What is the difference between traditional rhinoplasty, structural rhinoplasty, preservation rhinoplasty, and ultrasonic rhinoplasty?

To understand the different types of rhinoplasty, it's helpful to envision the nose as a house built on a framework made up of bones and cartilage, covered by the skin. The purpose of this structure is to allow air to pass from the outside to the trachea and lungs.v

Traditional rhinoplasty

Traditional rhinoplasty (20th century) involved overall reduction of the nose by breaking the bones and cutting the cartilage. The bones were mostly broken blindly using an osteotome and hammer, and the cartilage was cut and sometimes sutured with additional cartilage grafts.

This weakened the framework of the house, causing it to gradually collapse over time and also compromised its respiratory function. The cartilages positioned under the skin often became increasingly visible over time.

As a result, deformations of the nose would appear over time, such as pinching of the tip, upward rotation of the tip, retraction of the nostrils, clear demarcation between the bones and cartilages, or deviation of the tip or nasal axis. Moreover, breathing difficulties were frequent, sometimes related to septum or turbinate problems, but more often due to valve issues.

It's important to understand the role of the cartilages in the nasal tip, similar to the ribs of an umbrella, which keep the nasal passages open. Cutting cartilage in this area to refine the tip weakens this supportive role and often leads to a sensation of occasional air blockage, as if a valve is closing. Certain positions or pulling on the cheek can alleviate this discomfort.

Structural rhinoplasty

Structural rhinoplasty emerged following traditional rhinoplasties (starting from the 1990s) to avoid the aforementioned drawbacks. After removing the hump and breaking the bones to reduce the width of the nasal pyramid, the dorsum of the nose is reconstructed using various cartilage grafts or by reshaping the remaining cartilage.

For the tip, the resections are more moderate, and the tip is reinforced with buried supporting cartilages. Sutures are used to reshape the tip, avoiding the disadvantages of significant resections.

Continuing the house analogy, this approach directly works on the roof and walls of the house to make it shorter and narrower, while also reinforcing the house to maintain stability over time and preserve its function.

However, it becomes necessary to repair the traces of these modifications and strengthen them with cartilage grafts taken from the nasal septum. The main drawback of these techniques lies in the difficulty of reconstructing a perfect dorsum that remains perfect over time, as well as controlling the fractures of the bones. Consequently, defects on the dorsum or bony pyramid can become increasingly visible over time. This is what made preservation techniques and concepts popular for addressing dorsum-related issues.

Preservation rhinoplasty

Preservation rhinoplasty is a comprehensive concept, with the primary focus being the preservation of the dorsum to avoid the drawbacks of purely structural rhinoplasties on the nasal dorsum. The principle is to lower the bony and cartilaginous pyramid as a whole, or only the cartilaginous part, by conserving the surface of the hump while pushing it down by removing some septum underneath.

These techniques have many advantages but do not apply to all types of noses or humps. They also have their own drawbacks.

The principle of preservation rhinoplasties is either breaking the foundations of the house or the walls just below the roof, as well as the central pillar supporting the house to lower the roof. Sanding of the walls or roof is often necessary to complete the house's reduction.

It's understood that the house is less stable compared to structural rhinoplasty, but theoretically, there is no risk of defects occurring over time at the junction between the bones and cartilages.

Another issue with these techniques is that there is less available cartilage from the nasal septum to reinforce the nasal tip.

Ultrasonic rhinoplasty

Ultrasonic rhinoplasty has existed for 10 years but has gained popularity in the last 5-6 years. Initially, the interest in these techniques was to perform structural rhinoplasty while avoiding complications associated with dorsal reconstruction and bone defects.

With this gentle and precise method of rhinoplasty, it became possible to visualize the entire nasal pyramid, sculpt the nasal bones, and polish them for reshaping the nose.

Ultrasonic rhinoplasty has also facilitated the development of preservation rhinoplasty by enabling precise maneuvers on the nasal septum (determining the correction of the hump) and the nasal bones (allowing precise bone cuts in dorsum preservation techniques).

These instruments have thus allowed the development of house remodeling techniques, combining surface sanding, wall and roof reshaping while maintaining the stability of the house, and remodeling the central pillar while preserving its stability.

Ultimately, ultrasonic rhinoplasty complements structural and preservation techniques, making them more precise and reliable.

Difference between rhinoplasty R1, R2, R3...

Lastly, there is often a question about the difference between primary, secondary, and tertiary rhinoplasty. It's much simpler to explain:

Primary rhinoplasty is when there has never been any previous surgery on the nose.
Secondary rhinoplasty is when there has already been a prior operation on the nose, such as rhinoplasty or septoplasty. In this case, the surgery is much more complex and subject to certain uncertainties that must be understood and accepted.
Tertiary rhinoplasty is when there have already been two previous operations on the nose.

The more prior surgeries on the nose, the more uncertain the outcome and the more complex the rhinoplasty becomes. It is essential to seek specialized rhinoplasty surgeons for these challenging procedures.

Conclusion

Each nose surgeon has the freedom to choose the techniques they use: traditional rhinoplasty, structural rhinoplasty, or preservation rhinoplasty. The majority of rhinoplasty specialists have abandoned traditional rhinoplasty techniques due to the aesthetic and functional complications often associated with them.

Many surgeons combine structural and preservation techniques depending on the case, nose types, and patient preferences. The addition of ultrasonic rhinoplasty provides precision and stability to previous techniques, as well as gentler postoperative recovery due to the less traumatic nature of ultrasonic procedures, allowing a return to normal life without the need for nasal packing in the week following the surgery.