Common Dorsal Flaws Following Preservation Rhinoplasty: A Systemic Analysis

Guyuron B, Wells MW, Chang IA, Deleonibus A.

PubMed 37328654 Publisher (DOI)Free full text (PMC)

What this paper says

Reviewing 59 published preservation rhinoplasty patient images, three reviewers found bridge line irregularities in about 78 percent and an ideal front and side view in none.

Overview

Preservation rhinoplasty has surged in popularity for removing humps or lowering the bridge, but the authors state no one had examined the published photographs for recurring flaws. They searched PubMed, Cochrane, SCOPUS and EMBASE for studies from January 2000 to December 2022, then had three reviewers grade patient images for defects of the bridge.

Sections of note

Design: systematic review with image analysis. Level of evidence III.
59 patient images with 464 views from 24 studies were analyzed.
Optimal dorsal aesthetic lines were seen in 12 patients, 20.3 percent; an optimal profile in 15 patients, 25.4 percent, p equal to 0.66.
No patient had both an ideal front view and an ideal profile.
Most common flaws: dorsal aesthetic line irregularities in 45 patients, reported as 78.0 percent; dorsal deviation in 32, 54.2 percent; residual hump in 25, 42.4 percent.
Interrater agreement was excellent, measured by raw agreement and Krippendorff's alpha.
The reported 78.0 percent does not match 45 of 59, which is 76.3 percent, a small internal discrepancy.

What it means for a patient

The images published to showcase preservation rhinoplasty often show a leftover hump, a leaning bridge or an uneven bridge line.
Published photographs are selected by the authors of those studies, so they represent the results surgeons chose to show, which makes these flaw rates a floor rather than an average.
The analysis rates appearance in photographs only. It reports no breathing outcomes, revision rates or patient satisfaction.
Three reviewers agreed strongly with each other, but one of them is a prominent advocate of the competing structural approach.

Why this paper matters

Preservation rhinoplasty is usually reported by its own practitioners in single group series with positive conclusions. This paper audits their own photographs against a fixed standard and finds a consistent pattern of shortcomings. Whether structural rhinoplasty images would score better under the same review is not tested here.

Terms

Preservation rhinoplasty: reshaping that keeps native nasal structures intact.
Dorsal aesthetic lines: the two shadow lines running from the brows down each side of the bridge.
Residual hump: a bump remaining on the bridge after surgery.
Dorsal deviation: a bridge that leans off the facial midline.
Interrater reliability: how consistently different reviewers grade the same material.

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

Abstract

Background: There has recently been a resurgence of interest in preservation rhinoplasty (PR) for dorsal hump elimination or dorsal projection reduction. However, no studies have scrutinized aesthetic outcomes to identify common pattern of flaws seen in published images to aid those with ardent enthusiasm for this technique to become aware of the frequency of these flaws and find ways to reduce imperfections.

Methods: A systematic literature review was performed using search terms ("preservation" OR "let down", "push down") AND "rhinoplasty" on PubMed, Cochrane, SCOPUS, and EMBASE databases for studies between January 2000 and December 2022. Patient images from these studies were analyzed by three reviewers (MWW, IAC, and BG) for dorsal flaws. Raw interrater agreement percentage and Krippendorff's alpha were calculated to determine interrater reliability. A descriptive and comparative analysis with Fisher's exact test was performed for the aggregate data.

Results: There were 59 patient images with 464 views from 24 studies included for final analysis. Optimal dorsal aesthetic lines (DAL) were noted in 12 patients (20.3%), while optimal profile was observed in 15 patients (25.4%) (p = 0.66). Combined ideal front and profile view of dorsum was not observed on any patients. The most common flaws were DAL irregularities (n = 45; 78.0%), dorsal deviation (n = 32, 54.2%), and residual hump (n = 25, 42.4%). There was excellent interrater agreement.

Conclusions: While PR may have some advantages, it has shortcomings in outcomes, particularly dorsal irregularities, dorsal deviation, and residual humps. Awareness of these imperfections may compel those performing this procedure to modify their techniques and improve their results.

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).