Regarding 'Does dorsal preservation rhinoplasty preserve nasal airway function? A systematic review'

This letter responds to a recent systematic review of functional outcomes after dorsal preservation rhinoplasty and proposes where the next studies should look. Global symptom instruments cannot localise obstruction to the internal nasal valve, the structure that preservation is claimed to protect, so the outcome measures dominating this literature are insensitive to the hypothesis under test. Push-down and let-down differ mechanically at the bony vault and piriform aperture and should not be pooled. The review's framework is wholly geometric, yet perceived patency depends substantially on trigeminally mediated mucosal cooling; preservation of the middle vault mucoperichondrium and its innervation is an untested mechanism that would account for consistent subjective gains alongside inconsistent objective ones. Finally, patients selected for preservation have adequate baseline airways, leaving open whether the technique suits those presenting with obstruction. A study design addressing these points is proposed.