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• W4223506501 abstract "Facial Plastic Surgery & Aesthetic MedicineVol. 24, No. 3 Invited CommentaryFree AccessCommentary on “The Spare Roof Technique as a New Approach to the Crooked Nose” by Dias et al.Ivan WayneIvan Wayne*Address correspondence to: Ivan Wayne, MD, W Facial Aesthetics, 13904 Quailbrook Drive, Oklahoma City, OK 73134, USA, E-mail Address: [email protected]https://orcid.org/0000-0002-3881-0186W Facial Aesthetics, Oklahoma City, Oklahoma, USA.Search for more papers by this authorPublished Online:15 Jun 2022https://doi.org/10.1089/fpsam.2022.0050AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail The world of rhinoplasty surgery has entered an exciting era. What is old is new again with an international surge of interest in “preservation rhinoplasty.” The recent re-emergence of dorsal preservation (DPR) techniques is rapidly transforming the practice for many surgeons by offering an alternative to component dorsal hump reduction that has been accepted as the standard of care for so many years.Fueling this growth in DPR have been the educational efforts of well-respected rhinoplasty surgeons, including D. Toriumi, R. Daniel, and Y. Saban, among others. Although “preservation” techniques have been around since the early years of rhinoplasty surgery, their recent resurgence offers us several new tools to approach modification of the nasal dorsum, including both size reduction and treatment of axis deviations as outlined by the Dias et al. in of The Spare Roof Technique as a new approach to the Crooked Nose.1The term DPR Rhinoplasty is confusing as it encompasses several significantly different techniques that only share one common trait—the preservation of the connection between the upper lateral cartilages and most superior dorsal septum eliminating the need for spreader grafts or spreader flaps to restore the middle vault. Beyond this distinction there are multiple techniques related to changes in the shape and position of the bony dorsum as well as the level of intervention in manipulations of the nasal septum. Surgeons confronting this for the first time may become overwhelmed and easily confused. The reader will be well served to consult the excellent review in this journal, A Practical Classification System for Dorsal Preservation Rhinoplasty Techniques.2A wonderful review of the growth of the DPR movement among surgeons around the world by Patel et al.3 reveals that practice growth in South America and Asia has primarily been through education at the meetings and conference and rather than through formal surgical training. The authors nicely illustrate and summarize the different techniques for modification of the dorsum and septum that fall under the umbrella of preservation rhinoplasty. See Figures 1–3.Fig. 1. Lateral and transverse osteotomies mobilize the bony vault in the pushdown rhinoplasty technique. (Used with permission from Patel et al.).3Fig. 2. In the letdown rhinoplasty, a second lateral osteotomy allows for a wedge of frontal process of the maxilla is removed (highlighted in blue). (Used with permission from Patel et al.).3Fig. 3. (A) The subdorsal cartilage resection technique. (B) An alternative to the subdorsal cartilage resection. (C) A high-septal resection technique (Used with permission from Patel et al.).3The authors of “The Spare Roof Technique as a new approach to the Crooked Nose” seek to examine the effectiveness of their preferred version of DPR to correct axis deviations. They found using Utrecht Questionnaire answers and aesthetic Likert scale assessment a significant improvement in access deviation with the SRT. There are few alternative publications on the topic of DPR for the crooked nose.Correction of the crooked nose remains one of the premier challenges for the rhinoplasty surgeon. Traditional teaching advocates the use of medial and lateral osteotomies as powerful techniques to narrow the bony dorsum but often insufficient for correcting the deviated central bony segment and achieving significant central axis correction. Compounding our limited surgical armamentarium is the significant issue of underlying facial skeletal asymmetry noted in the majority of patients presenting with a crooked nose.6 These patients have both bony and cartilaginous side-to-side length discrepancies not to mention the skin soft tissue envelope asymmetries that can resist attempts at modifying the nasal framework.The major differences among the DPR approaches are how the dorsal bony skeleton is modified. In this article, the spare roof technique is used that modifies the surface of the dorsum through either rasping or an osteotome to remove the bony cap. The actual lowering of the dorsal height is achieved by removing a strip of cartilage somewhere below the dorsum; in this article the high strip is used. This removal of a strip of septum effectively frees the cartilaginous dorsum from the septum and is a key point in correcting axis deviations.In conventional rhinoplasty teaching, axis deviation is addressed with septal correction and osteotomies. With DPR, the cartilaginous dorsum is relatively free to move independently of the septum potentially reducing this source of “tethering.” The authors found consistent improvement in axis deviation using their assessment scale.In The Effectiveness of Asymmetric Dorsal Preservation for Correction of I-Shaped Crooked Nose Deformity in Comparison to Conventional Technique by B Ozucer and O Cxam4, the authors compared conventional component techniques to DPR for treatment of the crooked nose deformity. They applied a unilateral let down maneuver to shorten longer nasal bone facilitating medialization of the dorsum in an En-bloc fashion. They found the two techniques equally effective while importantly avoiding area (See Figure 4, diagram C).Fig. 4. Schematic of DPR (A) pushdown, (B) letdown, and (C) asymmetric pushdown, and (D) conventional osteotomies. Dashed lines = osteotomies; continuous lines = ostectomy. (Used with permission from Özücer and Çam's).4 DPR, dorsal preservation.A similar approach to the crooked dorsum was used by Finocchi et al. in the Pisa Tower Concept: A New Paradigm in Crooked Nose Treatment.5 They used a unilateral letdown on the long side of the nasal dorsum and found it highly effective with a mean follow-up of 18 months.Many DPR techniques include a cut through the perpendicular plate freeing bony dorsum from the underlying midline support. This is an extremely powerful cut when combined with one of the following preservation techniques: Ferreira-Ishida Technique-Spare Roof B, letdown, and pushdown. In all three the bony dorsum or cap is free to move with the attached cartilaginous dorsum and when combined with release at the fibrous junction at the piriform aperture, axis deviation can be addressed in a manner previously not possible with traditional component techniques.Freeing the bony cap or central segment to move by separating the dorsal skeleton from the underlying bony/cartilaginous septum represents and major departure from traditional component reduction techniques where the central segment of bone remains rigidly attached to the perpendicular plate bone and immune to the effects of traditional medial and lateral osteotomies, requiring a destabilizing transverse osteotomy to achieve axis correction.The authors have done an excellent job presenting new information and a fairly young technique in the modern era rhinoplasty for addressing a difficult challenge we all face. The question remains, does preservation rhinoplasty offer superior outcomes to more conventional approaches? There is limited long-term data. As patients become more aware of these often heavily marketed techniques, it will be helpful to be prepared and understand them even if we chose not to utilize them.Author Disclosure StatementNo competing financial interests exist.Funding InformationThe authors received no financial support for the research, authorship, and publication of this article.References1. Dias DR, Santos M, Sousa e Castro S, et al. The Spare Roof Technique as a new approach to the Crooked Nose. Facial Plast Surg Aesthet Med. [Epub ahead of print]; DOI: 10.1089/fpsam.2021.0055 Link, Google Scholar2. Gonçalves Ferreira M, Toriumi DM. A Practical Classification System for Dorsal Preservation Rhinoplasty Techniques. Facial Plast Surg Aesthet Med. 2021;3:15. Google Scholar3. Patel PN, Kandathil CK, Buba CM, et al. Global Practice Patterns of Dorsal Preservation Rhinoplasty. Facial Plast Surg Aesthet Med. 2021; DOI: 10.1089/fpsam.2021.0055 Link, Google Scholar4. Özücer B, Çam OH. The effectiveness of asymmetric dorsal preservation for correction of I-shaped crooked nose deformity in comparison to conventional technique. Facial Plast Surg Aesthet Med. 2020;22(4):286–293. Link, Google Scholar5. Finocchi V, Vellone V, Ramieri V, de Angelis F, Marianetti TM. Pisa tower concept: A new paradigm in crooked nose treatment. Plast Reconstr Surg. 2021;148(1):66–70. Crossref, Medline, Google Scholar6. Rohrich RJ, Villanueva NL, Small KH, Pezeshk RA. Implications of Facial Asymmetry in Rhinoplasty. Plast Reconstruct Surg. 2017;140(3):510–516. Crossref, Medline, Google ScholarFiguresReferencesRelatedDetails Volume 24Issue 3Jun 2022 InformationCopyright 2022, American Academy of Facial Plastic and Reconstructive Surgery, Inc.To cite this article:Ivan Wayne.Commentary on “The Spare Roof Technique as a New Approach to the Crooked Nose” by Dias et al..Facial Plastic Surgery & Aesthetic Medicine.Jun 2022.184-186.http://doi.org/10.1089/fpsam.2022.0050Published in Volume: 24 Issue 3: June 15, 2022Online Ahead of Print:April 11, 2022PDF download" @default.
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