Response to Commentary on: Dorsal Roof Technique for Dorsum Preservation in Rhinoplasty — Suleyman Tas PubMed

LETTER TO THE EDITOR Response to Commentary on: Dorsal Roof Technique for Dorsum Preservation in Rhinoplasty Su¨leyman Tas¸1 Received: 16 February 2020 / Accepted: 18 February 2020 /C211Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2020 AbstractRhinoplasty is a sophisticated surgery that needs high technical skills with knowledge. The DR technique is a refined technique to deal with the selected cases which are challenging for rhinology (wide dorsum, base and humpy nose). Still, so many things are unknown and one life span will be never enough to solve it. However, the author thinks that any solution fills the gaps, is the only thing we can improve the medicine. Level of Evidence V 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 Authorswww.springer.com/00266. KeywordsDorsum/C1Hump/C1Preservation/C1Roof/C1Let down/C1Push down/C1Pyramidal angle/C1Wide nose The author would like to thank Dr. Daniel who is the living legend of rhinoplasty, for his deep analysis and comments. It is really important and an honor for us to know his opinions about the dorsal roof (DR) technique. The author will enlighten the points Dr. Daniel is looking for and enlarge the scope of the article entitled ‘ ‘Dorsal Roof Technique for Dorsum Preservation in Rhinoplasty [ 1]’ ’ with the further discussion and comments. Technical Explanations of DR Technique ‘ ‘Patients with a high dorsum, wide dorsum, wide nasal base, and pyramidal angle who presented for a reduction procedure were selected to undergo the DR technique (Fig.2b and c) [1].’ ’ One must not necessarily narrow the dorsum in the DR technique; it is a preference that depends on the case, as it was stated in the article: ‘ ‘Although dorsal, lateral, and transverse osteotomies provide a nar- rower effect not only in the nasal base but also in the dorsum, and if much narrower dorsal aesthetic lines are requested, accurate narrowing of the DR could be per- formed from the edges of it [1].’ ’ The newly created dorsum should be truly a free-floating graft, if the radix is deep or high, and needs to be altered to create a straight dorsum. But if the radix is in the normal position, then radix osteotomy will be a green stick fracture rather than a complete fracture as stated in the article: ‘ ‘it is sensible to leave the nasal bones with a hinge [ 1].’ ’ To perform a green stick fracture in radix is possible with power instruments. Do I conduct an incremental longitudinal septal strip excision for lowering the DR? Answer is ‘ ‘The height of the vertical part of the dorsal bone-cartilage complex can be determined based on the appropriate reduction of the dorsal height or by leaving 2 mm to allow suturing of the septum. Then, gradual excision can be performed from the septum to the ethmoid bone.’ ’ ‘ ‘If there is dorsal deviation, then the author prefers to stabilize the DR side by side on the opposite side of the deviation; however, if there is no Electronic supplementary materialThe online version of this article (https://doi.org/10.1007/s00266-020-01656-8) contains sup- plementary material, which is available to authorized users. &Su¨leyman Tas¸ drsuleymantas@live.com 1 TAS Aesthetic Surgery Clinic, HakkıYeten Cad, No: 11, Terrace Fulya, Center: 1, Apt: 97 S¸ is¸li, Istanbul 34349, Turkey 123 Aesth Plast Surg https://doi.org/10.1007/s00266-020-01656-8

deviation, then the DR is sutured to the septum end-to-end to prevent any axle deviation [1].’ ’ So, if there is a devia- tion, since we are going to do a side-to-side stabilization, the height of the vertical part of the DR will be determined based on the dorsal reduction amount. For instance, if you plan 4-mm dorsal height reduction, the vertical strip of the DR will be 4 mm. If there is no deviation, it should be arranged with gradual excision after leaving 2 mm vertical height in the DR. The Results of the DR Technique The geometric projection of the pyramidal angle (PA) (Fig.1) meets with the cartilaginous part of the keystone area [2]. Utilizing this knowledge to decrease the PA, in the DR technique, upper lateral cartilages go under the DR as spreader flaps. However, nasal bones just touch the DR, instead of underlapping (Fig.2), as demonstrated in sur- gical pictures of the article [1]. Thus, a pinching appear- ance is not possible for the technique nor for the case#7, where it is really hard to understand how Dr. Daniel had a concern like that [ 3]. Two-and-half-year result of the case#7 was demonstrated in Video 1 from the frontal view, closed base view, top view, with smiling, while the patient was touching her dorsum, and while the doctor was checking her dorsum, please see the Video 1 (61 s), to understand the result is good as possible and is not related to any pinching appearance. Dorsal lights are one of the findings of a natural, pro- portioned, aesthetically good-looking nose rather than pinched appearance. Dorsum preservation (DP) is primar- ily indicated in the narrow and high noses since widening is a known issue for DP rather than narrowing, as seen in Fig. 7 of Dr. Daniel’s article [ 4]. One can easily realize when before picture had beautiful dorsal lights (Fig. 3a), and after has not, and also, a true widening in the dorsum and base is obvious (Fig.3b). This issue, to prevent the flat nose appearance, was thoroughly explained in the DR article [1]. Pyramidal Angle An easy and unique technique to measure the pyramidal angle was described in the DR article [ 1]. In order to measure the inclination angle of the nasal bones as Dr. Daniel suggested, a CT study must be performed. The author thinks, as how we do not perform a CT analysis for the calculation of the nasal hump, we should not admit to a CT analysis to measure the PA. The Limitations of DP First, Fig.2that Dr. Daniel [3] showed in his commentary has a totally straight dorsum and cannot be an example for bony hump (Fig. 4). Moreover, it is not possible to understand what has changed regarding a wide dorsum or wide pyramidal angle, from a profile picture. Since it can only be judged by the frontal or oblique basal views, please Fig. 1The pyramidal angle (PA) should be measured at the widest side of the nose to make sense clinically, and this side is very close to the apertura piriformis. The geometric projection of the pyramidal angle meets with the cartilaginous part of the keystone area. Utilizing this knowledge to decrease the PA, in the DR technique, the upper lateral cartilages go under the DR as spreader flaps. However, nasal bones just touch the DR as demonstrated in the surgical pictures of the original article. The red circle marks the widest side of the nose; the red arrow shows the geometric projection of the pyramidal angle Fig. 2To decrease the PA, in the DR technique, the upper lateral cartilages go under the DR as spreader flaps. However, nasal bones just touch the DR as demonstrated. The green arrow indicates that the nasal bone just touches the DR, instead of underlapping. This material was originally published in Dorsal Roof Technique for Dorsum Preservation in Rhinoplastyby Tas¸[1], and has been reproduced by permission of the Oxford University Press [https://academic.oup.com/ asj/advance-article/doi/10.1093/asj/sjz063/5370062][1] Aesth Plast Surg 123

see Fig.1of the article of DR technique [ 1], which is a perfect example for wide pyramidal angle. Second, a deviated nose always seems wider than it is. When it is corrected, it becomes narrower (Fig. 5). Thus, Fig.3that Dr. Daniel [3] showed in his commentary can- not point out the wide pyramidal angle. In fact, a severe step deformity is seen in that picture. Moreover, this step deformity was appreciated to the change in lateral wall inclination and to the base narrowing by Dr. Daniel [ 3]. However, to prevent this complication, the ‘ ‘fix down’ ’ technique has been established by the author recently [5]. The literature agrees with the limitations of DP [ 6]. Also, the conclusion about the limitations of DP was placed in an article [7] in which Dr. Daniel is the coauthor, as ‘‘When a truly wide or very asymmetric cartilaginous dorsum is present, other procedures should be considered.’ ’ ‘‘…the very kyphoticbony humpwith a deep nasofrontal angle or an irregular bony pyramid is not a good indication for dorsal preservation [7].’ ’ For wide dorsum, he men- tioned about the paramedian osteotomies to narrow the pyramidal angle as in the Cottle maneuver which really works well, but also he highlighted in his article as ‘ ‘A true Cottle procedure is always time consuming and it is a bit difficult to position the new dorsum [ 7].’ ’ So, there is a contradiction over there. On the other hand, with the push- down procedure, since nasal framework is impacted, a narrowing can be achieved in the base, but not directly in pyramidal angle, and also one should deal with narrowing the external ostium and a palpable bony ‘ ‘step’ ’ on the lateral surface of the bony pyramid [ 6]. That is why let down was proposed and invented by Huizing [6]. History Although Lothrop [8] was accepted as the first introducer of the dorsum preservation in the articles Dr. Daniel was the coauthor, the credit should be given to Goodale [ 9]. There are no drawings in Goodale’s descriptive article, but the original classic text books referred him [2,10]. Goodale Fig. 3Analysis of a case study from Daniel [ 4]. This 26-year-old female patientapreoperative andb1 year postoperative. One can easily realize when before picture had beautiful dorsal lights, and after has not, and also, a true widening in the dorsum and base is obvious. Red lines mark the change of the base and dorsum. Reprinted with permission from the Oxford University Press [4] Fig. 4Analysis of a case study from Daniel [3]: as seen, the case has a totally straight dorsum, and not an example for bony hump. Red line marks the straight dorsum, rather than a bony hump. Also, from the profile picture, it is not possible to understand what has changed regarding the wide dorsum or wide pyramidal angle, since it can only be judged by the frontal view. Reprinted with permission from the Oxford University Press [3] Fig. 5A deviated nose always seems wider than it is. When we correct it, it becomes narrower. However, this change cannot point out the wide pyramidal angle. Red lines mark the change of the base Aesth Plast Surg 123

[11] also used his technique to correct the lateral dis- placement of the nasal bones following the trauma; he slid the upper strip of septum on the lower part without any fixation. The stabilization was provided by using an external split, and an Asch splint was introduced into the nasal passage to hold the septum in place. Is the DR Technique Challenging? Nowadays, almost there is no surgeon without power instruments in his operating room. If there is anybody, the author strongly advices to have one immediately to keep up with the technology to get better results. To be precise is one of the keys to success. But it is obvious that the DR technique is easier under the open approach. There is no perfect technique for all kinds of noses. All techniques have limitations, indications, contraindications, etc. That is how the medicine goes. To accept this knowl- edge, and search from that view, will provide the solutions that make the scenario perfect. If we start to apply them without knowing these concerns, it will cause to abandon them. The DR is a very valuable technique, and the author is afraid that it is not understood enough. Closed rhinoplasty including DR and DP is thoroughly explained in ‘ ‘Closed Atraumatic Rhinoplasty Course [2]’ ’ which is held by the author annually and more will be in the upcoming book. These will be helpful for better understanding that it is not demanding as building a ship in a bottle. Apparently, only preservation cannot be enough for success in every type of nose. Thus, the author’s rhinoplasty philosophy is ‘ ‘not only preserve but also support’ ’ and the DR technique is a tool to achieve that. In summary, the author does not try to simplify rhino- plasty; in contrast, he accepts that rhinoplasty is a sophisti- cated surgery that needs high technical skills with knowledge. The DR technique is a refined technique to deal with selected cases that are challenging for rhinology (wide dorsum, base and humpy nose). The author appreciates Dr. Daniel for his amazing effort and contribution that shed light on our future. Still, so many things are unknown and one life span will be never enough to solve it. However, the author thinks that any solution fills the gaps, is the only thing we can improve the medicine. Compliance with Ethical Standards Conflict of interestThe author declares that he has no conflicts of interest, commercial associations, or intent of financial gain regarding this research. Ethical ApprovalThis article does not contain any studies with human participants or animals performed by the author. Informed ConsentInformed consent form was obtained from the patient in the video. Permissions for reprint of the figures were taken. References 1. Tas¸ S (2019) Dorsal roof technique for dorsum preservation in rhinoplasty. Aesthet Surg J pii:sjz063.https://doi.org/10.1093/asj/ sjz063 2. Tas¸ S (2019) Closed atraumatic rhinoplasty course. Endorsed by RSE (Rhinoplasty Society of Europe) and ISAPS (International Society of Aesthetic Plastic Surgery). November 16–17, 2019, Istanbul, Turkey.https://drsuleymantas.com/course/. Accessed 11 Aug 2019 3. Daniel RK (2019) Commentary on: dorsal roof technique for dorsum preservation in rhinoplasty. Aesthet Surg J pii:sjz291. https://doi.org/10.1093/asj/sjz291 4. Kosins AM, Daniel RK (2020) Decision making in preservation rhinoplasty: a 100 case series with one-year follow-up. Aesthet Surg J 40(1):34–48 5. Tas¸ S (2019) The alignment of the nose in rhinoplasty: fix down concept. Plast Reconstr Surg. https://doi.org/10.1097/prs. 0000000000006523 6. Huizing EH (1975) Push-down of the external nasal pyramid by resection of wedges. Rhinology 13(4):185–190 7. Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P (2018) Dorsal preservation: the push down technique reassessed. Aesthet Surg J 38(2):117–131 8. Lothrop OA (1914) An operation for correcting the aquiline nasal deformity: the use of a new instrument. Boston Med Surg J 170:835–837 9. Goodale JL (1899) A new method for the operative correction of exaggerated Roman nose. Boston Med Surg J 140:112 10. Huizing EH, Groot JA (2015) Functional reconstructive nasal surgery, 2nd edn. Thieme, Stuttgart 11. Goodale JL (1901) The correction of old lateral displacements of the nasal bones. Boston Med Surg J 145:538–539 Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Aesth Plast Surg 123