Simultaneous Bimaxillary Surgery and Rhinoplasty: Evolving Concepts in Orthofacial Surgery

Septorhinoplasty is usually performed at least 6 months after orthognathic surgery to reduce the risk of unfavorable results mainly related to intraoperative midface alterations after Le Fort I-type maxillary osteotomy, increased postoperative edema, and prolonged surgery time when performing a simultaneous procedure. Conversely, advocates of simultaneous orthognathic surgery and rhinoplasty believe that correction of the shape and function of the nose together with OS is advisable in order to obtain the best outcome in terms of aesthetics and respiratory efficacy. We have already published our experience with simultaneous orthognathic surgery and rhinoseptoplasty. Since 2018, we have begun to perform preservation rhinoplasty (PR), progressively expanding the clinical indications as the experience with this technique increased. Preservation rhinoplasty is based on three operative concepts: (1) preservation of the soft-tissue nasal envelope by dissecting in a subperichondral–subperiosteal plane with preservation of the fibrous nasal ligaments; (2) preservation of the osteocartilaginous (or only cartilaginous) dorsum by maintaining the integrity of the middle third and removing a strip of cartilage from the septum to lower the bridge; and (3) preservation of the alar cartilages with tensioning and suturing techniques, limiting the excisional procedure. The advantages of PR when compared to conventional structural rhinoplasty are: (1) preservation of the keystone area and attachment of the upper lateral cartilages to the septum; (2) maintenance of dorsal aesthetic lines; (3) preservation of the internal nasal valve; 4) greater precision in correcting the deviation of the nasal pyramid in the coronal plane; and (5) a lesser need for revision. However, patients with a large bony component, a deep nasofrontal angle, or an irregular bony pyramid are not ideal candidates for PR procedures or grafting.