Rib Cartilage Preservation Rhinoplasty for Asian Patients: A New Approach, Advanced Techniques, and Long-Term Results

Why Is Rib Cartilage Preservation Rhinoplasty an Interesting Option for Asian Patients?

Rhinoplasty in Asian patients involves anatomical considerations that may differ significantly from those commonly seen in Western populations. Many Asian patients have a relatively low nasal dorsum, low radix, and a short, rounded, or poorly projected nasal tip. Consequently, the primary surgical objective is often augmentation rather than the reduction procedures frequently performed in patients with more prominent nasal structures.

Traditional augmentation techniques have often relied on silicone implants. However, potential long-term complications include implant extrusion and thinning of the overlying skin. Another approach involves placing rib cartilage directly onto the nasal dorsum (dorsal onlay graft), which may be associated with graft migration, visible graft edges, cartilage warping, or partial graft resorption, particularly in patients with thin nasal skin.

Preservation Augmentation Rhinoplasty introduces a different concept. Instead of placing rib cartilage on top of the existing nasal bridge, the surgeon uses a “push-up” technique to elevate the native dorsal framework from beneath. This approach aims to preserve the original nasal bones and upper lateral cartilages (ULCs) as a natural outer covering over the graft. By maintaining these native structures, the technique seeks to create a more natural-looking dorsal contour and potentially improve structural stability over time. However, long-term comparative evidence remains limited, and outcomes depend on patient selection and surgical technique.

Understanding Asian Nasal Anatomy Before Rib Cartilage Rhinoplasty

1. Low Nasal Dorsum and Radix
Many Asian patients have a relatively low nasal bridge and a low radix, the uppermost portion of the nasal bridge between the eyes. The original article describes the midpupillary line as a reference for planning the radix position in Asian rhinoplasty. However, ideal radix height and position vary according to facial anatomy and aesthetic goals. When planning rib cartilage augmentation, the surgeon must determine whether the radix also requires elevation, because this decision affects both the surgical technique and the length of cartilage needed.

2. Nasal Skin and Soft Tissue Envelope
Asian nasal anatomy may include relatively thick skin and soft tissue, particularly around the nasal tip. This can contribute to a rounded or bulbous tip and make the underlying cartilage framework less visible. Conversely, patients who have previously received nasal implants may develop thinning of the overlying skin, especially after long-term implant pressure. These factors influence the selection and positioning of rib cartilage grafts.

3. Upper and Lower Lateral Cartilages (ULCs and LLCs)
Some Asian patients have smaller or less supportive nasal cartilages, contributing to limited dorsal height and nasal tip projection. Preserving the integrity of the upper lateral cartilages is particularly important in preservation augmentation techniques. The original article emphasizes preoperative CT imaging to assess nasal structures. In clinical practice, the need for CT scanning should be determined individually based on surgical complexity, prior operations, and anatomical findings.

4. Nasal Airway
The original article discusses nasal airway dimensions as an important consideration when placing rib cartilage beneath the native dorsal structures. Adequate space and the condition of the internal nasal valve must be assessed carefully to determine whether a subdorsal graft can be placed without compromising breathing. Airway dimensions vary substantially between individuals, and a wider airway or lower risk of obstruction should not be assumed solely on the basis of ethnicity.

Traditional Rib Cartilage Rhinoplasty vs. Preservation Augmentation: What Is the Difference?

Traditional vs. Preservation Augmentation Rhinoplasty

Before examining the newer techniques, it is useful to understand the fundamental differences between traditional structural dorsal onlay augmentation and the push-up dorsal preservation approach.

The principal differences can be summarized as follows.

Traditional Augmentation Rhinoplasty (Structural Dorsal Onlay Graft)

• Graft placement: Directly on top of the nasal dorsum. Rib cartilage, either carved as a solid graft or prepared in another form, or a synthetic implant, is placed over the patient's native bony and cartilaginous nasal bridge.
• Risk of graft visibility: Potentially higher in thin-skinned patients. As postoperative swelling subsides, graft edges may become noticeable beneath the skin.
• Risk of displacement or warping: Rib cartilage may warp, shift position, undergo dimensional changes, or be partially resorbed over time.
• Natural feel: A prominent or poorly contoured solid graft may be palpable as a firm structure along the nasal bridge.
• Long-term outcomes: Structural changes such as cartilage warping, migration, or resorption may alter the appearance of the nasal dorsum and produce asymmetry or irregularities.
• Surgical complexity: May be less complex than some subdorsal preservation techniques, depending on the case.
• Revision rhinoplasty: Can be considered in many revision cases, although suitability depends on the condition of the remaining tissues and previous surgery.

Preservation Augmentation Rhinoplasty (Push-up Technique)

• Graft placement: Beneath the native nasal dorsum. A structural rib cartilage graft is placed below the patient's existing dorsal framework to elevate the bridge from underneath rather than adding a graft directly onto its surface.
• Risk of graft visibility: Potentially reduced. Because the original nasal bones and upper lateral cartilages remain over the graft, they may help conceal graft edges and irregularities.
• Risk of displacement or warping: Subdorsal positioning may offer improved structural support in appropriately selected cases, although graft warping and displacement remain possible.
• Natural appearance and feel: Maintaining the native bony and cartilaginous dorsal framework may help preserve a smoother and more natural contour, rather than producing a clearly palpable graft.
• Long-term outcomes: The technique aims to reduce visible changes associated with warping, migration, or partial resorption of a dorsal onlay graft. The native dorsum acts as an outer structural layer over the cartilage graft. However, long-term superiority over conventional techniques has not been established for every patient group.
• Surgical complexity: High. The procedure requires considerable experience in structural rhinoplasty, rib cartilage grafting, and dorsal preservation techniques.
• Primary and revision rhinoplasty: May be suitable when the upper lateral cartilages and native dorsal framework remain sufficiently intact.

Three Rib Cartilage Preservation Augmentation Techniques for Asian Patients

Three principal techniques discussed in the literature apply dorsal preservation concepts to rib cartilage augmentation rhinoplasty. Each technique has different structural requirements, indications, and limitations.

Technique 1: Reverse Spare Roof Technique (rSRT)

Authors: Ferreira & Santos | Published in Facial Plastic Surgery & Aesthetic Medicine, 2022

The Reverse Spare Roof Technique (rSRT) is described as an approach that adapts preservation rhinoplasty principles to augmentation. Instead of placing a cartilage graft directly over the nasal dorsum, an en bloc cartilage graft is inserted between the dorsal septum and the patient's preserved cartilaginous middle vault, including the upper lateral cartilages (ULCs). This arrangement aims to elevate the cartilaginous bridge from below, mainly increasing the height of the middle vault toward the nasal tip. Its effect on the radix is comparatively limited.

Indications in Asian Augmentation Rhinoplasty: The technique may be considered for primary or selected revision rhinoplasty patients with a low nasal dorsum and intact upper lateral cartilages. It is particularly relevant when augmentation is needed in the cartilaginous middle vault and toward the nasal tip, without significant elevation of the radix.

Technique 2: Subdorsal Cantilever Graft (SDCG)

Author: Dean M. Toriumi | Discussed in Facial Plastic Surgery Clinics of North America, 2025

The Subdorsal Cantilever Graft (SDCG) is a comprehensive and technically demanding approach designed for substantial dorsal augmentation. Depending on its configuration, it can elevate the middle nasal vault and, when required, the radix. It may therefore be considered for Asian patients who need a significant increase in nasal bridge height. Toriumi describes two configurations based on whether radix augmentation is required.

SDCG Type A (SDCG-A): For Patients Who Do Not Require Radix Augmentation

SDCG-A uses a single structural rib cartilage graft placed within a surgically created space beneath the existing bony nasal vault and cartilaginous middle vault. The distal portion is secured to a caudal septal extension graft used to support and project the nasal tip. The greatest increase in dorsal height occurs around the middle vault, while the radix remains relatively unchanged. This configuration may be appropriate for patients seeking greater height from the middle bridge toward the nasal tip without substantial alteration of radix position.

SDCG Type B (SDCG-B): For Major Dorsal Augmentation with Radix Elevation

SDCG-B is designed for patients requiring elevation of both the middle vault and radix. This configuration uses a longer rib cartilage graft. Its proximal portion extends through a surgically created opening in the nasal bone near the radix and rests on the frontal bone, creating a cantilever support mechanism. The original article describes potential radix elevation of approximately 4–5 mm using this method. The actual amount achievable depends on the patient's anatomy and surgical assessment. This approach may be considered for patients with a very low radix who require substantial overall nasal bridge augmentation.

Both SDCG-A and SDCG-B require sufficiently strong autologous costal cartilage to support the reconstructed dorsal framework. The article's author suggests considering partially calcified rib cartilage because it may provide adequate rigidity while remaining suitable for carving and suturing. However, graft selection must account for cartilage quality, calcification pattern, donor-site risks, and the surgeon's technical assessment.

Indications in Asian Augmentation Rhinoplasty: SDCG may be considered for patients requiring considerable dorsal elevation. SDCG-A is intended primarily for middle vault augmentation without significant radix modification, whereas SDCG-B is designed for more extensive augmentation that includes radix elevation.

Technique 3: Push-up Preservation Technique

Authors: Szychta & Robotti | Published in Aesthetic Plastic Surgery, 2025

Szychta and Robotti described a push-up approach to increasing dorsal height using principles derived from preservation rhinoplasty. The technique applies preservation concepts specifically to augmentation and includes two variations intended for different anatomical conditions and levels of surgical complexity.

Standard Push-up Preservation Technique

The standard technique may be suitable for primary rhinoplasty patients whose native upper lateral cartilages remain intact. Extended spreader grafts prepared from rib cartilage, approximately 1–2 mm thick as described in the original article, are placed beneath the dorsal septal T-structure. These grafts elevate the cartilaginous middle vault from below, increasing its height while generally leaving the radix unchanged.

Modified Dorsal Split Extended Push-up (Hybrid)

The modified hybrid technique may be considered for revision rhinoplasty patients with extensive scarring or mucosal adhesions from previous surgery. In this approach, the surgeon first separates portions of the cartilaginous dorsum from the septal framework through a dorsal split, then elevates the middle vault using rib cartilage spreader grafts. The technique takes advantage of the flexibility of the junction between the bony and cartilaginous nasal dorsum, often discussed in relation to the dorsal keystone area (DKA). An additional proposed advantage is the ability to adjust middle vault width while increasing dorsal height. However, it is not primarily intended for radix augmentation.

In the study described by Szychta and colleagues involving 12 patients, postoperative Nasal Obstruction Symptom Evaluation (NOSE) scores improved significantly (p < 0.05). Ten patients reportedly rated their satisfaction at 9–10 out of 10, and no palpable dorsal irregularities were reported in the series. Because the study involved a small patient group, these findings should be interpreted as preliminary clinical evidence rather than proof of consistent outcomes across all patients.

Indications in Asian Augmentation Rhinoplasty: The standard and modified push-up techniques may be considered for primary or selected revision cases involving a low nasal dorsum and sufficiently preserved upper lateral cartilages. The modified technique may be particularly relevant where previous surgery has caused scarring or where adjustment of middle vault width is required. These approaches primarily target the cartilaginous middle vault rather than the radix.

Who Is a Suitable Candidate for Rib Cartilage Preservation Rhinoplasty?

Potential Indications

• Primary augmentation rhinoplasty in Asian patients with a low nasal dorsum or low radix. The exact technique depends on whether radix elevation is required.
• Selected revision rhinoplasty cases requiring removal of a previous silicone or other synthetic implant, particularly where the skin has become thin and a traditional dorsal onlay cartilage graft might be more visible.
• Selected cases of saddle nose deformity following infection, trauma, or previous septoplasty, provided the remaining upper lateral cartilages and middle vault structures are sufficiently intact.
• Patients seeking a natural-looking dorsal contour and stable reconstruction while attempting to reduce the visibility of potential rib cartilage graft irregularities, warping, or movement.

Contraindications and Precautions

• Revision rhinoplasty cases with severely damaged or structurally compromised upper lateral cartilages (ULCs).
• Traumatic injuries involving severe disruption or loss of the cartilaginous middle vault.
• Rib cartilage that is too soft or insufficiently rigid to support the required reconstruction, particularly for SDCG techniques.
• Patients with a very narrow nasal vestibule or inadequate internal airway space for the intended graft placement.
• Procedures performed without sufficient surgical experience in costal cartilage grafting and dorsal preservation rhinoplasty.

Important Preoperative Assessments for Preservation Augmentation Rhinoplasty

1. CT imaging: The source article recommends CT scanning to assess the integrity of the native nasal dorsum. Whether CT is necessary for every patient should be determined according to clinical indications and surgical complexity.
2. Computer-based surgical planning: Evaluate the desired radix position and dorsal height together with the patient.
3. Rib cartilage evaluation: Assess graft strength, rigidity, and suitability for the chosen reconstruction.
4. Nasal airway assessment: Evaluate nasal airway dimensions and suitability for subdorsal graft placement.
5. Nasal endoscopy: Assess septal deviation and other internal nasal structures that may affect surgical planning or breathing function.

Clinical Outcomes Reported in Published Research

Published studies have reported encouraging outcomes for selected preservation augmentation rhinoplasty techniques. Nevertheless, the available evidence includes small clinical series and technical reports, so the long-term effectiveness and comparative advantages of these approaches require further investigation.

Aesthetic Results

Clinical publications have described improvements in dorsal aesthetic lines following preservation augmentation procedures. The original article refers to Asian patients treated with SDCG who reportedly maintained satisfactory dorsal contours and nasal bridge height during follow-up extending to four years. It also cites the Szychta series, in which no palpable dorsal irregularities were reported among the study participants. These findings are encouraging but should not be interpreted as guaranteed outcomes.

A proposed advantage of dorsal preservation augmentation is the ability to maintain the native nasal bones and upper lateral cartilages as the outer dorsal framework. Because the rib cartilage graft is positioned beneath these structures, the resulting surface contour and reflected light patterns may appear more natural in appropriate cases. By contrast, a solid dorsal onlay graft placed directly beneath thin skin may produce visible edges or altered light reflections, particularly if the cartilage subsequently warps, shifts, or undergoes partial resorption.

Functional Results

Szychta and Robotti reported a statistically significant improvement in Nasal Obstruction Symptom Evaluation (NOSE) scores among 12 patients (p < 0.05). According to the figures presented in the source article, the mean score decreased from 74 before surgery to 23 at three months after surgery, suggesting improved patient-reported nasal breathing in this small group.

Long-Term Stability of Results

Toriumi describes the potential for favorable long-term dorsal stability using the Subdorsal Cantilever Graft (SDCG). In contrast to conventional onlay grafts, which can sometimes develop visible warping, displacement, or partial resorption over time, the subdorsal graft is supported beneath the elevated native dorsal framework. The source article also discusses preservation of the native costal perichondrium as a possible contributor to graft integration and stabilization. These proposed advantages are relevant to surgical planning, although graft survival, vascularization, and long-term stability depend on multiple factors and should not be assumed to be superior in every case.

Conclusion and Future Directions of Asian Preservation Augmentation Rhinoplasty

Preservation rhinoplasty applied to dorsal and nasal tip augmentation represents an evolving area of reconstructive and aesthetic nasal surgery. These approaches are of particular interest for selected Asian patients whose nasal anatomy and aesthetic objectives require increased bridge height and tip projection rather than reduction of existing nasal structures.

The three techniques discussed above—rSRT, SDCG, and Push-up Preservation—share the goal of retaining important portions of the native bony and cartilaginous nasal dorsum while using structural cartilage grafts to elevate the framework from underneath. By preserving the patient's own dorsal anatomy as an outer layer, these techniques seek to address some limitations of conventional dorsal onlay grafting and provide a natural-looking contour with durable support. However, appropriate patient selection, surgeon experience, and additional long-term studies remain essential.

Key Points to Consider Before Preservation Augmentation Rhinoplasty

• Assess the integrity of the native bony and cartilaginous nasal dorsum before considering preservation augmentation.
• Select the appropriate cartilage material, graft configuration, and surgical technique based on the patient's nasal anatomy and whether augmentation is required only in the middle vault or also at the radix.
• Use appropriate preoperative imaging and surgical planning to evaluate the nasal framework, dorsal height, and desired radix position. CT imaging should be guided by clinical indications.
• Choose a surgeon with sufficient experience in costal cartilage grafting, structural rhinoplasty, and dorsal preservation techniques.
• Preservation augmentation may help conceal graft edges and reduce certain visible irregularities by maintaining the native dorsum over the graft. Nevertheless, both preservation and conventional techniques have potential complications, and long-term superiority cannot be guaranteed.

Disclaimer

This article summarizes concepts and findings described in published medical literature. It is intended for patient education and general information only and should not be interpreted as a recommendation for any particular surgical technique. Rhinoplasty decisions should be made following consultation with a qualified surgeon experienced in nasal surgery, with consideration of individual anatomy, potential risks, and realistic expectations.

References

1. Ferreira MG, Santos M. Preservation Rhinoplasty in the Saddle Nose: The Reverse Spare Roof Technique. Facial Plast Surg Aesthet Med. 2022;24(3):168–170.
2. Toriumi DM. Dorsal Augmentation with Preservation Concepts. Facial Plast Surg Clin N Am. 2025;33:269–284.
3. Szychta P, Robotti E. Middle Vault Dorsal Augmentation in Rhinoplasty as “Push-up” Preservation Technique. Aesth Plast Surg. 2025;49:1239–1245.
4. Toriumi DM. Subdorsal cantilever graft for elevating the dorsum in ethnic rhinoplasty. Facial Plast Surg Aesthet Med. 2022;24(3):143–159.
5. Daniel RK. The preservation rhinoplasty: a new rhinoplasty revolution. Aesthetic Surg J. 2018;38:228–9.
6. Saban Y, Cakir B, Daniel R, et al. Preservation Rhinoplasty. Istanbul: Septum Publications; 2018.
7. Goksel A, Saban Y, Tran KN. Biomechanical nasal anatomy applied to open preservation rhinoplasty. Facial Plast Surg. 2021;37(1):12–21.
8. Robotti E, Cottone G, Leone F. Modified dorsal split preservation hybrid rhinoplasty. Facial Plast Surg. 2023;39(4):441–451.

Frequently Asked Questions About Rib Cartilage Rhinoplasty

Q: What are the advantages of rib cartilage rhinoplasty compared with silicone implants?

A: Autologous rib cartilage comes from the patient's own body and avoids the use of silicone as a nasal graft material. It may be useful in patients concerned about certain implant-related complications, such as silicone extrusion or long-term pressure on thin skin. However, rib cartilage grafting has its own risks, including donor-site pain, scarring, graft warping, resorption, infection, and possible revision surgery.

Q: What is rib cartilage Preservation Rhinoplasty?

A: Preservation augmentation rhinoplasty uses structural cartilage grafts beneath the patient's native nasal dorsum to elevate the bridge from below, rather than placing a graft directly on top of the bridge. By retaining the original dorsal framework as an outer covering, the procedure aims to maintain a natural contour and provide stable support.

Q: Is rib cartilage rhinoplasty painful, and where is the scar located?

A: Rib cartilage harvesting requires a separate incision on the chest, commonly near the lower rib region or beneath the breast fold, depending on anatomy and surgical technique. The original article describes an incision beneath the right breast. Some patients experience pain or discomfort around the donor site after surgery, and a scar will remain, although it may become less noticeable over time. Pain levels and recovery vary between individuals.

Q: Who is a suitable candidate for rib cartilage Preservation Rhinoplasty?

A: Potential candidates include selected Asian patients with a low nasal dorsum who seek augmentation while preserving their natural dorsal anatomy, as well as certain revision rhinoplasty patients undergoing removal of a previous silicone implant. Patients with thin nasal skin may benefit from having the native dorsal framework covering the graft, provided the underlying structures remain sufficiently intact. A detailed consultation is necessary to determine suitability.