Preservation rhinoplasty in Barcelona: what it is, who it suits and where it falls short
Preservation rhinoplasty is a technique that, instead of resecting the dorsal hump, lowers the whole dorsum as a block while keeping its support structure intact: the work is done underneath the dorsum, not on its surface. Its main advantage is that the resulting profile is the patient’s own profile, simply lower, with less risk of irregularities becoming visible or palpable over the years. Its main limitation is that it demands a particular anatomy and leaves less room to adjust as the operation proceeds. It does not suit every nose, and it is worth knowing why before asking for it by name.
How it differs from classic or structural rhinoplasty
In classic rhinoplasty, known as the structural technique, the hump is resected directly. Doing so opens what surgeons call the nasal roof, which then has to be rebuilt with osteotomies and grafts to avoid irregularities and to keep the nose breathing well. In preservation rhinoplasty the surface of the dorsum is never touched: it is released from below, removing a strip of septal cartilage and, depending on the variant, of bone as well, and the whole block descends. The junction between the nasal bones and the upper lateral cartilages — the area that supports the entire bridge — is never divided. A note on terminology, because it causes confusion: at conferences the term used is dorsal preservation, while patients write preservation rhinoplasty, preserving rhinoplasty or push-down rhinoplasty. They all refer to the same family of techniques.
Push-down and let-down: the two ways of lowering the dorsum
Preservation is not a single operation but a family of techniques, and the difference matters because it determines which noses can be treated. In a push-down, a strip of cartilage is removed beneath the septum and the nasal pyramid sinks into the bony aperture, like a lid dropping inside its frame. In a let-down, a strip of bone is also removed at the base of the pyramid, so that it descends and rests without having to wedge itself inside; this is used when the hump is larger or the nasal base is wide, because sinking the pyramid in those cases tends to widen the nose. There are also intermediate variants that preserve only the cartilaginous part of the dorsum while acting on the bone, and preservation techniques applied to the tip and the ligaments, which are another conversation. What matters for the patient is that the choice between them is not a matter of school allegiance: it depends on the height of the hump, the width of the base and the shape of the nasal root.
Why it is so widely discussed now
The key lies in the so-called keystone area, the junction between the nasal bone, the septum and the upper lateral cartilages, which acts as the structural support of the entire dorsum. Preserving that area intact, rather than dividing and rebuilding it, reduces the number of manoeuvres required and better respects the ligaments and the internal lining. There is an aesthetic reason behind the enthusiasm: the dorsal aesthetic lines — those two soft shadows running from the brows to the tip — are very hard to rebuild once broken, and in preservation they are simply never broken. The technique is also not new; it was described more than a century ago, fell out of use and has returned with far better instruments and anatomical understanding. The appropriate caution is the usual one with anything that returns: enthusiasm for a technique tends to precede knowledge of its recurrences.
Can it be done with a closed approach?
Yes, and in fact much preservation work lends itself well to the closed approach, with all incisions inside the nose and no external scar. The reason is simple: if the dorsum does not need to be exposed or rebuilt, one of the usual reasons for opening disappears. But the two decisions should not be conflated. Preservation versus structural is one question; closed versus open is another, and it depends above all on the work the nasal tip requires. A markedly asymmetrical tip or a revision case may call for the open approach even when the dorsum is treated by preservation. I go into this in more detail on the rhinoplasty page.
And ultrasonic preservation rhinoplasty?
They are two different things that are often combined, and industry advertising tends to blur them until they seem interchangeable. Preservation describes what is done with the dorsum; the ultrasonic scalpel describes what the bone is cut with. The piezoelectric instrument works on bone without damaging the surrounding lining and vessels, which is particularly useful in a let-down, where a very precise strip of bone must be removed at the base of the pyramid. Combining them makes technical sense, but neither turns a non-candidate nose into a candidate, nor guarantees a swelling-free recovery. I cover this in detail in the article on ultrasonic rhinoplasty.
Which noses it suits, and which it does not
The ideal candidate is a nose whose dorsum is well drawn but too high: harmonious dorsal lines, no marked deviation, a predominantly bony-cartilaginous hump and a tip that does not require major change. In that scenario preservation does exactly what it promises, because the only thing in excess is height. There are three situations in which I am reluctant, and I say so in consultation: a markedly deviated septum, because the manoeuvre depends on working through the septum and a significant deviation compromises both the lowering and the breathing; a dorsum with pre-existing irregularities or an S-shaped profile, where lowering the whole block also preserves the very defect the patient wants corrected; and a revision rhinoplasty, where the anatomy is already altered and predictability drops. Caution is also warranted with very large humps. In those cases the structural technique is not plan B: it is the correct plan.
The real drawbacks of preservation rhinoplasty
The most specific drawback, and the one least often mentioned in commercial material, is hump recurrence: the dorsum can rise partially over the following months and regain some of the height that was removed. It is a well-described complication in the literature and it is why so many technical variants have appeared, all aimed at fixing the dorsum more reliably in its new position. The second is the margin for correction: once the dorsum has been lowered, adjusting as you go is harder than with the structural technique, where you sculpt and check. The third is that the technique depends on septal anatomy far more than the classic one does, which narrows the group of patients it can be offered to. And there is a fourth, stated honestly: it is not an easy technique, it has its own learning curve, and in some cases the right decision during surgery is to convert to a structural approach. That this may happen should be discussed beforehand, not discovered afterwards.
What recovery involves
In essence, the same as any rhinoplasty: a splint for about seven days, bruising around the eyes that settles in ten to fourteen days when it appears, and a socially comfortable appearance from the first month. What does change is that, since the nasal roof has not been opened or rebuilt, the dorsal area tends to de-swell sooner and feels less rigid. That should not be extrapolated to the whole nose: the tip de-swells at the usual rate, and the definitive result is not assessed until twelve months, or longer in thick skin. If someone promises a substantially faster recovery on the grounds of using preservation, they are selling something the technique does not deliver.
Structural or preservation rhinoplasty: how the decision is made
The decision is made with the anatomy in front of you, not from a catalogue. In consultation I take standardised photographs and analyse the whole profile, and three questions follow: what shape the dorsum has beyond being high, what condition the septum is in, and how much work the tip needs. If the dorsum is only excessive in height and the septum cooperates, preservation is an excellent option. If the shape of the dorsum has to be redrawn, the structural technique allows that and preservation does not. There is also a question my maxillofacial training obliges me to ask every time, and it is not strictly nasal: in a fair number of patients who come in about their nose, part of the profile imbalance comes from an under-projected chin, in which case even the best possible rhinoplasty leaves the whole half-resolved. I develop that combined approach in the article on aesthetic and functional rhinoplasty.
The choice between a preservation technique and a structural one depends on the anatomy of each nose, not on a trend or on what ranks best online. In consultation I assess which approach offers the best balance between aesthetic result, breathing function and long-term stability, and I say plainly when preservation is not the right option, because a sound technique used on the wrong nose is still a poor indication.
Related specialty: Facial Aesthetic Surgery
Related article: Aesthetic and functional rhinoplasty: how they differ and when they overlap
References
- 1.Saban Y, Daniel RK, Palhazi P. Preservation Rhinoplasty. 3rd ed. Istanbul: Septum Publishing; 2020.
- 2.Daniel RK. The Preservation Rhinoplasty: A New Rhinoplasty Revolution. Aesthet Surg J. 2018;38(2):228-229.
- 3.Kosins AM, Daniel RK. Decision Making in Preservation Rhinoplasty: A 100 Case Series With One-Year Follow-Up. Aesthet Surg J. 2020;40(1):34-48.
- 4.Tham T, Bhuiya S, Wong A, Zhu D, Romo T, Georgolios A. Clinical Outcomes in Dorsal Preservation Rhinoplasty: A Meta-Analysis. Facial Plast Surg Aesthet Med. 2022;24(3):187-194.
- 5.Tuncel U, Aydogdu IO, Kurt A. Reducing Dorsal Hump Recurrence Following Push Down-Let Down Rhinoplasty. Aesthet Surg J. 2021;41(4):428-437.
- 6.Daniel RK, Palhazi P. Rhinoplasty: An Anatomical and Clinical Atlas. Cham: Springer International Publishing; 2018.
About the author
Dr. Pablo Vaquero is an attending Oral and Maxillofacial Surgeon at Vall d’Hebron University Hospital (Barcelona) and a surgeon at the Instituto Maxilofacial at Centro Médico Teknon. Trained in Hong Kong, Buenos Aires and Charité Berlin, he is Spain’s National Trainee Representative to the EACMFS and the author of scientific publications and the Lifting Surgery chapter of the SECOM CyC reference manual.