Dorsal Flattening with Periosteal Tensioning: Management of the Central Keystone Blocking Point in Dorsal Preservation Rhinoplasty: A Clinical and Anatomic Study

Kovacevic M, Veit J, Goksel A, Saban Y, Patron V, Davis RE, Zweyer I.

What this paper says

Releasing the central keystone area and tensioning a periosteal flap over the bone-cartilage junction prevented hump recurrence in 204 preservation rhinoplasties followed for a median of 12 months.

Overview

Residual and recurrent humps are the most common unwanted outcomes of dorsal preservation. The authors (a multinational group including Saban, Goksel and Davis) tested a solution in cadaver dissection and in 204 clinical cases since 2020. Dissecting the central keystone, not only the lateral keystone, lets the curved cartilaginous hump slide under the bony vault and releases the recoil that produces the "spring effect"; a periosteal flap then tensions the bone-cartilage junction to hold the flattened dorsum.

Sections of note

Evidence from cadaveric dissection plus 204 patients operated since 2020.
Median follow-up 12 months.
Central keystone dissection releases recoil forces that otherwise push the hump back up.
A periosteal flap tensioned across the bone-cartilage connection provides further flattening and stabilisation.
Reported outcome: stable results and no hump recurrence.

What it means for a patient

Hump recurrence is the recognised weak point of preservation rhinoplasty; this paper addresses it directly.
In this series the modification eliminated recurrence at one year of median follow-up.
The authors state the method lets preservation be used on a wider range of noses than before.

Why this paper matters

It is a large series from leading preservation surgeons targeting the technique's main failure mode, with anatomical backing. Limits: no comparison group, median 12-month follow-up, outcome reported without a validated score in the abstract.

Terms

Keystone area: the junction where nasal bones, upper lateral cartilages and septum meet at the middle of the bridge.
Periosteum: the thin membrane covering bone; here used as a flap for tensioning.
Kyphotic cartilaginous hump: the outward-curved cartilage part of a hump.
Spring effect: the tendency of released cartilage to recoil to its original curved shape.
Recurrent hump: a bump that returns after being lowered.

Summary written by rhinoplasty.cc from the abstract, 2026-09-08; not medical advice. The authors' own abstract follows.

From the abstract

“The most common unwanted outcomes in preservation rhinoplasty continue to be the residual and the recurrent hump. Objective And Hypotheses: We propose a new solution, contributing to preexisting techniques, to overcome this obstacle. Study Design: Our study shows evidence from cadaveric dissection and in 204 clinical…”

Excerpt; the full abstract is on PubMed.