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"A hybrid rhinoplasty technique to hope for a more durable and natural result"
We will discuss the developments in rhinoplasty over the past few years in terms of technique as well as patient expectations.
The demand from patients has significantly evolved over the past ten years.
The influence of social media is not foreign to this evolution. It mainly concerns young patients aged 18 to 25.
Regarding the dorsum, a majority of young people prefer a slightly concave profile. Social media has introduced the concepts of 'barbie nose' or 'baby nose,' which our Turkish colleagues, in particular, promote.
Regarding the tip of the nose, in the same logic, the demand is heading towards a highprojected tip.
In discussing with rhinoplastic surgeons and considering the lectures at international congresses, this trend seems to be spreading worldwide: United States, England, Brazil, Russia, Korea, etc.
The correction of a drooping tip has become a classic and increasingly requested procedure year after year.
Patients mostly seek a nasolabial angle close to 110°.
Patients are also seeking increasingly pronounced aesthetic lines while remaining natural. Social media, the development of makeup, and nasal contouring influence the expected outcome for this connected population.
This technique is, to this day, an additional powerfull tool in the practice of rhinoplasty in 2025. The idea is not to elevate it to a revolutionary technique since it was already practiced over 200 years ago with Goodale (1).
On the other hand, in recent years, an adaptation was made by several surgeons from around the world. They have allowed for the correction of its initial flaws.
The major trend in the practice of this technique comes from the 'defects' that a structural technique could cause: functional discomfort (internal valve), irregularities of the dorsum, small deviations, and small asymmetries of the dorsum.
The concept of preservation rhinoplasty is to maximize the preservation of the initial nose anatomy in order to achieve a more durable, stable natural result and to reduce the number of touch-ups in rhinoplasty.
In my practice, the focus is mainly on the dorsum (the nasal bones and the superior lateral cartilages seen from the front and side).
A patient who naturally has beautiful aesthetic lines deserves to 'preserve' their basic anatomy in order to enhance the result of a rhinoplasty.
For the record, from a technical standpoint, the idea is not to break the bump but to bury it. With the structural technique, a section of the osteocartilaginous bump is performed, followed by the reconstruction of the open roof with spreader grafts or spreader flaps.
In preservation rhinoplasty, the bony block is completely fractured to be able to bury the nose and hide the bump. The techniques vary according to the habits or particularities of the nose. The goal is not to develop all its characteristics. Push down, let down with high strip, low strip...everything is possible if the indication is good.
The preservation technique, however, suffers from criticism, such as the risk of recurrence of a lump and the non-universal nature of the surgical indication.
Preservation rhinoplasty was initially reserved for quite specific cases: nice aesthetic lines, a small non-complex bump, or a 'harmonious' deviated nose, which remains, in my opinion, the best indication for preservation rhinoplasty.
This is the case for these young women on whom a pure preservation technique on the dorsum has been performed.
Case 1: young girl with a harmoniously deviated nose and a very large deviation of the septum. Modified Cottle-type preservation rhinoplasty.
Case 2: classic bump: preservation technique after let down and low strip.
The concept of preservation rhinoplasty has evolved in my practice towards a hybrid approach combining preservation techniques and structural techniques.
Noses that are notoriously difficult to create using the preservation technique can benefit from the advantages of each technique. These two techniques do not oppose each other but can complement each other (2).
We will illustrate this proposal with a concrete case. This patient has a rather large bump and lacks aesthetic lines. We chose to use a hybrid technique to achieve a more durable and natural result.
Initially, the bony hump was reduced by the piezotome through a rhinosculpture. This bony open roof allowed the transformation of an osteocartilaginous hump into a cartilaginous hump because the upper part of the triangular bones extends under the roof of the OPN.
By doing this, it is easier to be able to 'go down' the profile.
In a second step, a lateral (let down) transverse osteotomy allowed for complete mobilization of the nose.
We added a paramedian fracture to create beautiful aesthetic lines. Indeed, a greenstick paramedian fracture allows the lateral shadows of the nasal bones to appear. The difficulty arises from the fact that we are performing a very unstable fracture, hence the need for good mastery and to carry out this paramedian greenstick fracture.
The septum is then completely released at its lower and anterior part in order to perform a low strip and correct a fairly significant deviation.
It is a delicate step because the nose is unstable. With experience, the nose is stabilized (thanks to a mix of push and let down) on the bony plane and by fixing the septum to the anterior nasal spine.
It was therefore not useful in this patient to take an excess of septal grafts to perform spreader grafts. The dorsum is very soft to the touch thanks to the piezotome on the bony part and the preservation of the initial triangular cartilages.
To date, the work on the tip is based on a good projection and a good rotation of the tip. Several years ago, the concept of polygons and the surgical sequence for the nasal tip by Baris Cakir (3) marked a true evolution in the management of the tip.
Nevertheless, structural rhinoplasty of the tip remains very common since we still predominantly use structural grafts. It may involve septal extension grafts to maintain projection and prevent a drooping tip over time. We can also use grafts to shape the tip of the nose, such as the cap graft, alar rim, etc.
Nose tip rhinoplasty thus benefits from a combination of the two rhinoplasty techniques.
Hybrid rhinoplasty combines ultrasonic, structural, and preservation rhinoplasty. This technique is modern because it can be applied in the majority of cases. It increases, for me, the chances of a natural and stable result over time. This technique requires a learning curve, of course, but it offers one more alternative in our toolbox of rhinoplasty techniques.
