year of publication, country of the associated institution, sample size, mean patient age (years), study type, level of evidence, study inclusion criteria, surgical intervention, primary outcome, open versus closed surgical approach, mean duration of follow-up (months), outcome results, complication rate, postoperative dorsal hump recurrence rate, and revision rate. A total of 46 studies were included in Group 1. Of these 46 studies, 9 studies had overlap with Group 2, 1 study had overlap with Group 3, and 5 studies were included in all the three groups. Thirty-one studies were included in the dorsal preservation category (Group 1 alone). The 46 total studies included in Group 1 had a mean sample size of 307 ± 939, a range of 16 to 5,660 patients, and a median sample size of 62 patients with a mean patient age of 27.5 ± 3.4 years. Group 2 consisted of 17 studies in total. Of these 17 studies, 9 studies had overlap with Group 1, 3 studies had overlap with Group 3, and 5 studies were included in all the three groups. Zero studies were included in the soft-tissue preservation group alone. The 17 total studies included in Group 2 had a mean sample size of 129 ± 112, a range of 25 to 520 patients, and a median sample size of 102 with a mean patient age of 26.9 ± 2.1. Group 3 consisted of 30 studies in total. Of these 30 studies, 1 had overlap with Group 1, 3 had overlap with Group 2, and 5 were included in all the three groups. Twenty-one studies were included in the lateral crural preservation group alone. The 30 total studies included in Group 3 had a mean sample size of 84 ± 72 patients, a range of 14 to 306 patients, and a mean sample size of 54 patients with a mean patient age of 29.1 ± 5.4 years. Study characteristics and outcomes for each group may be found in [Tables 2]
[3] to [4].
Table 2
Evidence characteristics and outcomes—dorsal preservation technique
|
Author(s)
|
Groupa
|
Year
|
Country
|
No. of patients
|
Patient age (mean y)
|
Study type
|
Level of evidence
|
Surgical intervention
|
Approach
|
Primary outcome
|
Mean duration of follow-up (mo)
|
Result summary
|
Significant findingb
|
Complication rate
|
Postoperative hump recurrence rate:
|
Revision rate:
|
|
Alan et al[6]
|
1
|
2022
|
Turkey
|
34
|
23.7
|
Prospective cohort
|
III
|
SR vs. PR
|
Closed
|
NOSE, SCHNOS, rhinomanometric evaluation
|
12
|
Rhinomanometric evaluation:
TNV
SR pre: 717.3 (148.5)
SR 12 mo: 753.2 (92.4)
PR pre: 692.6 (108.0)
PR 12 mo: 758.5 (80.0) (
p
= 0.031)
TNR
SR pre: 0.215 (0.051)
SR 12 mo: 0.199 (0.033)
PR Pre: 0.223 (0.049)
PR 12 mo: 0.198 (0.024)
NOSE:
SR pre: 65.7 (23.4)
SR 12 mo: 10.5 (7.0) (
p
< 0.001)
PR pre: 69.3 (19.3)
PR 12 mo: 8.6 (4.4) (
p
= 0.001)
SCHNOS-O:
SR pre: 13.3 (3.7)
SR 12 mo: 1.5 (1.2) (
p
< 0.001)
PR pre: 14.0 (3.0)
PR 12 mo: 1.9 (1.6) (
p
= 0.001)
SCHNOS-C:
SR pre: 21 (7.5)
SR 12 mo: 1.0 (0.8) (
p
< 0.001)
PR pre: 25.5 (5.3)
PR 12 mo: 1.4 (0.9) (
p
= 0.001)
|
1
|
NR
|
NR
|
NR
|
|
Azimov[8]
|
1
|
2021
|
Azerbaijan
|
210
|
27.8
|
Prospective cohort
|
IV
|
CDRT
|
Open: 58; Closed 152
|
Subjective, PE
|
18
|
Limited edema, more rapid patient recovery, no serious complications
|
0
|
NR
|
NR
|
NR
|
|
Cabbarzade[9]
|
1
|
2019
|
Azerbaijan
|
372
|
23
|
Retrospective cohort
|
III
|
DP vs. DR
|
Open: 350, Closed: 22
|
Photography, endoscopic examination, PE
|
15
|
NR
|
0
|
0.00%
|
NR
|
0.27%
|
|
Dewes et al[11]
|
1
|
2021
|
Brazil
|
3282
|
NR
|
Retrospective cohort
|
IV
|
SPAR
|
NR
|
Complications/revision rates
|
NR
|
31% SPAR-A, 43% SPAR_B
|
0
|
NR
|
NR
|
9.50%
|
|
Ferreira et al[13]
|
1
|
2021
|
Portugal
|
250
|
35.2
|
Randomized prospective cohort study
|
III
|
CDR vs. SRT
|
CDR: 87 closed, 38 open. SRT: 112 closed, 13 open
|
OAR, VAS
|
20
|
VAS-C:
CDR pre: 3.66 (1.36)
CDR 12 mo: 7.35 (2.13)
SRT pre: 3.81 (1.29)
SRT 12 mo: 8.45 (1.10)
Aesthetic improvement higher in SRT group (
p
< 0.001).
OAR:
CDR pre: 14.4 (3.5)
CDR 12 mo: 7.8 (2.8)
SRT pre: 13.5 (3.4)
SRT 12 mo: 7.8 (3.1)
VAS- F:
Right side:
CDR pre: 4.76 (1.64)
CDR 12 mo: 7.43 (1.57)
SRT pre: 4.98 (1.76)
SRT 12 mo: 8.10 (1.57)
Left side:
CDR-pre: 5.00 (1.60)
CDR 12 mo: 8.11 (1.29)
SRT-pre: 4.69 (1.67)
SRT-12 mo: 8.69 (1.32)
SRT significantly better than CDR at 1 y (
p
= 0.001)
|
1
|
1.20%
|
1.60%
|
3.60%
|
|
Ferreira et al[14]
|
1
|
2016
|
Portugal
|
40
|
30.6
|
Prospective cohort
|
IV
|
SRT
|
Open: 10, closed: 30
|
Photographic evaluation of BTL, subjective
|
8.72
|
Very good BTL: 80%, good BTL: 15%, bad BTL: 5%. Subjective improvement in nasal function
|
0
|
NR
|
NR
|
NR
|
|
Ishida et al[15]
|
1
|
1999
|
Brazil
|
120
|
NR
|
Prospective cohort
|
IV
|
PR
|
NR
|
Subjective cosmetic and functional results
|
NR
|
All patients with thin and fair skin had satisfactory aesthetic and functional result
|
0
|
NR
|
15.00%
|
15.00%
|
|
Ishida et al[16]
|
1
|
2020
|
Brazil
|
48
|
27.6
|
Retrospective cohort
|
IV
|
PD
|
Open: 48, closed: 6
|
Subjective, complications/revision rates
|
NR
|
Nasal hump adequately corrected in 95.8% of patients
|
0
|
4.17%
|
2.08%
|
NR
|
|
Levin et al[19]
|
1
|
2020
|
Canada
|
NR
|
NR
|
Systematic review
|
II
|
PR (4 references) vs. SR (25 references)
|
3/4 closed, 1/4 NR
|
Various PROM
|
NR
|
Statistically significant improvement in 56% of SR (25 studies included) and 25% of PR studies (4 studies included)
|
1
|
NR
|
NR
|
NR
|
|
Neves and Arancibia-Tagle[20]
|
1
|
2021
|
Portugal, Spain
|
100
|
NR
|
Retrospective cohort
|
IV
|
Tetris concept technique vs. lateral Tetris technique vs. modified SPAR B
|
NR
|
Subjective, complications/revision rates
|
NR
|
Lateral Tetris technique indicated in tilted noses. SPAR-B technique in complex cases
|
0
|
NR
|
36.9% in SPAR B, 3.9% in Tetris
|
4.00%
|
|
Öztürk[21]
|
1
|
2022
|
Turkey
|
36
|
24.81
|
Retrospective cohort
|
IV
|
Combination PR: semi-LD and semi-PD
|
NR
|
ROE, patient satisfaction
|
19.8
|
Median ROE:
Pre-op median: 55.5
12-mo post-op: 91.00 (
p
< 0.001)
Patient satisfaction: 91.6%
|
1
|
NR
|
5.56%
|
0.00%
|
|
Öztürk[22]
|
1
|
2021
|
Turkey
|
64
|
23.8
|
Retrospective cohort
|
IV
|
Semi-LD vs. semi-PD
|
Closed
|
ROE, patient satisfaction
|
19.2
|
Median ROE:
Pre-op median: 61.6
12-mo post-op: 92.2 (
p
< 0.001)
Patient satisfaction: 93.75%
|
1
|
NR
|
10.94%
|
0.00%
|
|
Öztürk[23]
|
1
|
2020
|
Turkey
|
51
|
23.2
|
Retrospective cohort
|
IV
|
LD technique
|
Closed
|
ROE, patient satisfaction
|
15.1
|
Median ROE:
Pre-op median: 65.2
12-mo post-op: 90.2 (
p
< 0.001)
Patient satisfaction: 92%
|
1
|
0.00%
|
NR
|
0.00%
|
|
Öztürk[24]
|
1
|
2020
|
Turkey
|
62
|
27.2
|
Retrospective cohort
|
IV
|
PD without osteotomy
|
Closed
|
ROE, patency score, patient satisfaction
|
14.2
|
Patient satisfaction: 90.32%.
Patency score:
Pre-op: 6 (4–7)
12-mo post-op: 8 (8–9)
(
p
= 0.003)
Median ROE:
Pre-op median: 68.5
12-mo post-op: 90.5
(
p
= 0.001)
|
1
|
0.00%
|
NR
|
0.00%
|
|
Öztürk[26]
|
1
|
2021
|
Turkey
|
52
|
22.2
|
Retrospective cohort
|
IV
|
PD with ostectomy
|
Closed
|
ROE, patency score, patient satisfaction
|
15.1
|
Median ROE:
Pre-op median: 63.4
12-mo post-op 91.6
(
p
< 0.001)
Patient satisfaction: 85%.
Patency:
Pre-op: 5.7
12 mo post-op: 9.1
(
p
< 0.001)a
|
1
|
0.00%
|
NR
|
0.00%
|
|
Özücer and Çam [29]
|
1
|
2020
|
Turkey
|
22
|
29.3
|
Nonrandomized clinical trial
|
III
|
ADP rhinoplasty vs. conventional midvault technique
|
Closed
|
Mean angle of deviation, success rate
|
14.4
|
No significant difference in post-op mean angle of deviation or mean success rate between groups
|
0
|
NR
|
4.55%
|
NR
|
|
Patel et al[30]
|
1
|
2021
|
USA, Egypt
|
22
|
32.1
|
Retrospective cohort
|
IV
|
MSSM rhinoplasty +/− functional rhinoplasty
|
Open
|
SCHNOS-O, C, VAS-F, C
|
4
|
VAS-F (all patients)
Pre-op: 4.05 (2.94)
Post-op: 1.82 (1.82)
(
p
= 0.003)
VAS-C (all patients)
Pre-op: 2.68 (1.70)
Post-op: 8.95 (1.13)
(p
< 0.001)
SCHNOS-O (all patients)
Pre-op: 41.59 (31.11)
Post-op: 21.82 (17.83)
(
p
= 0.009)
SCHNOS-C (all patients)
Pre-op: 62.12 (21.14)
Post-op: 6.96 (11.35)
(
p
< 0.001)
VAS-F and SCHNOS-O did not change significantly in cosmetic operation alone
|
1
|
0.00%
|
0.00%
|
NR
|
|
Patel et al[31]
|
1
|
2022
|
USA, Egypt
|
163
|
NR
|
Retrospective matched cohort
|
III
|
SPR vs. CHR
|
Open
|
SCHNOS-O, C; VAS-F, VAS-C
|
NR
|
SCHNOS-O:
SPR group:
Pre-op: 31.1 (28.71)
Post-op < 6 mo: 19.76 (19.84) (
p
= 0.0030)
Long-term follow-up: 12.3 (16.41) (
p
< 0.0001)
CHR group:
Pre-op: 38.35 (34.66)
Post-op < 6 mo: 19.95 (19.37) (
p
< 0.0001)
Long-term follow-up: 16.94 (20.2) (
p
= 0.0006)
SCHNOS-C:
SPR group:
Pre-op: 65.4 (18.4)
Post-op < 6 mo: 7.64 (14.60) (
p
< 0.0001)
Long-term follow-up: 7.27 (11.42) (
p
< 0.0001)
CHR group:
Pre-op: 65.44 (19.1)
Post-op < 6 mo: 11.18 (14.29) (
p
< 0.0001)
Long-term follow-up: 11.63 (14.59) (
p
< 0.0001)
VAS-C:
SPR group:
Pre-op: 2.63 (1.66)
Post-op < 6 mo: 8.92 (1.59) (
p
< 0.0001)
Long-term follow-up: 8.73 (2.1) (
p
< 0.0001)
CHR group:
Pre-op: 3.05 (2.07)
Post-op < 6 mo: 8.20 (2.29) (
p
< 0.0001)
Long-term follow-up: 8.25 (1.84) (
p
< 0.0001)
VAS-F:
SPR group:
Pre-op: 3.1 (2.89)
Post-op < 6 mo: 1.90 (2.13) (
p
= 0.004)
Long-term follow-up: 1.13 (1.62) (
p
= 0.02)
CHR group:
Pre-op: 3.72 (3.13)
Post-op < 6 mo: 1.78 (2.04) (
p
< 0.0001)
Long-term follow-up: 1.41 (1.92) (
p
< 0.0001)
VAS-C scores at <6 mo post-op statistically higher in SPR group (
p
= 0.03). No other significant difference between groups
|
1
|
NR
|
NR
|
NR
|
|
Patel et al[3]
|
1
|
2020
|
USA
|
16
|
NR
|
Prospective cohort
|
IV
|
DP rhinoplasty
|
NR
|
SCHNOS-O, C; VAS
|
4
|
SCHNOS-O
Pre-op: 39.4 (29.7)
Post-op: 20.3 (15.8) (
p
= 0.003)
SCHNOS-C:
Pre-op: 62.3 (18.0)
Post-op: 6.9 (10.9) (
p
< 0.001)
VAS-C:
Pre-op: 2.6 (1.4)
Post-op: 8.8 (1.1) (
p
< 0.001)
VAS-F:
Pre-op: 3.9 (3.0)
Post-op: 1.94 (1.7) (
p
= 0.016)
|
1
|
NR
|
NR
|
NR
|
|
Patel et al[32]
|
1
|
2021
|
USA, Egypt
|
22
|
NR
|
Prospective cohort
|
IV
|
SSM +/− functional rhinoplasty
|
NR
|
SCHNOS-O, C
|
4
|
SSM + functional:
SCHNOS-O
Pre-op: 66.5 (19.4)
Post-op: 18.0 (14.0) (
p
< 0.001)
SCHNOS-C
Pre-op: 54.7 (24.9)
Post-op: 11.3 (15.5) (
p
< 0.001)
SSM – functional:
SCHNOS-C
Pre-op: 68.3
Post-op: 3.3 (
p
< 0.001)
No significant change in SCHNOS-O
|
1
|
NR
|
NR
|
NR
|
|
Pirsig and Konigs[33]
|
1
|
1988
|
Germany
|
100
|
NR
|
Prospective cohort
|
IV
|
WR
|
NR
|
Subjective cosmetic results
|
18
|
Good long-term results in 93%. Under correction in 6%. Overcorrection in 1%. Better results than classic osteotomy technique
|
0
|
NR
|
NR
|
NR
|
|
Rodrigues Dias et al[36]
|
1
|
2022
|
Portugal
|
54
|
34.5
|
Prospective cohort
|
II
|
Primary rhinoplasty with SRT
|
Open-10, Closed- 44
|
OAR, VAS-F
|
12
|
OAR:
Mean pre-op: 13.4 (0.5)
Mean 3-mo post-op: 9.2 (0.15)
Mean 9-mo post-op: 9 (0.5) (
p
< 0.001)
VAS-F (worst breathing side):
Mean pre-op: 4.52 (0.22)
Mean 3-mo post-op: 7.84 (0.19)
Mean 9-mo post-op: 8.2 (0.16) (
p
< 0.001)
|
1
|
NR
|
NR
|
NR
|
|
Rodriquez et al[37]
|
1
|
2022
|
Spain
|
300
|
26
|
Retrospective cohort
|
IV
|
PR w/ recycled dorsum preservation technique
|
Open
|
Subjective, complications/revision rates
|
NR
|
Subjective results: 2 patients dissatisfied with scar. 50% extremely satisfied, 40% highly satisfied, 10% moderately satisfied
|
0
|
6.00%
|
NR
|
NR
|
|
Saban et al[2]
|
1
|
2018
|
France, USA, Italy Hungary
|
320
|
29
|
Retrospective cohort
|
IV
|
Dorsal reduction with PDO or LDO
|
NR
|
Complications/revision rates
|
29
|
PDO preferred for <4 mm reduction. LDO for > 4 mm reduction
|
0
|
NR
|
0.63%
|
3.40%
|
|
Saban and de Salvador[48]
|
1
|
2021
|
France
|
352
|
NR
|
Retrospective cohort
|
IV
|
Full DP vs. DP + resurfacing vs. DP + bony cartilaginous disarticulation vs. traditional rhinoplasty
|
NR
|
Subjective, complications/revision rates, functional complaints questionnaire
|
12
|
Most benefit in groups: straight noses—Full DP. Tension noses: DP + resurfacing and/or Cottle variation. Kyphotic noses: cartilage only DP. Difficult noses: traditional rhinoplasties
|
0
|
NR
|
NR
|
9.94%
|
|
Santos et al[38]
|
1
|
2019
|
Portugal
|
100
|
32.8
|
Prospective, interventional, longitudinal study
|
II
|
SRT
|
Open: 18, closed: 82
|
OAR, VAS-F, VAS-C
|
12
|
10-point VAS-C:
Pre-op: 3.67 (0.15)
3 mo: 8.1 (0.12) (p < 0.001)
12 months: 8.44 (0.11) (p < 0.001)
OAR:
Pre-op: 13.9
3 mo: 8.26 (p < 0.001)
12 mo: 7.08 (p < 0.001)
VAS-F right:
Pre-operative: 5.13 (0.25)
3 mo: 8.44 (0.16) (
p
< 0.001)
12 mo: 8.62 (0.18) (
p
< 0.001)
VAS-F left:
Pre-operative: 4.49 (0.22)
3 mo: 8.29 (0.16) (
p
< 0.001)
12 mo: 8.72 (0.14) (
p
< 0.001)
|
1
|
NR
|
NR
|
NR
|
|
Stergiou et al[39]
|
1
|
2022
|
Switzerland, Italy, France
|
30
|
30.7
|
Prospective cohort
|
IV
|
PR
|
NR
|
ROE, complication/revision rate, INV angle
|
8.4
|
Radiological analysis—INV angle:
Pre-op: 20.77° ± 3.2°
Post-operative: 21.82° ± 5.7° (
p
= 0.18)
Mean ROE post-op: 18.4. High patient satisfaction in all cases
|
1
|
23.33%
|
NR
|
6.67%
|
|
Stergiou et al[40]
|
1
|
2022
|
Switzerland, Italy, France
|
58
|
32
|
Prospective cohort
|
IV
|
PR
|
Closed, hybrid open
|
ROE, radiological analysis
|
19.7
|
Overall ROE converted score:
Pre-op: 37.9 ± 9.2
Post-op: 81.25 ± 14.17 (
p
< 0.0001)
Radiological analysis:
Pre-op INV angle: 19.88 ± 3.3
Post-op INV angle: 22.04 ± 4.1, (
p
= 0.023)
ROE2 (subjective breathing):
Pre-op: 1.471 ± 0.90
Post-op: 3.1 ± 0.88; (
p
= 0.0001)
|
1
|
25.80%
|
NR
|
8.60%
|
|
Taş[42]
|
1
|
2020
|
Turkey
|
44
|
23.2
|
Prospective cohort
|
IV
|
DRT
|
Closed
|
ROE, subjective evaluation, pyramidal angle measurements, patency score
|
12
|
Mean pyramidal angle:
Pre-op: 80.
Post-op: 60.4 (
p
< 0.001)
Mean ROE: 90.1% patient satisfaction.
Patency score:
Pre-op: 5.1
Post-op: 8.2 (
p
< 0.001)
|
1
|
0.00%
|
0.00%
|
0.00%
|
|
Taş and Erden[43]
|
1
|
2021
|
Turkey
|
50
|
27.5
|
Prospective cohort
|
III
|
Open rhinoplasty with spreader graft vs. LD technique
|
Open-24, Closed- 26
|
NOSE, SNOT-22, VAS
|
6
|
LD technique
:
Nose:
Pre-op: 13.19 (5.32)
Post-op: 3.81 (2.92) (
p
< 0.001)
Snot-22:
Pre-op: 41.77 (23.58)
Post-op: 13.12 (11.51) (
p
< 0.001)
VAS:
Pre-op: 6.96 (2.27)
Post-op: 2.00 (1.38) (
p
< 0.001)
Spreader technique:
Nose:
Pre-op: 13.42 (4.23)
Post-op: 3.58 (2.63) (
p
< 0.001)
Snot-22:
Pre-op: 47.50 (19.76)
Post-op: 14.58 (9.69) (
p
< 0.001)
VAS:
Pre-op: 7.38 (1.86)
Post-op: 2.04 (1.12) (
p
< 0.001)
No significant difference between groups
|
1
|
NR
|
NR
|
NR
|
|
Tham et al[44]
|
1
|
2022
|
USA
|
5660
|
NR
|
Systematic review and meta-analysis
|
II
|
PR
|
NR
|
Subjective, complications/revision rates
|
NR
|
Post-op rate of infection: 1.89%. Wide variety of functional outcomes—heterogeneity precluded further analysis. Prevailing method: Type 1 DP (impaction osteotomies of the nasal pyramid-LD/PD). Minority method: Type 2 DP (dorsal hump modulation of soft tissue without impact osteotomies)
|
0
|
3.02%
|
4.18%
|
3.48%
|
|
Almazov et al[7]
|
3
|
2022
|
Russia, Barcelona, Azerbaijan
|
134
|
28
|
Retrospective cohort
|
IV
|
PD vs. LD vs. Combination (with PIE)
|
Closed
|
ROE, patient satisfaction
|
12
|
Median ROE:
Pre-op: 58.3
12 mo post-op: 92.5 (
p
< 0.001)
Patient satisfaction: 96%
|
1
|
NR
|
0.75%
|
0.75%
|
|
Erdal and Genç[12]
|
3
|
2022
|
Turkey
|
36
|
25.3
|
Retrospective cohort
|
IV
|
DP +/− transection of Pitanguy's midline ligament
|
Closed
|
Photograph analysis, ROE, subjective patient satisfaction. complications
|
9
|
Supratip depression detected:
Preservation group: 4/6 (25%)
Transection group: 0 (
p
< 0.05)
Median ROE score:
Preservation group: 83
Transection group: 87
Patient satisfaction score:
Transection group: 90%
Preservation group: 87.5%
|
1
|
15.38%
|
NR
|
NR
|
|
Kosins[17]
|
3
|
2021
|
USA
|
100
|
29
|
Retrospective cohort
|
IV
|
DP + SSM vs. DP + cartilage- only PD + separate bony pyramid modification vs. DP + cartilage reduction + separate bony pyramid modification
|
Open
|
Complication/revision rates, technique
|
12
|
Average lowering: SSM: 4.5 mm, cartilage only PD: 2.5 mm, cartilage modification: 2 mm
|
0
|
1.00%
|
2.00%
|
0.00%
|
|
Öztürk[27]
|
3
|
2021
|
Turkey
|
45
|
24.2
|
Retrospective cohort
|
IV
|
Mix-down: PD + LD
|
Closed
|
ROE, patency score
|
14.1
|
Median ROE:
Pre-op: 60.1
12 mo post-op: 92.2 (p < 0.001)
Patient satisfaction: 92%.
Patency score:
Pre-op: 6.1
12 mo post-op: 9.3 (p = 0.001)
|
1
|
0.00%
|
NR
|
0.00%
|
|
Öztürk[28]
|
3
|
2021
|
Turkey
|
48
|
23.6
|
Retrospective cohort
|
IV
|
Partial PD or partial LD
|
Closed
|
ROE
|
14
|
Median ROE:
Pre-op: 60.0
12 mo post-op: 93.6 (p < 0.001)
Patient satisfaction: 92%
|
1
|
NR
|
NR
|
0.00%
|
|
Robotti et al[35]
|
3
|
2019
|
Italy, South Africa
|
41
|
NR
|
Prospective cohort
|
IV
|
Modified dorsal cartilaginous PD after component separation
|
Open
|
Subjective cosmetic results
|
6
|
All patients had favorable outcomes
|
0
|
0.00%
|
0.00%
|
0.00%
|
|
Taglialatela Scafati and Regalado-Briz[41]
|
3
|
2021
|
Italy, Mexico
|
107
|
28.7
|
Retrospective cohort
|
IV
|
PR + PIE osteotomy
|
Closed: 88, 19: combined
|
Subjective, complications/revision rates, RHINO score
|
18
|
RHINO score:
Mean post-op: 85.6 (12.7) Significant increase (
p
< 0.001)
|
1
|
NR
|
3.74%
|
8.40%
|
|
Tuncel, Aydogdu[45]
|
3
|
2019
|
Turkey
|
520
|
NR
|
Retrospective cohort
|
IV
|
LD or PD
|
Closed
|
Subjective satisfaction, complication/revision rate
|
13
|
< 2 mm hump recurrence in 6.5%: 2–3 mm hump recurrence in 2.1%. 3–4 mm hump recurrence in 3.5%. Successful cosmetic results achieved
|
0
|
NR
|
12.12%
|
3.50%
|
|
Tuncel et al[47]
|
3
|
2021
|
Turkey
|
150
|
29.11
|
Retrospective cohort
|
IV
|
PD: dorsal hump under 4 mm vs. LD: dorsal hump over 4 mm
|
Closed
|
Subjective, photograph evaluation
|
12.68
|
PD for 67 cases. LD for 83 cases. All recurrent cases had a pre-op hump deformity over 4 mm. Correlation between preoperative hump height and hump recurrence
|
0
|
NR
|
5.30%
|
5.30%
|
|
Öztürk[25]
|
4
|
2021
|
Turkey
|
43
|
24.2
|
Retrospective cohort
|
IV
|
New suture technique
|
NR
|
ROE
|
15.8
|
Median ROE:
Pre-op: 60.6
12 mo post-op: 90.8 (
p
< 0.001)
Patient satisfaction: 90.47%
|
1
|
0.00%
|
NR
|
0.00%
|
|
Cakir et al[10]
|
6
|
2012
|
Turkey
|
228
|
24.3
|
Retrospective cohort
|
IV
|
Subperichondrial dissection with repair of Pitanguy's midline ligament
|
Open
|
Subjective, complications/revision rates
|
9, 36
|
Limited edema, more rapid patient recovery, subperichondrial dissection easier in revision patients
|
0
|
12.72%
|
NR
|
5.26%
|
|
Kosins, Daniel[1]
|
6
|
2020
|
USA
|
100
|
27
|
Retrospective cohort
|
IV
|
PR-C or PR-P
|
Open
|
Surgical details, subjective cosmetic and functional outcomes, complication/revision rates
|
13
|
Details of surgical technique.
|
0
|
0.00%
|
0.00%
|
3.00%
|
|
Kosins[18]
|
6
|
2022
|
USA
|
100
|
28
|
Retrospective cohort
|
III
|
PR-open vs. PR-closed
|
Open: 56, closed: 44
|
Surgical details, complication/revision rates
|
12
|
Closed approach favored in minimal dorsal modification and for osseocartilaginous preservation. Open favored for extensive dorsal modifications, complex tip deformity, and tip augmentation
|
0
|
0.00%
|
2.00%
|
4.00%
|
|
Qaradaxi et al[34]
|
6
|
2022
|
Iraq
|
113
|
27.19
|
Prospective cohort
|
III
|
Subdorsal septal approach to manage V-shaped vs. S-shaped dorsum
|
NR
|
SCHNOS-C, O, operative time, complication/revision rates
|
NR
|
Overall SCHNOS-O, C: Significant improvement post-op. Obstructive improved more in S-shaped deformity
|
1
|
22.10%
|
13.30%
|
NR
|
|
Tuncel et al[46]
|
6
|
2022
|
Turkey
|
25
|
28.64
|
Prospective cohort
|
IV
|
DRF; mirrors technique of Robotti et al[35]
|
Open: 13, closed: 12
|
Nasolabial and nasoglabellar angles
|
10.3
|
Nasoglabellar angle:
Pre-op: 136.3°
Post-op: 138.8°
Nasolabial angle:
Pre-op: 89.8°
Post-op: 95.4° (p < 0.014)
|
1
|
0.00%
|
0.00%
|
0.00%
|
Note: For abbreviations and footnotes, please see “Notes for Tables 2–4.”
Table 3
Evidence characteristics and outcomes: soft-tissue preservation techniques
|
Author(s)
|
Groupa
|
Year
|
Country
|
No. of patients
|
Patient age (mean y)
|
Study type
|
Level of evidence
|
Surgical intervention
|
Approach
|
Primary outcome
|
Mean duration of follow-up (mo)
|
Result summary
|
Significant findingb
|
Complication rate
|
Post-op hump recurrence rate
|
Revision rate
|
|
Almazov et al[7]
|
3
|
2022
|
Russia, Barcelona, Azerbaijan
|
134
|
28
|
Retrospective cohort
|
IV
|
PD vs. LD vs. Combination (with PIE)
|
Closed
|
ROE, patient satisfaction
|
12
|
Median ROE:
Pre-op: 58.3
12 mo post-op: 92.5 (
p
< 0.001)
Patient satisfaction: 96%
|
1
|
NR
|
0.75%
|
0.75%
|
|
Erdal and Genç[12]
|
3
|
2022
|
Turkey
|
36
|
25.3
|
Retrospective cohort
|
IV
|
DP +/− transection of Pitanguy's midline ligament
|
Closed
|
Photograph analysis, ROE, subjective patient satisfaction. complications
|
9
|
Supratip depression detected:
Preservation group: 4/6 (25%)
Transection group: 0 (
p
< 0.05)
Median ROE score:
Preservation group: 83
Transection group: 87
Patient satisfaction score:
Transection group: 90%
Preservation group: 87.5%
|
1
|
15.38%
|
NR
|
NR
|
|
Kosins[17]
|
3
|
2021
|
USA
|
100
|
29
|
Retrospective cohort
|
IV
|
DP + SSM vs. DP + cartilage- only PD + separate bony pyramid modification vs. DP + cartilage reduction + separate bony pyramid modification
|
Open
|
Complication/revision rates, technique
|
12
|
Average lowering: SSM- 4.5 mm, cartilage only PD: 2.5 mm, cartilage modification: 2 mm
|
0
|
1.00%
|
2.00%
|
0.00%
|
|
Öztürk[27]
|
3
|
2021
|
Turkey
|
45
|
24.2
|
Retrospective cohort
|
IV
|
Mix-down: PD + LD
|
Closed
|
ROE, patency score
|
14.1
|
Median ROE:
Pre-op: 60.1
12 mo post-op: 92.2 (p < 0.001)
Patient satisfaction: 92%.
Patency score:
Pre-op: 6.1
12 mo post-op: 9.3 (p = 0.001)
|
1
|
0.00%
|
NR
|
0.00%
|
|
Öztürk[28]
|
3
|
2021
|
Turkey
|
48
|
23.6
|
Retrospective cohort
|
IV
|
Partial PD or. partial LD
|
Closed
|
ROE
|
14
|
Median ROE:
Pre-op: 60.0
12 mo post-op: 93.6 (p < 0.001)
Patient satisfaction: 92%
|
1
|
NR
|
NR
|
0.00%
|
|
Robotti et al[35]
|
3
|
2019
|
Italy, South Africa
|
41
|
NR
|
Prospective cohort
|
IV
|
Modified dorsal cartilaginous PD after component separation
|
Open
|
Subjective cosmetic results
|
6
|
All patients had favorable outcomes
|
0
|
0.00%
|
0.00%
|
0.00%
|
|
Taglialatela Scafati and Regalado-Briz[41]
|
3
|
2021
|
Italy, Mexico
|
107
|
28.7
|
Retrospective cohort
|
IV
|
PR + PIE osteotomy
|
Closed: 88, 19 combined
|
Subjective, complications/revision rates, RHINO score
|
18
|
RHINO score:
Mean post-op: 85.6 (12.7)
Significant increase (
p
< 0.001)
|
1
|
NR
|
3.74%
|
8.40%
|
|
Tuncel, Aydogdu[45]
|
3
|
2019
|
Turkey
|
520
|
NR
|
Retrospective cohort
|
IV
|
LD or PD
|
Closed
|
Subjective satisfaction, complication/revision rate
|
13
|
< 2 mm hump recurrence in 6.5%: 2–3 mm hump recurrence in 2.1%. 3–4 mm hump recurrence in 3.5%. Successful cosmetic results achieved
|
0
|
NR
|
12.12%
|
3.50%
|
|
Tuncel et al[47]
|
3
|
2021
|
Turkey
|
150
|
29.11
|
Retrospective cohort
|
IV
|
PD—dorsal hump under 4 mm vs. LD—dorsal hump over 4 mm
|
Closed
|
Subjective, photograph evaluation
|
12.68
|
PD for 67 cases. LD for 83 cases. All recurrent cases had a pre-op hump deformity over 4 mm. Correlation between preoperative hump height and hump recurrence
|
0
|
NR
|
5.30%
|
5.30%
|
|
Küçüker et al[49]
|
5
|
2014
|
Turkey
|
147
|
29.2
|
Prospective cohort
|
IV
|
Cartilage—saving PR
|
Open
|
Subjective, complications/revision rates
|
19.6
|
91.7% overall satisfaction rate. 86.3% functional satisfaction rate
|
0
|
NR
|
NR
|
1.36%
|
|
Öztürk[50]
|
5
|
2020
|
Turkey
|
190
|
24.3
|
Retrospective cohort
|
IV
|
Superior-based sliding flap technique
|
Closed
|
ROE, patency score
|
12
|
Patient satisfaction: 95%.
Patency scores:
Pre-op: 6.2
12 mo post-op: 8.8 (
p
< 0.001)
ROE: Median 12 mo post-op score of 90.5
|
1
|
NR
|
NR
|
0.00%
|
|
Sazgar and Most[51]
|
5
|
2011
|
USA, Iran
|
102
|
NR
|
Prospective cohort
|
IV
|
lobular refinement w/ CHF vs. reduction of vertical height of LC + CHF vs. crural setback with CHF vs. horizontal and vertical reduction of LC + CHF
|
NR
|
Subjective cosmetic and functional results, complications
|
15
|
Satisfactory results achieved
|
0
|
0.00%
|
NR
|
0.98%
|
|
Cakir et al[10]
|
6
|
2012
|
Turkey
|
228
|
24.3
|
Retrospective cohort
|
IV
|
Subperichondrial dissection with repair of Pitanguy's midline ligament
|
Open
|
Subjective, complications/revision rates
|
9, 36
|
Limited edema, more rapid patient recovery, subperichondrial dissection easier in revision patients
|
0
|
12.72%
|
NR
|
5.26%
|
|
Kosins and Daniel[1]
|
6
|
2020
|
USA
|
100
|
27
|
Retrospective cohort
|
IV
|
PR-C or PR-P
|
Open
|
Surgical details, subjective cosmetic and functional outcomes, complication/revision rates
|
13
|
Details of surgical technique
|
0
|
0.00%
|
0.00%
|
3.00%
|
|
Kosins[18]
|
6
|
2022
|
USA
|
100
|
28
|
Retrospective cohort
|
III
|
PR-open vs. PR-closed
|
Open: 56, closed: 44
|
Surgical details, complication/revision rates
|
12
|
Closed approach favored in minimal dorsal modification and for osseocartilaginous preservation. Open favored for extensive dorsal modifications, complex tip deformity, and tip augmentation
|
0
|
0.00%
|
2.00%
|
4.00%
|
|
Qaradaxi et al[34]
|
6
|
2022
|
Iraq
|
113
|
27.19
|
Prospective cohort
|
III
|
Subdorsal septal approach to manage V-shaped vs. S-shaped dorsum
|
NR
|
SCHNOS-C, O, operative time, complication/revision rates
|
NR
|
Overall SCHNOS-O, C: Significant improvement post-op. Obstructive improved more in S-shaped deformity
|
1
|
22.10%
|
13.30%
|
NR
|
|
Tuncel et al[46]
|
6
|
2022
|
Turkey
|
25
|
28.64
|
Prospective cohort
|
IV
|
DRF
|
Open: 13, closed: 12
|
Nasolabial and nasoglabellar angles
|
10.3
|
Naso-glabellar angle:
Pre-op: 136.3°
Post-op: 138.8°
Nasolabial angle:
Pre-op: 89.8°
Post-op: 95.4° (p < 0.014)
|
1
|
0.00%
|
0.00%
|
0.00%
|
Note: For abbreviations and footnotes, please see “Notes for Tables 2–4.”
Table 4
Evidence characteristics and outcomes: lateral crura preservation techniques
|
Author(s)
|
Groupa
|
Year
|
Country
|
No. of patients
|
Patient age (mean y)
|
Study type
|
Level of evidence
|
Surgical intervention
|
Approach
|
Primary outcome
|
Mean duration of follow-up (mo)
|
Result summary
|
Significant findingb
|
Complication rate
|
Post-op hump recurrence rate
|
Revision rate
|
|
Abdelwahab et al[58]
|
2
|
2021
|
USA, Egypt
|
94
|
NR
|
Retrospective cohort
|
III
|
LCSG vs. mini-LCSG vs. LCO with/without additional support vs. cephalic trimming vs. cephalic turn-in flaps
|
NR
|
LWI, NOSE, VAS, SCHNOS
|
9
|
Zone 1 LWI: Significant improvement in LCO with/without support, LCSG and mini-LCSG (p = 0.042, p = 0.041, p < 0.001). Zone 2 LWI: Significant improvement in LCO with support, LCSG (p = 0.022, p = 0.004). NOSE: significant improvement in all subgroups analyzed for zone 2 (p < 0.05). SCHNOS-C, VAS-C: significant improvement in all subgroups (p < 0.05)
|
1
|
NR
|
NR
|
NR
|
|
Abdelwahab and Most[66]
|
2
|
2020
|
USA, Egypt
|
33
|
32
|
Retrospective cohort
|
IV
|
Mini-LCSG in cosmetic or combined rhinoplasty
|
NR
|
SCHNOS-C, O, NOSE, VAS, LWI
|
20
|
Cosmetic group
:
LWI - Zone 1:
Pre-op: 0.31 (0.47)
Post-op: 0.00 (0.00) (
p
= 0.003)
NOSE
Pre-op: 15.96 (15.94)
Post-op: 13.85 (15.51)
SCHNOS-O
Pre-op: 15.19 (19.82)
Post-op: 14.04 (16.85)
SCHNOS-C
Pre-op: 66.92 (18.50)
Post-op: 9.61 (16.54) (
p
= 0.001)
VAS-F
Pre-op: 1.23 (1.68)
Post-op: 1.23 (1.21)
VAS-C
Pre-op: 2.50 (2.00)
Post-op: 8.85 (1.52) (
p
= 0.001)
Combined group:
LWI- Zone 1:
Pre-op: 0.57 (0.53)
Post-op: 0.00 (0.00) (
p
= 0.03)
NOSE
Pre-op: 77.86 (14.96)
Post-op: 23.92 (30.95) (
p
= 0.003)
SCHNOS-O
Pre-op: 82.86 (12.54)
Post-op: 27.50 (31.12) (
p
= 0.004)
SCHNOS-C
Pre-op: 65.24 (19.23)
Post-op: 11.66 (10.83) (
p
= 0.001)
VAS-F
Pre-op: 8.00 (1.29)
Post-op: 3.00 (3.06) (
p
= 0.008)
VAS-C
Pre-op: 4.57 (1.51)
Post-op: 7.43 (3.64)
|
1
|
NR
|
NR
|
NR
|
|
Alkarzae and Bafaqeeh[61]
|
2
|
2020
|
SAU
|
120
|
23
|
Retrospective cohort
|
IV
|
Turn-in flap
|
Open
|
Subjective, complications/revision rates
|
24
|
Symmetrical reduction of LLC
|
0
|
0.00%
|
NR
|
5.00%
|
|
Boccieri and Marianetti[62]
|
2
|
2010
|
Italy
|
32
|
NR
|
Prospective cohort
|
IV
|
Barrel roll technique—rotation of lateral crus
|
NR
|
Rhinomanometric data, subjective aesthetic improvement, revision/complication rate
|
NR
|
Significant improvement in nasal airway resistance using rhinomanometric data. All displayed functional and aesthetic improvement
|
0
|
NR
|
NR
|
3.13%
|
|
Bulut[60]
|
2
|
2021
|
Turkey
|
30
|
31.6
|
Prospective cohort
|
IV
|
CLCA flap
|
Open
|
ROE, VAS
|
12
|
ROE: 93% satisfaction rate. VAS-F:
Pre-op: 4.56 (1.53)
12 mo post-op: 9.0 (0.65) (
p
< 0.001)
|
1
|
NR
|
NR
|
0%
|
|
Cabbarzade[72]
|
2
|
2022
|
Azerbaijan
|
94
|
34
|
Retrospective cohort
|
IV
|
Skin tensioning technique
|
Open
|
Subjective, complications/revision rates
|
24
|
All patients verbally stated satisfaction
|
0
|
0.00%
|
NR
|
NR
|
|
Darzi et al[71]
|
2
|
2021
|
Iran
|
54
|
26.32
|
Randomized controlled trial
|
II
|
LCC vs. MCC
|
Open
|
SCHNOS, nasolabial angle and projection
|
12
|
Nasal tip projection:
Pre op:
MCC 64.08 (5.09)
LCC 62.22 (4.64)
Post-op: 3 mo
MCC 62.90 (5.04)
LCC 6216 (4.30)
Post op: 12 mo
MCC 61.03 (4.24) (
p
= 0.003)
LCC 61.16 (4.60)
Nasal tip rotation:
Pre op:
MCC 90.45 (10.49)
LCC 90.56 (11.43)
Post-op: 3 mo
MCC 104.51 (6.92)
LCC 104.7 (10.21)
Post op: 12 mo
MCC 102.28 (6.15) (
p
= 0.0001)
LCC 102.43 (10.06) (
p
= 0.0001)
SCHNOS-O: % difference between 3 and 12 mo post-op
MCC -31.92 (35.01)
LCC -23.40 (28.13)
SCHNOS-C: difference between 3 and 12 mo post-op
MCC -51.15 (2.013)
LCC -42.87 (20.52)
MCC resulted in significantly higher change in SCHNOS-C (
p
= 0.046)
|
1
|
0.00%
|
NR
|
0.00%
|
|
Foda and Kridel[68]
|
2
|
1999
|
Egypt
|
28
|
32.5
|
Prospective clinical trial
|
II
|
LCS vs. LCO
|
Open
|
nasofacial angle, Goode ratio, nasolabial angle, rotation angle
|
6
|
Goode-Ratio pre- and post-op mean difference:
LCS 0.06 (0.03)
LCO -0.05 (0.02) (
p
< 0.001)
Nasofacial angle pre- and post-op mean difference:
LCS 3.22 (1.52)
LCO -3.80 (1.32)
Nasolabial angle pre- and post-op mean difference:
LCS 9.67 (6.64)
LCO 12.80 (4.47)
Rotation angle pre- and post-op mean difference:
LCS 9.77 (1.63)
LCO 12.40 (1.35) (
p
< 0.001)
|
1
|
NR
|
NR
|
NR
|
|
Foda[67]
|
2
|
2003
|
Egypt
|
306
|
26.5
|
Retrospective cohort
|
III
|
LCS vs. LCO vs. TING
|
Open
|
nasolabial angle, rotation angle, Goode ratio, nasofacial angle
|
12
|
Nasolabial angle pre- and post-op mean difference:
LCO 11.8 (4.3) (p < 0.001)
LCS 8.9 (4.5) (p < 0.001)
TING 7.1 (4.6) (p < 0.001)
Rotation angle pre- and post-op mean difference:
LCO 13 (2.8) (p < 0.001)
LCS 11 (1.4) (p < 0.001)
TING 8.5 (1.8) (p < 0.001)
LCO- significantly more rotation (
p
< 0.001)
Goode-Ratio pre- and post-op mean difference:
LCO -0.06 (0.03) (p < 0.001)
LCS 0.07 (0.02) (p < 0.001)
TING 0.02 (0.04)
Nasofacial angle pre- and post-op mean difference:
LCO -4.1 (1.4) (p < 0.001)
LCS 3.2 (1.2) (p < 0.001)
TING 0.4 (0.9)
|
1
|
NR
|
NR
|
NR
|
|
Foulad et al[57]
|
2
|
2017
|
USA
|
114
|
43
|
Retrospective cohort
|
IV
|
LCT method rhinoplasty
|
NR
|
Complications/revision rates
|
8.7
|
NR
|
0
|
1.80%
|
NR
|
5.30%
|
|
Gentile and Cervelli[69]
|
2
|
2022
|
Italy
|
35
|
NR
|
Randomized controlled trial
|
II
|
LCS + TING vs. cartilage grafts control group
|
NR
|
Subjective cosmetic and functional results
|
36
|
82.9% of patients showed excellent cosmetic and functional results in LCS + TING. 40% in control. Tip projection maintenance and contour restoring higher in LCS + TING group
|
0
|
NR
|
NR
|
NR
|
|
Ghazipour et al[70]
|
2
|
2008
|
Iran
|
60
|
26.2
|
Prospective clinical trial
|
II
|
Group A: Narrowing transdomal sutures + columellar strut. Group B: Narrowing transdomal sutures + columellar strut + LCS
|
Open
|
Nasofacial angle, Goode ratio, nasolabial angle
|
6
|
Mean difference- Goode Ratio pre- and post-op:
Group A: -0.063 (0.02) (p < 0.001)
Group B: -0.065 (0.018) (p < 0.001)
Mean difference- nasofacial angle pre- and post-op:
Group A: -4.34 (1.95) (p < 0.001)
Group B; -2.107 (1.19) (p < 0.001)
Mean difference- nasolabial angle pre- and post-op:
Group A: -16.68 (5.48) (p < 0.001)
Group B: -11 (4.89) (p < 0.001)
Group B: Significantly more increase in tip projection and rotation (
p
< 0.05)
|
1
|
NR
|
NR
|
NR
|
|
Gruber et al[56]
|
2
|
2010
|
USA
|
14
|
NR
|
Prospective cohort
|
IV
|
Rhinoplasty with preservation of lateral crus
|
Open
|
Subjective, complications/revision rates
|
NR
|
Bulbosity corrected in each case. No significant increase in alar- nostril axis measurement
|
0
|
NR
|
NR
|
21.43%
|
|
Langsdon et al[55]
|
2
|
2021
|
USA
|
20
|
NR
|
Retrospective cohort
|
IV
|
LCST
|
NR
|
nasolabial angle measurement
|
NR
|
Mean nasolabial angle:
Pre-op: 86.9
Post-op: 98.5 (
p
< 0.0001)
|
1
|
NR
|
NR
|
NR
|
|
Murakami et al[54]
|
2
|
2009
|
USA
|
18
|
NR
|
Prospective cohort
|
IV
|
Turn in flap
|
Open
|
Subjective, complications/revision rates
|
9
|
Satisfactory nasal tip refinement in all cases. Symmetric reduction of lower lateral cartilage in all cases
|
0
|
0.00%
|
NR
|
NR
|
|
Öztürk[52]
|
2
|
2020
|
Turkey
|
51
|
29.2
|
Retrospective cohort
|
IV
|
Sandwich technique with scroll ligament preservation
|
Closed
|
ROE, nasal patency, patient satisfaction
|
14.2
|
Median ROE:
Pre-op: 70.1
12 mo post-op: 91.2 (
p
= 0.002)
Patient satisfaction: 92%
Patency score:
Pre-op: 9.4
12 mo post-op: 6.1 (= 0.003)
|
1
|
0.00%
|
NR
|
0.00%
|
|
Paquet et al[65]
|
2
|
2016
|
USA
|
54
|
41.3
|
Prospective cohort
|
III
|
LCR
|
Open
|
photograph analysis and measurement, modified Gunter technique
|
11.3
|
Mean anterior nostril apex:
Pre-op: 31.3° (8.9°)
Post-op: 24.5° (6.8°)
Net decrease all groups: 6.8° (
p
< 0.001)
Net decrease (LCR only): 6.9 (
p
< 0.001)
Net decrease (LCR + LCSG): 6.7 (
p
< 0.001)
|
1
|
NR
|
NR
|
NR
|
|
Sazgar[64]
|
2
|
2010
|
Iran
|
28
|
NR
|
Prospective cohort
|
IV
|
HRCH
|
Open
|
Subjective, complications/revision rates
|
14
|
Nasal tip fine and stable in all patients
|
0
|
0.00%
|
NR
|
0.00%
|
|
Sazgar[63]
|
2
|
2010
|
Iran
|
23
|
NR
|
Retrospective cohort
|
IV
|
LCST + cephalic turn in flap
|
Open
|
nasal tip rotation and projection
|
11
|
Increase in the degree of nasal tip rotation. Notable increase in the postoperative values of the nasolabial angle. Symmetric reduction of LLC
|
0
|
0.00%
|
NR
|
NR
|
|
Tebbetts[53]
|
2
|
1994
|
USA
|
235
|
NR
|
Retrospective cohort
|
IV
|
no scoring, morselization, transection, or resection of rim strip
|
NR
|
Subjective, complications/revision rates
|
NR
|
NR
|
0
|
0.00%
|
NR
|
0.85%
|
|
Tellioglu and Cimen[59]
|
2
|
2007
|
Turkey
|
32
|
24
|
Prospective cohort
|
IV
|
Turn-in folding
|
Open
|
Subjective, complications/revision rates
|
NR
|
Satisfactory results were achieved
|
0
|
0.00%
|
NR
|
NR
|
|
Öztürk[25]
|
4
|
2021
|
Turkey
|
43
|
24.2
|
Retrospective cohort
|
IV
|
New suture technique
|
NR
|
ROE
|
15.8
|
Median ROE:
Pre-op: 60.6
12 mo post-op: 90.8 (
p
< 0.001)
Patient satisfaction: 90.47%
|
1
|
0.00%
|
NR
|
0.00%
|
|
Küçüker et al[49]
|
5
|
2014
|
Turkey
|
147
|
29.2
|
Prospective cohort
|
IV
|
Cartilage- saving PR
|
Open
|
Subjective, complications/revision rates
|
19.6
|
91.7% overall satisfaction rate. 86.3% functional satisfaction rate
|
0
|
NR
|
NR
|
1.36%
|
|
Öztürk[50]
|
5
|
2020
|
Turkey
|
190
|
24.3
|
Retrospective cohort
|
IV
|
Superior based sliding flap technique
|
Closed
|
ROE, patency score
|
12
|
Patient satisfaction: 95%.
Patency scores:
Pre-op: 6.2
12 mo post-op: 8.8 (
p
< 0.001)
ROE: Median 12 mo post-op score of 90.5
|
1
|
NR
|
NR
|
0.00%
|
|
Sazgar and Most[51]
|
5
|
2011
|
USA, Iran
|
102
|
NR
|
Prospective cohort
|
IV
|
lobular refinement w/ CHF vs. reduction of vertical height of LC + CHF vs. crural setback with CHF vs. horizontal and vertical reduction of LC + CHF
|
NR
|
Subjective cosmetic and functional results, complications
|
15
|
Satisfactory results achieved
|
0
|
0.00%
|
NR
|
0.98%
|
|
Cakir et al[10]
|
6
|
2012
|
Turkey
|
228
|
24.3
|
Retrospective cohort
|
IV
|
Subperichondrial dissection with repair of Pitanguy's midline ligament
|
Open
|
Subjective, complications/revision rates
|
9, 36
|
Limited edema, more rapid patient recovery, subperichondrial dissection easier in revision patients
|
0
|
12.72%
|
NR
|
5.26%
|
|
Kosins and Daniel[1]
|
6
|
2020
|
USA
|
100
|
27
|
Retrospective cohort
|
IV
|
PR-C or PR-P
|
Open
|
Surgical details, subjective cosmetic and functional outcomes, complication/revision rates
|
13
|
Details of surgical technique
|
0
|
0.00%
|
0.00%
|
3.00%
|
|
Kosins[18]
|
6
|
2022
|
USA
|
100
|
28
|
Retrospective cohort
|
III
|
PR-open vs. PR-closed
|
Open-56, Closed- 44
|
Surgical details, complication/revision rates
|
12
|
Closed approach favored in minimal dorsal modification and for osseocartilaginous preservation. Open favored for extensive dorsal modifications, complex tip deformity, and tip augmentation
|
0
|
0.00%
|
2.00%
|
4.00%
|
|
Qaradaxi et al[34]
|
6
|
2022
|
Iraq
|
113
|
27.19
|
Prospective cohort
|
III
|
sub-dorsal septal approach to manage V-shaped vs. S-shaped dorsum
|
NR
|
SCHNOS-C, O, operative time, complication/revision rates
|
NR
|
Overall SCHNOS-O, C: Significant improvement post-op. Obstructive improved more in S-shaped deformity
|
1
|
22.10%
|
13.30%
|
NR
|
|
Tuncel[46]
|
6
|
2022
|
Turkey
|
25
|
28.64
|
Prospective cohort
|
IV
|
DRF
|
Open- 13, Closed- 12
|
Nasolabial and nasoglabellar angles
|
10.3
|
Nasoglabellar angle:
Pre-op: 136.3°
Post-op: 138.8°
Nasolabial angle:
Pre-op: 89.8°
Post-op: 95.4° (p < 0.014)
|
1
|
0.00%
|
0.00%
|
0.00%
|
Note: For abbreviations and footnotes, please see “Notes for Tables 2–4.”
Of note, the majority of studies in Groups 1 and 2 were published in 2019 or later (89.4%, 82.4%). However, 50% of studies included in Group 3 were published prior to 2019. Most studies were also published from institutions outside of North America with only 25.7% submitted by institutions within the United States or Canada. 11.4% of included references were level II evidence with 88.6% being level III or IV. No level I evidence was found. In total, 53% (37) studies reported standardized outcome measures. 47% (33) and 57% (40) of references included complication and revision rates, respectively.
Discussion
DPR has become increasingly popular among rhinoplasty surgeons since 2018 with descriptions of surgical techniques and outcomes increasing in the literature starting in 2019. Contemporary preservation rhinoplasty technique includes a combination of three independent components including reduction of the dorsal bony-cartilaginous complex, subperichondrial dissection with preservation of ligaments and the soft-tissue envelope, and minimal resection of lateral crura with innovative graft or suture techniques. Despite a renewed interest in contemporary preservation techniques, there is a lack of high-level evidence and appraisal of patient outcomes in the current literature. We aim to evaluate the current evidence-based literature available for the three independent components of the modern preservation technique.
Group 1: Dorsal Preservation Component
We defined the dorsal preservation component as any technique that reduces the bony-cartilaginous complex in the process of hump reduction without disruption of the dorsal vault or destruction of tissue. This group includes the largest number of references which is 46 in total, with 4 containing level II evidence (8.7%), 8 being level III evidence (17.4%), and 34 being level IV evidence (73.9%). Nine of these references are also included in Group 2 (19.6%), one in Group 3 (2.2%), and five in all the three groups (10.9%). Forty-two (91.3%) of these references were published in 2019 or later and only 9 (19.6%) were published by an academic institution located in the United States or Canada. Of the references reporting surgical details, 66.7% used closed approach for the majority of cases, with 33.3% open approach. Twenty-four (52.2%) cohort studies used validated patient-reported outcome measures (PROMs) to evaluate cosmetic and/or functional results following a variety of dorsal preservation techniques. PROMs used include the Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty (OAR), Visual Analog Scale—functional and cosmetic (VAS-C, VAS-F), Rhinoplasty Outcome Evaluation (ROE), Likert scale for nasal patency, Standardized Cosmesis and Health Nasal Outcomes Survey—cosmetic and obstructive (SCHNOS-C, SCHNOS-O), and the Rhinoplasty Health Inventory and Nasal Outcomes scale (RHINO). Please see the dorsal preservation group included in [Table 2] for all reference details.[1]
[2]
[3]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
[42]
[43]
[44]
[45]
[46]
[47]
[48]
To our knowledge, only four studies directly compare dorsal preservation technique to conventional dorsal resection rhinoplasty.[6]
[13]
[31]
[43] Ferreira et al conducted a randomized prospective cohort study examining PROMs following component dorsal hump reduction (CDR) versus spare roof technique (SRT).[13] In 125 randomly selected patients undergoing primary rhinoplasty, compared to CDR, the SRT technique resulted in significantly more improvement in both the VAS-C (4.6 vs. 3.7, p < 0.001) and VAS-F (4.0 vs. 3.1, p = 0.001).[13] Additional comparative studies focus on traditional preservation techniques (e.g., let-down technique, push-down technique). Support for the let-down preservation rhinoplasty technique is provided by Taş and Erden with a prospective cohort study of 50 patients resulting in significant postoperative improvement in mean [SD] NOSE (13.2 [5.3] vs. 3.8 [2.9], p < 0.001), SNOT-22 (41.8 [23.6] vs. 13.1 [11.5], p < 0.001), and VAS scores (7.0 [2.3] vs. 2.0 [1.4], p < 0.001).[43] However, when compared to traditional open rhinoplasty with spreader graft, there was no significant difference in PROM between groups.[43] Alan et al also demonstrated no significant difference in NOSE or SCHNOS-O/C scores between a structural rhinoplasty and preservation rhinoplasty group in a prospective trial of 34 patients.[6] Similarly, Patel et al conducted a retrospective matched cohort study of 163 patients directly comparing structural preservation rhinoplasty to conventional hump resection.[31] No significant difference in SCHNOS-O or VAS-F was seen between groups at both short-term (<6 months) and long-term (>6 months) follow-up. VAS-C scores were significantly higher in the structural preservation group at short-term follow-up (8.9 [1.6] vs. 8.2 [2.3], p = 0.03), but this did not persist long-term.[31]
Of other noncomparative studies that include PROMs, evidence for use of the SRT was the most robust.[36]
[38] In the first 100 patients undergoing this technique, there was a significant improvement in mean aesthetic VAS-C scores at 3 and 12 months (3.7 [0.2] vs. 8.1 [0.1] vs. 8.4 [0.1], p < 0.001).[38] Complete preservation of all three components with the subdorsal septal approach has also resulted in significant improvement postoperatively for both V- and S-shaped nasal dorsum deformities, with obstruction improving more in the S-shaped group.[34] Patel et al also provided support for the use of the subdorsal strip method with or without functional rhinoplasty.[30]
[32] In 22 patients, VAS-F and SCHNOS-O did not significantly change following cosmetic preservation rhinoplasty alone. However, there was no deterioration in SCHNOS- O scores, suggesting that dorsal preservation techniques do not worsen nasal obstruction.[30]
[32]
Additional level IV studies demonstrate statistically significant improvement in cosmetic and functional outcomes based on ROE, patency Likert scale, SCHNOS-O/C, VAS-C/F, and RHINO scores following a variety of dorsal preservation techniques including let-down technique, push-down technique, suturing techniques, subdorsal strip method, and dorsal roof technique. However, none of these studies directly compare preservation rhinoplasty techniques to conventional resection.[3]
[7]
[12]
[21]
[22]
[23]
[24]
[25]
[26]
[27]
[28]
[40]
[41]
[42] The remaining references include subjective or photographic evaluation of cosmetic and/or functional outcomes as well as analysis of complication rate, postoperative dorsal hump recurrence, and revision rates.[1]
[2]
[8]
[10]
[11]
[14]
[15]
[16]
[17]
[20]
[33]
[35]
[37]
[39]
[45]
[46]
[47]
[48] Overall, the DPR techniques are reported to have a complication rate ranging from 0 to 25.80% with the majority of reported complications being minor.[1]
[9]
[10]
[12]
[13]
[16]
[17]
[18]
[23]
[24]
[25]
[26]
[27]
[30]
[34]
[35]
[37]
[39]
[40]
[44]
[46] Reported postoperative dorsal hump recurrence rates ranged from 0 to 36.9% with the most dorsal hump recurrence occurring following the classical septum pyramidal adjustment and repositioning (SPAR) approach in complex rhinoplasty cases.[1]
[2]
[7]
[13]
[15]
[16]
[17]
[18]
[20]
[21]
[22]
[29]
[30]
[34]
[35]
[41]
[42]
[44]
[45]
[46]
[47] Postoperative dorsal hump revision rates were reported by 25 studies and ranged from 0 to 15%.[1]
[2]
[7]
[9]
[10]
[11]
[13]
[15]
[17]
[18]
[20]
[21]
[22]
[23]
[24]
[25]
[26]
[27]
[28]
[35]
[40]
[41]
[42]
[44]
[45]
[46]
[47]
[48] The most benefit was seen after dorsal preservation in straight noses with traditional rhinoplasty being suggested in difficult cases or in patients with thick skin across multiple references.[15]
[20]
[48]
Although there has been an increase in the number of references including PROMs following dorsal preservation techniques since 2019, many of these studies provide low levels of evidence. We identified only four studies that directly compare dorsal preservation techniques to conventional hump resection. Although numerous studies report high patient satisfaction following dorsal preservation techniques, three out of the four comparative studies included found no significant difference in PROMs between preservation rhinoplasty and conventional structural rhinoplasty. Further research should focus on high-level, prospective, comparative studies to fully understand the benefit, as well as the complication rate, of dorsal preservation techniques across different patient populations
Group 2: Soft-Tissue Preservation Component
We defined soft-tissue preservation as any technique including subperichondrial dissection for the preservation of ligaments and other soft tissue. This group includes the smallest number of references which is 17 in total, with 2 (11.8%) being level III evidence and 15 (88.2%) being level IV. Of these 17 references, all overlap with other groups, with 9 overlapping with Group 1 (52.9%), 3 overlapping with Group 3 (17.6%), and 5 being included in all the three groups (29.4%). Fourteen (82.4%) of these articles were published in 2019 or later and 4 (23.5%) were published by academic institutions in the United States. Of the references reporting surgical details, 53.3% used a closed approach rhinoplasty for the majority of cases, with 46.7% using an open approach. Please see the soft-tissue preservation group included in [Table 3] for all reference details.[1]
[7]
[10]
[12]
[17]
[18]
[27]
[28]
[34]
[35]
[41]
[45]
[46]
[47]
[49]
[50]
[51]
No studies included in this category directly compare preservation techniques to conventional structural rhinoplasty. The highest level of evidence is available for the subdorsal septal approach proposed by Qaradaxi et al.[34] The goal of this technique is nasal hump reduction with minimal dissection of the soft-tissue envelope of the nasal dorsum, which encompasses all three preservation techniques well.[34] In 113 prospectively analyzed patients, there was a significant improvement in overall SCHNOS-O/C scores following the use of this comprehensive preservation technique (p < 0.001). Improved subjective outcomes after osseocartilaginous preservation were also found after closed preservation rhinoplasty when directly compared to the open approach.[18] However, this retrospective analysis was based on subjective physician-graded outcomes and does not include statistically analyzed data.
Six additional, low-level, noncomparative studies use the RHINO score, ROE scale, and/or nasal patency Likert scale for the evaluation of cosmetic and functional outcomes following soft-tissue preservation techniques.[7]
[12]
[27]
[28]
[41]
[50] Notably, significant improvement in RHINO score (p < 0.001) and nasal patency scores (6.2 vs. 8.8, p < 0.001) following scroll and pyriform ligament preservation during rhinoplasty was demonstrated in two studies.[41]
[50] However, Erdal and Genç demonstrated no significant difference in ROE scores following DPR either with or without transection (87 vs. 83) of Pitanguy's midline ligament, although supratip depression was found to be higher in the preservation group when compared to conventional transection (25 vs. 0%, p < 0.05).[12]
The remaining studies in this group report subjective outcomes, complication rates, or revision rates with no statistically analyzed data. Overall, 10 included studies report complication rates ranging from 0.0 to 23.3% following preservation rhinoplasty techniques that include soft-tissue conservation.[1]
[10]
[12]
[17]
[18]
[27]
[34]
[35]
[46]
[51] No major complications or pollybeak deformities were reported.[12] One study found decreased edema following subperichondrial dissection with preservation of Pitanguy's midline ligament as well as more rapid patient recovery.[10] Subperichondrial dissection was also noted to be easier in revision rhinoplasty patients.[10] Fifteen studies also reported revision rates ranging from 0.0 to 8.40% with most patients reporting high cosmetic or functional satisfaction following soft-tissue preservation rhinoplasty techniques.[1]
[7]
[10]
[17]
[18]
[27]
[28]
[35]
[41]
[45]
[46]
[47]
[49]
[50]
[51]
Overall, the evidence for contemporary soft-tissue preservation techniques is severely lacking, with no studies that directly compare preservation techniques to conventional rhinoplasty. Prospective, comparative, longitudinal studies analyzing PROMs following a variety of soft-tissue preservation techniques will be imperative as preservation rhinoplasty techniques grow in popularity.
Group 3: Lateral Crural Preservation Component
We defined lateral crural preservation as any technique aimed at nasal tip refinement with minimal lateral crural resection. Techniques reviewed in this group include lateral crural steal (LCS), lateral crural overlay (LCO), tongue in groove technique (TING), lateral crural strut grafts (LCSG), cephalic turn-in flaps, and the cephalic hinged flap. Our focus for this section was on published literature that includes outcomes following lateral crural tensioning. We acknowledge that many additional techniques exist and that our search does not encompass all suture methods used in preservation rhinoplasty procedures. The group included 30 total references with 4 (13.3%) level II studies, 5 (16.7%) level III studies, and 21 (70%) level IV studies. Of the 30 references included in this group, 1 (3.3%) is included in Group 1, 3 (10%) are included in Group 2, and 5 (16.7%) are included in all the three groups. Of note, half of these references were published prior to 2019 and 37% were published by academic institutions located in the United States. Of the references reporting surgical details, 10% used a closed approach rhinoplasty for the majority of cases, with 90% utilizing an open approach. Please see the lateral crural preservation group included in [Table 4] for all reference details.[1]
[10]
[18]
[25]
[34]
[46]
[49]
[50]
[51]
[52]
[53]
[54]
[55]
[56]
[57]
[58]
[59]
[60]
[61]
[62]
[63]
[64]
[65]
[66]
[67]
[68]
[69]
[70]
[71]
[72]
To our knowledge, there are no references that directly compare lateral crural preservation techniques to conventional rhinoplasty. The highest level of evidence (level II) is currently available for LCS, LCO, and TING techniques.[68]
[69]
[70]
[71] Foda and Kridel first demonstrated rhinoplasty technique with LCS or LCO for nasal tip repositioning in 1999.[68] In this prospective clinical trial, 28 patients had a significant increase in nasal tip projection and rotation following the LCS technique (p < 0.001), but only a significant increase in tip rotation following the LCO technique (p < 0.001). It was concluded that the LCO technique resulted in a significantly higher change in rotation (12.4 [1.4] vs. 9.8 [1.6], p < 0.001) when compared to LCS, and should be used for patients with severe tip under-rotation.[68] Similarly, a significant difference in Goode ratio (-0.1 [0.01], p < 0.001), nasofacial angle (−2.1 [1.2], p < 0.001), and nasolabial angle (−11.0 [4.9], p < 0.001) was seen by Ghazipour et al with a prospective clinical trial for the treatment of underprojected nasal tip with LCS.[70] When compared to traditional suture techniques, the addition of LCS resulted in a significantly greater change in nasal tip projection and rotation (p < 0.05). Recently, references have assessed PROMs following the LCO, LCS, and TING techniques in primary preservation rhinoplasty.[69]
[71] Darzi et al demonstrated no significant difference in change in SCHNOS-O at 3 and 12 months postoperatively in the lateral crural cut and overlay group when compared to the medial crural cut and overlay group (−23.4 [28.1] vs. −31.9 [35.0]).[71] Gentile and Cervelli then demonstrated better tip projection maintenance and contour following primary preservation rhinoplasty with either LCS or TING techniques when compared to a traditional cartilage graft control group (p < 0.001).[69]
Seven additional references included PROMs in the analysis of lateral crural preservation techniques.[25]
[34]
[50]
[52]
[58]
[60]
[66] Significant improvement in ROE, nasal patency scores, SCHNOS-C/O, NOSE, and VAS-F/C was seen following the sandwich technique described by Öztürk, as well as the mini-LCSG, LCSG, cephalic lateral crural advancement (CLCA) flap, LCO technique, cephalic turn-in flap, and superior-based sliding flap technique with complete cartilage preservation.[25]
[50]
[52]
[58]
[60]
[66] Significant improvement was also seen in SCHNOS-O/C scores following a subdorsal septal approach encompassing all three preservation techniques.[34] Abdelwahab et al found a significant improvement in both SCHNOS-C and VAS-C (p < 0.05) for all lateral crural preservation techniques in cosmetic rhinoplasty.[58]
[66] Similarly, Öztürk and Bulutboth demonstrated a significant improvement in ROE score at 12 months following either the sandwich technique or CLCA flap.[52]
[60] Improvement in SCHNOS-O score was seen only in combined cosmetic and functional rhinoplasty with mini-LCSG, although there was an improvement in nasal patency Likert scale scores or VAS-F following both the sandwich technique and CLCA flap.[52]
[60]
[66]
The remaining references included in this group focus on subjective outcomes, complication rates, and revisions rates with no statistically significant data available.[1]
[10]
[18]
[46]
[49]
[51]
[53]
[54]
[56]
[57]
[59]
[61]
[62]
[63]
[64]
[72] Seventeen studies reported complication rates ranging from 0.00 to 22.10%.[1]
[10]
[18]
[25]
[34]
[46]
[51]
[52]
[53]
[54]
[57]
[59]
[61]
[63]
[64]
[71]
[72] Notably, the highest complication rate occurred following the subdorsal septal approach for the complete preservation of all three components in either S- or V-shaped nasal deformities.[34] Similarly, 16 studies reported low revision rates ranging from 0.00 to 5.3%.[1]
[10]
[18]
[25]
[46]
[49]
[50]
[51]
[52]
[53]
[57]
[60]
[61]
[62]
[64]
[71] A single study by Gruber et al demonstrated a high revision rate of 21.4% following a rhinoplasty technique with preservation of the lateral crus in 14 patients with alar retraction.[56]
Much of the evidence for lateral crural preservation techniques is not comparative and does not include validated PROMs. New, prospective, comparative studies focused on validated outcome measures such as the SCHNOS and VAS surveys are needed to better inform rhinoplasty surgeons on the best techniques for preservation of the lateral crura.
The objective of this study was to evaluate the current evidence-based literature available for the three independent components of the modern preservation technique. Our search strategy resulted in the identification of two systematic reviews summarizing PROMs, as well as complication and revision rates following preservation rhinoplasty. Tham et al found similar results to our current study in an analysis of 22 studies of the preservation rhinoplasty technique.[44] With grouped analysis of 18 studies, they determined overall complication rates, dorsal hump recurrence rates, and revision rates of 3, 4.2, and 3.5% respectively. Unfortunately, analysis of functional and cosmetic outcomes was not run due to heterogeneity in the wide variety of PROMs.[44] Levin et al similarly found a low number of studies quantifying patient satisfaction following a variety of preservation rhinoplasty techniques.[19] It is evident that critical analysis of long-term patient-reported cosmetic and functional outcomes is imperative as preservation rhinoplasty techniques become increasingly popular. Although numerous studies have reported positive patient outcomes following all three categories of preservation technique, the analysis of how long-term outcomes compare to conventional dorsal hump reduction techniques is needed.
