Preservation rhinoplasty has become a staple in the modern aesthetic surgeon’s toolkit. But with the surge in dorsal preservation rhinoplasty (DPR), one issue continues to test even the most skilled surgeons: hump recurrence. It’s the Achilles heel of an otherwise elegant technique. Up to 15% of DPR patients may experience a reemergent dorsal hump, often requiring revision surgery. And for patients whose primary concern is hump reduction, recurrence can seriously erode trust. A recent article in Plastic and Reconstructive Surgery (Cason et al., 2025) outlines five key tenets to help you get control of this issue before it controls your outcomes. We’ve boiled them down for you to create the ultimate DPR prevention checklist.
1. Don’t Skip the Patient Selection Filter
Preservation is not for everyone, and pushing it in borderline cases increases the odds of hump recurrence. S-shaped nasal bones, long nasal bones, deep nasofrontal angles, prior trauma, or poor septal quality? These are all red flags. If the nasal dorsum is predominantly bony or shows significant asymmetry, conventional techniques may deliver better long-term aesthetics. Patients with a previous conventional rhinoplasty? Generally poor candidates for DPR. Those who’ve had prior DPR may be considered for revision preservation with caution. Know your patient’s anatomy. Don’t chase idealism where it doesn’t belong.
2. Address All Anatomic Blocking Points
The success of DPR hinges on your ability to release resistance. Hump recurrence is rarely about incomplete resection—it’s usually about persistent tensile forces or “memory” within the nasal framework.
Goksel et al. have identified eight anatomical blocking points: subdorsal cartilage remnants, bony spicules of the perpendicular plate, overlapping osteotomy edges, the Webster triangle, mucoperiosteal tethering, medial canthal ligament attachment, lateral keystone resistance, and scroll tension.
Each must be addressed intraoperatively. Ignoring even one can undermine the entire construct. Releasing these points systematically and thoroughly can drastically reduce the risk of dorsum rebound.
3. Lock It Down With Suture Fixation
You’ve modified the septum and released the keystone, but if you don’t stabilize the dorsum, memory will still win.
Suture fixation is mandatory. Whether you’re working with high, mid, or low septal strip techniques, mechanical fixation anchors the dorsum in its new contour and prevents the creeping return of convexity. Crisscross sutures in high strip cases, end-to-end or overlapping septal sutures for mid-level work, and a 3-point fixation to the anterior nasal spine for low strips—these techniques are your insurance policy.
4. Match the Technique to the Nose
Kosins’ procedural stratification offers clarity when the anatomy throws you curveballs. For smaller humps and S-shaped nasal bones, surface techniques work well. For larger humps and V-shaped bones, lean into impaction methods like let-down or push-down. Type 3 and 4 techniques involve radix osteotomies and high/low septal modifications, and these are powerful tools when used appropriately.
Get smart with your DPR. Choose the least invasive approach that still gets you the result you want. And always retain the option to convert to conventional techniques mid-procedure if the anatomy resists.
5. Don’t Underestimate Ancillary Measures
If things still aren’t laying flat, think deeper. The pyriform ligament, a fascial structure that provides nasal vault support, can contribute to resistance at the keystone. Partial release of this ligament has been shown to improve dorsum flexibility and flattening. It’s an advanced maneuver, but in tough cases, it might be the final step to preventing recurrence.
Prevention Is Still the Best Revision Strategy
True hump recurrence in DPR reflects a mechanical failure. Fortunately, that failure is preventable when you approach DPR methodically, apply algorithmic procedural selection, and release all resistance points. And, of course, fixation sutures are no longer just an extra step.
As you integrate or refine DPR in your practice, these five tenets should serve as your north star. Nail your patient selection. Clear the resistance. Lock in the structure. Match the technique to the nose. And don’t forget the small stuff. It’s what keeps those pesky revisions off your schedule.
SOURCE: Plastic and Reconstructive Surgery
This editorial blog piece is intended for informational purposes only and does not constitute medical or professional advice. The information provided is based on current medical literature and expert opinions, but individual patient outcomes may vary. Surgical procedures, including preservation rhinoplasty, carry inherent risks and complications. It is essential to consult with a qualified and board-certified plastic surgeon to discuss any specific medical needs and determine the most appropriate treatment plan. The content of this blog should not be used as a substitute for professional medical advice, diagnosis, or treatment.
