SPECIAL TOPIC
A New Understanding and a Minimalist
Approach for Rhinoplasty
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Teoman Dogan, MD, PhD
Summary: In this article, a new understanding and minimalist rhinoplasty
Istanbul, Turkey approach is presented. This technique has many novelties, and this article aims
to simplify, make the operation more predictable, and correct primary deformi-
ties with a 20-step procedure. (Plast. Reconstr. Surg. 152: 549, 2023.)
R
hinoplasty is known as a difficult, complex
and unpredictable operation, and the rhi-
noplasty surgeon is advised to be ready to
use different techniques for each case.1 In this
article, a rhinoplasty approach that aims to sim-
plify, make the operation more predictable, and
correct basic primary deformities is presented.
There are 20 basic steps that are used in each
case, and some complementary maneuvers are
added when necessary.
This approach is only for primary cases with-
out obvious congenital deformities or severe
trauma sequelae. Some steps may be used for
clefts or secondary cases, but these cases are more
a reconstruction rather than an aesthetic proce-
dure with a deformed anatomy, and surgical tech-
nique must be adapted for each case.
The technique is published by the author as a
self-published textbook2 and has been presented
at many meetings. Most steps are minor modifica-
tions of well-known and published techniques3–7;
other steps that cover unique and innovative sur-
gical ideas are as follows.
INCISIONS
The technique can be performed open or
closed. Closed approach is performed only by
From the Department of Plastic Surgery, American Hospital.
Received for publication December 9, 2021; accepted August
11, 2022.
Presented at the Moroccan Society of Aesthetic and Plastic
Surgeons Meeting, in Marrakech, Morocco, November
26 through 27, 2021; the 48th Annual International
Symposium Aesthetic Plastic Surgery, in Puerto Vallarta,
Jalisco, Mexico, November 11 through 14, 2021; and the
44th Annual Meeting of the European Academy of Facial
Plastic Surgery, in Nice, France, September 15 through 18,
2021.
Copyright © 2023 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000010213
www.PRSJournal.com
marginal incisions, and the technique is unique
for this feature. There are two reasons: (1) multi-
ple incisions disturb the integrity of the nose and
cause disorientation, and (2) each incision is an
additional trauma.
A NEW UNDERSTANDING OF BREATH
PHYSIOLOGY
By definition, respiration describes the
amount of air reaching the alveolar level, and to
reach the alveolar level air must accelerate and
gain kinetic energy. According to a rule of physics
known as the Venturi effect, air flows much faster
through narrower channels than wider ones,
and the same principle applies to the respiratory
physiology. Inspired air is accelerated at the rest-
ing angle that is formed between lateral crura
and upper lateral cartilage,8 and have a decisive
effect on aesthetics and function. If the lateral
crus of the alar cartilage stays flat facing the dor-
sal surface, the lateral crus will receive the load
from the side and will stand stable. This nose tip
breathes well and is aesthetically appealing to the
eye (Fig. 1).
One also should note that there is some
amount of deviation and base crest on each
nose. These are parts of normal human anat-
omy, are not pathologic, and function to accel-
erate airflow. Therefore, it is neither necessary
nor correct to clean each crest, to correct each
deviation.
Disclosure statements are at the end of this article,
following the correspondence information.
Related digital media are available in the full-text
version of the article on www.PRSJournal.com.
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Fig. 1. Resting angle determines aesthetics and function. (Above) When the lateral crus is flat, it is
resistant to collapse during inhalation. This is also the best shape aesthetically. (Below) When the
crus is vertically positioned, it is weak, collapses easily, and is aesthetically poor.

PLANNING AND ANALYSIS
In this technique, no measurement is made,
and no golden ratio or imaginary polygons are
used. The plan is made simply by shaping the tip
with fingertips and finding the new dome point
and correcting the resting angle. The only cri-
terion is to create a new nose shape pleasing to
the eye.
PROJECTION BASED ON A MONOPOD
CONCEPT
Tip drop in the postoperative period occurs
more or less in all cases, and tip projection is still
an unresolved dilemma after many decades. The
suture thread has an active force on the tissues
they hold together. This will typically make the tip
stronger at the end of the operation. In contrast,
with tissue healing, tension on tip sutures relaxes
in days to weeks.
In a natural nose, the tip stands on a tripod,
with left and right lateral crura and two medial
crura, which together form the third leg. In this
model, tip projection is related to the length of
the legs of the tripod, and not to the shape or
strength.
A short alar cartilage will always result in
underprojection. Strengthening of the tripod
legs, with techniques such as medial or lateral cru-
ral struts, will not add to the length of the tripod
and will be ineffective for the projection.
Ligament suspension techniques are also
overrated in terms of their effect on projection.
The Pitanguy ligament originates from the nasal
dorsum, and this soft tissue cannot have any effect
on a point above that level.
For this reason, a new strut graft is described.
The strut graft acts like an invisible elastic mono-
pod that will hold the tip in place and still allow
the tip to be mobile (Fig. 2).
THE “L PROFILE” CONCEPT
In ideal conditions, two medial crura have
a 90-degree angle in between. This architecture
gives the two cartilages a shape of an L profile and
makes the columellar leg of the tripod stronger.
(Fig. 3).
NO DISSECTION PUSH-DOWN DORSAL
REDUCTION
Large dissections cause edema and disturb
the integrity of the nasal dorsum. If the bony pyr-
amid is infractured during manipulations, there
will be nothing but the skin envelope to hold the
broken bone pieces together. For this reason, the

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Fig. 2. This is an elastic triangular cartilage fixed to the septum.
Its top point is fixed to the dome. This is the only attachment
between the tip and the graft.
Fig. 3. To strengthen the columella in the cephalocaudal direc-
tion, the L profile shape configuration of medial crura is restored
by suturing the soft-tissue attachments between medial crura.
skin envelop is not dissected except a 4-mm-wide
dorsal tunnel.
NO-CAST APPROACH WITH A NEW
DORSAL STABILIZATION SUTURE
This is the first and only rhinoplasty tech-
nique where a cast is not used. The idea behind it
is simple. When the bony pyramid is pushed down
into the nasal antrum, the bony edges of the bony
pyramid become trapped and will fix the mobile
bony unit in lateral directions. Then, the bony
pyramid is fixed to the septum by a new percu-
taneous suture technique and immobilized. This
suture also flattens the dorsum.
SURGICAL STEPS
There are 20 steps in this technique, as
follows.
Fig. 4. Finding the new dome point. Cartilage is then marked
with percutaneous methylene blue injection.
1. Marking
The ideal tip point is found and marked.
This is the most important stage of the surgery,
and very similar to marking the new nipple-areola
position in reduction mammaplasty operations.
Looking from the immediate side, the tip is
folded with index fingers and thumbs of both
hands, and a tip shape that is most appealing to
the eye is formed (Fig. 4). By doing so, lateral
crura will bend on a new tip point and will turn
inward, and the resting angle is also corrected.
Then, the new dome points are marked on carti-
lage by percutaneous methylene blue injections
with 27-gauge needles. [See Video 1 (online),
which demonstrates marking of the new dome
point.]
2. Injection
The tip and osteotomy lines are infiltrated
with 6 cc of 1:50,000 adrenaline with 2% lido-
caine. The septum is then infiltrated with 6 cc of
1:200,000 adrenaline and 2% lidocaine.
A 27-gauge long (0.4 × 40 mm) needle is used
for injection. All tip injections are made through
mucosa. Septal injection should always start at the
far back and the highest point, so that the closest
point to the skull base is well infiltrated.
3. Incisions
In the closed approach, only marginal inci-
sions are used. For the open approach, only a col-
umellar incision is added. To make the dissection
easier, in the next step, a modified intercartilagi-
nous marginal incision that leaves a small segment
of lateral crural rim on the skin edge is used.
Medial crura is also incised on the rim level.
Then, both incisions are connected. For the open
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Fig. 5. Subperichondrial plane is dissected with a fine-tip instru-
ment. Leaving a small segment of lateral crural rim on the skin
edge helps for finding the dissection plane.
approach, an inverted-V incision is added to the
columella.
4. Tip Dissection
There are two options for the dissection: sub-
perichondrial and supraperichondrial. In the
author’s experience in the follow-up with the
patients who had different dissection planes on
the right and left sides, no difference in terms of
edema, shape, or prognosis has been detected.
Although the subperichondrial plane creates a
cleaner surgical field and allows for more control
over the anatomy, it weakens the alar cartilage;
this can be a disadvantage in weak cartilages, such
as in Latino phenotypes.
The dissection starts at the level of intercarti-
laginous cut on lateral crura (Fig. 5). [See Video 2
(online), which demonstrates subperichondrial
plane dissection of alar cartilages.]
Fig. 6. In the closed approach, soft tissue between the alar carti-
lages is cut for delivery.
7. Opening the Window
The soft tissue that remains intact between
the two alar cartilages is cut to the level of the
methylene blue traces in the soft tissues. In the
open approach, this tissue is cut after columel-
lar incision. In the closed approach, it is cut by
stretching the columella skin with the Crile retrac-
tor (Fig. 6).
8. Dorsal Tunnel and Rasping
Rasping is done only for weakening the
K point. This is done through a dorsal tunnel
using a thin rasp designed for this purpose.
A tiny tunnel is dissected with the periost ele-
vator. The dissection plane is supraperichondrial
on upper lateral cartilage, and subperiosteal at
the bony level. The tunnel should only be wide
enough to insert the 4-mm rasp. Then, the thin
bony cover at the apex of the dorsal hump is
rasped (Fig. 7).

5. Checking the Dome Points

Symmetry and the position of the new dome
points are checked by pulling out the cartilages
equally with two forceps and comparing the posi-
tions of the blue marks. If the dome points are to
be adjusted during surgery, the ideal dome points
are generally where the tip is most projected.

6. Cephalic Resection
Cephalic resection aims to create room for the
hemitransdomal sutures, and to free the lateral
crus from its medial attachments to turn inward
for correction of the resting angle. The incision is
made parallel to the rim. The remaining cartilage
width should be 6 mm at the new dome level in Fig. 7. The dorsal tunnel is dissected and the bony hump is
both sexes. rasped. Rasping is done only to weaken the K area.

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9. Septum Dissection
The upper half of the septal cartilage is dis-
sected at the subperichondrial plane. All septum
work is done through the marginal incision.
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10. Strip Removal from the Septum
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A superior strip that is larger on cephalic
end is removed.9 This cartilage will be used for
the strut (Fig. 8). [See Video 3 (online), which
demonstrates superior strip removal from the
septum.]
11. Osteotomies
The bone structure is made a mobile as one
piece with osteotomies. Percutaneous radix and
transfer osteotomies with a 2-mm chisel, and lat-
eral osteotomies with standard lateral osteotomes
are performed.
The radix is very close to the skull base, and
one should never perform a high radix cut. The
safe zone is the caudal inclination of the radix
toward the nasal dorsum. [See Video 4 (online),
which shows osteotomies.]
12. Push Down
First, the bony dorsum is mobilized by moving
it to the sides and simply pressing down into the
nasal cavity. There is no size limit for hump reduc-
tion. When the dorsum descends, it will flatten at
the K point.
Fig. 8. After a straight upper cut under the upper lateral carti-
lage level, a second lower cut is performed with the angled scis-
sors parallel to the first incision in the supratip area and by going
deeper to harvest a graft of suitable size for the tip strut. Lastly,
the strip is separated from the bony septum with the periost ele-
vator. Only one-fifth of patients will require resection of the bony
septum, and this must be done cautiously with a Caplan scissors
under good vision with headlights and magnification.
With a high radix, a step deformity will be pal-
pated. Removal of this bony excess will deepen the
radix. This can be done by rasping the step with the
4-mm rasp, or the step can be crashed with a 2-mm
osteotome as multiple superficial microfractures. As
there has been no skin dissection, bone segments will
behave like the broken pieces of a hard-boiled egg
shell and will remain in place. [See Video 5 (online),
which demonstrates the push-down maneuver.]
13. Dorsal Fixation Suture
A new percutaneous suture technique is
described for stabilization of the dorsum. A 5-0
polydioxanone (PDS) suture is passed through
the middle of the septum. Then, a 22-gauge hypo-
dermic needle is inserted at the K area, and the
free end of the PDS is passed through the sharp
end and pulled out from the other end. The nee-
dle is retracted out but stays under the skin and
is slid toward the other side. The thread is then
taken out from the tip of the needle. The suture
has two effects: (1) it locks down the bony pyra-
mid in the nasal antrum; and (2) it flattens the
dorsum.
As a general rule, the bony pyramid will always
tend to elevate over time but never descend and
cause a saddle deformity at the bony level.10 The
sutures will prevent the hump recurrence.
At least two sutures are necessary. The sutures
are not removed and are left to resorb, which usu-
ally takes 3 weeks. [See Video 6 (online), which
demonstrates the dorsal fixation suture.]
14. Upper Lateral Cartilage Excision
When the hump is pushed down, the upper
lateral cartilage almost always widens.11 To correct
this deformity, the junction of the upper lateral car-
tilage and the septum is simply cut with iris scissors
on its dorsal surface. Excess cartilage is trimmed
if necessary. To prevent a potential late middle
vault collapse, only two-thirds of the length of the
upper lateral cartilage is cut, and the cartilage ends
are fixed on both sides with absorbable sutures to
reconstruct a stable cartilaginous dorsum.
15. Gruber Hemitransdomal Sutures
These sutures construct the new dome and
correct the resting angle12 (Fig. 9). [See Video 7
(online), which demonstrates the Gruber domal
sutures.]
16. A New Strut for Projection
A triangular graft approximately 6 to 8 mm
wide and long enough for the desired projection
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Fig. 9. Three 6-0 polypropylene sutures on the medial rim,
approximately 2 mm below the new dome. The goal is to capture
an expanding angle like the capital letter A.
is harvested from the high strip material.
The graft can be sutured on the left or right
side, and the surgeon should decide which side
fits better for the facial asymmetry and har-
mony. As the human face is asymmetric with-
out exception, one side is always better than
the midline. The angle of the graft determines
the tip rotation, and the point where the dome
is fixed on the graft determines the projection
(Fig. 10).
A figure-of-eight suture is used for inter-
domal fixation. The free ends of the figure-of-
eight suture are then wrapped around the strut
and the dome point is fixed to the strut. Two
Fig. 10. The graft is fixed to the septum with 6-0 polypropylene
sutures.
554
Fig. 11. Both domes are fixed at the tip of the strut graft.
extra loop sutures are necessary for secure fixa-
tion (Fig. 11).
17. L Profile Reconstruction
Medial crura will be fixed to each other at a
90-degree angle. The remnants of the soft tissue
cut when opening the window in step 7 are sutured
with a few 6-0 PDS stitches. A standard medial crural
overlap may be necessary if there is bowstringing.
18. Lateral Crural Excision
At the end of the operation, the lateral crura
are always too long and cause bowstring defor-
mity, resulting in bulbosity. The cartilage is cut in
full thickness 2 to 3 mm close to its cephalic end.
The free ends of the cartilage are left free to over-
lap and are fixed when the mucosa is sutured at
this level (Fig. 12).
19. Ozkan Test
This simple test described by Ozkan Kahveciler
simulates what will occur in the long run. Viewing
the nose from the side, the tip is gently pressed
down with fingertips, applying a very small amount
of pressure. This is done four or five times in a row.
What one sees is what one will get in the long
term. With a strut properly placed, the tip should
be very elastic and there should not be any change
in tip shape or projection. [See Video 8 (online),
which demonstrates the Ozkan test in different
situations.]
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Fig. 12. Lateral crural excess is corrected with a simple cut, and
the edges are left to overlap freely. This should be done in all
cases to prevent bowstringing of the crura.
20. Closing
The final step is to stitch everything with
6-0 polyglactin 910, in both closed and open
approaches. Next, the septum is sutured over and
over to prevent a dead space with 4-0 polyglactin
910.
No intranasal splint is necessary. The nose is
taped with 1.27-cm (0.5-inch) Micropore surgical
tape for 5 days (Fig. 13).
Fig. 13. The nose is only taped, and no cast is used (the frontal
area is taped for fat injection).
A patient operated on with these 20 steps at 19
months postoperatively is shown (Fig. 14).
COMPLEMENTARY MANEUVERS
Some extra steps may be added in selected
cases. In case of overresection of the septum in
the supratip area, correction is simple and is done
by insertion of alar cephalic resection materials
into the tiny dorsal tunnel created in step 8. No
fixation is necessary.
In some cases, alar rims are too weak to stand
straight, or have retracted. Standard rim grafts are
the best solution in these cases.
Rim excisions may also be a choice in selected
cases. Similarly, a strong nasal spine or caudal sep-
tal excess can be removed to shorten the nose. Or
adding a thin piece of alar cartilage will increase
the projection, sharpen the tip, and lengthen the
tip lobule.
MANAGEMENT OF DEVIATIONS
Correction of a deviation is necessary only if it
causes an aesthetic problem or completely blocks
the airway. These extra parts are performed dur-
ing steps 10 and 11.
Septal Deviations
If the septum is deviated, this is always because
it is too large to fit into the nasal cavity. In most
cases, removing the high strip will relax the sep-
tum and correct the deviation. A lower strip can
be removed if the deviation persists after this step.
The smaller the amount of cartilage removed
from the bottom, the more stable the septum. In
extreme cases with severe septal angulations, scor-
ing is necessary.
Bony Pyramid Asymmetries
Bony pyramid asymmetries are corrected dur-
ing the push-down maneuver by simply pushing
one side more than the other.
DISCUSSION
The main difference of the technique is its
philosophy, rather than its innovative surgical
maneuvers. The approach is based on the follow-
ing principles, which are the personal opinion of
the author based on experience over the years:
1. Aesthetics and function are related. Human
beauty perception is related to function, and
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Fig. 14. (Left) Preoperative frontal and side views. (Right) Frontal and side views at 19
months postoperatively.

for this reason beautiful noses breathe well,
and a nose that breathes well is beautiful.
2. The surgeon must trust his or her own eye
and sense of aesthetics. Sense of beauty is
by instincts; it is universal and cannot be
taught or be simplified by golden ratios.
3. Excellent results can be achieved by pre-
serving the existing anatomy and perform-
ing a minimalist surgical approach.
4. The basic 20 steps are the same for each
nose and additional steps are added only
if necessary. Preserving and leaving the
same anatomy behind gives the advantage
of being able to use the basic technique
in all cases. This technique is focused
on the end result rather than the defor-
mity. Overprojection deformity is treated
exactly like the underprojection defor-
mity by finding the ideal dome point on
the strut graft. Similarly, preoperative
rotation will not change the operation
plans, because rotation is determined by

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the angle of strut fixed on the septum in
all cases.
This gives many advantages to the surgeon.
First of all, preoperative planning becomes sim-
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pler, and the surgeon will mostly focus on the final
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aesthetic of the nose, rather than the preoperative
deformity. Second, he or she will perform a very
similar technique in each case and will master one
approach.
For each step, the surgeon has to decide how
much of it is useful. Some steps may not be neces-
sary in some cases, and some may be exaggerated.
Rarely, an additional maneuver can be used, such
as an onlay alar graft for the tip, but the main 20
steps do not change.
Rhinoplasty surgery has been performed rou-
tinely for over a century, and the cast was always
the standard. This is the first technique per-
formed without a cast. Fixation of the dorsal bony
pyramid is performed with a novel fixation suture.
The monopod concept is a new and revolu-
tionary approach in rhinoplasty that changes all
tip dynamics. Alar cartilages will not be bearing
any weight for projection. Tip grafts of any kind,
including columellar and lateral crural strut grafts
and septocolumellar sutures, are no longer neces-
sary. Similarly, lateral crura can be shortened freely.
This new monopod strut has many positive
effects on the tip aesthetics: (1) skin becomes tighter
and thinner, (2) supratip break point is formed, (3)
tip inferosuperior length is reduced on side view,
(4) tip bulbosity is reduced, and (5) dome point
and tip definition in general are further sharpened.
Teoman Dogan, MD, PhD
Sezai Selek sok
20/4 Nisantasi
Istanbul, Turkey 34365
teomandogan3@gmail.com
Instagram: @teorhinoplasty
DISCLOSURE
The author receives royalties from the publication
of the self-edited book Teorhinoplasty, A Minimalist
Approach (Istanbul: Ofset Yapimevi, 2020. ISBN: 978-
625-400-265-6) and self-produced surgical instruments.
PATIENT CONSENT
Patients provided written informed consent for the
use of their images.
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