Clarification and Classification of Dorsal Preservation Rhinoplasty: Lessons from a Continuous 1,191-Case Experience

BACKGROUND: Dorsal preservation rhinoplasty (DPR) has attracted significant attention in recent years. However, the rapid dissemination of diverse techniques and terminology has generated confusion regarding definition, indications, methodology, and outcomes. A unified conceptual framework remains lacking. METHODS: We retrospectively reviewed 1,191 consecutive primary rhinoplasties performed by a single senior surgeon between 2010 and 2024. Three chronological series were analyzed. Series 1 (2010-2014; n = 320) introduced push-down and let-down osteotomies in selected cases. Series 2 (2015-2019; n = 352) expanded indications to more complex morphologies, exposing limitations. Series 3 (2020-2024; n = 519) applied a unified framework developed from the previous series. Revision rates and clinical lessons were compared. RESULTS: : Series 1 reported 11 revisions (3.4%), confirming feasibility in favorable cases. Series 2 recorded 35 revisions (9.9%) during the uncontrolled expansion of indications. Series 3 demonstrated 17 revisions (3.3%) after refinement of patient selection and operative decision-making informed by earlier experience, with revision rates differing significantly across the three series (χ²(2) = 21.61, p < 0.001). The third series validated that systematic application of a dorsal preservation framework produced reliable outcomes, minimized revisions, and helped formulate a pyramidal classification with named septoplasty modulators. CONCLUSIONS: The evolution of DP rhinoplasty follows a U-shaped learning curve, characterized by initial proof-of-concept, uncontrolled expansion, and subsequent consolidation through classification. Integration of the pyramidal framework with W-point septoplasty clarifies terminology, standardizes methodology, and establishes DP rhinoplasty as a reproducible and mature approach in contemporary practice.