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Chapter Component Dorsal Hump Reduction and Dorsal Reconstitution 245
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Type 3A dorsal
reconstitution
6 mm
15 mm
Surgical Plan
1. Use an open approach with a stair-step transcolumellar incision and bilateral
infracartilaginous extensions.
2. Perform component dorsal hump reduction (mm).
3. Perform septal reconstruction and cartilage harvest leaving an L-strut.
4. Reconstitute the dorsum with spreader ap modication with tension-
spanning suture (type a).
5. Perform cephalic trim, leaving a mm alar rim strip.
6. Place a columellar strut.
7. Use intercrural, interdomal, and transdomal sutures (- PDS).
8. Perform low-to-low percutaneous perforated lateral osteotomies.
9. Place alar contour gras.
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Comparison views of the patient’s preoperative and -month postoperative appearance demonstrates redenition of symmetrical dorsal aesthetic lines, correction of the dorsal hump, narrowing of the bony base, and renement of the tip.
KEY POINTS
■
A graduated approach is critical, with preservation and proper reconstitution
of upper lateral cartilages when reducing a dorsal hump.
■
Preservation or creation of dorsal aesthetic lines with a smooth, symmetrical,
continuous contour is critical in rhinoplasty.
■
e radix is located between the supratarsal fold and the upper eyelid lashes,
and its position aects the apparent length and projection of the nose on the
lateral view.
■
e width of the dorsum at the keystone area must be preserved. e width of
the bony base should be equal to % to % of the intercanthal distance or
normal alar base width.
Chapter Component Dorsal Hump Reduction and Dorsal Reconstitution 247
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■
In women, the dorsum should lie just below a line connecting the nasofrontal angle with the tip-dening points, whereas the dorsum should be no lower
than this line in men to avoid feminizing the nose.
■
Preservation of the lateral so tissue and periosteal attachments to the bony
sidewalls provides signicant support and stability for the nasal pyramid aer
osteotomies have been performed; therefore lateral dissection must be limited
to the amount necessary to allow access for bony hump reduction.
■
Creation of bilateral submucoperichondrial tunnels before component reduction of the dorsal hump prevents cicatricial narrowing of the internal nasal
valve and webbing of the vestibule.
■
Excessive resection of the dorsal edges of the upper lateral cartilages can lead
to an inverted-V deformity or an overly narrow midvault.
■
Reduction of the bony hump is most commonly carried out with a downbiting rasp; large humps may require a guarded osteotome or a power oscillating
burr with a dorsal skin protector.
■
Use of the three-point palpation test aer each maneuver will help ensure the
creation of a smooth, straight dorsum.
■
It is important to make certain that the upper lateral cartilages are pulled in a
dorsal direction to their correct position, because they have a tendency to fall
away from the dorsum giving the false impression that they have been appropriately aligned relative to the dorsal septum and bony vault when in fact they
are still excessive.
■
Preservation of the transverse portions of the upper lateral cartilages and
proper reconstitution of the dorsum are necessary to maintain patency of the
internal nasal valve and the shape of the dorsal aesthetic lines.
■
Aer the osteotomized segments have been appropriately positioned, the dorsum should be reevaluated to ensure that no dorsal irregularities have been
created. is is particularly important at the keystone area.
REFERENCES
1. Lee MR, Unger JG, Rohrich RJ. Management of the nasal dorsum in rhinoplasty: a systematic review
of the literature regarding technique, outcomes, and complications. Plast Reconstr Surg :ee, .
2. Sheen JH. Spreader gras: a method of reconstructing the roof of the middle nasal vault following
rhinoplasty. Plast Reconstr Surg :-, .
3. Rohrich RJ, Shemshadi H. Dorsal reduction and osteotomies. In Gunter JP, ed. Twelh Annual
Dallas Rhinoplasty Symposium. Dallas: University of Texas Southwestern Medical Center, .
4. Roostaeian J, Unger J, Lee MR, Geissler PJ, Rohrich RJ. Reconstitution of the nasal dorsum follow-
ing component dorsal reduction in primary rhinoplasty. Plast Reconstr Surg. Nov . [Epub
ahead of print].
5. Geissler PJ, Roostaeian J, Lee MR, et al. Role of upper lateral cartilage tension spanning suture in
restoring the dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg (in press).
6. Rohrich RJ, Muzaar AR, Janis JE. Component dorsal hump reduction: the importance of main-
taining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg :-; discussion -,
.
Part ree e Dorsum248
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7. Rohrich RJ, Hollier LH. Use of spreader gras in the external approach to rhinoplasty. Clin Plast
Surg :-, .
8. Manavbaşi YI, Başaran I. e role of upper lateral cartilage in dorsal reconstruction aer hump
excision: section. Spreader ap modication with asymmetric mattress suture and extension of
the spreading eect by cartilage gra. Aesthetic Plast Surg :-, .
9. Manavbaşi YI, Kerem H, Başaran I. e role of upper lateral cartilage in correcting dorsal irregu-
larities: section. e suture bridging cephalic extension of upper lateral cartilages. Aesthetic Plast
Surg :-, .
10. Mojallal A, Ouyang D, Saint-Cyr M, Bui N, Brown SA, Rohrich RJ. Dorsal aesthetic lines in rhi-
noplasty: a quantitative outcome-based assessment of the component dorsal reduction technique.
Plast Reconstr Surg :-, .
11. Daniel RK. e radix and the nasofrontal angle. In Gunter JP, Rohrich RJ, eds. Sixteenth Annual
Dallas Rhinoplasty Symposium. Dallas: University of Texas Southwestern Medical Center, .
12. Gunter JP. e open approach for rhinoplasty. In Gunter JP, Rohrich RJ, eds. Sixteenth Annual Dal-
las Rhinoplasty Symposium. Dallas: University of Texas Southwestern Medical Center, .
13. Ishida J, Ishida LC, Ishida LH, Vieira JC, Ferreira MC. Treatment of the nasal hump with preserva-
tion of the cartilaginous framework. Plast Reconstr Surg :-; discussion -, .
14. Rohrich RJ, Hollier LH. Rhinoplasty-dorsal reduction and spreader gras. Sixteenth Dallas Rhi-
noplasty Symposium. Dallas: University of Texas Southwestern Medical Center, .
15. Gruber RP, Melkun ET, Woodward JF, et al. Dorsal reduction and spreader aps. Aesthet Surg J
:-, .
16. Boccieri A, Macro C, Pascali M. e use of spreader gras in primary rhinoplasty. Ann Plast Surg
:-, .
17. Ponsky D, Eshraghi Y, Guyuron B. e frequency of surgical maneuvers during open rhinoplasty.
Plast Reconstr Surg :-, .
18. Gruber RP, Park E, Newman J, Berkowitz L, Oneal R. e spreader ap in primary rhinoplasty.
Plast Reconstr Surg :-, .
19. Byrd HS, Meade RA, Gonyon DL Jr. Using the autospreader ap in primary rhinoplasty. Plast Re-
constr Surg :-, .
20. Boccieri A. Mini spreader gras: a new technique associated with reshaping of the nasal tip. Plast
Reconstr Surg :-, .
21. Rohrich RJ, Adams WP. Transcutaneous osteotomies. In Toriumi D, ed. Facial Plastic and Recon-
structive Surgery. Boston: Lippincott-Raven, .
22. Rohrich RJ, Janis JE, Adams WP, et al. An update on the lateral nasal osteotomy in rhinoplasty: an
anatomic endoscopic comparison of the external versus the internal approach. Plast Reconstr Surg
:-; discussion , .
23. Rohrich RJ, Sheen JH, Burget G. Secondary Rhinoplasty. St Louis: Quality Medical Publishing,
.
■ ■ ■ ■ ■ ■
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14
Nasal Osteotomies
Rod J. Rohrich William P. Adams Jr. Jamil Ahmad
I n rhinoplasty, osteotomies can be used to close an open roof deformity,
straighten deviated nasal bones, or to narrow the bony nasal pyramid. Although
various methods exist to perform osteotomies, including internal and percutaneous (external) techniques, no one denitive technique has proved to be superior
to all others.
of cosmetic, functional, and surgical complications can arise.
-
If an osteotomy is performed inadequately, however, a number
-,
ANATOMY
e bony nasal vault consists of the paired nasal bones and the ascending frontal process of the maxilla and constitutes the upper third of the nose. e nasal
bones articulate with one another medially, the maxilla laterally, the frontal bones
superiorly, and the perpendicular plate of the ethmoid posteriorly.
ey average .cm long, and approximate an hourglass conguration. Nasal bones are widest at the
nasofrontal suture line (mm), narrowest at the
nasofrontal angle (mm), then widen to mm
approximately to mm inferior to the radix, aer
which they gently narrow toward the tip.
sally, nasal bones are thickest at the nasofrontal suture line ( to mm) and thin progressively toward
the tip. From this position, the bony vault acts as a
cantilever that supports the upper nose and upper
lateral cartilages.
,
Dor-
249
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e keystone area is the name given to the critical anatomic region where the
cephalic portion of the upper lateral cartilages attaches to the undersurface of
the distal nasal bones. e nasal bone overlaps the upper lateral cartilages nearly
mm in the midline, which decreases in the lateral direction. is region is
important in supporting the middle nasal vault and is at risk for excessive narrowing during osteotomy.
A complete understanding of nasal anatomy and its inherent variations is essential for optimizing outcomes of nasal osteotomies.
For optimal results, osteotomies should be designed to cut through intermediate
or transition zones of bony thickness along the lateral nasal wall. Such a zone
exists along the ascending frontal processes of the maxilla from the piriform aperture to the radix. Anatomic studies have demonstrated that this region of the
nasal wall is less than .mm thick and can be reliably osteotomized with small
osteotomes, producing predictable fracture patterns.
,
A transition zone of bony thickness exists along the frontal processes of the max
illa near the junction with the nasal bones. is area of relatively thin bone is
easily and consistently mobilized during lateral nasal osteotomies.
-
Chapter Nasal Osteotomies 251
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CONTRAINDICATIONS
Osteotomies may be contraindicated in elderly patients with thin, fragile nasal
bones, patients who wear heavy eyeglasses, patients with congenitally short nasal
bones (where the caudal border is less than cm below the intercanthal line), or
patients with thick nasal skin and/or a history of hypertrophic scar formation.
,
Patients of certain nonwhite races with extremely low, broad noses should be
approached with extreme caution, because osteotomies can be dicult in this
patient subpopulation.
CLASSIFICATION
Osteotomies may be classied according to the type (lateral, medial, transverse,
or a combination of these types), level (low-to-high, low-to-low, and double), and
approach (internal or percutaneous). Selecting the appropriate technique will depend on specic aspects of the patient’s anatomy, type of deformity, desired outcome and the cosmetic and functional aects the changes will have on the nose.
Type
Lateral Osteotomies
e purpose of lateral nasal osteotomy is to narrow a widened lateral nasal wall,
close an open roof deformity, and mobilize a deviated nasal pyramid. is procedure traditionally consists of cutting or perforating the most lateral aspect of
the bony pyramid along the transition zone of thinner bone, followed by medial,
transverse, or digital greenstick fracturing of the lateral and/or superior bony attachments. is maneuver produces enough mobilization to permit narrowing
or repositioning of the nasal bones.
e purpose of lateral nasal osteotomy is to narrow a widened lateral nasal wall,
close an open roof deformity, and mobilize a deviated nasal pyramid.
Lateral osteotomies can be used to alter the width of the bony vault at the nosecheek junction, the width of the superior aspect of the dorsal aesthetic lines, or
to change the angle of inclination of the bony nasal sidewalls.
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Medial Osteotomies
A medial osteotomy is dened as a separation of the nasal bones and the bony
septum. Numerous orientations have been proposed in the literature, including
paramedian, medial oblique, superior oblique, transverse, and inferiorly oriented,
as well as adjuncts such as a high septal osteotomy. A wedge of medial nasal bone
may be excised with a paramedian osteotomy to allow further medialization of
the nasal bones. In any case, the most cephalic extent should not course superior
to the intercanthal line.
Transverse ParamedianSuperior oblique
Medial osteotomies may be performed when the bony dorsum is excessively
wide, the nasal bones are deviated, or the bony dorsum is excessively narrow and
needs to be widened with spreader gras. Medial osteotomies are generally used
in patients with thick nasal bones or a wide bony base, as greenstick fractures
within these subgroups tend to be dicult and can lead to unpredictable fracture
patterns. e basic objective is to produce medial shi of the nasal bones in a
controlled manner, thus avoiding undesirably large greenstick fractures that tend
to increase the risk of airway narrowing and bony collapse. Medial, transverse,
or greenstick fractures of the upper bony segment can be combined with lateral
osteotomies, depending on the eect desired. ey are usually performed aer
dorsal hump resection and before lateral osteotomy, allowing for a stable bony
vault to work with. In many cases, dorsal hump reduction will mimic medial osteotomies and obviate their need.
Medial osteotomies may be performed when the bony dorsum is excessively wide,
the nasal bones are deviated, or the bony dorsum is excessively narrow and needs
to be widened with spreader gras.
Chapter Nasal Osteotomies 253
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Despite previous descriptions, it remains dicult to perform medial osteotomies
in such a way as to provide aesthetically pleasing and reliable results. e nasal
bony vault varies in thickness regionally, making controlled narrowing with osteotomies challenging.
e nasal bony vault varies in thickness regionally, making controlled narrowing challenging; thus aesthetically pleasing and reliable results remain dicult
to obtain with medial osteotomies.
Superior oblique
osteotomy
Transverse fracture
Webster’s triangle
It is critical to avoid a “rocker deformity,” whereby the upper portion of the fractured nasal bone “kicks out,” resulting in a widened upper dorsum. is can be
avoided by canting the medial osteotomy in a medial oblique direction.
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Level
Lateral osteotomies can be described based on their position along the bony
vault and proximity to the nasal dorsum or maxilla. Lateral osteotomies made
closer to the maxilla are referred to as low and those made closer to the dorsum
are referred to as high.
Low-to-High
e low-to-high osteotomy begins low at the piriform aperture, extends cephalad toward the intercanthal line, and ends high on the nasal dorsum. e nasal
bones are subsequently medialized via a greenstick fracture, which follows predictable fracture patterns based on nasal bone thickness. is type of osteotomy
is generally used to mobilize a moderately wide nasal base or to correct a small
open roof deformity. is type of osteotomy is much less frequently performed
compared with a low-to-low technique.
Low-to-Low
Low-to-low osteotomies result in more medial movement of the nasal bones and
are therefore considered to be a more powerful technique. ey are classically
used to correct a large open roof deformity or to narrow an excessively wide nasal base. is osteotomy starts low along the piriform aperture and remains low
along the base of the bony vault ending at a location near the intercanthal line.
Frequently, a medial osteotomy is performed in conjunction with a low-to-low
osteotomy to better mobilize the nasal bones, as there is a greater amount of bone
present between the midline and the lateral osteotomy line.
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