Removing a dorsal hump while preserving the natural nasal lines.
Push down and let down lower the bridge by repositioning it instead of cutting it away. The result keeps the dorsal aesthetic lines the nose was born with, when anatomy allows it.
A dorsal hump can be treated in two broad ways. Classic rhinoplasty removes the bump by rasping or cutting bone and cartilage, then rebuilds the open roof. Preservation rhinoplasty lowers the whole bridge as a unit through push down or let down, keeping the original dorsal surface and its natural light reflections. Dr. Guilherme Sella, an ENT surgeon with a doctorate from HCFMRP-USP and published articles on dorsal preservation, selects the technique after examining the nose, since not every hump is suitable. Indication, risks and plan are always defined in consultation.
What a dorsal hump really is
The bridge of the nose is made of bone above and cartilage below. A hump is usually a combination of both, with extra bone near the radix and extra cartilage over the middle third. Some noses also have a short nasal bone, thick skin or a deviated septum underneath, and all of this changes how the profile should be treated.
Two people can have humps that look identical in a photograph and still need different operations. That is why a profile photo is never enough to plan surgery. The internal exam, the septum, the width of the bony pyramid and the thickness of the skin all weigh in.
Classic hump removal versus preservation
In conventional technique the surgeon removes the convexity. Taking the hump down opens the roof of the nose, which then has to be closed with osteotomies and often with spreader grafts. This approach works and remains necessary in many cases. Its main trade-off is that the original dorsal surface, the one that produces smooth light reflections along the bridge, is gone and has to be reconstructed.
In preservation rhinoplasty the logic is different. The dorsum is kept intact and lowered as a single block. Bone and cartilage are released from below, a strip of septum is removed, and the whole bridge settles into a lower position. The roof is never opened, so there is nothing to reconstruct on top.
| Classic hump removal | Dorsal preservation | |
|---|---|---|
| What happens to the hump | Rasped or cut away | Lowered as one unit |
| Dorsal roof | Opened, then closed | Kept closed |
| Spreader grafts | Frequently needed | Often unnecessary |
| Dorsal aesthetic lines | Rebuilt by the surgeon | Original lines maintained |
| Typical candidates | Large, irregular, asymmetric humps; thick bone; revisions | Smooth humps, straight or slightly deviated noses, good septal anatomy |
| Main limitation | Irregularities can appear over time | Not every anatomy allows it; hump can partially recur |
Neither column is superior in the abstract. The correct answer depends on the nose in front of the surgeon.
Push down and let down: what is the difference
Both are preservation maneuvers. Both lower the bridge. They differ in what is done with the bone at the base of the nasal pyramid.
- Push down: the bony pyramid is pushed into the piriform aperture, sliding slightly inward as it descends. It is better suited to narrower bony bases and smaller reductions.
- Let down: a thin wedge of bone is removed at the base on each side, and the pyramid is lowered without moving inward. It avoids widening the bony base and is useful in wider noses and in larger reductions.
In practice the surgeon chooses during the operation, based on how the bone behaves once released. The septal work underneath is what actually controls how much the dorsum comes down and whether the tip rotates.
Why the dorsal lines matter more than the profile
Patients tend to judge a nose by the side view. Other people see the front view. What makes a nose look operated from the front is usually not the size of the bridge, it is the quality of the two lines that run from the eyebrows to the tip. When those lines are irregular, too narrow or interrupted, the eye reads surgery.
Keeping the native dorsum is the most direct way to keep those lines continuous. This is the reason dorsal preservation grew so quickly in rhinoplasty over the last decade and why it is a recurring theme in the surgical literature, including articles co-authored by Dr. Sella in Facial Plastic Surgery Clinics of North America on expanding indications and on the Brazilian approach to dorsum preservation.
Ultrasonic instruments and precision on bone
Piezoelectric devices cut bone and spare soft tissue. In hump surgery this allows controlled osteotomies, fine bone shaving and a cleaner release of the pyramid, with less trauma to the mucosa and vessels around it. Many patients notice less bruising, although swelling still follows its own timeline.
Ultrasonic rhinoplasty pairs well with preservation because both depend on precision at the bony base. The combination does not change the indication. A nose that is not a preservation candidate does not become one because of the instrument.
Who is a good candidate
Favorable signs include a smooth hump, reasonable nasal length, a septum that can be worked on and skin of average thickness. Less favorable situations include very large and irregular humps, severe deviations of the bony pyramid, previously operated noses and some S-shaped dorsal profiles. Revision cases are usually handled with structural technique, discussed in revision rhinoplasty.
Before surgery, the assessment includes a one-hour consultation with internal nasal exam, standardized photographs and digital simulation. The simulation is a communication tool and typically approaches 60 to 70 percent of the final result. High-frequency dermatologic ultrasound is used when it adds information, such as skin thickness, previous fillers or grafts and columellar vascularization.
Having the surgery in Brazil
Brazil has a long tradition in facial surgery and a high national volume of aesthetic procedures according to ISAPS surveys. Specialist credentials are public: every Brazilian surgeon has a CRM number and specialists hold an RQE, both verifiable online. Dr. Sella holds CRM-PR 33.018 and RQE 17.984 in Otorhinolaryngology, with certification by the European Board in Facial Plastic and Reconstructive Surgery.
Surgery takes place in Maringa, in the state of Parana, at a boutique hospital with adult and neonatal ICU and intensivists on site. Rhinoplasty is performed under general anesthesia and usually lasts three to five hours, with an overnight stay of twelve to twenty-four hours. An external splint stays in place for about seven days, followed by one week of taping. Most patients do not need nasal packing.
International patients and Brazilians living abroad are seen regularly. The usual path is an online consultation first, preoperative tests done at home, arrival one or two days before surgery and about seven days in the city until the splint comes off. Flying is released after that. Follow-up at one, three, six and twelve months can be in person or online. Details are explained in information for international patients. The team communicates in Portuguese, English and Spanish.
Timeline of the result
Swelling is not uniform. The tip is the last area to settle. Expect a presentable nose within a few weeks, a stable shape around six months and the definitive result between six and twelve months, sometimes up to eighteen months in thick skin or in revisions. Revision rates reported in the rhinoplasty literature range from five to fifteen percent, and any discussion of revision only makes sense after twelve months.
Preservation is a strategy, not a promise. The goal is a nose that matches the face and breathes well, chosen case by case.
When to see Dr. Sella
A consultation makes sense if you dislike your profile, if you breathe poorly through one or both sides, or if you want to understand which technique your anatomy allows. The appointment includes examination, photographs, simulation and a clear explanation of the plan and the recovery schedule. Learn more about rhinoplasty or get in touch with the team.
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
Does preservation rhinoplasty always avoid grafts?
No. Preservation refers to how the dorsum is handled, and the tip often still needs cartilage support from the septum or the ear. The plan is defined after examination.
Can the hump come back after push down or let down?
Partial recurrence is described in the literature and is one of the reasons the technique requires careful case selection and adequate septal work. It is discussed openly during the consultation.
Is dorsal preservation better for breathing?
Keeping the dorsal roof closed preserves the internal nasal valve anatomy, which can be favorable. Functional problems such as septal deviation or turbinate hypertrophy are still treated in the same operation when present.
How long do international patients need to stay in Brazil?
Usually about seven days after surgery, until the external splint is removed, plus one or two days before the procedure. Flying is released after the splint comes off.
Will a simulation show exactly how my nose will look?
No. The digital simulation is a communication tool and typically approaches 60 to 70 percent of the final result. Skin thickness, healing and cartilage behavior influence the outcome.
When is the final result visible?
Most of the shape is defined around six months, with the definitive result between six and twelve months, and up to eighteen months in thick skin or revision cases.
How do I know if my hump can be treated with preservation instead of classic removal?
That decision depends on the shape of the hump, the width and thickness of the bony pyramid, the septum underneath and the skin covering the bridge. Smooth humps with favourable septal anatomy tend to be good candidates, while very large, irregular or asymmetric humps often do better with classic reduction. Dr. Sella examines the inside of the nose and uses standardised photographs, and high frequency ultrasound when indicated, before choosing the technique in consultation.
Is a dorsal hump only an aesthetic problem, or can it affect breathing?
A hump is often accompanied by a deviated septum, narrow internal valves or enlarged turbinates, and these do affect airflow. The bump itself is not what blocks the nose, but the anatomy around it frequently does. That is why the consultation includes an internal exam, and functional steps such as septoplasty or turbinoplasty can be planned in the same surgery when indicated.
Does push down or let down hurt more than classic rhinoplasty?
Patients usually describe rhinoplasty as uncomfortable rather than painful, with pressure and nasal obstruction in the first days. Preservation techniques do not open the dorsal roof, which tends to mean less dorsal manipulation, though swelling and bruising still occur. Pain is controlled with prescribed medication, and the recovery plan is explained in detail before surgery.
Can preservation rhinoplasty be used in a revision case?
It can in selected situations, but revisions are more complex because the previous surgery has already changed the bone, cartilage and scar tissue. Many revision noses need structural grafts from septum, ear or rib rather than a preservation manoeuvre. Dr. Sella reviews the prior operative report when available and may request nasal ultrasound to map grafts and scarring before planning.
Book a consultation with Dr. Guilherme Sella
In person in Maringá, Brazil, or by video consultation. English-speaking team.