Push-down: small humps + narrow bony base. Let-down: larger humps + wider bases. Same closed-approach incisions, same recovery timeline, same final naturalness — different bone manoeuvre under the surface.
Why both techniques exist
The original idea of dorsal preservation, popularised by Cottle in the mid-twentieth century, was to lower the bridge by impacting the entire bony pyramid downward — what we now call push-down. It worked elegantly for modest humps but had a limitation: when the bony base was too wide, simply pushing the pyramid down would leave the lower nose looking too broad.
The let-down evolution solves this: instead of just impacting the pyramid, the surgeon removes a precisely measured wedge of bone at the base of the nasal sidewall. This allows the dorsal block to drop further, and the bony base narrows in the process. The dorsum is still preserved as a single continuous unit; only the supporting walls beneath are adjusted.
Direct comparison
| Variable | Push-down | Let-down |
|---|---|---|
| Hump size best handled | Small (1–3 mm) | Medium to large (3–6+ mm) |
| Bony base width | Already narrow | Wide / needs narrowing |
| Bone removal | None | Small lateral wedges |
| Dorsal block movement | Impaction only | Impaction + descent |
| Cartilaginous vault | Intact | Intact |
| Closed approach possible | Yes | Yes |
| Recovery timeline | Identical | Identical |
How Dr. Erdal decides
The decision is made on three signals from the photo and clinical examination:
- Hump size on profile. A small, smooth hump suggests push-down may be enough. A taller hump usually needs let-down.
- Bony base width on the front view. If the bony nose is already narrow, push-down preserves that. If it is too wide for the patient's face, let-down narrows it as part of the same lowering motion.
- Septal length and quality. Both techniques rely on a controlled septal resection (LSR or HSR — see our main preservation guide) to allow the dorsum to drop. The available septal height influences which variant works best.
Common misconceptions
"Let-down is more aggressive"
It isn't. Let-down removes very small wedges at a structurally non-critical area. The dorsum itself is treated identically to push-down. From the patient's perspective, the recovery and the result feel the same.
"Push-down is the original, so it must be better"
Both techniques are part of the modern preservation toolkit. The "original is best" argument confuses historical priority with technical suitability.
"Let-down means more bleeding or bruising"
Bleeding and bruising correlate with surgical time and dissection extent, not with the choice of push-down vs let-down specifically. Modern closed-approach preservation produces minimal bruising in either technique.
Combining with other manoeuvres
In real-world practice, push-down and let-down are not isolated procedures. They are usually combined with:
- Septal resection (LSR or HSR) to permit the dorsal block to descend
- Septal stabilization — Dr. Erdal has published a simplified technique on this in Annals of Plastic Surgery (2023)
- Tip refinement using cartilage-respecting closed-approach manoeuvres
- Two-point fixation for long-term stability (published in Facial Plastic Surgery 2026)
- Pitanguy's midline ligament transection to control supratip shape (published in Aesthetic Surgery Journal 2023, presented at the EURAPS Annual Meeting Stockholm 2023)
This is why a fragmented description — "I want push-down" or "I want let-down" — rarely captures what your nose actually needs. The full operation is a coordinated set of decisions, all of which preserve the dorsum.
Frequently asked questions
In modern preservation practice, let-down (or hybrid approaches that incorporate small lateral bone removal) is more common because it handles a wider range of anatomies. Pure push-down without any base modification is reserved for selected smaller humps.
Yes. Although the plan is set before surgery based on photo analysis and examination, the surgeon may adjust the precise extent of bone removal during the operation based on intra-operative findings. The patient does not need to commit to a single acronym — they commit to the surgeon's plan.
Mild to moderate asymmetry can usually be handled within preservation. Severe deviation, especially post-traumatic, may need more structural correction. Photo review will clarify which category your nose falls into.
