From Resection to Preservation: Anatomy’s Role in Redefining Rhinoplasty

Abstract

The history of otolaryngology and facial plastic surgery has evolved in accordance with our understanding of anatomy. The challenge surgeons face is to reconstruct from a functional perspective while maintaining or enhancing facial aesthetics—a task directly related to a profound knowledge of structures and tissues. Since the 20th century, various surgeons have made invaluable contributions to the dynamic support of facial structures, leading our specialty through a revolution: from resection to preservation and to the precise manipulation of deep structures.

In the early 20th century, some of the pioneering founders of rhinoplasty, such as Jacques Joseph, laid important foundations for the time through ablative procedures. Anatomy was understood in blocks of skin, bone, and cartilage, with techniques based on en bloc resection to shape and reduce size, but which, in the long term, irreversibly compromised nasal support.

The pursuit of natural and lasting results, with preservation of function, motivated microscopic study of anatomy. Ivo Pitanguy marked a milestone by discovering the dermocartilaginous ligament, revealing the existence of anatomical tensors that influence rotation and tip support. He taught us that the nose is not a rigid structure but a delicate set of forces in balance.

In Colombia, Dr. Fernando Pedroza stands out for introducing concepts that forever changed the way the nose is sculpted. With the “seagull wings” technique, the creation of “new domes,” and the use of the “banner” graft, he prioritized structural support over resection. As mastery of this support grew, innovation shifted toward conserving the original anatomy. In this transition, Dr. Baris Cakir popularized subperichondrial dissection—including the septum, dorsum, lateral walls, and nasal tip—allowing us to work beneath the ligamentous network without destroying it.

These first steps introduced perfection in managing the nasal pyramid, consolidated with the let-down and push-down maneuvers by Dr. Yves Saban, aimed at preserving the pyramid in both functional and aesthetic dimensions. This field has been masterfully explored by surgeons such as Dr. José Carlos Neves, with the Tetrix concept, seeking balance between naturalness, function, and aesthetics; and Dr. Froilán Páez, with his deep analysis of adaptive valvuloplasty and the use of “armadillo” grafts to balance tension and tip support. In parallel, Dr. Sercan Göde, from a reconstructive perspective, has provided solutions to complex functional defects such as septal perforation and columellar tissue loss, using flaps and grafts that avoid the extensive and visible scars once considered inevitable.

Advances in facial anatomy research cannot be overlooked, particularly the historic leap provided by the description of the Superficial Musculoaponeurotic System (SMAS) by Mitz and Peyronie in 1976. This discovery demonstrated that the face is not merely a skin envelope but a three-dimensional architecture layered in planes, which we have learned to respect to achieve better results. From then on, facial surgery evolved toward deeper planes. In 1990, Dr. Sam Hamra described the deep plane rhytidectomy, and Dr. Andrew Jacono contributed by releasing the zygomatic and masseteric retaining ligaments to mobilize tissues without tension. More recently, anatomists and surgeons such as Drs. Bryan Mendelson and Lennert Minelli have taught us that aging is a process of deflation and descent of compartments through facial glide spaces, dictating that modern surgery must focus on repositioning while respecting the true biology of the face.

When I began my specialty, I believed everything had already been discovered and that techniques were infallible. Time taught me that everything can be improved, and within our specialty, there are restless minds obsessed with optimizing patients’ quality of life, continuously thinking about how to refine procedures. Much remains to be studied and discovered regarding inflammation, healing, and the behavior of skin under surgical trauma. We often assume that ligaments, muscles, and the SMAS are standard structures for all individuals; however, tissues vary in trophism, dramatically influencing final outcomes.

The combination of patient-specific factors—skin, cartilage, muscles, subcutaneous fat, and immune response—together with adherence to postoperative care recommendations, is essential to achieve results close to what both patient and surgeon seek. Reading, observing surgeries, interacting with new techniques, and learning new technologies bring us closer each day to a comprehensive understanding of rhinoplasty.

For example, piezoelectric technology, discovered by the Curie spouses in the early 20th century, was timidly introduced by maxillofacial surgeons little more than two decades ago. Gradually, it extended into our specialty, enabling precise bone cuts with less surgical trauma and complementing maneuvers necessary for preservation techniques. Likewise, new facial ultrasound studies now allow evaluation of skin characteristics, vascularization, aging level, and even identification of previously deposited filler materials. This opens challenges at knowledge levels previously unconsidered, reinforcing the need for detailed understanding of cutaneous layers—once almost exclusively reserved for dermatologists.

From the perspective of preservation rhinoplasty technique, each surgeon has a different interpretation of this vast field, whose ultimate goal is to conserve dorsal tissues as much as possible. Increasingly, specialists perform this technique, even through closed approaches. The future lies in achieving more controlled cuts with less trauma, lowering the pyramid without sequelae such as bony steps or hump recurrence, and cleaner tip dissections with less bleeding, preserving or repositioning ligaments and muscles to reduce dead spaces and achieve better definition.

Regarding our patients, over time we learn to listen to what they truly want. Within the subjective criterion of beauty, we navigate different nasal shapes and proportions to approach their expectations. We also learn that our role is not only to operate but to inform clearly and objectively about risks and possible suboptimal outcomes. We face medico-legal challenges that oblige us to master informed consent and explain that, despite immense scientific advances, we still lack deep knowledge of unpredictable variables such as inflammation, healing, or adverse reactions.

The evolution of nasal surgery seems to be oriented toward preservation, without implying that the structural philosophy is destined to disappear. At the reconstructive level, it remains a fundamental pillar. We face the permanent challenge of learning from the world’s best about the use of endoscopic flaps for reconstructing large perforations associated with columella loss due to trauma, prior surgeries, or inhaled substances.

Preservation surgery is a challenge to imagination, especially in conserving the dorsum and in the myriad maneuvers available to reduce hump size, granting the correct shape to dorsal aesthetic lines. Techniques vary, and new ideas emerge for tissue management with less inflammation, yielding incredible results that constantly make us wonder where the exact point lies to approximate clinical perfection.

Finally, our work as otolaryngologists and facial plastic surgeons must never detach from our true essence: being physicians. This means accompanying patients by providing necessary preoperative information, grounding their expectations, and guiding them through postoperative care. Hopefully, in most cases, this path culminates in successful outcomes and happy patients; but when faced with less optimal results, we also suffer alongside dissatisfied patients. It is precisely this vocation that drives us. Constant anatomical research and progress in surgical techniques are the tools that bring us, day by day, closer to the longed-for shared satisfaction between patient and surgeon.