The Brazilian school of dorsal preservation, explained.
Preservation rhinoplasty lowers the hump without dismantling the natural roof of the nose. Here is how the Brazilian approach evolved, what the published papers describe, and what it means for a patient's result.
Brazilian dorsal preservation is a way of lowering the nasal hump that keeps the patient's own dorsum intact instead of cutting it off and rebuilding it. The bone and cartilage roof is lowered as a unit through push down or let down maneuvers, after bone or septal cartilage is removed from below. The Brazilian contribution, described in papers co-authored by Dr. Guilherme Sella in Facial Plastic Surgery Clinics of North America in 2023 and 2025, is a flexible, hybrid use of these maneuvers combined with ultrasonic instruments, which widens the range of noses that can be treated this way.
What "Brazilian dorsal preservation" actually means
Dorsal preservation is not a brand or a single operation. It is a family of techniques that share one principle: the bridge of the nose is lowered without being removed.
In classic hump reduction, the surgeon rasps or cuts away bone and cartilage from the top of the nose. That opens the roof of the nasal vault and the surgeon then has to close and reconstruct it, usually with grafts. In preservation, the hump stays where it is. Bone or cartilage is taken from underneath, at the base of the septum and the bony walls, and the whole dorsal unit settles down into the new space.
The word "Brazilian" refers to how surgeons in Brazil adapted and combined these maneuvers over the last decade, and to the way that experience was published. The Dr. Sella is a co-author of three of those papers and teaches the approach in courses described on the preservation rhinoplasty page.
How preservation differs from classic hump removal
The difference is easier to see side by side.
| Structural reduction | Dorsal preservation | |
|---|---|---|
| Hump | Removed with rasp, chisel or piezo | Kept and lowered as one block |
| Nasal roof | Opened, then closed with sutures and grafts | Never opened |
| Dorsal lines | Rebuilt by the surgeon | The patient's original lines |
| Spreader grafts | Often needed | Needed less often |
| Main risk profile | Irregularities, open roof, inverted V | Hump recurrence, radix issues |
| Best for | Thick or irregular dorsum, previous surgery | Straight or mildly curved humps, smooth bone |
Neither column is superior in the abstract. The anatomy decides. A nose with a short nasal bone, a deep radix or a rebuilt dorsum from a previous operation may do better with structural work. Many primary noses with a harmonious dorsal shape are good candidates for preservation.
Push down and let down: the two base maneuvers
Both maneuvers start with a septal strip. A piece of cartilage and bone is removed from the base of the septum, creating room for the dorsum to descend.
- Push down. The lateral bony walls are cut and the whole pyramid is pushed inside the piriform aperture. It slightly narrows the nose.
- Let down. A thin wedge of bone is removed from the base of the lateral walls, and the pyramid sits down onto the remaining bone. It is more stable in wide or thick bony vaults.
Ultrasonic instruments changed how precisely these cuts can be made. A piezoelectric tip cuts bone and spares soft tissue, mucosa and vessels, which makes the osteotomies more predictable and often reduces bruising. The combination of preservation and piezo is described in detail on the page about ultrasonic rhinoplasty.
What the published papers describe
Three peer reviewed articles co-authored by the surgeon frame the Brazilian experience.
- Indications for Preservation Rhinoplasty: Avoiding Complications, Facial Plastic Surgery, 2021;37(1):45-52. It maps which noses are suited to preservation and which situations predict trouble.
- Brazilian Approach to Dorsum Preservation, Facial Plastic Surgery Clinics of North America, 2023;31(1):131-142. It describes how Brazilian surgeons mix maneuvers inside the same operation instead of following a single recipe.
- Expanding Indications to Dorsal Preservation Rhinoplasty, Facial Plastic Surgery Clinics of North America, 2025;33(2):187-195. It reviews cases once considered off limits, such as deviated noses, larger humps and selected revision cases.
The practical message of this literature is simple. Preservation is a tool inside a complete rhinoplasty, not a replacement for the rest of the operation.
That matters for patients. A preservation case can still include tip work, septoplasty, turbinate reduction, valve repair and cartilage grafts from septum, ear or rib. The dorsum is preserved. Everything else is treated according to need.
What it means for your result
For a patient, three consequences are worth understanding.
The dorsal lines are yours. When the roof is never opened, the brow to tip lines keep the thickness and contour the nose always had. Many patients describe the result as looking like their own nose, lighter.
Fewer reconstructive steps. Because the keystone area and the mucosal lining stay in continuity, the surgeon usually needs fewer grafts to rebuild support, which can also help the internal nasal valve and breathing.
A different set of risks. Preservation has its own list. The hump can partially come back, the radix can feel full, and the septal strip must be planned carefully. Revision rates in the rhinoplasty literature in general sit around 5 to 15 percent, and a revision is only discussed after 12 months. Honest planning means accepting these trade-offs before surgery, not after. Revision rhinoplasty follows different rules entirely.
How the plan is made before surgery
The consultation takes about an hour. It includes history, physical examination with an internal look at the septum and turbinates, standardized photographs, digital simulation and an explanation of the technique chosen.
High frequency dermatologic ultrasound is used when indicated. It shows skin thickness, old fillers, previous grafts, bone irregularities and the vascular anatomy of the columella. In preservation planning, knowing whether the dorsal hump is mostly bone or mostly cartilage, and how thick the skin is above it, changes the maneuver chosen.
Digital simulation is a communication tool. The agreed reference is that it reflects roughly 60 to 70 percent of what the final nose will look like. Swelling, skin thickness and healing do the rest, over 6 to 12 months, and up to 18 months in thick skin or revision cases.
Preservation for patients traveling to Brazil
Maringa is served by MGF airport with direct flights from Sao Paulo and Curitiba. Surgery is performed under general anesthesia, usually 3 to 5 hours, with 12 to 24 hours of hospital stay at a private hospital in the city.
The external splint stays about 7 days. Most patients stay in town for roughly a week, fly after the splint is removed, and keep follow up at 1, 3, 6 and 12 months in person or online. The team works in Portuguese, English and Spanish. Details are gathered on the international patients page, and the first step is usually a teleconsultation arranged through contact.
When to see Dr. Sella
A consultation makes sense if you have a dorsal hump, a deviated nose, breathing complaints, or a previous rhinoplasty you are unhappy with, and you want to know whether a preservation approach fits your anatomy. The answer depends on your bone shape, skin and septum, and can only be defined after examination. You can read more about rhinoplasty and about the surgeon's training and publications before booking.
Otolaryngologist and facial plastic surgeon · CRM-PR 33.018 · RQE 17.984. PhD from FMRP-USP, founder of the Sella Learning Center. Updated on 2026-10-15.
Frequently asked questions
Is Brazilian dorsal preservation a different operation from preservation rhinoplasty elsewhere?
The maneuvers are the same family of techniques used internationally. The Brazilian contribution is the flexible, hybrid way of combining push down, let down and ultrasonic osteotomies within one case, as described in papers published in 2023 and 2025.
Can the hump come back after dorsal preservation?
Partial hump recurrence is a known limitation of the technique. Careful septal strip planning and fixation reduce the risk, and the possibility is discussed openly before surgery.
Does preservation rhinoplasty help breathing?
It can, because the nasal roof and internal valve area are not dismantled. Functional problems such as a deviated septum or enlarged turbinates still need to be treated specifically during the same operation.
Who is not a candidate for dorsal preservation?
Noses with very irregular bone, a heavily operated dorsum, or certain radix shapes may be better served by structural techniques. The decision is made after physical examination and, when indicated, nasal ultrasound.
How long until I see the final result?
The nose is presentable within a few weeks, but the definitive result takes 6 to 12 months, and up to 18 months in thick skin or revision cases.
Can international patients have this surgery in Maringa?
Yes. Planning usually starts with a teleconsultation, with tests done in the patient's home city, arrival 1 to 2 days before surgery and about a week in town until the splint is removed.
What is the difference between push down and let down in practice?
Both maneuvers begin with removing a strip from the base of the septum so the dorsum has room to descend. In a push down, the lateral bony walls are cut and the pyramid slides inside the piriform aperture, which slightly narrows the nose. In a let down, a thin wedge of bone is removed and the pyramid sits onto the remaining bone, which tends to be more stable in wide or thick bony vaults. Which one fits your bone structure is decided during the consultation and sometimes only confirmed during surgery.
Why are ultrasonic instruments used in dorsal preservation?
The piezoelectric instrument cuts bone while sparing soft tissue, so the osteotomies can be made with more control and less trauma to the surrounding structures. In preservation, where the dorsal unit has to descend evenly, the precision of those cuts matters for the final dorsal lines. Dr. Sella uses ultrasonic instruments as part of the hybrid approach described in the published papers, not as a separate operation.
Does preservation rhinoplasty avoid the need for cartilage grafts?
It often reduces the need for spreader grafts, because the nasal roof is never opened and does not have to be reconstructed. Grafts may still be used at the tip, the columella or the base, depending on support and projection. Many cases combine preservation of the dorsum with structural work on the tip, which is why the plan is individual.
Can preservation be used in a nose that has already been operated on?
Sometimes, but it is less common. A previously rebuilt dorsum, a scarred septum or missing bone changes how the dorsal unit behaves, and structural techniques may be safer in those situations. High frequency dermatological ultrasound in the preoperative visit helps show previous grafts, fillers and bone irregularities before the technique is chosen. Revision cases are assessed individually in consultation in Maringa or by teleconsultation.
Book a consultation with Dr. Guilherme Sella
In person in Maringá, Brazil, or by video consultation. English-speaking team.