Abstract
Background:
Dorsal preservation (DP) caused privilege change in the concept of rhinoplasty and a promising superior functional and aesthetic transformation in rhinoplasty surgery. Avoiding dissection of the dorsal nasal bone and cartilage will leave the soft-tissue envelope intact, leading to a fine and smooth appearance, faster operation with less subsequent edema, and overall preservation of the dorsal aesthetic line.
Methods:
This prospective study included 113 patients who underwent DP rhinoplasty for nasal hump treatment with minimum dissection of nasal dorsum soft-tissue envelope. Results were evaluated using the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS).
Results:
The mean preoperative SCHNOS score was 7.21; the mean obstructive score was 2.95 ± 1.068 and the mean aesthetic score was 4.27 ± 0.771. The average lowering of the dorsal hump was 4.4 mm. Approximately 96% of patients showed improvement in the SCHNOS score after surgery, 86.7% (98 patients) showed improvement in the obstructive symptoms and 95.6% (108 patients) showed improvement in the aesthetic score. Complications were seen in 22.11% (most commonly residual hump in 13.27% of cases and dorsal indentation in 5.31%), bleeding was seen in 2.65%, and granuloma formation at the dorsal osteotomy site was seen in 0.88%. There was a very significant improvement in the aesthetic, obstructive, and overall SCHNOS score (P = 0.000) for each parameter.
Conclusions:
DP rhinoplasty is a safe and very effective procedure, with very low risk of complications. Most of the treated patients have improvement of the obstructive and aesthetic outcome after surgery.
CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
Dorsal preservation (DP) caused privilege change in the concept of rhinoplasty and a promising superior functional and aesthetic transformation in rhinoplasty surgery. Nasal hump treatment with preservation of the dorsum goes back to Lothrop in 1914, and the term was first described by Daniel in 2018. The main idea behind the DP is that the usual standard technique of reducing and rebuilding is replaced with preserving and reshaping the nose. The classic structural rhinoplasty has evolved when surgeons noticed that when the nasal anatomy is changed or made smaller, these structures must be rebuilt to resist the forces of scar contracture. If anatomy is preserved, structural rebuilding will still be required, but to lesser extent.1–6
Preservation rhinoplasty involves three major steps to perform the surgery; these include elevation of the soft-tissue envelope by means of the subperichondrial and the subperiosteal approach, preservation of the osteocartilaginous dorsum, and maintenance of the alar cartilages with minimum resection. Most operations for rhinoplasty involve resection of the dorsal hump, resulting in the creation of an open roof that requires osteotomy and reconstruction of the midvault with upper lateral cartilage (ULC) tension-spanning suture to reconstitute the ULCs into the normal anatomical position, spreader flaps, or spreader grafts, whereas DP surgery aims to maintain the dorsal structures and eliminate the dorsal hump through subdorsal septal resection, which is followed by osteotomy to decrease the height of the dorsal line. By this technique, the surgeon is able to modify the nasal dorsum without major destruction of the nasal anatomy with maintenance of the dorsal aesthetic line.1,7
The Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) for functional and cosmetic rhinoplasty is a recently introduced, validated, multimodal patient-reported outcome scale that measures the patient’s perception of their nasal appearance and nasal function and its impact on social performance; it is more specific, more inclusive, and has been the most extensively validated. The SCHNOS score is the first patient-reported surgery outcome measure that has been developed adopting the accepted international standards for evaluation of both functional and cosmetic components of rhinoplasty surgery. This includes a standard questionnaire that contains a 10-item self-reported questionnaire concerning the functional and the aesthetic points before rhinoplasty surgery and reporting the outcomes after that.8–13 The aim of this study is to explore domains of the SCHNOS questionnaire after functional, cosmetic, and combined (functional and cosmetic) outcomes in preservative rhinoplasty over 15 months’ follow-up.
PATIENTS AND METHODS
This is a prospective study that was conducted between November of 2018 and March of 2020. This study was approved by the Ethical Committee and Research Registration of Duhok medical college. Informed written consent was taken from each patient to be enrolled in the current study.
A total of 113 patients who underwent DP rhinoplasty for nasal hump treatment with minimum dissection of the nasal dorsum soft-tissue envelope were included. Patients with genetic or congenital facial disorders, patients who had previously undergone hump treatment, patients who required midvault reconstruction, and patients with severe nasal septal deviation were excluded from this study. The dorsal deformity was ordered depending on the anticipated amount of dorsal reduction and the dorsal shape using the classification described by Lazovic et al.14
We determined the anticipated amount of dorsal hump reduction by photographic imaging using profile photographs of the cases. The nasal hump is either V or S shape; when the caudal portion of the nasal bones is straight from nasion (N point) to keystone junction (R point) without angulation, this will result in a “V-shape” configuration, whereas cases that have distinct kyphion point (K point) and kyphion angulation result in an “S-shape” nasal bone configuration. We put single septal piece to augment the dorsal area cephalic to the supratip breaking point.
Surgical Technique
All operations were performed under general anesthesia; regardless of adopting an open or closed approach, we used subdorsal septal excision (Saban subdorsal strip technique) and the nasal dorsum was not undermined in all cases. (See Figure, Supplemental Digital Content 1, which shows a schematic representation of the subdorsal excision of septum, starting from the M point, http://links.lww.com/PRS/G93.)
In case of the open approach, the surgery started with transcolumellar incision until we reached the tip, and then we cut only the superficial Pitanguy ligament and stopped there, leaving the deep Pitanguy ligament intact. (See Figure, Supplemental Digital Content 2, which shows an intraoperative photograph demonstrating opening the tip and stopping the dissection there, leaving the deep midline Pitanguy ligament and lateral scroll area intact, http://links.lww.com/PRS/G94.)
A hemitransfixion incision is then made, leaving 1 mm of the caudal septal cartilage untouched; this is regarded as a posterior strut, preserving the midline Pitanguy ligament coming from the dorsum attachment to the nasal septum spine. Then, the posterior septum is undermined in a subperichondrial plane on both sides; after complete septum dissection, Saban subdorsal septal excision is performed without disrupting the M-shaped connection between the ULC (lateral process). In cases that required septoplasty after or required harvesting of the septal cartilage for graft, we removed the lower septal area, leaving not less than 20 mm as an L-shaped septum behind to support the nose.
Initially, a conservative resection is performed using a baby Rongeur and multiple small bites are removed; this will avoid any twisting motion. Then, an incremental excision is performed. Lateral nasal osteotomy is performed by means of internal or external chisel. For transverse fractures, when present ahead of the dorsal hump, a transcutaneous access may be chosen with a 2- to 3-mm-thick angled osteotome, it should be an oblique transverse fracture. Push-down is performed if dorsal lowering is less than 4 mm, whereas let-down is performed for greater lowering (ie, in the range of 5 to 14 mm). [See Figure, Supplemental Digital Content 3, which shows a schematic depiction showing the direction of push-down that is performed when the dorsal lowering is less than 4 mm, whereas let-down is performed for greater lowering (5 to 14 mm), http://links.lww.com/PRS/G95.]
In some patients with deviated nasal septum, it may be necessary to remove the horizontal septal cartilage with the maxillary crest. It is important to clarify that the osteocartilaginous parts can be removed en bloc if both have deviation, paying particular attention to remove a sufficient amount to lower the dorsum with no fluctuation. In cases of deviated nose and when there is bony asymmetry, more bone pieces are removed from the larger lateral nose starting from Webster region. [See Figure, Supplemental Digital Content 4, which shows (in the case of deviated nose) that more bone is excised starting forom the Webster triangle from the more deviated side, http://links.lww.com/PRS/G96.]
In cases of S-shaped dorsum, certain extra maneuvers are essential to prevent spring recurrence of the dorsum, such as making sure that adequate bony septum is removed, multiple incisions (scoring) are performed in the subdorsal septum, and proper fixation of the dorsum to the septum by suturing the lateral keystone area (bone cartilage split) (ie, ballerina maneuver). In addition, we usually place a 5- to 9-mm septal piece cephalic to the supratip point to avoid saddling at that critical area in patients with an S-shaped dorsum. Some adjustments may be necessary, such as reduction of alae and internal nasal splints.
Surgery on the remaining tip is carried out according to the surgeon’s preference, internal nasal splinting is left in place, and the cast and splint are removed after 7 to 9 days. The specific postoperative restrictions for this procedure are not different from conventional rhinoplasty.
Patients were examined 9 days, 12 weeks, and 15 months after surgery with physical examination and/or photographs. and the results were documented for evaluation. We reported the functional and cosmetic analysis preoperatively by means of the SCHNOS instrument for functional and cosmetic purposes. (See Figure, Supplemental Digital Content 5, which shows images of four patients who underwent preservation rhinoplasty before and after surgery, http://links.lww.com/PRS/G97.)
Statistical Analyses
Statistical analyses are described in frequencies for categorical variables and means and SD for numerical variables, and correlations are made using the P value, with values of P ≤ 0.05 considered significant. The comparisons of SCHONS scores between before and after surgery were examined using a paired t test. Data were analyzed using IBM SPSS Version 25.0 (IBM Corp., Armonk, NY).
RESULTS
The mean age of the patients involved in this study was 27.98 years; women constituted approximately 61.1%; and most of the involved patients had an S-shaped dorsal nasal hump. The mean preoperative SCHNOS score for obstructive symptoms was 3, and the mean preoperative SCHNOS aesthetic score was 2.95 (Table 1).
Table 1.
General Characteristics of the Involved Patients
| Category | Value (%) |
|---|---|
| Age, yr | |
| Mean ± SD | 27.98 ± 11.195 |
| Range | 18–24 |
| Sex | |
| Male | 44 (38.9) |
| Female | 69 (61.1) |
| Type of dorsal hump | |
| V-shaped | 28 (24.8) |
| S-shaped | 85 (75.2) |
| Preoperative SCHNOS score | |
| Mean ± SD | 7.21 ± 1.515 |
| Range | 2–10 |
| Preoperative SCHNOS score (obstructive symptoms) | |
| Mean ± SD | 3 ± 1.068 |
| Range | 1–5 |
| Preoperative SCHNOS score (obstructive symptoms) | |
| 1 | 10 (8.8) |
| 2 | 26 (23.0) |
| 3 | 48 (42.5) |
| 4 | 18 (15.9) |
| 5 | 11 (7) |
| Preoperative SCHNOS score (obstructive symptoms) score | |
| Mean ± SD | 2.95 ± 1.068 |
| Range | 1–5 |
| Preoperative SCHNOS score (aesthetic score) | |
| 2 | 3 (2.7) |
| 3 | 13 (11.5) |
| 4 | 47 (41.6) |
| 5 | 50 (44.2) |
| Preoperative SCHNOS score (aesthetic score) | |
| Mean ± SD | 4.27 ± 0.771 |
| Range | 2–5 |
The mean operation time was 132.85 minutes, and the mean lowering of the dorsal nasal hump was 4.4 mm. The postoperative SCHNOS score improved, by a mean of 3.04, with a mean obstructive score of 1.49 and a mean aesthetic score of 1.6 (Table 2).
Table 2.
Operative and the Postoperative Data
| Category | Frequency (%) |
|---|---|
| Operation time, min | |
| Mean ± SD | 132.85 ± 14.528 |
| Range | 100–167 |
| Lowering the dorsal hump, mm | |
| Mean ± SD | 4.40 ± 1.386 |
| Range | 1–7 |
| Postoperative SCHNOS score | |
| Mean ± SD | 3.04 ± 1.695 |
| Range: 0-8 | 0–8 |
| Postoperative SCHNOS score (obstructive symptoms) | |
| Mean ± SD | 1.49 ± 0.857 |
| Range | 0–4 |
| Postoperative SCHNOS scores (obstructive symptoms) | |
| 0 | 11 (9.7) |
| 1 | 50 (44.2) |
| 2 | 40 (35.4) |
| 3 | 10 (8.8) |
| 4 | 2 (1.8) |
| Postoperative SCHNOS score (aesthetic score) | |
| Mean ± SD | 1.60 ± 1.065 |
| Range | 0–5 |
| Postoperative SCHNOS score (aesthetic score) | |
| 0 | 15 (13.3) |
| 1 | 43 (38.1) |
| 2 | 33 (29.2) |
| 3 | 17 (15.0) |
| 4 | 4 (3.5) |
| 5 | 1 (0.9) |
| Postoperative obstructive symptoms | |
| Improved | 98 (86.7) |
| No improvement | 15 (13.3) |
| Postoperative aesthetic score | |
| Improved | 108 (95.6) |
| No improvement | 5 (4.4) |
The majority of the patients involved in the current study developed no complications (77.88%); however, some patients developed complications such as residual hump, dorsal indentation, bleeding, and granuloma at dorsal osteotomy site. The bleeding was minor in all cases (Fig. 1).
Fig. 1.
A simple bar chart showing the rate of complications in our patients.
The study showed that SCHNOS scores for obstructive, aesthetics, and total were significantly decreased from before surgery to after surgery (P = 0.000). The SCHNOS scores for before and after surgery of obstructive, aesthetics, and total were 2.95 versus 1.49; 4.27 versus 1.60; and 7.21 versus 3.04, respectively (Table 3 and Fig. 2).
Table 3.
Comparison of Preoperative and Postoperative SCHNOS Scores
| Category | Before | After | 95% CI of Mean Difference | P a | |
|---|---|---|---|---|---|
| Lower Quartile | Upper Quartile | ||||
| SCHNOS score of obstructive symptoms | 2.95 ± 1.07 | 1.49 ± 0.86 | 1.24 | 1.68 | 0.000 |
| SCHNOS score of aesthetic score | 4.27 ± 0.77 | 1.60 ± 1.07 | 2.44 | 2.90 | 0.000 |
| Total SCHNOS score | 7.21 ± 1.52 | 3.04 ± 1.70 | 3.80 | 4.56 | 0.000 |
Two-tail paired t test was performed for statistical analyses.
Fig. 2.
A simple bar chart showing the overall outcome after surgery.
DISCUSSION
Traditionally, rhinoplasty involves elevation of the soft-tissue envelope (STE) in either a subcutaneous or subsuperficial musculoaponeurotic system plane because it is relatively avascular and causes less disruption than the subcutaneous plane, but is still associated with variable degrees of postoperative edema and numbness, a long period of scar remodeling, and induration. Long-term thinning of the STE is a major concern; elevation of the STE with a continuous subperichondrial-subperiosteal dissection causes minimum edema, better sensation, minimum remodeling of the scar, and minimum long-term thinning of the STE. Elevating the STE as a single sheet is crucial to minimize both short- and long-term complications. In contrast, it requires experience and meticulous technique; sometimes skin surface irregularities are encountered that require new instruments.15
Many of the young rhinoplasty surgeons are not familiar with the concept of nasal dorsum preservation (namely, the push-down and let-down techniques) and the major difference of it from the resection rhinoplasty. The essential goals of the push-down technique are to maintain preservation of the keystone area and ensure continuity of the cartilaginous vault with the septum, which share the same embryologic origin; thus, the preservation technique prevents collapse of the nasal valve, which enhances the function and has adverse effects on the dorsal aesthetic lines. Lowering the cartilaginous vault intact in the push down-technique will result in a vertical vector downward on the scroll area junction between the ULCs and lower lateral cartilages, resulting in a cephalic rotation of the lower lateral cartilages.1,16
In our study, patients with an S-shaped deformity constituted the majority of the patients (75.2%). The mean preoperative SCHNOS score was 7.21 ± 1.515, the mean obstructive score was 2.95 ± 1.068, and the mean aesthetic score was 4.27 ± 0.771. This signifies that most patients seek surgical intervention because of cosmetic considerations. The improvement of the nasal appearance has been shown by many authors to be associated with a dramatic improvement in the functional outcome.17,18
The ability to avoid skin undermining eliminates the requirement for fascia grafts and leads to a fine, smooth appearance, faster operation, with less edema; subsequently, the dorsal aesthetic line will be more preserved, the risk of long-term thinning will be decreased, and also the risk of dorsal deformity will be decreased. No skin undermining of the dorsum is performed when patients have a V-shaped dorsum with minimal or no hump. A high subdorsal septal strip is removed, and osteotomies are performed with an osteotome, adopting an external approach to release the osteocartilaginous vault from the midface. In cases of S-shaped dorsum, certain extra maneuvers are essential to prevent spring recurrence of dorsum, such as making sure that adequate bony septum is removed, multiple incisions (scoring) are performed in the subdorsal septum, proper fixation of dorsum using 4-0 polydioxanone suture to the septum, and release of the lateral keystone area. This maneuver should be subtle, typically 3 to 4 mm, which means that one never detaches completely the entire relation of the ULCs and the lateral keystone area (bone cartilage split). Generally, for 1-mm lowering of the dorsum, there should be 1 mm of subdorsal septal excision. In cases of S-shaped dorsum, we usually place a 5- to 9-mm septal piece cephalic to the supratip point to avoid saddling at that critical area through a small tunnel on the side of deep Pitanguy ligament, harvested from the lower part of the septum, leaving minimally a 20-mm L-strut septum.19
The average lowering of the dorsal hump in our patients was 4.4 ± 1.386 mm, this is regarded as acceptable when compared with other published articles, and some articles reported similar results, although the technique is new and future studies are still required. Approximately 96% of the patients who were involved in our study showed improvement in the SCHNOS score after surgery; 86.7% of patients (98 patients) showed improvement in the obstructive symptoms and 95.6% of them (108 patients) showed improvement in the aesthetic score. Some studies have reported a lower rate of improvement than our study. Review of the literature supports improvement of the results after surgery in both structural and preservation rhinoplasty and shows high satisfaction score in both. There are no supporting references explaining that dorsal hump is related to nasal obstruction, so it is probably an insubstantial factor.4
Because the technique of preservation rhinoplasty is a new one, more studies must be conducted to further assess and compare the satisfaction score regarding both obstructive and aesthetic scores following preservation rhinoplasty and appropriately comparing rhinoplasty techniques.20
The reported complication rate in our study was 22.11%. The most common type of complication was residual hump, which was reported in 13.27% of the cases, followed by dorsal indentation in 5.31%; bleeding and granuloma formation at the dorsal osteotomy site constituted 2.65% and 0.88%, respectively. Dorsal indentation or “stepoff” were faced after the initial operations; then, we tried to reduce the occurrence of this problem by angulating the dorsal osteotomy 40 degrees to hang it down without stepoff appearance. There was a very significant improvement in the aesthetic, obstructive, and the overall SCHNOS score after surgery (P = 0.000) for each parameter. The functional complications were related to preexisting elements of allergic rhinitis in 15 patients, whereas the aesthetic-related complications were minor according to the patients’ reported outcomes such as minor residual hump or indentation of the proximal dorsum. No revisions were necessary for the dorsal preservation cohort and no patients had revision surgery for nasal airway obstruction. Meticulous attention to detail of the operative steps is the major factor to optimize the operative results and decrease the rate of complications and suboptimal results.21
Limitations
The use of cone-beam computed tomography is more accurate to define the anatomy and is very helpful to plane for bony and cartilaginous resection to reduce the nasal hump, which was not used in our study. Comparative studies between the traditional and the preservation techniques with a larger patient population will evaluate the efficacy of this technique more.
CONCLUSIONS
The no-dissection of the nasal dorsum using subdorsal septal excision in preservation rhinoplasty technique has a low risk of major complications. The majority of patients have improvement of the obstructive and aesthetic outcome after surgery. As surgeons continue to develop and use these techniques, critical assessment of patient-reported outcomes and objective nasal measurements with an emphasis on comparison with standard hump takedown techniques will be valuable.
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
PATIENT CONSENT
Patients provided written informed consent for the use of their images.
Supplementary Material
Footnotes
Disclosure statements are at the end of this article, following the correspondence information.
Related digital media are available in the full-text version of the article on www.PRSJournal.com.
REFERENCES
- 1.Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P. Dorsal preservation: the push down technique reassessed. Aesthet Surg J. 2018;38:117–131. [DOI] [PubMed] [Google Scholar]
- 2.Daniel RK. The Preservation Rhinoplasty: A New Rhinoplasty Revolution. New York: Oxford University Press US; 2018. [Google Scholar]
- 3.Kosins AM, Daniel RK. Decision making in preservation rhinoplasty: a 100 case series with one-year follow-up. Aesthet Surg J. 2020;40:34–48. [DOI] [PubMed] [Google Scholar]
- 4.Kosins AM. Expanding indications for dorsal preservation rhinoplasty with cartilage conversion techniques. Aesthet Surg J. 2021;45:174–184. [DOI] [PubMed] [Google Scholar]
- 5.Saban Y, Braccini F, Polselli R. Rhinoplasty: morphodynamic anatomy of rhinoplasty. Interest of conservative rhinoplasty (in French). Rev Laryngol Otol Rhinol (Bord.) 2006;127:15–22. [PubMed] [Google Scholar]
- 6.Neves JC, Arancibia-Tagle D, Dewes W, Ferraz M. The segmental preservation rhinoplasty: the split tetris concept. Facial Plast Surg. 2020;37:36–44. [DOI] [PubMed] [Google Scholar]
- 7.Gruber RP. Preservation rhinoplasty. Plast Reconstr Surg. 2020;145:594. [DOI] [PubMed] [Google Scholar]
- 8.Moubayed SP, Ioannidis JPA, Saltychev M, Most SP. The 10-item Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) for functional and cosmetic rhinoplasty. JAMA Facial Plast Surg. 2018;20:37–42. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Kandathil CK, Saltychev M, Patel PN, Most SP. Natural history of the standardized cosmesis and health nasal outcomes survey after rhinoplasty. Laryngoscope 2021;131:E116–E123. [DOI] [PubMed] [Google Scholar]
- 10.van Zijl FV, Mokkink LB, Haagsma JA, Datema FR. Evaluation of measurement properties of patient-reported outcome measures after rhinoplasty: a systematic review. JAMA Facial Plast Surg. 2019;21:152–162. [DOI] [PubMed] [Google Scholar]
- 11.Saltychev M, Kandathil CK, Abdelwahab M, Spataro EA, Moubayed SP, Most SP. Confirmatory factor analysis of the standardized cosmesis and health nasal outcomes survey. Plast Reconstr Surg. 2019;143:454e–456e. [DOI] [PubMed] [Google Scholar]
- 12.Abdelwahab M, Saltychev M, Elkholy NA, Elsisi H, Moubayed SP, Most SP. Arabic validation of the standardized cosmesis and health nasal outcome survey for Arabic-speaking rhinoplasty patients. Plast Reconstr Surg. 2019;143:673e–675e. [DOI] [PubMed] [Google Scholar]
- 13.Atallah M-R, Milad D, Benamer YH, Saltychev M, Most SP, Moubayed SP. Translation, cultural adaptation and validation of the SCHNOS in French. J Otolaryngol Head Neck Surg. 2019;48:1–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Lazovic GD, Daniel RK, Janosevic LB, Kosanovic RM, Colic MM, Kosins AM. Rhinoplasty: the nasal bones—anatomy and analysis. Aesthet Surg J. 2015;35:255–263. [DOI] [PubMed] [Google Scholar]
- 15.Daniel RK, Kosins AM. Current trends in preservation rhinoplasty. Aesthet Surg J Open Forum 2020;2:ojaa003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Varoquier M, Rumeau C, Vuissoz PA, Perez M, Hossu G, Jankowski R. Do the upper lateral nasal cartilages exist? The concept of septolateral cartilages. Eur Ann Otorhinolaryngol Head Neck Dis. 2021;138:77–81. [DOI] [PubMed] [Google Scholar]
- 17.Stergiou G, Tremp M, Finocchi V, Saban Y. Functional and radiological assessment after preservation rhinoplasty—a clinical study. In Vivo 2020;34:2659–2665. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Ferreira MG, Santos M, E Carmo DO, et al. Spare roof technique versus component dorsal hump reduction: a randomized prospective study in 250 primary rhinoplasties, aesthetic and functional outcomes. Aesthet Surg J. 2021;41:288–300. [DOI] [PubMed] [Google Scholar]
- 19.Kandathil CK, Saltychev M, Abdelwahab M, Spataro EA, Moubayed SP, Most SP. Minimal clinically important difference of the standardized cosmesis and health nasal outcomes survey. Aesthet Surg J. 2019;39:837–840. [DOI] [PubMed] [Google Scholar]
- 20.Levin M, Ziai H, Roskies M. Patient satisfaction following structural versus preservation rhinoplasty: a systematic review. Facial Plast Surg. 2020;36:670–678. [DOI] [PubMed] [Google Scholar]
- 21.Cochran CS, Landecker A. Prevention and management of rhinoplasty complications. Plast Reconstr Surg. 2008;122:60e–67e. [DOI] [PubMed] [Google Scholar]