Dorsal Roof Technique for Dorsum Preservation in Rhinoplasty

Dr. Süleyman Taş presents the Dorsal Roof technique for selected patients with a high and wide dorsum, wide nasal base and pyramidal angle, aiming to preserve the dorsal bone-cartilage complex while reducing and narrowing the nose.

Background and Objective

Management of the nasal dorsum is one of the central challenges in rhinoplasty. Traditional hump removal opens the dorsal roof and disrupts the keystone area, frequently requiring reconstruction with spreader grafts, flaps or camouflage. The Dorsal Roof (DR) technique was developed to preserve the dorsal bone-cartilage complex while reducing dorsal height, narrowing the dorsum and base, and supporting the internal nasal valve.

The study specifically addresses patients for whom standard push-down or let-down preservation techniques may be insufficient because they have a wide dorsum, wide nasal base, substantial bony hump or wide pyramidal angle.

Study Design

Between June 2016 and March 2017, 52 patients—35 women and 17 men—underwent primary closed septorhinoplasty using the DR technique. Standard photographs were taken at 1, 3, 6 and 12 months. Two independent plastic surgeons evaluated the results, and palpation was used to detect dorsal irregularities.

A nasal mold and protractor were used to measure the pyramidal angle before surgery and at one year. Functional improvement was assessed by a 0–10 self-evaluated nasal patency score. The validated six-question Rhinoplasty Outcome Evaluation (ROE) questionnaire assessed functional, social and aesthetic satisfaction.

Dorsal Anatomy and the Keystone Area

The dorsum extends from the radix to the supratip and is described as a trapezoidal structure formed by an upper bony portion and a lower cartilaginous portion. The keystone area is a complex junction among the nasal bones, upper lateral cartilages, septum and transition-zone ligaments.

The dorsal cartilaginous septum extends under the nasal bones, creating overlap that is crucial to the DR procedure. The paper contrasts the desired anatomical trapezoidal dorsal aesthetic lines with a narrow, straight tubular appearance that can look surgically altered.

Patient Selection

Patients with a high dorsum, wide dorsum, wide nasal base and wide pyramidal angle presenting for reduction were selected. The study excluded important contraindications such as bleeding disorders, smoking, drug addiction, severe traumatic deformity, wound-healing problems and a completely low dorsum.

The paper discusses proportional landmarks, including the relationship of bony-base width to alar-base width, intercanthal distance, interphiltral distance and radix position. Pyramidal angle can be assessed clinically, with molds or in selected circumstances by axial computed tomography.

Step 1: Dorsal Dissection

After superior intracartilaginous and transfixion incisions, the dorsum is undermined in subperichondrial and subperiosteal planes. Submucosal tunnels are prepared beneath the upper lateral cartilages, which are then separated from the septum so that the dorsal cartilaginous septum is exposed.

Step 2: Preparation of the Dorsal Roof

Dorsal osteotomies are performed following the dorsal aesthetic lines, followed by a radix osteotomy. The author describes a preference for power instruments for controlled bone cuts. The preserved dorsal roof—the dorsal bone-cartilage complex—is then separated from the septum and ethmoid region.

The amount of septal reduction is adjusted according to the required lowering of the dorsum, with adequate tissue retained to allow secure stabilization. The goal is to move the preserved dorsal roof to the correct level instead of excising the surface and rebuilding it.

Step 3: Stabilization and Internal Valve Support

Once dorsal height is established, the roof is sutured back to the septum and upper lateral cartilage. In a deviated nose, side-to-side stabilization can be performed opposite the direction of deviation; in a nondeviated nose, end-to-end fixation can maintain the central axis.

Excess upper lateral cartilage can be converted into spreader flaps rather than discarded, strengthening the framework and supporting the internal valve. A deep radix can be raised by inserting a small bone or cartilage fragment between the dorsal roof and ethmoid area.

Step 4: Narrowing

Lateral osteotomies, with partial or complete transverse osteotomies when necessary, can narrow the nasal base and alter the pyramidal angle. If narrower dorsal aesthetic lines are required, controlled trimming can also be performed at the edges of the stabilized dorsal roof.

Because different parts of the framework can be modified independently, asymmetric osteotomies or adjunctive procedures can be added for a deviated radix, bony asymmetry, maxillary hypoplasia or soft-tissue asymmetry.

Clinical Results

The mean patient age was 23.2 years. Of 52 patients, 44 completed the one-year follow-up and ROE questionnaire. The study reported no residual hump or palpable dorsal irregularity and no functional or aesthetic complication during the reported follow-up.

Mean DR lowering was 4.3 mm, with a range of 3–10 mm. Mean pyramidal angle decreased from approximately 80.2 degrees preoperatively to 60.4 degrees postoperatively (P < 0.001). Two independent evaluators rated all completed cases as successful or acceptable, with substantial agreement.

ROE results showed approximately 90.1% satisfaction with form and function. Mean nasal patency increased from 5.1 to 8.2 out of 10 (P < 0.001). No revision surgery was required during the reported follow-up.

Discussion and Limitations

The DR technique combines preservation and controlled structural modification. Unlike conventional down techniques, it can change the relationship between height and width and directly influence the pyramidal angle. The publication also describes ways to manage a low radix, wide base and bony angulation without sacrificing the entire dorsal surface.

The technique is technically demanding and was reported from a single-surgeon experience in selected patients. Larger, multicenter and long-term studies would be useful to further establish reproducibility and durability.

Conclusion

The study concludes that the Dorsal Roof technique can be incorporated into reduction rhinoplasty for selected patients. It is intended to preserve the dorsal bone-cartilage complex while allowing the surgeon to determine dorsal height, narrow a wide dorsum and base, treat a hump without traditional surface resection, and support the internal nasal valve.

Official Publication and External Source

DOI: https://doi.org/10.1093/asj/sjz063

Journal: Aesthetic Surgery Journal. This is a comprehensive educational presentation derived from the supplied scientific publication. It does not replace individualized medical evaluation.