Atlas of Asian Rhinoplasty (Volume 1) – Tác giả chưa rõ – Hướng Dẫn Giải Phẫu & Phẫu Thuật Mũi (file pdf)

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Straight Osteotome
The straight osteotome is used for humpectomy, medial osteotomy, and percutaneous osteotomy. It can also be used for lat-
eral osteotomy, but this is a rare occurrence.
Curved Osteotome
The curved osteotome is the mainstay of lateral osteotomy.
Guarded Osteotome
The guarding portion of the osteotome exists to protect the skin or the mucosa but is also useful in preventing slippage when
the instrument is in contact with the bone. The guard also helps to have the surgeon confirm the location and direction of the
osteotome by being palpated by the finger of surgeon’s nondominant hand. The guard can be used to protect the mucosa, but
most surgeons prefer to point the guard towards the skin.
Guardless Osteotome
Most guardless osteotomes are difficult to handle.
Among straight osteotomes without guard, a 6–10 mm osteotome is used for hump reduction. Medial osteotomy is usually
performed using 3 mm osteotome. Percutaneous osteotomy is performed using a 2 mm osteotome.
Among guarded osteotome, the 3 mm straight osteotome is used for medial osteotomy. The 3–4 mm curved osteotome is
used for lateral osteotomy.
The width of an osteotome is proportional to the degree of trauma to the endonasal mucosa. However, even the narrowest
osteotome can cause significant trauma during lateral osteotomy, if the instrument is used improperly by a pair of inexperi-
enced hands.
Lateral Osteotomy
Lateral osteotomy has four relatively common applications: to decrease width of bony nasal base, to close the open roof
created by dorsal bony hump resection, to correct deviated nasal bone, and to improve the contour of the brow-tip dorsal
aesthetic line (Fig. 8.39).
The course of the lateral osteotomy follows a curved line from the insertion of the inferior turbinate on the pyriform aper-
ture to a point medial to the medial canthus (Fig. 8.40).
The planned line of osteotomy is marked and injected with a local anesthetic mixed with epinephrine. The local anesthetic
should also be injected into the mucosa underlying the osteotomy line.
Lateral osteotomy can be performed via two techniques: linear continuous technique and perforating technique. The lin-
ear continuous technique is performed via the intranasal approach, whereas the perforating technique is performed through
a percutaneous access. There is a controversy as to superiority of each technique, and the choice is usually a matter of prefer-
ence or familiarity for a given technique.
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a
b
Fig. 8.39 Improvement of dorsal aesthetic line. (a) Interrupted dorsal aesthetic line is observed between nasal bone and upper lateral cartilages.
(b) Improved dorsal aesthetic line after lateral osteotomy
Fig. 8.40 Pathway for lateral osteotomy. The
course of lateral osteotomy follows a curved line
from the insertion of the inferior turbinate on the
pyriform aperture to a point medial to the medial
canthus
Osteotomy

240
Intranasal Continuous Osteotomy
The intranasal access for lateral osteotomy starts with a small vestibular incision at the pyriform aperture (Fig. 8.41). This ves-
tibular incision is performed using No. 11 blade or monopolar cautery on the mucosa at or just above the anterior attachment of
the inferior turbinate according to the inferior turbinate position. The incision is directed deep and laterally towards the bony
pyriform aperture. If the osteotomy starts below the inferior turbinate insertion, the inferior turbinates move medially, which can
lead to nasal obstruction (e.g., low-to-high or low-to-low osteotomy). Starting the lateral osteotomy above the attachment of
a
b
c
d
Fig. 8.41 Procedures of intranasal continuous lateral osteotomy. (a) This vestibular incision is performed at or just above the anterior attachment
of the inferior turbinate. (b) Periosteal elevation using the periosteal elevator along the planned osteotomy line. (c) A 4 mm curved guarded osteo-
tome is engaged at the pyriform aperture. (d, e) The initial portion of osteotomy is directed at an angle perpendicular to the pyriform aperture and
advanced a short distance to convert the osteotomy position from high to low dorsum. (f) The handle of osteotome is lowered in the posterior
direction; the osteotome in the low position is directed towards the point medial to inner canthus. The advancement is then curved gently along the
nasofacial groove and continued cephalically to the level of medial canthal area. (g) After completion of lateral osteotomy, the bony segment is
in-fractured for inward mobilization
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241
e
f
g
Fig. 8.41 (continued)
Osteotomy

242
inferior turbinate can protect the small triangle of bone at the pyriform aperture (Webster’s triangle) (e.g., high-low-high or high-
low-low osteotomy) (Fig. 8.42). This can prevent the medial mobilization of the inferior turbinate and also preserve the lateral
attachments of the suspensory ligament, which prevents changes to vestibular shape. The periosteum is elevated along the
planned osteotomy line. There is a bit of controversy regarding periosteal elevation during continuous osteotomy. Those opera-
tors who oppose periosteal elevation argue that the elevation can injure the overlying vessels, which is associated with bleeding
and ecchymosis. The author feels that the osteotomy under the periosteum is important for lateral osteotomy, because it confines
the bone bleeding within the subperiosteal space and prevents bleeding from spreading to the eyelid soft tissue, which serves to
minimize the periorbital ecchymosis. However, periosteal elevation should not be extended into the cephalic portion of the
osteotomy line (near the medial canthus) to decrease the risk of injury to medial canthal tendon or lacrimal sac.
The 3–4 mm curved guarded osteotome is engaged at the sulcus of frontal process of maxilla and passed along the planned
osteotomy line with light taps from a mallet. The direction of the initial osteotomy is directed at an angle perpendicular to the
pyriform aperture, advanced a short distance, gently steered cephalically along the nasolabial groove towards the medial infra-
orbital rim, and continued cephalically to the level of medial canthal area to meet the medial osteotomy line. During this
maneuver, the progression of the osteotome should be evaluated by the palpation of the osteotome guard through the skin.
Once the lateral osteotomy comes in contact with the medial oblique osteotomy, either a medial rotation with osteotome
or a digital pressure can push the lateral bony segment inward, with resultant complete or greenstick fracture.
With the osteotomy complete, the vestibular incision is repaired using absorbable suture.
Intranasal continuous osteotomy is a complete osteotomy. As such, the repositioned bony segment is less likely to return
to its original position. It is, however, more likely to result in arterial or mucosal injury, and the risk is higher for the actual
osteotomy to veer away from the planned osteotomy line. The underlying periosteal tearing leads to instability of the bony
segment, and in inexperienced hands can be associated with poor long-term predictability and nasal bone asymmetry.
Webster’s
triangle
Fig. 8.42 Webster’s triangle
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Percutaneous Perforating Osteotomy
The perforating osteotomy is performed through one or two skin punctures. For a single-point access, the incision is made at
the midpoint between vestibule and medial canthus, along the transition between the nasal and cheek skin. Lateral traction
of the skin can be helpful in decreasing the risk of injury to the angular artery (Fig. 8.43). For a long nose, a single-point
access may not provide adequate spatial coverage for the osteotomy. In such cases, two incisions should be made to divide
the whole of perforating osteotomy line into thirds. Regardless of the number of percutaneous access, perforating osteotomy
does not require periosteal elevation.
The tip of 2 mm unguarded sharp micro-osteotome is introduced through the skin puncture. The osteotome is then tilted
at a 45 degree angle, with the sharp edge of the osteotome in contact with the bone (Fig. 8.44). The nasal bone is perforated
with gentle but deliberate strikes from a mallet, at regular intervals (1–2 mm) along the length of the planned osteotomy line
(Fig. 8.37). The nasal bone is perforated first towards the pyriform aperture and continued in the cephalic direction. In the
cephalic direction, the bone is thicker and resists the osteotomy strikes, which makes it easier to injure the underlying mucosa
from overcompensated blows of the mallet. Because of this, the surgeon must be familiar with the changes in the tactile
feedback and sound of the instrument tip passing the inner cortical bone.
The perforating lateral osteotomy line must become continuous with the medial oblique osteotomy, even if a transverse
osteotomy is employed to accomplish this goal (Fig. 8.45). The transverse osteotomy requires an additional skin puncture at
the midpoint between the medial canthus and nasion.
Digital pressure is applied onto the nasal bone to induce greenstick in-fracture and to translate the lateral nasal bone seg-
ment medially. A gentle pressure should suffice in promoting the fracture along the perforation. If the operator must use
significant force in order to induce the fracture, then the osteotome should be reintroduced through the access and additional
perforating osteotomies should be considered to further reduce the resistance.
The skin access is small enough such that they do not require any suture for primary closure.
Across a perforating osteotomy line, the small periosteal bridges maintain stability of the bony segment. According to
Rohrich et al., mucosal tear is associated with 11% of external perforating osteotomy as compared to 74% for internal oste-
otomy. Many authors have argued that percutaneous perforating osteotomy allows for a more accurate osteotomy, with
decreased risk of mucosal injury. The periosteum of undersurface of the nasal bone is preserved, and the resulting fracture is
more stable, which makes it less likely for the bony segment to collapse. The risk is also lower for injury to lateral nasal and
angular arteries, with decreased bleeding and edema, relative to intranasal osteotomy.
This technique does not have much in the way of contraindications and is very useful for small and short nasal bones, for
secondary revisional osteotomy, and in cases where precise control of the osteotomy line is important. In high nasal dorsum
so common among Caucasian patients, the pathway of lateral osteotomy has to finish in a high position near the medial can-
thus, which requires an abrupt change of direction for the osteotome. This abrupt transition is very difficult to manifest dur-
ing intranasal continuous osteotomy because the osteotome handle will be restrained by the ala soft tissue. This limitation is
not an issue for percutaneous osteotome.
Lateral osteotomy transposes the nasal bone medially. This also mobilizes the upper lateral cartilages more medially, with
resultant narrowing of the airway. The decrease in airway cross section is more significant for osteotomy of longer nasal
bones. If this airway problem is a real possibility, a spreader graft will be needed to prevent the functional issue as well as
the inverted V-shaped indentation between the nasal bone and upper lateral cartilage.
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244
Fig. 8.44 The osteotome should be laid at a 45-degree angle to the
bone
transverse
osteotomy
Fig. 8.45 Transverse osteotomy connects lateral osteotomy and medial
osteotomy
Fig. 8.43 The percutaneous access for perforating lateral osteotomy. A
single-slit incision is made at the midpoint between vestibule and
medial canthus, along the transition between nasal and cheek skin.
During the incision, lateral traction of the skin helps to avoid injury to
the angular artery
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Position of Lateral Osteotomy
The lateral osteotomy starts at the most lateral lower point of the pyriform aperture and runs cephalomedially to a point
medial to the medial canthus. In osteotomy vernacular, the “high” and “low” designation used to describe the position of
lateral osteotomy refers to the coronal plane while patient is supine, where a “high” lateral osteotomy is closer to the dorsum
and a “low” lateral osteotomy is closer to the maxilla (Fig. 8.46). The lateral osteotomy can be made in four configurations:
low-to-low, low-to-high, high-to-high, and high- to- low (Fig. 8.47).
a
b
c
d
Fig. 8.47 Types of lateral osteotomy. (a) Low-to-low lateral osteotomy. (b) Low-to-high lateral osteotomy. (c) High-to-high lateral osteotomy. (d)
High-to-low lateral osteotomy
Fig. 8.46 Various paths for lateral osteotomy
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246
Low-to-Low Osteotomy
Low-to-low osteotomy maintains a path that is close to the maxilla (low) throughout the whole osteotomy line. The osteot-
omy begins at the junction between pyriform aperture and frontal process of maxilla, and continues cephalically as close to
the maxilla as possible towards a point just medial to the medial canthus. A percutaneous transverse osteotomy is required to
connect a low-to-low lateral osteotomy to a medial osteotomy (Fig. 8.45).
A low starting position for osteotomy is more advantageous in correction of a wide bony base and minimizes the risk for
bony step deformity.
This osteotomy begins at a position lower than the inferior turbinate insertion, which makes inward mobilization more
likely for inferior turbinate (Fig. 8.48).
a
c
b
Fig. 8.48 Lateral osteotomy
and inferior turbinate. (a, b) A
low starting point for lateral
osteotomy is useful for
correction of wide bony base.
It also avoids the problem of
bony step deformity.
However, it has a greater
potential for inward
mobilization of inferior
turbinate. (c) High-to-low
osteotomy does not affect the
inferior turbinate
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Low-to-High Osteotomy
The low-to-high osteotomy was popular in the past. The starting point is similar to that of low-to-low osteotomy, but takes a
more medial line in the cephalic area. This is associated with decreased risk of injury to the lacrimal sac and less of a peri-
orbital ecchymosis.
In Caucasian patients with thinner nasal skin, a true low- to- high osteotomy can frequently cause a visible or palpable
bony step deformity. For this reason, some surgeons recommend low-to-low osteotomy over low-to-high osteotomy.
Clinically, lacrimal sac injury is a rare occurrence. The use of curved osteotome can result in an osteotomy path that is higher
than intended, which can induce bony step deformity. Therefore, it is more advantageous to stay in a low osteotomy line.
High-to-High Osteotomy
Technically speaking, high-to-high osteotomy really is a high-to-low-to-high osteotomy, which is the most commonly
employed form of osteotomy path. This lateral osteotomy starts at the pyriform crest at or just above the insertion of the
inferior turbinate, which is 3–4 mm cephalic to the base of the pyriform aperture, leaves the most caudal lateral Webster’s
small triangle bone of the pyriform crest in place, and prevents medial mobilization of the inferior turbinate (Fig. 8.42).
With 2–3 mallet taps, the osteotome is wedged into the pyriform aperture plane with right angle and advanced a short
distance to change the high osteotomy line into a lower position. Afterwards, the hand holding the osteotome is lowered in
the posterior direction (Fig. 8.41e). The osteotome tip in the low position is directed and driven towards the point medial to
inner canthus of the eye. This creates the typical high-to-low-to-high lateral osteotomy.
Once the osteotome is at the level of inner canthus, the osteotome is rotated. This will normally fracture the nasal bone
inward, creating a controlled greenstick back fracture. A greenstick fracture created using manual fracture is less predictable but
more stable. If the in-fracture of bony segment does not appear definitive or a predictable complete back fracture is required,
additional osteotomies may be required, such as a percutaneous perforating osteotomy or a medial osteotomy (Fig. 8.49).
For a wide nasal bone, a high osteotomy starting point can result in a palpable bony step (Fig. 8.50). In order to prevent
this, osteotomies performed on wide bony bases should begin at a lower position. If the osteotomy results in medial mobiliza-
tion of inferior turbinate or nasal obstruction, the surgeon should consider turbinate reduction or out-fracture of the turbinate
(see Chap. 15).
Fig. 8.49 Percutaneous perforating osteotomy may be required for a
complete back fracture
Bony step deformity
Fig. 8.50 Bony step deformity
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248
High-to-Low Osteotomy
High-to-low osteotomy can more accurately be described as high-to-low-to-low osteotomy.
This pathway shares the same starting position as a high- to- high osteotomy but ends as a low position. This technique is
more commonly performed in patients with wide bony base or with thinner nasal skin, where palpable step-off is a
concern.
In summary, to limit inward mobilization of inferior turbinate, the Webster’s triangle should be preserved, and the oste-
otomy should adopt either the high-low-high or the high- low- low path. However, certain situations require a low starting
point for lateral osteotomy, such as a wide bony base. In such cases, medial mobilization of inferior turbinate by low lateral
osteotomy can cause airway obstruction, which may require turbinate out-fracture or turbinate reduction (see Chap. 15).
A transverse osteotomy is required to connect a medial osteotomy to the cephalic end of a low-to-low or high-to-low
osteotomy. If this is the case, it is better to first perform the transverse osteotomy of the lateral nasal wall, followed by the
lateral osteotomy.
Medial Osteotomy
Medial osteotomy starts between nasal bone and dorsal septum or at the cephalolateral margin of the open roof formed by
hump reduction. The osteotomy is continued in a slight cephalolateral direction, and connects to the cephalic end of lateral
osteotomy or the back fracture formed after lateral osteotomy (Fig. 8.51). It is rare to perform medial osteotomy by itself,
and in most cases it is performed along with a lateral osteotomy.
Indications for medial osteotomy are as follows:
1. To convert incomplete back fracture after a lateral osteotomy into a complete fracture
2. To close a post-humpectomy open roof, for which lateral osteotomy by itself is not sufficient
3. To allow complete mobilization of nasal bone (e.g., for deviated nose correction)
4. To address a wide nasal bone, especially wide bony dorsum
5. To widen a narrow nasal bone
a
b
Fig. 8.51 Medial oblique osteotomy. (a) Medial osteotomy starts between nasal bone and dorsal septum in the cephalolateral direction. It is con-
tinued to connect with the cephalic end of lateral osteotomy. (b) Medial osteotomy starts at the cephalolateral margin of the open roof formed by
hump reduction
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Medial osteotomy is performed using a 3–4 mm straight osteotome with guard. The osteotome is first placed at the caudal
margin of the nasal bone, lateral to the dorsal septum, and advanced cephalically with gentle tapping using a mallet. If the
medial osteotomy begins too laterally at the caudal margin in an Asian patient with small nasal bone, there is a high risk of
nasal bone fragmentation. Therefore, the starting point of medial osteotomy should be made as close to the midline as pos-
sible to minimize dorsal irregularity. In post- humpectomy, the osteotome is placed at the cephalic margin of the open roof
and advanced in the cephalolateral direction.
In a nose with wide bony roof, the starting point of a medial osteotomy should be much more lateral—at the most lateral
cephalic margin of the open roof. Otherwise, the medial osteotomy will not allow adequate narrowing of nasal bone or clos-
ing of the open roof (Fig. 8.79). In patients with wide medial nasal bone, a strip or wedge excision of bone may be required
to effectively decrease the nasal bone width (Figs. 8.80 and 8.81).
Medial osteotomy has two types of technique: medial oblique osteotomy and medial straight osteotomy.
Medial oblique osteotomy follows the natural cleavage line between the thick and thin layers of the nasal bone, which is
about 15 degrees away from the midline (Fig. 8.51). Medial vertical osteotomy (paramedian osteotomy) is performed within
the thick bone area and is technically more challenging because of this (Fig. 8.52).
Fig. 8.52 Medial vertical osteotomy
(paramedian osteotomy)
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250
Medial Oblique Osteotomy
The oblique osteotomy is more frequently performed of the medial osteotomies and is used to close open roof, fully mobilize
the lateral bony segment, and correct deviated nose. This osteotomy can be performed either intranasally or percutaneously,
though the intranasal access is more frequently used.
The osteotomy is performed using a 3 mm guarded straight osteotome. From the starting point, the osteotome is advanced in
the cephalolateral direction, about 15 degrees off the midline. As the osteotome is advanced, the osteotomy line is directed more
laterally until it connects to the lateral osteotomy line at the medial canthal level (Fig. 8.51). Since nasal bone becomes thicker
from caudal to cephalic direction and from lateral to medial direction, there exists a curvilinear transition zone between thicker
and thinner area of nasal bone. This transition line gives natural cleavage line for the medial oblique osteotomy. A less angulated
osteotomy that stays cephalic to this cleavage line will cut into the thicker nasal bone and frontal bone, which will result in the
rocker deformity discussed below. If the osteotomy line does not follow the cleavage line, the medial osteotomy should be
stopped at the intercanthal line, and a percutaneous vertical osteotomy is performed to connect the medial osteotomy to the
lateral osteotomy. The operator must take care not to injure the keystone area near the starting point of medial osteotomy.
Medial Straight Osteotomy (Paramedian Osteotomy)
This osteotomy is used to widen narrow nasal bone or to decrease a wide nasal bone without a hump.
A 3 mm straight osteotome is placed at the caudal margin of nasal bone and is advanced in a straight vertical direction
(Fig. 8.52). In order for this straight osteotomy line to intersect with lateral osteotomy line, a percutaneous transverse osteotomy
is necessary (Fig. 8.53). The transverse osteotomy can be performed using a 2 mm osteotome percutaneously in the midpoint
between the nasal dorsum and medal canthus to connect the lateral and medial osteotomy. The skin punctured for transverse
osteotomy should be placed much more anteriorly on the nasal dorsum to facilitate the osteotomy while decreasing the potential
for angular artery injury. Several percutaneous perforating osteotomies are possible through this single skin puncture. Percutaneous
osteotomy is performed in multiple interrupted punctures of the nasal bone, which will result in a greenstick fracture.
To avoid the rocker deformity, the paramedian osteotomy should not be advanced past the intercanthal line into the frontal
bone. It is important for the operator to understand the shift from sharp to dull tactile feedback of the osteotome as the instru-
ment tip nears the frontal bone.
Medial osteotomy is not indicated for all open roof or wide nasal bone. Its use should be carefully considered for thin
dorsal skin because of the potential for visible dorsal irregularity. According to Ahmarani et al., lateral osteotomy performed
without a medial osteotomy results in a greenstick fracture superiorly and incomplete mobilization of the bony nasal side-
walls, in the absence of humpectomy. When combined with a medial osteotomy, however, the lateral osteotomy becomes
reliable, and complete mobilization of the nasal sidewalls can be obtained.
Both types of medial osteotomies are commonly performed in conjunction with lateral osteotomy. However, they can be
used sans lateral osteotomy for deviated nose correction, where only the dorsal portion of the nasal bone is spread apart
without altering the bony base (see Chap. 15).
Fig. 8.53 To connect the medial straight
osteotomy with a lateral osteotomy, a
percutaneous transverse osteotomy is necessary
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251
Transverse Osteotomy
Transverse osteotomy is performed to connect a low-to-low (or high-to-low) osteotomy line and a medial osteotomy line
(Figs. 8.45 and 8.53). This osteotomy is especially useful for free mobilization of the bony segment between paramedian
osteotomy and lateral osteotomy, which usually does not give away to digital pressure without the transverse osteotomy.
Transverse osteotomy is performed through a skin puncture just above the medial canthus, using a 2 mm perforation
osteotome. This should be performed ahead of a planned lateral osteotomy. When a low-to-low osteotomy is performed, the
osteotomy line can often follow the cleavage line away from the operator’s intended low line. Performing the transverse
osteotomy beforehand is helpful in directing the lateral osteotomy line in the low position.
Intermediate Osteotomy
Intermediate osteotomy is an osteotomy performed along the sidewall of nasal bone between the medial and lateral osteoto-
mies (Fig. 8.54). This osteotomy is not commonly performed in Asian patients with small nasal bone. Indications for inter-
mediate osteotomy are as follows:
1. To decrease the excessive convexity of sidewall of the nasal bone (very wide nasal bone)
2. To correct the severe deviation or asymmetry of nasal bone
3. To close the open roof of the nose with narrow bony base
When performing the double-level osteotomy by doing lateral and intermediate osteotomies, the lateral osteotomy should
follow the low-to-low path.
Intermediate osteotomy is performed for thin bone. Thus, a 3 mm osteotome is used with extremely delicate manipulation
of the mallet, to avoid advancing the osteotomy in the unwanted direction. This osteotomy should be performed before the
lateral osteotomy. Otherwise, a lateral osteotomy- first operation will result in an unstable bony fragment that will make for
a difficult intermediate osteotomy. If possible, soft-tissue attachment to the nasal bone should be preserved as much as pos-
sible to maintain bone stability. The exact location of intermediate osteotomy varies according to the shape of nasal bone and
other clinical factors.
Fig. 8.54 Intermediate osteotomy
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252
Order of Osteotomy
In most cases, the medial osteotomy is performed before the lateral osteotomy. If the lateral osteotomy is performed first, the
resulting bony segment can be quite unstable during the medial osteotomy. Both intermediate and transverse osteotomies
should be performed before a lateral osteotomy.
Considerations for Osteotomy
In Asian patients with small nasal bone, osteotomy can easily lead to fragmentation of the nasal bone with resultant collapse.
In such patients, camouflage techniques should be considered before diving headlong into multiple osteotomies.
Prior to the osteotomy, both the mucosa and skin along the planned route of osteotomy should be injected with local
anesthetic mixed with epinephrine to minimize bleeding.
The nasal bone segment resulting from lateral osteotomy should be made as large as possible to minimize the risk of
palpable bony step.
The medial osteotomy and lateral osteotomy should be connected to each other for a complete fracture. The bony segment
should be attached to the periosteum for stability. If the medial and lateral osteotomies are not contiguous, a percutaneous
perforating osteotomy should be used to complete the connection.
It is very important to maintain the sharpness of osteotome. Dull osteotome can over-resect bony hump and may result in rough
and imprecise osteotomy. The osteotome should be sharpened against the stone and should be replaced at regular intervals.
Postoperative Dressing
Upon completion of osteotomy, paper tape is used as a compression dressing from the radix to the supratip, upon which an
external splint is applied. The splint minimizes postoperative edema, prevents the hematoma, and maintains the bony seg-
ment in its mobilized locations. If the bony segment is suspected to be unstable, a Merocel packing can be placed intranasally
for 5–7 days. If there is a possibility of synechiae between mucosa and septum due to a mucosa tearing, a silicone sheet
should be placed within the nasal cavity for 2–3 weeks.
Complications of Nasal Osteotomy
The following list represents a fairly comprehensive overview of complications following a nasal osteotomy:
Complication #1: The most common complication is incomplete osteotomy, which can lead to incomplete mobilization
of the bony segment, relapse of the bony deviation, and incomplete correction of the wide nasal bone.
Complication #2: An osteotomy should be delicate and accurate. Otherwise, it can lead to inadequate correction, asym-
metry, and/or irregularity. Intraoperatively, bony irregularity may be masked by soft-tissue edema, which may become con-
spicuous as the swelling subsides in the postoperative period. Therefore, bony irregularities should be evaluated by palpation
during the operation and should be removed with rongeur or rasping, if present.
Complication #3: Open-roof deformity is possible if the lateral osteotomy is incomplete after a humpectomy.
Complication #4: After low osteotomy, medial mobilization of the inferior turbinate can lead to nasal obstruction.
Complication #5: In patients with thin nasal skin, high osteotomy can result in visible and palpable bony step.
Complication #6: A rocker deformity occurs when the medial and lateral osteotomies take place far too cephalically, onto the nasal
process of the frontal bone, or when the osteotomies create a cephalic fracture higher in the thicker part of the frontonasal junction.
Complication #7: Bony irregularity due to new bone formation after periosteal tearing (hyperostosis).
Complication #8: Bony indentation from necrosis of fragmented bone.
Complication #9: Separation of medial osteotomy line, leading to visible longitudinal groove on the nasal dorsum.
Complication #10: Severe mucosal injury can lead to mucosal synechiae between the septum and lateral wall.
Complication #11: Bony collapse due to comminuted fracture: This is especially the case for short and small nasal bones,
where the lateral osteotomy and in-fracture to close an open roof can lead to mid-vault collapse.
Complication #12: On rare occasions, low osteotomy can result in injury to lacrimal sac or lacrimal duct. This injury
can lead to epiphora, but not all epiphora is a consequence of such injury. In order to distinguish the cause, a lacrimal duct
patency test may be required.
Complication #13: Lateral osteotomy accompanying in- fracture airway in the upper third as well as at the internal nasal valve.
Complication #14: Bleeding: Bleeding from raw osteotomy surface can be difficult to control but, usually, is not copious
in quantity and stops spontaneously. Another common source of bleeding is at osteotomy starting point at the pyriform aper-
ture, where a nicked small vessel could be identified and controlled.
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a
b
Fig. 8.55 Correction of bony step deformity. (a) If the deformity is due to high osteotomy, a lower osteotomy is placed at a more lateral location.
(b) The strip of bone segment is pushed inward to reduce the step-off
Correction of Bony Step Deformity
High-to-high lateral osteotomy can lead to bony step and groove in the lateral nose, with the nose lateral to the bony step still
appearing to be wide (Fig. 8.50). Even with a low- to- high osteotomy, a bony step-off may become conspicuous in the mid-
portion of the lateral nose.
If a bony step is discovered during the operation, a low- to- low osteotomy should be performed to medially reposition the
lateral bone (Fig. 8.55). Intranasal continuous osteotomy technique can be a bit imprecise for this purpose, and percutaneous
perforating osteotomy technique is a more safe option.
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254
Rocker Deformity
One of the complications of medial or lateral osteotomy is rocker deformity (Fig. 8.56).
During lateral osteotomy, the back fracture ideally takes place along the cleavage line between the thin and thick areas of
the nasal bones. If the fracture takes place through the thicker superior bone, a rocker deformity may result. The deformity
occurs when the medial and lateral osteotomy takes place too far cephalically, onto the nasal process of the frontal bone, or
creates a cephalic fracture higher in the thicker part of the frontonasal junction.
When the nasal bone is medialized by lateral osteotomy, the caudal portion becomes narrower, but the cephalic portion
protrudes outward resulting in lateralization of that segment, based on a fulcrum at or about the radix, causing visible defor-
mity and persistent widening. In general, to avoid the rocker deformity, osteotomies should either be performed below the
level of the medial canthus or course medially before arriving at the nasofrontal junction.
A rocker deformity should be addressed by a percutaneous osteotomy in the appropriate back-fracture location.
Fig. 8.56 Rocker deformity.
A rocker deformity occurs
when the medial and lateral
osteotomies take place too far
cephalically onto the nasal
process of the frontal bone or
create a cephalic fracture
higher in the thicker part of
the frontonasal junction
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a
b
Fig. 8.57 Hump nose in an Asian patient. This patient has a large dorsal hump with wide nasal bone and drooping tip
Hump Nose Correction in Asians
Nasal dorsal hump is more common in the Caucasian population. At the same time, it is not an extremely rare occurrence
among Asian patients with increasing trend for wanting corrective operation (Fig. 8.57). A hump nose is defined by a nasal
dorsum that protrudes anterior to an imaginary line drawn between the radix and nasal tip. The hump itself consists of nasal
bone, upper lateral cartilage, and dorsal septal cartilage (Fig. 8.1) and is frequently accompanied by a wide bony base and
drooping tip.
Correction of hump nose usually consists of hump reduction, osteotomy, and tip plasty.
From the lateral perspective, the ideal dorsal bridge should be at a natural height without any significant deflections in the
profile. The nasal tip should not be lower but can be a little higher than the dorsum for a more aesthetic profile. In female
patients, the dorsal profile should form a natural curvature from the radix to the nasal tip. Most male patients prefer a rela-
tively straight dorsal line (Figs. 8.24 and 8.58).
In addition to the lateral view, the dorsal aesthetic line should not be interrupted from the frontal view. With hump reduc-
tion, the dorsal aesthetic line can be disrupted by a mid- vault narrowing or a wide bony base (Fig. 8.59).
The approach to hump correction should begin with the understanding that the anatomy and aesthetic standard for Asian
patients are different from those of Caucasian patients. Unlike simple removal of the hump in Caucasian patients, hump
removal in Asian patients needs to be performed in consideration of the height of radix and the nasal tip. During the opera-
tion, the hump should be removed in small increments while avoiding potential factors for dorsal depressions.
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256
a
b
c
d
Fig. 8.58 The dorsal line preferred
among East Asian patients. (a)
Preoperative view of a female patient
with a mild dorsal hump. (b)
Postoperative view reveals a slightly
curved profile. (c) Preoperative view of
a male patient with readily noticeable
nasal hump. (d) Postoperative view
revealed a straightened dorsum
Fig. 8.59 Interrupted dorsal aesthetic line. In this patient, the dorsal aesthetic line is
interrupted because the upper lateral cartilage is extremely narrow in comparison to the
wide bony base
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Preoperative Evaluation and Planning of Asian Hump Nose
In Caucasian patients, the radix cephalic to the dorsal hump can be high in some cases. However, the radix can be quite low in Asian
patients with hump nose (Fig. 8.60). Therefore, radix augmentation should be considered for dorsal hump operation in Asian
patients. In addition, it is relatively common to observe relatively smaller dorsal hump with lower dorsum in Asian patients.
Accordingly, it is important to consider the ideal dorsum shape (e.g., nasal tip or radix augmentation), prior to a humpectomy opera-
tion. In certain cases, a nasal hump may actually be better addressed by augmenting an abnormally low radix, using cartilage graft
or an implant, while leaving the “dorsal hump” itself alone.
It is also important to distinguish between a true nasal hump and a pseudohump from saddle nose, from a depression in
the septum and upper lateral cartilage (Fig. 8.61).
After hump removal, the nasal bone can appear wider even after an osteotomy. Also, removal of the hump can lead to the
illusion of the intercanthal distance being wider than it previously appeared.
As with hump reduction in Caucasian patients, nasal tip plasty is usually helpful in hump reduction in Asian patients.
a
b
Fig. 8.60 Comparison of dorsal hump and radix height in Caucasian and Asian patients. (a) Normal height of radix. (b) Low radix
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258
a
b
c
d
Fig. 8.61 A patient with pseudohump. (a, b) In this patient, the saddle nose deformity had developed after submucosal resection of the
septal cartilage—or a pseudohump. (c, d) Postoperative view after L-strut reconstruction and tip plasty. The “hump” was left alone in this
patient
Approach and Dissection
In Asian patients with small nostril, the open approach is recommended to facilitate component resection of the hump. The
closed approach can be used for several scenarios: nasal hump with wide nostrils, lack of need for component resection, and
partial humpectomy and radix augmentation plus tip plasty.
The dissection is carried in the supraperichondrial plane up to the border of nasal bone, where the dissection plane
switches into the subperiosteal plane. It is advantageous to limit the periosteal dissection to the hump, as preservation of
periosteum is important for bony stability after medial and lateral osteotomy.
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a
b
c
Fig. 8.62 Tip projection can make the supratip appear depressed. (a) A patient with hump nose and tip drooping. (b) The patient underwent hump
reduction and tip projection using septal extension graft. Relative to the nasal tip and dorsum, the supratip area appears sunken. (c) Crushed septal
cartilage graft was used to augment the sunken area
Hump Reduction
Technical details regarding hump reduction have been discussed earlier in this chapter.
For hump reduction, component resection is preferable over composite resection. Component resection removes the bony
hump and only dorsal septal portion of the cartilage. The component technique preserves transverse portion of the upper
lateral cartilage, which prevents the medialization of the ULC and narrowing of the cartilaginous vault. The benefits of using
the component technique are that it minimizes the risk of inverted-V deformity, preserves the dorsal aesthetic lines, and
reduces the need for spreader grafts.
Component resection of the nasal hump requires six steps for precise and symmetric resection (Fig. 8.7):
1. Division of the ULCs from the dorsal septum
2. Stepwise reduction of the dorsal cartilaginous hump
3. Reduction of the nasal bony hump
4. Checking the surface irregularity of dorsum by digital palpation
5. Final shaping of the irregularity with rasping and blade
6. Repair of the ULCs to the lowered dorsal septum with or without spreader graft and osteotomies
For a large dorsal hump, the dorsal border of septal cartilage should be excised adequately to the anterior septal angle.
Otherwise, the hump reduction will result in protrusion of the supratip and a pollybeak deformity (Fig. 8.32). This can be
prevented by adequate excision of the cartilage hump and tip plasty.
In a patient with drooping nasal tip, projection of the tip can make the supratip appear lower in comparison. As such, the
hump reduction should be performed while keeping in mind that tip projection will alter the relative height of the supratip.
It is sometimes necessary to even augment the area between the hump and the nasal tip (Fig. 8.62).
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260
Correction of Open Roof After Hump Reduction
Post-humpectomy open roof of the bony dorsum can be ignored if the defect is small and the skin is thick. If that is not the
case, one of the following techniques should be employed to close the open space.
Coverage with Implant or Autogenous Tissue
If the open roof is accompanied by low radix, the whole of nasal dorsum can be covered with an implant or dermofat graft
(Fig. 8.63). The use of an artificial implant can be controversial when implanted during the same operation as a hump reduc-
tion, out of concern for infection. The author thinks infection is unlikely if the vestibular mucosa is not violated. The pres-
ence of mucosal injury should preclude the use of any implants.
a
b
Fig. 8.63 Open-roof coverage with silicone implant. (a) A female
patient with hump nose, low radix, and tip drooping. (b)
Postoperative view after hump reduction, dorsal augmentation with
silicone implant, and tip plasty with columellar strut graft and
cartilage onlay graft
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Osteotomy
A post-humpectomy open roof can be closed by medialization of the nasal bone. With lateral osteotomy, the back fracture
extends from the superolateral edge of the open roof to the cephalic end of lateral osteotomy line. The fracture usually tracks
the boundary between thick and thin bones (Fig. 8.27). If this fracture is incomplete, a medial oblique osteotomy should be
performed to ensure that the fracture is complete.
To close an open roof in a patient with narrow nasal bone, an intermediate osteotomy (midlevel osteotomy) may be more
appropriate (Figs. 8.28 and 8.64).
a
b
c
d
Fig. 8.64 Midlevel osteotomy for open roof with narrow bony base in a patient with nasal hump. (a, b) This patient with hump nose has a narrow
bony base. (c, d) The patient at 3 weeks after hump reduction, midlevel osteotomy, and tip plasty using septal cartilage
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262
Spreader Graft
Component resection of the hump usually does not require the use of a spreader graft. The spreader graft, however, is
required when one cannot exclude the possibility of inverted- V deformity, dorsal septal deviation, or internal valve
insufficiency.
An inverted-V deformity may not be apparent during an operation but can slowly become conspicuous over the first few
years after the operation. When the operator cannot predict whether a hump resection will result in this deformity, he/she
should error on the side of safety and perform a spreader graft in a prophylactic capacity.
The ideal donor for spreader graft is septal cartilage, but either auricular cartilage or costal cartilage can also be used in a
pinch.
Long spreader grafts, about 3 mm in height and 10–20 mm in length, are inserted on both sides of the dorsal septum, from
bony gap to the caudal margin of the lower lateral cartilages (Fig. 8.23). The grafts are fixated using 5–0 PDS suture.
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Radix/Supratip/Dorsal Augmentation in Asian Hump Nose
Typically, hump nose correction in Asian patients includes hump reduction itself in addition to osteotomy and tip plasty
(Fig. 8.65).
Fig. 8.65 Typical example of hump
nose correction: hump reduction,
osteotomy, and tip plasty. (a–c) Hump
nose with tip drooping and deviated
nasal axis. (d–f) Postoperative views
after typical hump nose correction
procedures. Operation included hump
reduction, medial and lateral
osteotomies for the deviated nose
correction and open-roof closure, and
tip projection with L-shaped columellar
strut graft using septal cartilage
a
d
c
f
b
e
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264
In Asian patients with hump nose, the radix is often too low and requires augmentation. Three methods are available to
address this issue.
Small Hump and Low Dorsum
If the hump is small and the remainder of dorsum is low, dorsal augmentation by itself may be sufficient in creating the
desired shape of a straight dorsum without the need for a hump removal (Fig. 8.66).
a
c
b
Fig. 8.66 Small hump and low dorsum. (a) An implant can be used to augment whole of the dorsum if the hump is relatively small. In this case,
the hump is left alone. (b) This patient has a small hump and low dorsum. (c) Postoperative view after dorsal augmentation with silicone and tip
plasty with septal cartilage without hump reduction
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Medium-Sized Hump and Low Radix
In a medium-sized hump with low radix, the dorsum can be addressed by radix and supratip augmentation with autogenous
tissue and tip plasty to the height of the preexisting hump (Fig. 8.67). For autogenous tissue, auricular or septal cartilage is
preferred. Soft tissue options include dermis or temporal fascia graft (Fig. 8.68).
To minimize significant step-offs when using a cartilage graft, the graft edge should be softened with a cartilage crusher.
Alternatively, the graft can be diced and wrapped in temporal fascia. Dermis graft or purely fascial graft demonstrates a rela-
tively higher resorption rate and demands over- augmentation. Cartilage grafts do not require overcorrection (Fig. 8.69).
Fig. 8.67 Autogenous graft can be used to augment the radix and supratip area to the height of a hump
Hump Nose Correction in Asians

266
a
b
c
Fig. 8.68 Radix augmentation with autogenous tissues. (a) Temporal fascia graft. (b) Cartilage graft. (c) Cartilage wrapped in temporal fascia
graft
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267
Fig. 8.69 Medium-sized hump with low
radix and supratip. (a–c) He has a moderate
hump, and low radix and supratip. (d–f) 5
months postoperatively after having
conchal cartilage grafts on the radix and
supratip combined with tip plasty using
columellar strut graft using the conchal
cartilage
a
b
c
d
e
f
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268
Big Hump and Low Radix
When the hump is big, a good solution is the combination of partial humpectomy, cartilage graft in the radix and/or without
supratip graft, and tip plasty (Fig. 8.70). For augmentation of the radix, the graft choice includes cartilage, fascia, or fascia-
wrapped cartilage.
Another solution is the partial removal of the hump with whole dorsal augmentation with implant and tip plasty (Fig. 8.71).
This method yields a smooth dorsal line without any irregularity. However, it is more controversial in that the approach may
appear to be wasteful with the amount of tissue removed only to be replaced with an implant.
a
b
Fig. 8.70 Large hump with low radix. (a) This patient has a big hump, low radix, and drooping tip. (b) Postoperative view after partial humpec-
tomy, auricular graft on the radix and supratip, and tip plasty with columellar strut graft
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269
b
c
d
e
f
a
Fig. 8.71 Total humpectomy and dorsal
augmentation with silicone implant. (a–c)
This female patient has a deviated nose,
dorsal hump, low radix, and tip drooping.
(d–f) 10 months postoperatively after total
humpectomy, osteotomy, dorsal
augmentation with silicone implant (3 mm
in height), and tip plasty with columellar
strut graft using septal cartilage
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270
Tip Plasty in Asian Hump Noses
Most instances of hump nose are accompanied by long nose and drooping tip in Caucasian patients. In Asian patients, it is
not unusual for a hump nose to have normal length of tip or even a short nasal tip. When present along a hump in an Asian
patient, the tip drooping can assume one of the three variations (Fig. 8.72):
1. Tip drooping with normal length
2. Tip drooping with short nose
3. Tip drooping with long nose
The appropriate methods of tip plasty for short and long noses are described in further detail in Chaps. 9, 11, and 12.
a
b
c
Fig. 8.72 Three types of tip drooping in Asian hump noses. (a) Tip drooping with normal length. (b) Tip drooping with short nose. (c) Tip droop-
ing with long nose
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Drooping Tip with Normal Length
In drooping tip with normal dorsal length, tip onlay graft is a simple method of tip projection. However, onlay graft is only
appropriate if the medial crura are strong and straight (Fig. 8.73). In many patients, the medial crura are not strong enough
to support the onlay graft and require columellar strut graft. Cephalic rotation of the tip from strut graft can be balanced with
spanning suture, derotation suture, and/or derotation graft.
To avoid conspicuous cartilage step-off, the margin of the cartilage onlay graft should be tapered thinly and morselized
prior to graft placement.
Fig. 8.73 Hump nose with normal length of
drooping tip. (a–c) Preoperative views. (d–f) 7
months postoperatively after performing the hump
reduction, osteotomy, and tip projection with septal
cartilage onlay graft and medial crural-septal suture
a
b
c
d
e
f
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272
Drooping Tip with Long Length
Long drooping tip requires cephalic trimming of lateral crus to ease the cephalic rotation of lower lateral cartilages and colu-
mellar strut graft (Fig. 8.74). Patients with smiling tip will require reposition of the depressor septi nasi (DSN) muscle.
a
b
c
d
e
f
Fig. 8.74 Hump nose with long drooping tip.
(a–c) Preoperative views. (d–f) 5 months after a
corrective operation consisting of hump
reduction, osteotomy, SMR, tip plasty with caudal
septal shortening, columellar strut graft, medial
crural-septal suture, and DSN muscle
repositioning
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Drooping Tip with Short Length
Short nose with dorsal hump is not uncommon among Asian patients. For the correction of short nose, lower lateral cartilage
must be released from the following regions: scroll area, hinge complex, and membranous septum. The released lower lateral
cartilage can be pulled caudally and anteriorly for both lengthening and projection of tip, and fixed using the septal extension
graft or derotation graft combined with columellar strut graft (Fig. 8.75).
a
b
c
d
Fig. 8.75 Hump nose with
short drooping tip. (a, b)
Preoperative views. (c, d) 3
weeks after hump reduction,
radix augmentation with
implant, and tip plasty with
septal extension graft
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274
a
b
c
Fig. 8.76 Gruber’s classification of wide nasal
bone. (a) Broad nasal base (type I), (b) broad
base and dorsum (type II), (c) broad dorsum only
(type III)
Order of Operations in Hump Nose
The operative sequence varies across surgeons. Some prefer to address the dorsal hump first and the nasal tip second, while
others operate in the opposite order. The author finds that reserving the tip plasty as the last portion of the operation is advan-
tageous. If the tip plasty is performed first, the stitches can break while the dorsal hump is reduced. One downside to tip
plasty-last operation is that it is easy to create a supratip depression. Because of this, the dorsal hump at the septal angle
should be reduced conservatively at first. The height of the angle should be finalized after tip plasty is performed, by either
trimming the remaining excess or by augmentation.
If the dorsum and/or radix needs to be augmented during hump reduction, the author prefers to perform the hump reduc-
tion first, followed by tip plasty, and then any necessary augmentation.
Correction of Wide Nasal Bone
Wide nasal bone is not a rare occurrence, even in Asian patients. The general idea in correcting wide nasal base is to medial-
ize the nasal bone after an osteotomy. The main challenge is how this is accomplished in the wide spectrum of minute differ-
ence that exists across individual patients. Gruber classified broad nasal bone into three types (Fig. 8.76):
Type I: Broad base
Type II: Broad base and dorsum
Type III: Broad dorsum only
Among these, type III is seldom seen after a lateral osteotomy that reduces the base but typically fails to reduce the dorsum.
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Reduction of Wide Nasal Bone
Gruber type I nose has a relatively normal dorsum (anterior width) with a wide bony base (posterior width) and can ade-
quately be addressed using a low-to-low lateral osteotomy (Fig. 8.77). For reducing the possibility of operative failure, a
medial oblique osteotomy can be added to ensure a complete back fracture.
Type II with a wide bony base with nasal hump requires humpectomy and lateral osteotomy. If, however, the cephalic
medial nasal bone is wide and complete greenstick fracture is difficult, a medial oblique osteotomy should be performed
along with the lateral osteotomy (Fig. 8.78). The medial osteotomy should begin at the cephalolateral margin of the open
roof, so that the nasal bone segment can be mobilized inward after lateral osteotomy (Fig. 8.79). The resulting small bony
edge should be smoothed over with a rasp.
In certain situations, a small strip or wedge of bone must be resected from the upper margin of open roof (Fig. 8.80). To
connect to the lateral osteotomy, a transverse osteotomy may be necessary.
Lateral osteotomy of a type II wide nose without hump will result in a persistently wide dorsum, which represents a con-
version into a type III wide nose. Strip resection of medial portions of the nasal bones may be required to adequately reduce
the nasal width in patients with this type II wide nose. To decrease excessively wide nasal bones, Cochran has suggested
paramedian osteotomy and a parallel osteotomy that is offset by 2 mm, to remove the intervening strip of nasal bone
(Fig. 8.81). For this, the more lateral side osteotomy is performed first and medial side second. Then transverse and lateral
osteotomies are performed to close the open roof, which can effectively decrease the width of large bony dorsum (Fig. 8.82).
The strip resection osteotomy or wedge osteotomy is performed using a 3 mm straight osteotome. The cephalic central part
of nasal bone consists of a zone of dense bone (Fig. 8.83). If the strip excision is performed too medially, the excision will
a
b
Fig. 8.77 Correction of broad nasal bony base (type I). (a) A patient with wide bony base and deviated dorsal septum. (b) The bony base was
made narrower using lateral osteotomy. Dorsal septal deviation was corrected with dorsal septal rotation suture and spreader graft
Correction of Wide Nasal Bone

276
a
b
c
d
Fig. 8.78 Correction of dorsal hump and broad bony base (type I). (a, b) This patient has a wide nasal bone along with a dorsal hump. (c, d) The
nasal bone became narrower with hump reduction, lateral osteotomy, and medial oblique osteotomy. She also had a tip plasty with columellar strut
graft using septal cartilage
a
b
Fig. 8.79 Starting point of medial oblique osteotomy in a wide open roof. (a) In a patient with wide nasal bony roof, medialization of lateral bony
segment is difficult if the starting point of medial osteotomy is at the medial portion of the open roof. (b) The medial osteotomy needs to begin at
the most lateral cephalic margin of the open roof to allow effective closure of the roof as well as narrowing of the bony base
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277
Fig. 8.80 Wedge resection of the nasal bone
Fig. 8.81 Strip resection of wide medial nasal bone. The lateral osteotomy is performed first and medial osteotomy second
Correction of Wide Nasal Bone

278
a
b
c
d
Fig. 8.82 A patient with broad base and dorsum (type II). (a) In this patient, the nasal bone is wide both at the base and in the dorsum, which is
accompanied by a wide alar base. (b) A bony gap can be observed in the left side of nasal bone after a strip resection. (c) The resected strip of nasal
bone from the paramedian area. (d) 5 months after paramedian resection of the bone, lateral osteotomy, and alar base reduction. No dorsal aug-
mentation had been performed
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279
Fig. 8.83 Zone of dense bone. The cephalic midline portion of nasal
bone is thick and vascular. Complete osteotomy is not easy, and bleed-
ing is a real concern. As such, osteotomies should be avoided in this
area
Fig. 8.84 Double-lateral osteotomy. Lateral osteotomy in the lower
pathway should be performed using percutaneous perforating
osteotomy
prove to be challenging due to increased bleeding as well as incomplete osteotomy through the thicker bone. Therefore, the
author prefers a strip resection of the slightly lateral portion of the nasal dorsum.
If the sidewall of nasal bone has an excessive convexity, a single lateral osteotomy can worsen the contour of the
sidewall. To overcome this issue, an intermediate osteotomy can be combined with lateral osteotomy for a double-level
(Fig. 8.54). Intermediate osteotomy should be performed before doing the lateral osteotomy, because the lateral nasal
bony segment becomes unstable after the lateral osteotomy, which makes the intermediate osteotomy inaccurate for the
unstable bone.
Some authors perform the intermediate osteotomy in a very lateral location. This approach can make for an easier medi-
alization of the thick bony base, avoid bony step deformity usually seen with a more medially located osteotomy, and mini-
mize the risk of nasal obstruction from medialization of nasal bony segment in a more dorsal location (Fig. 8.84). The lateral
osteotomy is performed in either the high-to-low or the low-to-low path.
A type III wide nasal bone (wide dorsum with normal bony base) can be addressed by medial oblique osteotomy and
intermediate osteotomy (Fig. 8.85).
Correction of Wide Nasal Bone

280
a
b
Fig. 8.85 Medial oblique osteotomy and intermediate
osteotomy. (a) In this patient with a type III wide nose, the
nasal base is of relatively normal width, but the dorsum is
broad. (b) Postoperative view after medial oblique
osteotomy and midlevel osteotomy
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281
Reduction of Wide Upper Lateral Cartilages
If the upper lateral cartilages are wide, medialization of the nasal bone may either be difficult or fail to stay medialized in the
postoperative period. This is because the upper lateral cartilages overlap the caudal portion of the nasal bone, and the elastic-
ity in the overlapping portion of the upper lateral cartilages tends to keep the nasal bone lateralized. In such cases, a strip
excision should be performed for the upper lateral cartilage (Fig. 8.86).
First, the upper lateral cartilage is separated from the dorsal septum, and the transverse wing of the dorsal septum is
resected. If this step is not adequate in narrowing the mid- vault, strips of equal width can be excised from the paramedian
portions of the upper lateral cartilages, using No. 15 blade. The cartilage should be incised with the blade beveled medially,
to excise more of the dorsal portion of the ULC. During this maneuver, care should be taken not to injure the nasal mucosa.
Once the strip excision is completed, the open edges of ULCs are repaired back to the dorsal septum (Fig. 8.87). Internal
valve narrowing is relatively rare when using this method of ULC excision. If valve narrowing is a concern, the strip excision
can be limited to cephalic to caudal one-fourth of the upper lateral cartilages.
Fig. 8.86 Reduction of wide upper lateral
cartilages: Strip resection of paramedian portions
of ULCs can reduce the width of cartilaginous
dorsum
Correction of Wide Nasal Bone

282
a
b
c
d
e
f
Fig. 8.87 Reduction of a wide mid-vault. (a) In this patient with wide mid-vault, the nasal bone itself is of relatively normal width. (b) Exploration
reveals wide ULCs. (c) The upper lateral cartilages are separated from dorsal septum, and the most medial portions are excised in a strip. (d) Strip
resection of both ULCs has resulted in cartilage gaps. (e) ULCs are repaired to the dorsal septum. (f) 4 months after operation demonstrated main-
tenance of the narrower mid-vault width
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Medial Osteotomy and Implant Use in Asians
Most surgeons would be concerned if an implant is used during the same operation as a medial osteotomy. If the mucosal
injury is identified after a medial osteotomy, the idea of using an implant in the space should be abandoned in favor of autog-
enous tissue. However, situations arise when an implant must be used to augment the dorsum after having performed a
medial osteotomy. In such cases, the tips and tricks in this situation include:
1. Mucosal inflation with local anesthetic prior to performing the medial osteotomy
2. Mucosal uncovering from the overlying bone to avoid the mucosal injury from the medial osteotomy (Fig. 8.88)
3. Use of double-guarded osteotome to protect both the skin and underlying mucosa
Even with the most carefully performed medial osteotomy, the underlying mucosa should be evaluated thoroughly prior
to any implant insertion.
a
b
c
d
Fig. 8.88 Mucosal uncovering and use of double-guarded osteotome. (a) Using a periosteal elevator, the upper lateral cartilage is disarticulated
from the nasal bone. (b) The elevator is advanced in the cephalic direction to detach the underlying mucosa from beneath the nasal bone. Prior to
the dissection, the mucosa should be inflated using local injection to avoid mucosal tearing. (c, d) The double-guarded osteotome is useful in
preserving both the mucosa and skin during the medial osteotomy
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284
Further Reading
1. Harshbarger RJ, Sullivan PK. The optimal medial osteotomy: a study of nasal bone thickness and fracture patterns. Plast Reconstr Surg.
2001;108:2114–9.
2. Tardy ME Jr. Rhinoplasty: the art and the science. Philadelphia, PA: W.B. Saunders Company; 1997.
3. Tasman A-J. Rhinoplasty – indications and techniques. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2007;6:Doc09.
4. Guyuron B. Nasal osteotomy and airway changes. Plast Reconstr Surg. 1998;102(3):856–60.
5. Spencer Cochran C, Ducic Y, DeFatta RJ. Rethinking nasal osteotomies: an anatomic approach. Laryngoscope. 2007;117:662–7.
6. Gabra N, Rahal A, Ahmarani C. Nasal osteotomies. A cadaveric study of fracture lines. JAMA Facial Plast Surg. 2014;16(4):268–71.
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M. K. SUH, Atlas of Asian Rhinoplasty,
Nasal Tip Plasty: Suture Techniques
and Cartilage Grafts
Across the wide spectrum of subdisciplines within rhinoplasty, nasal tip plasty is one area in which a great variety of tech-
niques have successfully been developed to improve the overall outcome from rhinoplasty. Tip plasty is technically demand-
ing but is a required mastery for any rhinoplasty expert. A surgeon’s knowledge, technical competency, and experience all
contribute to the degree to which one can apply the appropriate technique for each and every variation in the anatomy and
clinical context, with predictable long- term outcomes while avoiding unwanted complications. As such, operative outcome
following tip plasty varies widely across surgeons.
The stereotypic low, short, and bulbous nasal tip in Asian patients is technically demanding and represents a significant
challenge in rhinoplasty. Because of the anatomical differences, nasal tip plasty for Asian patients requires varying approaches
and techniques than those developed for Caucasian patients, with expected variances in the prognosis.
The key structure that determines the shape, height, and length of the nasal tip is the lower lateral cartilage. The size,
shape, and strength of the lower lateral cartilages vary across ethnicity and across individuals (Fig. 9.1). However, the lower
lateral cartilages are not the only determinants of the shape and position of the nasal tip, which are also influenced by the
relationship between the lower lateral cartilages and neighboring structures (septum and upper lateral cartilages). In addition,
the thickness of the nasal tip skin and soft tissue also contributes to the appearance of the nasal tip. For tip plasty in Asian
patients, thick skin and soft tissue of the tip is just as important of a factor as the configuration of the lower lateral cartilages
and acts as a limiting factor in obtaining successful outcomes in many cases.
The lower lateral cartilages are different from the upper lateral cartilages in that the septum does not directly support the
lower lateral cartilages. Instead the lower lateral cartilages are supported and maintained by fibrous connecting tissues which
connect lower lateral cartilages to the surrounding structures (see Chap. 1). In many Asian patients, the lower lateral carti-
lages are small and weak. If silicone implant is placed on top of the nasal tip, the small lower lateral cartilages without septal
support may collapse, which can result in polybeak deformity (Fig. 9.2). To further compound the issue, implant located at
the nasal tip exerts pressure to the overlying skin, which increases the risk for skin thinning and rupture with implant expo-
sure (Fig. 9.3). Multiple-layered cartilage onlay graft on the weak lower lateral cartilages to project the tip in some Asians
may not be maintained well because of the weak medial crural support.
For these reasons, nasal tip plasty in Asians requires a lot more than the sole use of an implant or a simple cartilage onlay
graft. Also, suture techniques are often inadequate in bringing about significant changes to the small lower lateral cartilages
in Asian patients. While the fundamental principles for nasal tip plasty are the same for all patients, there is a significant dif-
ference in the technical details and operative outcomes following nasal tip plasty between Asian and Caucasian patients.
Typically, Asian patients tend to have thicker nasal tip skin and soft tissue with less defined tip, more retracted columella,
and wider ala, when compared with Caucasian patients (Fig. 9.4).
From the frontal view, the ideal nasal tip connects the two dorsal aesthetic lines from the glabella. A naturally round tip
end is preferred over a pointed nasal tip. The alar rims should resemble the “seagull wing” shape without excessive nostril
show (Fig. 9.5). From the side profile, the ala-columellar relationship should be harmonious without hanging or retraction of
the alar rim. In Asia, patients express significant dislike for hanging columella or nostril showing. The nasolabial angle is
appropriate at around 90 to 95 degrees. From the basal view, the alar base should not be too wide, with the alar-tip shape
forming a triangle. The infratip lobule should not be excessively long, and the nostril should assume the shape of a teardrop
(Fig. 9.6). Above and beyond metric standards, a nasal tip plasty should result in a nasal tip that is harmonious with the rest
of the nose and the face. The supratip break should not be drastically obvious, and the tip should be defined while maintain-
ing the ethnic identity of the patient.
9

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a
c
b
d
Fig. 9.1 Ethnic differences in nasal tip anatomy. (a, b) Lower lateral cartilages are usually large and well developed in Caucasians. (c, d) Among
Asian patients, it is not uncommon to observe small lower lateral cartilages with relatively thick nasal tip skin
9 Nasal Tip Plasty: Suture Techniques and Cartilage Grafts