Published online: 2020-09-04

Original Research

The Segmental Preservation Rhinoplasty:

The Split Tetris Concept
Jose Carlos Neves, MD1 Diego Arancibia Tagle, MD2 Wilson Dewes, MD3 Mario Ferraz, MD4

1 Department of Facial Plastic Surgery, My Face, Clinics and Academy,
Lisbon, Portugal
2 Department of Otolaryngology – Head and Neck Surgery, Hospital
Universitari Son Espases, Baleares, Spain
3 Department of Facial Plastic Surgery, Clinica Dewes,
Lajeado, Brazil
4 Department of Facial Plastic Surgery, Clinica Mario Ferraz,
Campinas, Brazil
Address for correspondence Diego Arancibia Tagle, MD, Department
of Otolaryngology – Head and Neck Surgery, Hospital Universitari Son
Espases, Carretera de Valldemossa 79, Planta 0, Modulo D,
Despacho Q018, Secretaria Otorrinolaringologia Palma de Mallorca,
Baleares 07120, Spain (e-mail: arancibiadiego@gmail.com).

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Abstract Dorsal preservation rhinoplasty has seen considerable advances in the recent years as
many doctors have improved and developed new ideas on the subject. In the era of

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minimal trauma surgery, it is important to achieve a beautiful nasal aesthetic result
Keywords with minimum injury to the nose. Preserving the main structures of the nasal pyramid
► preservation has been pursued for more than a century, and some different approaches have been
rhinoplasty described and developed since then. Their strengths and weakness have been shown.
► letdown The present society’s demand for perfection is an added reason for improving the
► pushdown stability and predictability of preservation rhinoplasty. We describe a brand-new
► split Tetris concept philosophy of approaching the nasal dorsum hump that combines both safety and
► Vitruvian Man split delicacy in dealing with the anatomical structures with elegancy and accuracy and
maneuver achieving the aesthetic goal required.

Our article on split preservation rhinoplasty1 showed the
real advantage of the intermediate resection in stabilizing
the rhinion position by putting a suture from our free
anterior dorsal septal cartilaginous flap to the basal posterior
stabile septum. In fact, this is a critical stitch for predictably
keeping the rhinion in the desired position and helping avoid
the criticism of the so-called “pushdown” family techniques
for its supposed lack of accuracy.
This fixation can be made with a single stitch including
the contralateral perichondrium or, eventually for more
stability, a running figure-of-eight stitch can be used.
Criticisms to the Split Preservation Rhinoplasty
The weakest aspect of the split preservation rhinoplasty1
technique we described was apparently that the caudal
border of the septum was cut and needed to be stabilized
with sutures since some colleagues believed this could lead
to instability in the structure with a consequent lateraliza-
tion. Nevertheless, in our practice, this problem did not
occur, probably because if any instability was felt, we used
to suture a cartilaginous strut laterally to the caudal border of
the septum. However, there was room for improvement in
this intermediate approach, and this is when the split Tetris
concept was developed.
Goals of the Tetris Concept
The goals of the preservation approaches to the nasal dorsal
line are very clear: keep the nasal pyramid framework unit
intact to avoid healing problems, achieve a natural and stable
result preserving the patient’s own anatomy, and create the
best conditions for promoting an easy revision if needed.
The goals of the Tetris concept are as follows: design a block
of cartilage below the cartilaginous hump that will fit the
designed box, which will be sutured so that the final rhinion

Issue Theme Preservation Rhinoplasty: Copyright © by Thieme Medical DOI https://doi.org/

An Update; Guest Editor: Jose Carlos Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0040-1714672.
Neves, MD New York, NY 10001, USA. ISSN 0736-6825.
Tel: +1(212) 760-0888.
Segmental Preservation Rhinoplasty Neves et al.

height is stable and accurate; resect a small amount of cartilage
and eventually bone under the bony pyramid (similarly to the
high resection approach) in a progressive way to avoid the
creation of a step at the level of the traverse osteotomies; and
preserve a caudal septal cartilage wide strut from the caudal
border of the upper lateral cartilage (ULC) till the caudal septal
border, whose height will be adjusted at the end of the
procedure, so that a supra tip saddle cannot be seen.
The Tetris Concept Technique
Lateral Wall Letdown
We always start treating the lateral wall first using the
letdown concept. This is paramount for performing the
lateral wall split maneuver1 so that the elastic articulation
between the ULCs and pyriform ligaments with the lateral
bones do not promote a relapse of the hump. We will dissect
the bones from these structures and at some level the
mucosa, leaving a few millimeters not dissected at the dorsal
level to prevent instability of the unit.
Drawing the Cartilaginous Block
A rectangular piece of septal cartilage will be designed below
the cartilaginous hump in between the most prominent point
of the hump (at or slightly caudal to the rhinion) and the caudal
border of the ULC (►Fig. 1A). We start measuring a 5 to 8 mm
perpendicular line to the dorsum at the level of the ULC caudal
border. This line represents the caudal border of our rectangle.
Another perpendicular line is drawn at the level of the most
prominent point of the hump with approximately the same
height. This represents the cephalic border of the rectangular
piece. A new line is drawn uniting the two previous ones at
their posterior end, which creates the posterior border of the
block. The septal–UCL connection represents the anterior
border. We prefer the block (quadrangular or rectangular)
figure compared with a triangular shape, for instance. This is

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Fig. 1 (A) The Tetris block is designed in between the highest point of the hump and the WASA. (B) The two slots are created to permit the
pushdown maneuver of the block. (C) The nasal hump is pushed down and the block fits its slot. The caudal and the posterior borders are
stabilized using 5–0 PDS sutures. The caudal septal natural strut keeps, at this point, its original height (left panel); it will be trimmed to fit the
ideal profile (right panel). (D) Harvesting septum below the stabilized structure. We respect the L-shape concept.

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 Segmental Preservation Rhinoplasty Neves et al.

because it is designed to achieve a stabler structure, and once
we have stabilized a vertical and a horizontal vector, we can
avoid tilting of the free pyramid.
Isolating the Block
Using a no. 15 blade we cut the caudal, posterior, and
cephalic borders of the rectangular block. It must free the
cartilaginous hump. When pushed down, the block overlaps
with the stable septal cartilage, and we create a saddle nose
below the UCL caudal border.
Drawing the Space Slots
Two new geometrical shapes will be designed: one below the
rectangular block and another below the bony hump. The one
below the block must have the height that we intend to
deproject the dorsum. Since the deprojection will be bigger
under the highest point of the hump and less the more caudal
we go, on most occasions the slot shape will be trapezoid.
Below the bony bone, we draw (or assume without drawing)
a triangular shape with its vertices ending at the level of the
transverse osteotomies (►Fig. 1B). These new shapes will be
resected, and thus the space for the pushdown maneuver will
be created (►Fig. 2A).
Removing Cephalic Septal Excess
We remove our triangle below the bony hump with scissors,
and we always start at a tangent to the undersurface of the
bony vault to avoid big resections that can lead to a radix step.

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Fig. 2 (A) The Tetris block was created. The slots below the block and below the bony dorsum were created. The caudal border of the block was
trimmed to perfectly fit its slot after the rotational movement. (B) Pushdown maneuver. A posterior and caudal movement is produced in the
mobile cartilage so the nasal pyramid adapts to the desired profile. (C) Stabilizing the caudal border of the block. The spring effect can be seen as
a small residual hump appears. (D) Stabilization of the posterior border of the block. After we stabilize the block below the rhinion no more
relapse of the hump will be seen.

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Segmental Preservation Rhinoplasty Neves et al.

We like to remove a smaller triangular piece, and then perform

the pushdown maneuver and analyze how much we have
deprojected. If this is not enough, we go in again and remove
another triangular slice until reaching the desired level. In
some cases, we only remove cartilage; hence, scissors are
enough, but sometimes we have to remove a small piece of
bone, for which we often use scissors. However, we rarely use a
baby rongeur since it can create a bigger space than is needed,
and the radix step will appear as a consequence.

Removing Intermediate Septal Excess

Now, the hump can be reduced, and the cartilage block
overlaps the posterior stable septal cartilage, and as we
have isolated the Tetris block, we press it down, and at the
level of the cephalic chondrotomy we can create the side split
effect (similar to the Vitruvian side splits described previ-
ously), bringing it posteriorly and caudally in a rotation
movement. At this moment, we check if the previously
designed trapezoid slot below the block matches the dorsal
height, and we try to achieve this by moving the dorsal

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framework. We are ready to remove this piece of cartilage
and create the slot our Tetris piece will occupy when we push
the nasal pyramid down (►Fig. 2B). Eventually, in deviated
noses, we suture the overlapped cartilages side by side
(without resection the trapezoid piece, ►Fig. 3), with the
rectangular block being sutured on the opposite side of the
deviation so that it can compensate (►Fig. 4) (will be
described next).
Adjustments to the Block
The rectangular block movement is caudal and posterior in a
rotational fashion, as already described. This movement will
Fig. 4 The block overlaps and is sutured to the septum on the
opposite side of the deviation.
create a caudal overlap of a small portion of the cartilage
block with the caudal septum strut we have left intact. Thus,
we trim the caudal border of the block so that it fits the slot
created perfectly (►Fig. 2A).
Split Tetris Preservation
This movement brings the pieces down into their spaces in a
perfect match resembling the Tetris game, so we have called
it the “Tetris preservation concept” (►Fig. 5).

Fig. 3 In high septal deviations, we can overlap the block to the stable Fig. 5 The Tetris block. Intraoperative image showing the block
septum without creating a slot. sutured in this slot.

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Suturing Splitting the Tetris Block

It is now time to stabilize the mobile structure. Three
fundamental points must be perfectly controlled. First is
the radix region, where the septal resection meets the
transverse osteotomy, whose importance we have already
stressed. We must maintain a perfect nasal septum support
below this point, avoiding the bony dorsum to come down
and create a step. Second, the suture of the caudal border of
the Tetris block to the caudal septal strut will stretch and
bring the dorsum down. This movement resembles what we
performed in the Cottle pushdown technique,2,3 and because
of this here we can see a mini-Cottle using an intermediate
approach but preserving the caudal border of the septum and
the stability of its attachment with the anterior nasal spine
(ANS). Third, after performing the previous suture, the hump
is reduced. Nevertheless, immediately we observe a small
relapse of the hump that will slightly increase with time, the
spring effect (►Fig. 2C), which is one of the major problems
of the preservation concept, leading to certain fragility, and
has been criticized. So, we perform a second suture that
The cartilaginous component is always convex in a nasal
dorsal hump. This can lead to two phenomena: a curved line
that creates a small hump in-between the rhinion and supra
tip region (the cephalic cartilage), and a supratip saddling
(the caudal cartilage).
If this kind of effect is seen, it is essential to flatten the
cartilaginous curve. One (or eventually two) vertical cuts of the
Tetris block can be made by splitting it into two (►Fig. 6) (or
eventually three, ►Fig. 7) pieces. The caudal block will be
brought more anterior and caudal in a rotational movement.
This movement resembles maintaining the fingers of a hand
together and then separating them from each other. The more
the block pieces are apart, the more concave the profile is, and
what we can achieve with this movement is really spectacular.
Performing this movement can produce too much tension in
the caudal ULC septal joint. The more we curve anteriorly the
septum to achieve a concave profile, the more distorted the ULCs
are. Based on this, it is sometimes necessary to free these caudal
articulations until the level the ULCs are not distorted. The block

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definitely solves this problem. At the level of the rhinion, we
suture the cephalic border of the Tetris block to the stable
septal cartilage and the profile remains stable during the
healing process (►Figs. 1C and 2D). These sutures can be
performed as one simple interrupted stitch or as a figure-of-
eight continuous stitch. Additional sutures can be made at
the caudal and the posterior borders of the Tetris block with
the surrounding stable septal cartilage. To increase stability,
in our sutures we include the contralateral perichondrium
and mucosa on the side we are working on. The sutures are
5–0 polydioxanone.
pieces are then sutured individually in their ideal position.
The Segmental Dorsal Preservation
The split Tetris is an evolution of the intermediate split
approach whose fundamental goal is the stabilization and
predictability of the nasal dorsum final position. It was
designed to avoid conceptual weakness, mainly regarding
coronal axis deviations and caudal septal border instabilities.
At first, this technique may seem demanding, but once it has
been learnt it is really simple to perform.

Adjustments to the Caudal Septal Strut

At this point, we have brought the dorsum to the ideal
position except at the level of the caudal septal strut that
we preserved. In fact, the result is a polybeak appearance.
The anterior border of this natural strut must be addressed.
We can trim it following the height of the dorsum we
achieved or leave a higher end at the level of the anterior
nasal septal angle to act like a strut to the tip.
Since we performed the lateral wall split and put sutures
at the fundamental spots, we have a very stable flat dorsum.
We can achieve a more concave dorsum if we are more
aggressive at the level of the rhinion and remove a bigger
amount of cartilage below it. However, a problem can be
created. If the rhinion was brought down too aggressively, we
can promote a slope and a deflection at the cephalic carti-
laginous hump level (reaching the rhinion), which leaves a
nonnatural transition from the cartilage to bone. This effect
shows how powerful the technique is. In those cases, the
stitch below the rhinion must be released and restored in a
looser fashion.
As the shape of the bony dorsal line can vary a great deal,
we perform an osteosculpture after we have defined and
stabilized the final dorsal height so that we can have a
smooth transition. Also, the lateral bony wall is sculpted as
a refinement. We prefer burrs, but ultrasonic devices or rasps Fig. 6 The Tetris block split. It creates a more flatness or concavity of
can be also used. the cartilaginous dorsum.

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Segmental Preservation Rhinoplasty Neves et al.
Fig. 7 The split of the Tetris block. We can achieve a concave aspect
of the cartilaginous dorsum.
The preservation techniques 2–16 have been criticized for
many years due to their lack of precision and the stigma of the
outcome. The main problems are relapsing of the hump,
difficulty to produce a precise flat or even concave profile,
supratip saddling, and radix step. Our approach offers sol-
utions to these problems.
We address the nasal dorsum as segments.
Bony Segment
By addressing the septum to be removed below the pyramid
cephalically to the split with scissors or any other delicate
cutting in a progressive fashion, we prevent an excessive
resection and the consequent radix step. In many cases, we
only resect the septal cartilage, with one solitary cut in the
perpendicular ethmoidal plate to free the pyramid. It is
interesting to observe that sometimes we create a pivotal
point in between the split and the transverse osteotomy by
removing septal cartilage but not the ethmoidal plate. This
causes an elevation of the cephalic free pyramid when we
push the hump down and creates an upper step (opposing to
the classic lower step). To avoid this problem, we do not
connect the two transverse osteotomies in the midline. Then,
we create a greenstick fracture at the radix level to avoid a
complete disconnection of the bone.
Upper Lateral Cartilage Segment
It represents the Tetris block area from the WASA until the
split. We can play with the position of the block: more or less
rotation, more or less caudalization, more or less deprojec-
tion. And since we stabilize the block, we can be very accurate
in avoiding relapses of the hump. If we can improve the
design of the new dorsal profile, making it flat or eventually
slightly concave, we can split the Tetris block and create an
anterior and caudal rotation for the caudal block by achieving
concavity in between the two new smaller blocks. Again,
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these two blocks are sutured and stabilized with a high level
of predictability. It works like a subdivision of this segment.
Caudal Septal Strut Segment
By preserving the septum caudal to the WASA, we can play
with its position after stabilizing the mobile pyramid in its
new position. The new design of this segment avoids the
creation of a supratip saddling. In fact, before sculpting it, a
polybeak aspect is visible. Also, depending on the way, we cut
the caudal septal strut defining whether the profile is flatter
or more concave following the tendency of the last segment.
This strong natural septal strut can also be used for tip
supporting maneuvers, with or without grafts.
Indications
In coronal straight noses, both the split Tetris1 and other pre-
servation approaches are indicated. In fact, the best candidate is
the one with a straight narrow delicate nose with a dorsal hump.
If the nasal pyramid has a slight deviation (mainly in the
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cephalic–caudal axis), we can take advantage of the block by
overlapping it with the basal septum and suturing it contral-
aterally to the deviation (►Figs. 3 and 4). In bigger deviations
and severe crocked noses, if a preservation approach is indi-
cated, we prefer to indicate a classical septum pyramidal
adjustment and repositioning (SPAR)/Cottle approach.
If the septal deviation is mainly basal, we can perform the
split Tetris preservation rhinoplasty and then perform the
septoplasty. In fact, it works exactly as the L structure preser-
vation in direct hump resection procedures.17,18 Because our
Tetris block is around 5 to 7 mm high, if we stabilize it to a 5 bar
of the stable septum, it means that we end up with 10 to 12 mm
of septum we cannot harvest. Below it we can proceed with a
traditional septal harvesting (►Fig. 1D).
In broader noses at the upper third, it is possible to adapt
the technique by adjusting the width of the bony dorsum at
the end of the procedure. We use an ultrasonic device to
produce two green stick osteotomies at the level of the dorsal
aesthetic lines. The device will not completely cut the bone in
its depth. After the partial osteotomy, a squeeze movement is
produced in the bony dorsum achieving a narrower anatomy.
We do not use preservation techniques in wide middle third
dorsum (broad cartilage roof).
Conclusion
Recently, and for more than a decade, the main author has
been dedicated to achieving stable, accurate, and predictable
results in preservation rhinoplasty. Inspired by the SPAR
concept4,5 developed by Wilson Dewes, the big advantages
of this approach are the stability of the rhinion area, based on
the central suture, the stability of the caudal septal border
and its attachment to the ANS, and the way that by means of
splitting the Tetris block we can achieve a flat or, eventually
concave profile, of the cartilaginous segment.
To date, we believe that the split Tetris preservation
technique performed in indicated noses consistently pro-
motes these goals.
 Segmental Preservation Rhinoplasty Neves et al.

Clinical Cases

Case 1

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Case 1 Close approach, dorsal segmental preservation rhinoplasty, pre- and postoperative images. (A) Frontal view. (B) Lateral view. (C) Three-
quarter view.

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Case 2

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Case 2 Open approach, dorsal segmental preservation rhinoplasty, pre- and postoperative images. (A) Frontal view. (B) Lateral view.
(C) Three-quarter view.

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Conflict of Interest 8 Saban Y, Braccini F, Polselli R. Rhinoplasty: morphodynamic

None.
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