Nasal Dorsum Preservation

Introduction to Nasal Dorsum Preservation

• The preservation of the nasal dorsum is best achieved through techniques that maintain the integrity of anatomical structures, such as castellation, batten grafts, and preservation of periosteal insertions during osteotomies, as recommended by Rhinology guidelines 1

Surgical Techniques for Nasal Dorsum Preservation

• Castellation, batten grafts, minimal osteotomies, periosteal preservation, "figure of 8" sutures, and spreader grafts are techniques used in nasal dorsum preservation to maintain the integrity of anatomical structures 1
• A sequence of osteotomies that medializes the nasal bones and the osseous septum, "like opening a book", is recommended in cases of severe osseous deviation 1
• Autogenous cartilage grafts, typically harvested from the septum, can be used to fill depressions, and thin cartilage wafers can improve and sometimes completely correct asymmetries, as recommended by the American Academy of Facial Plastic and Reconstructive Surgery 1

Avoiding Complications in Nasal Dorsum Preservation

• Morselization is not recommended for weakening cartilage, as it increases the surface area with a higher risk of absorption and makes secondary revisions more difficult 1
• The sequence of osteotomies should be changed to medialize the nasal bones and the osseous septum in cases of severe osseous deviation, to avoid visible irregularities or stepped deformities 1
• The American Academy of Otolaryngology recommends identifying the exact location of the nasal deformity and determining optimal osteotomy sites to achieve proper correction, considering the patient's nasal anatomy and skin thickness, and using a piezoelectric device with settings of 25-30 kHz frequency to follow a specific osteotomy path 1
• The American Academy of Otolaryngology and the American Rhinologic Society suggest preserving periosteal and mucosal attachments when possible, and using the smallest possible osteotomies to achieve desired mobilization, which can be performed with small skin punctures 1
• Percutaneous lateral osteotomy is recommended for more severe cases with associated functional issues, particularly effective when combined with middle vault problems, providing anatomical restoration for both aesthetic improvement and better respiratory function 1
• Avoid intermediate osteotomies halfway up the nasal bone as they risk visible irregularities or step-off deformities, especially where skin covering is thin, and be cautious with short nasal bones as they are a relative contraindication for osteotomies due to risk of bony communication 1

Post-Surgical Care and Follow-Up

• The American College of Surgeons recommends regular clinical and functional assessments, and radiographic evaluation at 12 months post-surgery, with earlier assessment if bone deformity worsens or clinical concerns arise 2
• The use of piezoelectric ultrasound for percutaneous osteotomy offers superior precision and safety compared to conventional techniques, particularly in cases where precise bone cuts are essential, and when working near important neurovascular structures, although it may be more time-consuming than conventional techniques 1
• Controlled fracture patterns and camouflaging techniques can help prevent additional step-off deformities and achieve complete correction 1
• Training is necessary to master the technique, which is not a substitute for proper surgical planning and anatomical understanding, and may not be suitable for all types of nasal deformities 1