Exploring the Resurgence of the Preservation Rhinoplasty: A Systematic Literature Review

Wells MW, DeLeonibus A, Barzallo D, Chang IA, Swanson M, Guyuron B.

PubMed 37130993 Publisher (DOI)Free full text (PMC)

What this paper says

A systematic review covering 5967 preservation rhinoplasty patients across 30 studies found the push-down technique had lower rates of leftover hump and revision than the let-down technique.

Overview

Preservation rhinoplasty keeps the soft tissue covering, the bridge and the tip cartilages intact as far as possible. Its two main bone maneuvers are push-down, which sinks the bony bridge, and let-down, which removes a wedge of bone first so the bridge settles. The authors searched PubMed, Cochrane, SCOPUS and EMBASE for reports on these techniques and compared outcomes between the two.

Sections of note

Design: systematic review of 30 studies covering 5967 preservation rhinoplasty patients, with subgroups of 307 push-down and 529 let-down patients. Level of evidence III.
Rhinoplasty Outcome Evaluation scores rose significantly, reported as 62.13 before versus 91.14 after, p less than 0.001.
Residual or recurrent dorsal hump: 1.3 percent, 4 patients, push-down versus 4.6 percent, 23 patients, let-down, p equal to 0.02.
Revision rate: 0 percent push-down versus 5.0 percent, 25 patients, let-down, p less than 0.001.
The authors state push-down is often chosen for patients with smaller humps, which affects the comparison.
Note the reported percentages do not precisely match the stated let-down group size.

What it means for a patient

The push-down technique had no revisions in this pooled data, but it is used on easier cases with smaller humps, so the two groups are not equivalent.
Leftover hump is the recognized weak point of preservation rhinoplasty, and it appeared in both groups.
The satisfaction figures come from pooled single group studies, not from comparison against conventional hump removal.
Limits: no randomized trials included, heterogeneous studies, selection differences between the two techniques, and no comparison with structural rhinoplasty.

Why this paper matters

Preservation rhinoplasty has grown quickly on the argument that keeping the bridge intact produces smoother, more natural results. This review assembles the largest pooled patient count available and reports a real difference between its two main bone maneuvers. It does not resolve whether that difference reflects the technique or the noses each is used on.

Terms

Preservation rhinoplasty: reshaping that keeps native nasal structures intact.
Push-down: lowering the bony bridge into the face after cutting its supports.
Let-down: removing a wedge of bone from the side walls so the bridge settles lower.
Residual dorsal hump: a bump remaining on the bridge after surgery.
Rhinoplasty Outcome Evaluation: a patient questionnaire scoring satisfaction with the nose.

Summary written by rhinoplasty.cc from the abstract, 2026-09-09; not medical advice. The authors' own abstract follows.

Abstract

Introduction: The underlying principles of preservation rhinoplasty (PR) center around maintaining the soft tissue envelope, dorsum, and alar cartilage through surgical manipulations and tip suture techniques. In particular, the let-down (LD) and push-down (PD) techniques have been described, although reports of indications and outcomes in the literature are sparse.

Methods: A systematic review of the literature was performed using search terms "preservation" OR "let down" OR "push down" AND "rhinoplasty" on PubMed, Cochrane, SCOPUS, and EMBASE databases. Patient demographic information, operative details, and surgical outcomes were recorded. Sub-cohorts for patients who underwent LD and PD techniques were analyzed utilizing Fischer's exact test for categorical variables and Student's t test for continuous variables.

Results: Overall, there were 5967 PR patients in 30 studies in the final analysis, with 307 patients in the PD cohort and 529 patients in the LD cohort. The Rhinoplasty Outcome Evaluation Questionnaire showed a significant increase of patient satisfaction after PR compared to before PR (62.13 vs 91.14; p < 0.001). There was a significantly lower rate of residual dorsal hump or recurrence of 1.3% (n = 4) in the PD when compared to 4.6% (n = 23) in LD cohorts (p = 0.02). The revision rate of PD (0%, n = 0) was also significantly lower than that of LD (5.0%, n = 25) (p < 0.001).

Conclusion: Based on these published articles, it seems that preservation rhinoplasty is safe and efficacious procedure with improved dorsal aesthetic lines, reduced dorsal contour irregularities, and claimed excellent patient satisfaction. In particular, the PD technique has fewer reported complications and revisions than LD approach, although PD is often indicated in patients with smaller dorsal humps.

Level Of Evidence Iii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Abstract as indexed by PubMed; the article is open access (PubMed Central).