The Push Down Technique during rhinoplasty

The Let Down or Push Down Technique for the preservation of the nasal dorsum

Rhinoplasty  is one of the few disciplines of aesthetic surgery where a multitude of new techniques is being introduced recently, constantly striving to achieve the best result possible. 


While some of these techniques will not pass the test of time, they will eventually be replaced by new, apparently superior techniques. Nevertheless, some of them are experiencing a real revival due to crucial modifications, such as in the case of the "Push Down" or "Let Down" technique, which has been modified by Dr. Yves Saban from Nice. Since I am a member of the international group of rhinoplasty surgeons, I am also involved in this continuous development.

The photos show our patient after surgery of a crooked nose with a drooping nasal tip. Surgery of the nasal dorsum by means of the Let Down technique.


The guiding principle of this type of rhinoplasty is the preservation of the natural dorsum of the nose as far as possible with the displacement of the hump into the facial plane. 


Imagine a multi-storey building with a perfect because even roof. This building is to be reduced by one floor since all floors are not required anymore. At this point, there are two alternatives: First, you can tear off the roof, remove the floor, and then reconstruct the roof. This will allow for a smaller building - with a new roof. 

The other option is to save the roof and only remove the top floor by short term stabilization. Then the roof is lowered to the now uppermost, but lower floor. 

Which option would you choose?


When it comes to aesthetic rhinoplasty, one of the most important goals is to ensure that there are no irregularities at all, ideally. The more adjustments are necessary (but also performed), the higher the risk that irregularities occur. And this despite the most careful reconstruction! Furthermore, certain camouflage measures - i.e. the attempt to hide irregularities - are often not of lasting success because of patient-specific wound healing processes. 


Consequently, we strongly recommend the Let-Down / Push-Down technique  as the most suitable procedure for a symmetrical nasal dorsum.

Implementation of the Push Down/Let Down Technique

In this procedure, a bony and cartilaginous strip is cautiously removed from the nasal septum just below the nasal bridge. Next, the entire bony nasal pyramid is separated from the facial plane, which allows it to be mobilized and shifted into the facial plane ("Push-Down").


Depending on the prominence of the nasal hump, a bony strip can also be removed from the sides of the nasal pyramid. The resulting space can be used to shift the nose more clearly into the facial plane ("Let-Down").


It is most suitable to apply an ultrasonic scalpel (piezoelectric instrument) for the separation of the bone. The accuracy is significantly improved and, above all, unintentional fractures of the bone can be prevented - as this may occur by using a chisel.

Picture 1: Simplified representation of the nasal anatomy with a bony-cartilaginous hump.
Picture 1: Simplified representation of the nasal anatomy with a bony-cartilaginous hump.
Picture 2: Transection of the nasal pyramid, in this case by means of the ultrasonic blade.
Picture 2: Transection of the nasal pyramid, in this case by means of the ultrasonic blade.
Picture 3: Shifting the nose inwards and " retracting " the hump
Picture 3: Shifting the nose inwards and " retracting " the hump

The hump remains invisible

Picture 4: The so-called cartilage scales with endogenous fibrin /PRF
Picture 4: The so-called cartilage scales with endogenous fibrin /PRF

There is a muscle and excess fat tissue in the upper part of the nose, at the nasal root. Once the hump is shifted into the facial plane, the resulting cavity is filled in with this tissue. The former hump is located directly beneath the skin in the middle nasal region. "Cartilage relaxation measures" are implemented on the cartilaginous hump in the lower part - adjacent to the nasal tip - in order to compensate for the height. 


Ultimately, the aesthetic nose correction results in a very smooth nasal bridge in the long term, with a slight swing if desired. When necessary, a cartilaginous graft is positioned at the nasal root or above the nasal tip to provide for a smooth nasal bridge contour.

When can the Push-Down/Let-Down technique be applied?

Experience has shown that this technique is very effective for patients with a straight and laterally symmetrical nasal bridge or for patients with a crooked nose that is straight in its axis.


The so-called C-shaped nose (looking like the letter C) is not suitable for this type of rhinoplasty and has to be compensated with conventional techniques and corresponding transplants. 


However, in patients with a suitable nasal bridge ( less hump but very high), a change is even partially possible without skin detachment. Thus, the wound healing process is shorter and involves less swelling. 

Preservation Rhinoplasty – preserving soft tissue structures

Other anatomic conditions may also allow for many soft tissue structures (ligaments) to be preserved. In this case, the term "Preservation Rhinoplasty" is used.


This technique, like any other, carries certain risks, despite the extensive, impressive advertising by some surgeons on social networks - particularly abroad, where a "magic finger" seems enough to transform a hump nose into a gorgeous one in the blink of an eye.


Sometimes, despite all the measures taken, the hump may become visible again as a result of the healing process. In such (rare!) cases, a revision surgery is generally possible without any problems after one year.


In other patients, there may be a palpable and eventually observable ridge in the upper part of the nasal bridge (in the area of the nasal root). This can be remedied with basic masking measures involving the body's own cartilage. 


Illustrations from the book chapter:

Milos Kovacevic 'Refinements in Dorsal Preservation'

“Preservation Rhinoplasty”, Editor: Yves Saban, Baris Cakir, Rollin Daniel, Peter Palhazi