My Approach to Modern Structure Rhinoplasty: How I Create Beautiful, Natural, Long-Term Results
My Approach:
Rhinoplasty has evolved dramatically over the last decade. The most meaningful shift has been the transition from reductive techniques, which often removed too much support, to modern structural rhinoplasty, which focuses on preserving and simply modifying the nose’s natural framework. The other major shift has been in use of power instruments like piezoelectric surgery which replaced hammers and chisels for bony work as well as high speed burrs which replaced the rasp. These things have made rhinoplasty better and safer and with far less downtime and overall risk.
In my practice, I use a consistent, replicable surgical philosophy designed to achieve three things:
Stable long-term results
Natural appearing and beautiful aesthetic shape
Preserved breathing and internal support
Below, I’ll walk you through how I approach modern structural rhinoplasty, why I rely heavily on septal extension grafts, why I avoid old fashioned techniques like routine cephalic trim or columellar struts, and how power tools, ultrasonic instrumentation, and precise structural support allow me to achieve predictable, beautiful and lasting outcomes.
Understanding the Foundation: Anatomy & Support
A successful rhinoplasty begins with a deep understanding of nasal support mechanisms. The nose is held together by a combination of ligaments, cartilage junctions, and soft tissue attachments — all of which can be disrupted in surgery if not respected.
Two principles guide my entire approach:
1. Preserve structure whenever possible
The more native support we maintain, the more predictable the long-term stability.
2. Reinforce structure when necessary
When anatomy is weak, asymmetric, over-resected, or previously operated on, I can reinforce and improve it using small and strong cartilage grafting, precision sutures, and strengthening maneuvers.
Why I Use Septal Extension Grafts in Almost Every Case
The most common cause of long-term nasal deformity is loss of tip support. This leads to:
Tip drooping
Over-rotation
Polly-beak deformities
hanging columella
Loss of definition
Collapse after healing
To avoid this, I use a septal extension graft (SEG) in nearly all of my rhinoplasty surgeries — both primary and revision.
What an SEG does:
Acts as a midline “support beam” for the nasal tip
Allows precise control of rotation and projection, length and nostril position
Stabilizes the entire nasal base
Prevents long-term droop or collapse
Creates long-lasting, natural definition
Unlike columellar struts — which I never use — a septal extension graft provides superior structural integrity and makes results more predictable.
Minimal to No Cephalic Trim
In older rhinoplasty techniques, surgeons often removed significant portions of the lower lateral cartilage to “shrink” the nose. We now know that doing so destabilizes the nose and significantly increases the risk of collapse or pinching as well as scarring and alar retraction. We also know it wasnt necessary to make a beautiful nose and did nothing to create ideal tip shape.
I never perform traditional cephalic trim.
Instead, I:
Preserve as much of the lower lateral cartilage as possible, and in most cases perform zero trim of cartilage at all
Reposition or reshape it using sutures
Use structural techniques to refine definition without removing critical support
This allows me to achieve a refined tip without compromising strength.
Component Dorsal Reduction — With Precision
Every nose is unique, but many may require careful modification of the nasal dorsum to to rreduce bridge height or straighten the profile.
I use component dorsal reduction, which means:
Separating the dorsum into its anatomical layers
Correcting each element independently
Maintaining the integrity of the L-strut
Refining bony and cartilaginous components separately
This method ensures a smooth, natural, and stable dorsal contour.
Why I Prefer Power Tools and Ultrasonic Technology
Traditional rasps and osteotomes can be imprecise and create microfractures or major undesired fracture that may destabilize the nasal bones. In my practice, I rely on:
Power tools and surgical burrs
Used for sculpting cartilage and bone with millimeter-level accuracy.
Ultrasonic (piezo) instruments
Used to perform osteotomies with unmatched precision while preserving surrounding soft tissues and limiting trauma.
Benefits include:
major reduction in post operative bruising
Less trauma
More predictable and precise bone movement. Narrower dorsums.
Smoother contouring
Faster healing
This is especially critical in revision rhinoplasty, where anatomy is often scarred or weakened.
Spreader Grafts in Almost All Cases
Unless I’m performing specific dorsal modification techniques where there is no opening of the roof of the nose, I use spreader grafts or spreader flaps in the majority of surgeries.
They provide:
Internal valve support
A smoother dorsal aesthetic
Enhanced symmetry
Improved breathing
Stability after dorsal reduction for long term.
Spreader grafts or flaps are essential in maintaining the natural “keystone” region and preventing mid-vault collapse or pinching with healing overtime.
My Suturing Philosophy — Precision Over Reduction
Instead of removing cartilage to change shape, I use carefully placed sutures to:
Refine tip definition
Narrow the tip when appropriate
Improve symmetry
Smooth out irregularities
Adjust rotation and projection
This leads to a controlled, elegant, and natural look without sacrificing underlying support.
Side-to-Side Septal Extension Grafts Only
There are many ways to fixate an SEG — side to side or end to end — but each has limitations and benfits.
I use side-to-side fixation because it provides:
Maximum stability
Strong resistance to long-term droop
Better control
This technique gives me the ability to fine-tune projection, rotation, and contour with long-lasting precision.
Why Structural Rhinoplasty Creates Better Long-Term Results
Modern structural rhinoplasty produces results that:
Look natural
Age well
Breathe well
Maintain projection and stability
Avoid collapse
Have fewer revision risks
By focusing on anatomy, precision, and long-term strength, we avoid the issues caused by older reductive or destabilizing techniques.
Who Benefits Most From This Approach?
Structural rhinoplasty is ideal for:
Primary rhinoplasty patients seeking natural refinement
Patients with weakness, asymmetry, or droopiness
Someone with thick skin needing strong definition
Ethnic or Asian rhinoplasty cases
Any patient at risk of collapse
Revision rhinoplasty patients
Athletes or those with functional concerns
Long-term stability seekers
Most importantly, this approach reduces the need for future revisions.
Conclusion
Structural rhinoplasty is not a single technique — it’s a surgical philosophy.
My goal in every case is to create a nose that is:
gorgeous
functional
Natural
Breathable
Harmonious with the face
Long-lasting
By relying on modern structural methods, septal extension grafts, power tools, and ultrasonic technology, I’m able to achieve consistent outcomes that stand the test of time.
Considering rhinoplasty or revision rhinoplasty? Click here to book a consultation with Dr. Hyman.