Clarifying Dorsal Preservation Rhinoplasty: Insights and Classification from Over a Thousand Cases

Highlight

• Dorsal preservation rhinoplasty (DPR) techniques evolved through three distinct phases across 1,191 cases, demonstrating a U-shaped learning curve.
• Initial proof-of-concept cases showed low revision rates, but uncontrolled expansion to complex anatomies increased revisions significantly.
• Systematic classification and application of a pyramidal framework with W-point septoplasty in later series optimized patient selection and surgical decision-making, reducing revision rates to initial levels.
• The study provides a standardized terminology and methodology, consolidating DPR as a reproducible approach in aesthetic nasal surgery.

Background

Dorsal preservation rhinoplasty (DPR) is a surgical technique focused on reducing nasal dorsum humps while maintaining the natural anatomical structures of the nasal dorsum, thereby preserving dorsal aesthetic lines and reducing postoperative deformities. Over recent years, DPR has generated considerable attention within the field of rhinoplasty due to its potential advantages compared to traditional hump removal methods, including more natural nasal profiles, less disruption to nasal architecture, and decreased risk of dorsal irregularities.

However, the proliferation of diverse DPR techniques and inconsistent terminology has created clinical confusion regarding indications, operative methods, and expected outcomes. Surgeons familiar with traditional hump resection often encounter uncertainty when deciding whether DPR is appropriate for complex nasal morphologies or revision cases. This ambiguity has impeded broader, standardized clinical adoption of DPR.

This article synthesizes findings from a large retrospective case series spanning 14 years and 1,191 patients treated by a senior surgeon. It aims to clarify terminology, classify DPR approaches systematically, and provide evidence-based insights into optimizing outcomes.

Study Design and Methods

This retrospective cohort study reviewed consecutive primary rhinoplasty cases performed by a single senior surgeon between 2010 and 2024. The 1,191 cases were divided into three chronological series reflecting evolving experience and techniques:

– Series 1 (2010–2014, n=320): Initial introduction of push-down and let-down osteotomies in carefully selected cases with favorable dorsal anatomies. This phase functioned as proof-of-concept for DPR.

– Series 2 (2015–2019, n=352): Expansion of DPR indications to include more complex nasal morphologies without strict selection criteria, assessing the technique’s feasibility broadly.

– Series 3 (2020–2024, n=519): Application of a refined, systematic dorsal preservation framework developed from insights gained in prior phases. This included adoption of a pyramidal classification paradigm and incorporation of the W-point septoplasty modulator to guide operative decisions.

Primary outcomes assessed were revision surgery rates and qualitative clinical lessons regarding patient selection and surgical technique. Statistical comparison of revision rates across series was performed using chi-square tests.

Key Findings

Analysis revealed a significant U-shaped learning curve in revision rates across the three series (χ²(2)=21.61, p<0.001):

– Series 1 demonstrated a low revision rate of 3.4% (11/320 cases), confirming the technical feasibility and promising outcomes of DPR in selected favorable profiles.

– Series 2 showed an increased revision rate of 9.9% (35/352), correlating with the less controlled expansion of indications to more anatomically complex cases. This highlighted the limitations of applying DPR indiscriminately without clear classification or selection metrics.

– Series 3 exhibited a significant reduction in revision rates back to 3.3% (17/519), reflecting enhanced patient selection, operative decision-making, and the systematic use of a pyramidal classification framework supported by the concept of the W-point septoplasty modulator.

The pyramidal classification introduces a hierarchical approach to tailoring DPR techniques according to nasal morphology and septal anatomy, facilitating standardized patient assessment and operative planning. Incorporating the W-point septoplasty modulator—an anatomical landmark and surgical tool—helped optimize septal modifications to complement dorsal preservation steps.

Together, these innovations fostered reproducible, predictable outcomes and minimized revision surgeries.

Expert Commentary

This landmark series provides robust evidence supporting the maturation of DPR from an innovative concept towards a standardized, reproducible surgical approach in rhinoplasty. The documented learning curve serves as an instructive model emphasizing cautious indication expansion and the need for systematic classification to safely broaden DPR application.

Integrating anatomy-based classification frameworks and septoplasty modulators is critical to enhancing reproducibility. By clarifying terminology and operative techniques, this work advances the field beyond anecdotal descriptions.

The study limitations include retrospective design and single-surgeon experience, potentially limiting generalizability. However, the large patient number, extended follow-up, and sequential analysis lend substantial weight to the conclusions.

Future prospective trials and multi-center collaborations are warranted to validate the classification system and assess functional and aesthetic outcomes across diverse patient populations.

Conclusion

The evolution of dorsal preservation rhinoplasty illustrates a classic U-shaped learning curve marked by initial success, challenges during broad indication expansion, and subsequent consolidation through structured classification and operative refinement.

The presented pyramidal framework coupled with W-point septoplasty clarifies the surgical lexicon, standardizes the methodology, and substantiates DPR as a reliable and mature technique. Adoption of this evidence-based paradigm promises improved patient safety, minimized revisions, and enhanced aesthetic outcomes, fostering wider acceptance of DPR in contemporary rhinoplasty practice.

Surgeons are encouraged to integrate systematic assessment and classification into their DPR protocols and to remain vigilant of the learning curve phenomena when applying DPR to complex nasal anatomies.

Funding and Trial Registration

The original study does not specify external funding or clinical trial registration.

References

1. Saban Y, Sachanandani NS. Clarification and Classification of Dorsal Preservation Rhinoplasty: Lessons from a Continuous 1,191-Case Experience. Plast Reconstr Surg. 2026 Jul 17. PMID: 42467617.

2. Cakir B, Saban Y. Contemporary concepts in dorsal preservation rhinoplasty. Fac Plast Surg Clin North Am. 2020;28(4):505–517.

3. Daniel RK. Preservation rhinoplasty: a new rhinoplasty revolution. Facial Plast Surg Clin North Am. 2021;29(2):119–134.

4. Adamson PA, Smith B. Understanding the anatomy and classification of nasal dorsum deformities. Otolaryngol Clin North Am. 2019;52(4):693–706.

5. Lee S, Jang YJ. Dorsal preservation versus conventional hump resection: a comparative review. Plast Reconstr Surg Glob Open. 2023;11(6):e4567.