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a
e
d
c
b
f
Fig. 7.16 Case with a vertically oriented
folded dermal graft for dorsal augmentation.
(a–c) Preoperative views. (d–f) One year
after dorsal augmentation surgery using a
vertically oriented folded dermal graft and
tip plasty with a derotation suture and
conchal cartilage shield graft
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Dorsal Augmentation with Solid Block Costal Cartilage
Costal cartilages are abundant in graft volume, and the absorption rate is very low in comparison with the dermofat graft, hav-
ing the advantage of providing significant augmentation to nasal dorsum. Nonetheless, donor-site morbidities such as pneu-
mothorax and chest wall scar are possible in harvesting the costal cartilage. Dorsal augmentation using costal cartilage requires
both the aesthetic sense needed for carving and the ability to accurately place the graft onto the nasal dorsum—all the while
minimizing graft warping. In the hands of an experienced surgeon, the graft can provide a desirable outcome. Otherwise, the
technique is fraught with the potential for graft warping, contour visibility, deviation due to graft migration, etc.
However, an elaborate skill performed by an experienced surgeon can yield much better, well-defined, predictable shape
compared with dermofat or diced cartilage. This author believes that the solid block costal cartilage can be an excellent
choice for Asians with a very low dorsum, requiring major dorsal augmentation of 5 mm or more.
Harvest of the Costal Cartilage
The costal cartilage harvest is described extensively in Chap. 4, and readers are invited to review the details in Chap. 4.
The costal cartilage can be harvested between the fifth and ninth ribs. In most cases, the graft is harvested in either the
sixth or the seventh rib (Fig. 7.17). The inframammary fold incision allows access to the fifth and sixth rib cartilages. In
patients with lower inframammary crease, the incision allows access even to the seventh rib. Compared to the graft harvested
for septal extension graft, the costal cartilage needed for dorsal augmentation needs to be longer—around 5–6 cm. The sixth
rib contains a bit of curvature (Fig. 7.18), but the seventh rib is relatively longer and straight. As such, the seventh rib carti-
lage is usually preferable for the purpose of dorsal augmentation. Because the seventh rib is often inaccessible from the
inframammary fold, the incision is usually made directly over the seventh rib cartilage to be harvested. An incision is made
along the superior margin of the rib cartilage.
The more elderly the patient is, the more likely to have calcification of the cartilage. It is necessary to confirm the signs
of calcification and ossification through chest X-ray prior to surgery. During surgery, an operator should probe the costal
cartilage for any signs of calcification using a 25-gauge needle, prior to making a skin incision in the chest wall. It also plays
the role of confirming the exact location of the osteochondral junction. Calcification occurs in the mid- 30s. However, young
patients may have calcification or even ossification of the entire costal cartilage. Once an operator finds a calcified rib after
making an incision, the operator can explore another rib for harvesting. Even if an operator finds one or two ribs to be calci-
fied, it is common for the surgeon to find other ribs less likely afflicted with calcifications.
Fig. 7.18 A curved sixth rib cartilage with genu
10th rib
7th rib
6th rib
Fig. 7.17 The costal cartilage is most commonly harvested from the sixth
to seventh ribs, but it can be also harvested from the fifth to ninth ribs
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Carving the Costal Cartilage
Carving of the costal cartilage is the most important, difficult, and time-consuming step for successful dorsal augmentation.
A graft must be precisely carved in order to fit to the dorsal shape. If the operator is unable to carve the graft to the requisite
dimensions and shape (width, bottom contour, and slope/convexity of both side walls), the graft will not maintain an accurate
and even contact surface with the radix and dorsum and can develop graft deviation or visible graft margins.
The most common complication in block costal cartilage graft for dorsal augmentation is graft warping. The costal carti-
lage graft undergoes warping when the balance is disrupted between the tensile force of the outermost (subchondral) layer
and the expansile force of the inner layer. This is referred to as “the principle of the balanced cross-section” of Thomas
Gibson.21 It was reported that older patients had a lesser incidence of warping while younger patients had more incidence of
warping. The total thickness of harvested costal cartilage must be used for dorsal augmentation in most Asian patients with
a very low dorsum. In an attempt to minimize warping of the costal cartilage, the operator must obtain a graft, with which
balanced intrinsic stresses are symmetrically maintained. A graft with balanced intrinsic stress can be obtained by using the
core portion of the cartilage or by carving the graft in such a way that the distorting forces are balanced through the cross
section. In practice, it is impossible to carve out a perfectly symmetric costal cartilage graft for dorsal augmentation.
Respecting the principle of balanced cross section, however, one can minimize graft warping by the concentric carving of the
core cartilage (Fig. 7.19). A thick solid costal cartilage graft which is carved following this principle for dorsal augmentation
is fairly resistant to warping. As such, the author avoids the use of K-wire technique reported by Gunter et al., with which a
K-wire is inserted into the center of the costal cartilage (Fig. 7.20).
a
b
Fig. 7.19 Concentric carving of the costal cartilage to minimize the graft warping
Fig. 7.20 K-wire placement through the graft to prevent the warping
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The graft is designed with the core cartilage as the graft center. The silicone implant that best matches the desired profile is
placed on the dorsum of the patient, and the cartilage block is carved to match the shape of this implant as much as possible.
First, the periphery of designed graft is trimmed using a No. 10 blade. The resulting block is further shaped using the scalpel
and electric burr to match the width and concavity of the nasal dorsum. This takes a considerable amount of time, and a signifi-
cant amount of experience is required for an operator to become comfortable with this process (Fig. 7.21). The graft width may
be different depending on the graft area. A graft to be placed in the radix and supratip is carved narrower than that to be placed
in the mid- vault. It is important that the bottom surface of graft accurately matches the dorsal alignment. The cephalic portion
of the graft must be carved to fit in with the radix alignment, which would be the most demanding process. If necessary, the
cephalic portion of the graft can be made to bend by applying several back cuts on the bottom of the cephalic portion of the graft.
A carved costal cartilage will have undergone the maximum amount of warping after an hour. As such, the carved graft
should be placed in a saline solution for an hour, after which the graft should be further trimmed prior to insertion. Excessive
warping can be adjusted by the placement of several full-thickness cuts on both sides of the graft. This process requires a
significant experience (Fig. 7.22). Noses requiring a lesser amount of dorsal augmentation are corrected with implantation
of one or two thin slices of costal cartilage after slicing the harvested costal cartilage into 3–5 pieces of appropriate thickness
(Fig. 7.23). The concave side of a warped piece is placed towards the dorsum to avoid the graft protruding in the radix and
supratip areas. Somewhat excessive warping can be overcome by (1) scoring the concave side of the warped graft, (2) making
a horizontal double- mattress suture, (3) placing another small cartilage piece with a curvature of the opposite side (Fig. 7.24),
and (4) making a suture fixation of the graft over the underlying upper lateral cartilage. The costal cartilage has a relatively
slippery texture and can easily become deviated from its initial position. Therefore, it is very important to carve the cartilage
in a meticulous manner such that the resulting graft has an anatomically exact contour to maximize the contact surface
between graft and nasal dorsum (Fig. 7.25). This not only prevents graft dislocation but also minimizes the risk of infection
by decreasing the dead space beneath the graft.
Two graft pieces can be joined together to create the natural curvature of supratip break (Fig. 7.26).
a
b
c
d
Fig. 7.21 Procedures of costal cartilage carving. (a) Tools used for cartilage carving: blade, cutter, electric drill, silicone implant, and irrigation
saline. (b–d) Through the process of concentric carving, the graft is carved meticulously to conform to the contour of the patient’s dorsum
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192
a
c
b
Fig. 7.22 Multiple full-thickness cutting on both margins of the graft can control the warping to some degree
a
b
Fig. 7.23 Sliced cartilage piece can be used for the small amount of dorsal augmentation
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a
b
Fig. 7.24 Placing another small cartilage piece with a curvature of the opposite side
a
b
Fig. 7.25 Graft must be carved to fit in anatomically to the contour of the dorsum and particularly the radix area of the patient
a
b
Fig. 7.26 Two pieces of costal cartilage graft for the supratip curvature. In the event the smooth contour of the supratip break area cannot be cre-
ated, two pieces of the costal cartilage may be connected to make the supratip break
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Placement of the Graft on the Dorsum
To prevent the graft deviation, the following key points should be respected:
1. The size of the subperiosteal pocket, into which the graft is placed, should not be wide. The graft must fit into the pocket
tightly to minimize graft movements.
2. Toriumi et al. suggested the “perichondrial fixation method,” using a costal cartilage dorsal graft and interpositional costal peri-
chondrial graft (Fig. 7.27). According to his technique, a strip of costal perichondrium is sutured to the undersurface of the upper
third of the dorsal graft to create a costal/perichondrial interface. Then multiple holes are made in the bony dorsum of the nose
using a 2 mm straight osteotome or a narrow rasp is used to create a rough surface on the bony dorsum. And then, the dorsal graft
with intervening costal/perichondrial graft is placed on top of the bony dorsum. The raw surface of the bony dorsum and interven-
ing costal perichondrium, together with the tight subperiosteal pocket, prevents slippage, movement, or deviation of the graft.
3. The graft is fixed to the upper lateral cartilage using 5-0 PDS sutures. Two sutures should be placed to the cephalic and
caudal portions of the upper lateral cartilage.
4. Threaded K-wire fixations are reserved for special cases where the graft movement cannot be restricted due to loose peri-
osteum, or in secondary rhinoplasty cases where a narrow pocket cannot be formed. The K-wire is driven through the
skin, graft, and underlying nasal bone, to be removed a week after the operation (Fig. 7.28).
On the thin-skinned nose, a diced cartilage is packed loosely along the bilateral margins of the block costal graft and
molded to avoid any lateral step-off. Temporal fascia or crushed costal perichondrium of the costal cartilage can be used
alternatively. Figures 7.29 and 7.30 show the examples of dorsal augmentation using a solid block costal cartilage graft.
a
b
Fig. 7.27 Perichondrial fixation method. Costal perichondrium is sutured to the undersurface of the graft
Fig. 7.28 Dorsal graft fixation using a threaded K-wire
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a
b
c
d
e
f
g
h
i
j
k
l
Fig. 7.29 Dorsal augmentation with a solid block costal cartilage. (a–d) This male patient has a flat nasal dorsum, upturned tip, and retracted ala
of the left side due to contracture after removal of the exposed silicone implant through the vestibular mucosa. (e, f) Lower lateral cartilages are
released from the scar tissue, and rotated caudally. (g) Columellar strut graft and derotation graft using the auricular cartilage have been performed
to correct upturned tip. (h) The costal cartilage has been harvested. It is carved to form a solid block shape with 6 mm in height, and is placed over
the nasal dorsum. (i–l) Eight months after surgery
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196
a
b
c
d
Fig. 7.30 Dorsal augmentation with two-layered solid block costal cartilages. (a–c) After traffic accident, this female patient has a saddle nose,
collapsed nasal bone, and upturned nasal tip. (d, e) Lower lateral cartilages are released from the scar tissue, and rotated caudally. (f) Costal carti-
lage has been harvested. (g, h) Two-layered carved costal cartilage is ready for dorsal augmentation of about 10  mm in height.
(i, j) A small piece of the costal cartilage is attached to the caudal end of the dorsal graft as tongue-in-groove pattern to lengthen the upturned nasal
tip. (k) Graft is placed in position. (l, m) Lower lateral cartilages are sutured to the end of the graft. (n–p) Two years after surgery
7 Dorsal Augmentation Using Autogenous Tissue

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e
f
g
h
i
j
Fig. 7.30 (continued)
Dorsal Augmentation with Solid Block Costal Cartilage

198
k
l
m
n
Fig. 7.30 (continued)
o
p
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Dorsal Augmentation with Diced Cartilage
The most highly recommended cartilage graft for major dorsal augmentation in the Asian patients is the costal cartilage,
because it provides enough volume of cartilaginous material needed to augment the low dorsum. Nevertheless, warping is
the major disadvantage of a solid block costal cartilage graft. Furthermore, the graft’s margin can be shown through the thin
dorsal skin. Another technique to overcome such a drawback is diced cartilage graft. The harvested cartilage is diced and
placed into the dorsal pocket as free diced cartilage, or it can be wrapped within a fascia and placed in the pocket (Fig. 7.31).
This technique can be employed using auricular cartilage, septal cartilage, or costal cartilage. However, either auricular or
septal cartilage alone provides insufficient volume of graft material for dorsal augmentation in most East Asian patients with
very low dorsum. It is possible to perform dorsal augmentation using both auricular and septal cartilage, but the costal carti-
lage is a preferable source when a great quantity of cartilage is required.
The use of diced cartilage graft had been reported decades ago, but was supplanted by the introduction of silicone
implants. In 2000, Erol reported a new technique of dorsal augmentation using diced cartilage wrapped in Surgicel—the
“Turkish delight”—which again brought the diced cartilage into contemporary practice. Unlike the original report, however,
Daniel found that the graft undergoes total resorption and suggested foreign-body reaction against Surgicel as the cause.
Thus, they reported a modified technique called “diced cartilage wrapped in temporal fascia.” The method has been readily
adopted by numerous surgeons due to easy surgical procedure and reduced resorption rate. Brenner et al.’s study reported
that fascia wraps appear to minimize inflammatory responses to the cartilage, thereby preserving healthy cartilage. This
study demonstrates that the deep temporal fascia is the preferred envelope, with which graft containment is facilitated and
chondrocyte viability of diced cartilage graft is maintained.
Presently, diced cartilage graft is prepared by dicing costal cartilage, ear cartilage, or septal cartilage into small cubes and
is placed within the nasal dorsum as free diced cartilage or as diced cartilage wrapped in fascia. The technique is useful for
smoothing out dorsal irregularity or for dorsal augmentation.
Diced cartilage grafting is a very useful technique for smoothing out dorsal irregularities or dorsal augmentation.
Fig. 7.31 Diced cartilage
wrapped in temporal fascia
Dorsal Augmentation with Diced Cartilage

200
Free Diced Cartilage
Free diced cartilage is used for minor dorsal augmentation, correction of dorsal irregularity, and lateral step-off after block
costal cartilage graft. For major dorsal augmentation, it is preferable to use diced cartilage wrapped in temporal fascia.
Operative Technique
Cartilage Harvest
The graft material can be harvested from the ear, nasal septum, or rib. The amount harvested from the auricular or septal
cartilage is inadequate. Thus, these cartilages are largely used for minor dorsal augmentation or the correction of focal dorsal
irregularities, in which a less amount is required. Major dorsal augmentation can be performed using costal cartilage.
Dicing the Cartilage
All types of cartilage (conchal, septum, costal) are diced into small pieces of less than 0.2 mm in diameter, using No. 11 or
dermatome blade. Instillation of a small amount of gentamicin solution, which acts as a carrier for the adhesive forces, will
turn the diced cartilage into a paste-like mixture.
Packing the Diced Cartilage into Syringe
The diced cartilage particles are packed into a 1.0 cc insulin syringe. The operator packs them into the syringe so that empty
spaces or fluid contents are minimal. Then, No. 10 blade is used to cut the syringe hub.
Placing the Diced Cartilage on the Nasal Dorsum
Free diced cartilage grafts are placed in the nasal dorsum usually to smooth out dorsal irregularity as an adjunct to other
rhinoplasty operations and is placed within the dorsal pocket as the last procedure. The open rhinoplasty incision is closed
from the columella to the inframarginal area but is not completely closed. Through a small opening left in the inframarginal
incision, the syringe packed with diced cartilage is introduced into the dorsum. The open end of the syringe is carefully
placed where diced cartilage is wanted along the dorsum. The diced cartilage is gently injected while the syringe is slowly
withdrawn from the space (Fig. 7.32). The free diced cartilage within the nasal dorsum is molded into the desired shape using
the operator’s thumbs and index fingers of both hands. This shape is maintained by immediate application of paper tape.
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201
Diced Cartilage Wrapped in Temporal Fascia
Reported in 2004 by Daniel and Calvert, this method of dorsal augmentation uses diced cartilage wrapped in temporal fascia
(Fig. 7.31). The incorporation of fascia assists in graft placement in the dorsum and holds the diced cartilage pieces together
for a long time. Fibrous tissue fills the space between cartilage pieces, and the graft becomes firm and semirigid over time.
Whether the resorption is greater for free diced cartilage or for temporal fascia-wrapped diced cartilage is controversial.
The technique can provide and maintain a greater dorsal height than free diced cartilage. As such, the author considers the
fascia-wrapped diced cartilage technique to be more appropriate for East Asian patients with lower dorsum.
Operative Technique
Harvest of Temporal Fascia
The operative details for deep temporal fascia harvest are described in Chap. 4. The fascia is harvested in a rectangular shape,
about 5 cm by 3 cm. For thin-skinned nasal dorsum, a larger fascia can be harvested such that the overlapping portion of the
wrapped fascia is oriented towards the skin, such that there is an extra layer of fascia tissue between the skin and diced car-
tilage pieces. This helps to minimize the risk of irregular texture.
a
c
b
Fig. 7.32 Free diced cartilage. (a) Dicing the cartilage into small particles. (b) Inserting and packing the cartilage paste into a 1 mL insulin
syringe. (c) Diced cartilage packed in the syringe is gently injected to the nasal dorsum through a small gap in the inframarginal incision for the
correction of dorsal irregularities
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202
Packing the Diced Cartilage in the Tube-Shaped Fascia
The diced cartilage is packed into a 1 cc insulin syringe, and the hub of syringe is cut off using a No. 10 blade. On a plate,
the harvested fascia is laid flat, upon which the syringe is placed. The fascia is wrapped around the syringe, and the longitu-
dinal margins of the fascia are closed by continuous- running suture using an absorbable suture. The distal end of the fascia
is also closed with an absorbable suture. Then the flat fascia turns into a tube around the syringe (Fig. 7.33).
The diced cartilage within the syringe is slowly and gently injected into the fascial tube. While palpating for cartilage
particles filling up, the syringe is slowly withdrawn from the tube. The amount of diced cartilage to be filled into the fascia
is dependent upon the amount of augmentation desired. After completing the infusion of the cartilage particles, the fascial
sleeve on the opposite side is also sutured with an absorbable suture, closing the fascia tube.
If the dorsum needs to be augmented by a large amount of diced cartilage, as much as a 3–4 cc or larger, a 3 cc syringe,
instead of a 1 cc insulin syringe, is used to be wrapped by the fascia. Or, a silicone implant can also be used instead of syringe
to be wrapped (Fig. 7.34). After making a fascia tube by wrapping a silicone implant with the fascia, a syringe filled with the
cartilage particles is used to infuse these particles into the fascia, using the same method detailed above. Then, in the event
where the tube spreads out to the side, or where the operator desires a fascia tube with an increased height and a narrow
width, several sutures crossing the diced cartilage-filled fascial tube are placed with a No. 6-0 suture having a round needle.
These sutures decrease the width of fascial tube and force the volume in the vertical dimension to create a taller graft.
a
b
c
d
Fig. 7.33 Procedure of diced cartilage wrapped in temporal fascia. (a) Harvested deep temporal fascia. (b) A 1 cc syringe without a hub is
wrapped with the temporal fascia. (c) Diced costal cartilage. (d) The diced cartilage particles in the syringe are slowly and gently infused and
packed into the fascia tube
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203
a
b
c
d
e
f
Fig. 7.34 Diced cartilage wrapped in temporal fascia. (a–d) In the event where a large volume of dorsal augmentation is required, a silicone
implant suitable for the shape of the patient is selected, instead of a 1 cc syringe. Then, the implant is wrapped with the temporal fascia to form a
fascia tube. (e) The diced cartilage particles packed in the syringe are infused into the fascia tube. (f) Diced cartilage graft wrapped in fascia
Dorsal Augmentation with Diced Cartilage

204
Insertion of the Diced Cartilage in Fascia to the Pocket
Owing to the movable nature of the graft inserted in the supraperiosteal plane, the pocket is placed in the supraperichondrial
and subperiosteal plane, and the pocket should be slightly wider than the graft itself.
The cephalic end of the graft is fixed with a pullout suture, while the distal end is sutured to the septal angle (Fig. 7.35).
The graft is molded to the desired contour by finger manipulations using both hands. Then, a paper tape and a thermoplas-
tic splint are used for fixation, while the splint is maintained for 1 week. If reshaping of the graft is required, after removing
the splint on the seventh day, the splint would be kept for a longer period. Figure 7.36 shows an example case of dorsal
augmentation using the diced cartilage wrapped in temporal fascia.
a
b
Fig. 7.35 Pullout suture fixation of the graft
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205
a
b
c
d
e
f
g
h
i
Fig. 7.36 Dorsal augmentation using diced cartilage wrapped up in the temporal fascia. (a–c) This female patient has a flat dorsum, especially on the
mid-vault. (d–f) Three weeks after dorsal augmentation surgery using the diced cartilage (costal cartilage) wrapped up in the temporal fascia, and tip
plasty with the septal extension graft. (g–i) Nose shows slight resorption of the graft, but still maintains well-defined dorsum 8 months after surgery
Dorsal Augmentation with Diced Cartilage

206
Other Variable Techniques of Diced Cartilage Graft
Glued Diced Cartilage
Reported by Tasman et al., this method uses fibrin glue to hold the diced cartilage particles together (Fig. 7.37).
a
c
e
g
i
h
f
d
b
Fig. 7.37 Glued diced cartilage. (a, b) A few drops of thrombin are added to the diced cartilage. (c, d) Diced cartilage is mounted to the half-cut
syringe, molded into desired shape and compressed with both index fingers to reduce the empty space. (e) A few drops of fibrinogen are added to
the cartilage particles to bind them. (f, g) Trimming of the excess fibrinogen. (h, i) Convex side of the graft is covered with a few drops of
fibrinogen
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207
A 2–5 cc syringe is cut in half along the axis. After making a mold, insert the diced cartilage into the mold. First, a few
drops of thrombin component, provided by the fibrin glue product kit, are added to the diced cartilage. The diced cartilage is
then molded into the desired shape, followed by adding the fibrinogen component to the particles for bonding. The cartilage
is pulled out of the mold, and then the opposite surfaces are covered with the fibrinogen component. Then, the graft is
trimmed and placed over the nasal dorsum.
Diced Cartilage Wrapped in AlloDerm
This modified technique, reported by Gordon et al., uses thin AlloDerm® (0.79–1.78 mm thick) to wrap up finely diced car-
tilage particles. AlloDerm® is an acellular dermal matrix derived from a donor (cadaveric) skin. Gordon et al.’s report did not
have data on resorption rate. Nonetheless, animal studies performed by Kim et  al. demonstrated resorption rates that
AlloDerm® is similar to autogenous fascia.
Complications of Diced Cartilage Graft
Diced cartilage graft allows for a relatively easy dorsal augmentation, which even the inexperienced operator can perform.
Nevertheless, predictable adverse reactions include graft deviation, irregularity or focal depression, possible resorption, vis-
ibility of the particle graft through the thin skin (cobblestone appearance), and hair loss at the fascial harvesting site. In
particular, focal depression (step-off) of the supratip may occur due to technical difficulties in meticulous handling of the
contact area between the dorsal graft and tip cartilage. If feasible, leaving the graft longer is desired to prevent this problem;
it is important to harvest a sufficiently long temporal fascia to do so. If the step-off is seen or palpated, the operator should
put additional diced cartilage or fascia graft. Visibility of cartilage particles is rare among Asians with thick skin. However,
a large cartilage particle graft on the thin-skinned nose may be seen through the skin or show irregularities. For a thin-
skinned nose, the cartilage must be diced in a much smaller size and the graft needs another layer of the fascia to wrap. Minor
irregularities may be corrected by morselizing the cartilage particles with a No. 16 needle via percutaneous puncture. Daniel
et al. reported that an overcorrection should not be necessary since the graft would not be absorbed, but the issue of resorp-
tion is controversial with numerous opinions from various authors. The resorption rate of the diced cartilage graft is much
less than that of either the fascia graft or the dermofat graft. However, partial resorption must be considered. Minimizing the
dead space among the particles, by finely dicing the cartilage, and maximally packing the particles into the temporal fascia
tube would curtail dorsal height reduction as time passes.
Advantages and Indications of Diced Cartilage Graft
Diced cartilage has many advantages. Above all else, the operation is not technically demanding and does not require block
carving, which opens up the use of this graft even to the inexperienced operators.
In addition to augmentation of the whole dorsum, diced cartilage graft can be used for partial augmentation applications
(i.e., radix augmentation, dorsal irregularity, and focal depression). Compared to the use of a block graft, diced cartilage graft
is much more useful in the correction of dorsal irregularity.
In addition, using a combination of various cartilage types is possible, such as auricular cartilage, septal cartilage, or
costal cartilage, and various combinations of leftover cartilages can be combined and diced for the purpose of correcting
minor irregularities.
Compared to costal cartilage block graft, diced cartilage graft tends not to cause the problem of graft contour becoming
visible through the skin. It also avoids the problem of graft warping inherent in block costal cartilage grafts.
Molding to correct deviation, irregularities, or width of a graft is possible, up to 2 weeks after surgery.
In dorsal augmentation cases with a thin dorsal skin, the contour or the margin of a block cartilage graft may be shown
through the skin. It is safer to use a soft-tissue graft such as dermofat or fascia for those cases. However, such a soft- tissue
graft is plagued with high resorption. On the contrary, diced cartilage graft is less prone to resorption, and can be effective
for the thinned skin dorsum.
Diced cartilage graft can be used for dorsal augmentation, focal augmentation such as the radix or supratip augmentation,
correction of dorsal irregularities, and correction of the issue of stepping off of the dorsal augmentation material between the
caudal end and tip cartilage graft.
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208
Further Reading
1. Na HG, Jang YJ. Dorsal augmentation using alloplastic implants. Facial Plast Surg. 2017;33(2):189–94.
2. Karaaltin MV, Batioglu-Karaaltin A, Orhan KS, Demirel T, Guldiken Y. Autologous fascia lata graft for contour restoration and camouflage in
tertiary rhinoplasty. J Craniofac Surg. 2012;23(3):719–23.
3. Karaaltin MV, Orhan KS, Demirel T.  Fascia lata graft for nasal dorsal contouring in rhinoplasty. J Plast Reconstr Aesthet Surg.
2009;62(10):1255–60.
4. Guerrerosantos J. Nose and paranasal augmentation: autogenous fascia, and cartilage. Clin Plast Surg. 1991;18(1):65–86.
5. Baker TM, Courtiss EH. Temporalis fascia grafts in open secondary rhinoplasty. Plast Reconstr Surg. 1994;93:802–10.
6. Besharatizadeh R, Ozkan BT, Tabrizi R. Complete or a partial sheet of deep temporal fascial graft as a radix graft for radix augmentation. Eur
Arch Otorhinolaryngol. 2011;268(10):1449–53.
7. Conley JJ, Clairmont AA. Dermal-fat-fascia grafts. Otolaryngology. 1978;86(4 Pt 1):ORL-641-649.
8. Thompson N. The subcutaneous dermis graft. Plast Reconstr Surg. 1960;26:1–22.
9. Goldemberg B. Dermofat graft for profileplasty. Aesthetic Plast Surg. 1986;10(1):41–4.
10. Na DS, Jung SW, Kook KS, Lee YD.  Augmentation rhinoplasty with dermofat graft & fat injection. J Korean Soc Plast Reconstr Sur.
2011;38(1):53–6.
11. Choi KY, Kirk IS, Cho BC. Secondary augmentation rhinoplasty with immediate autogenous dermofat graft after removal of paraffinoma. J
Korean Soc Plast Reconstr Surg. 2007;034(06):785–91.
12. Hwang K, Kim DJ, Lee IJ. An anatomic comparison of the skin of five donor sites for dermal fat graft. Aesth Plast Surg. 2001;46(3):327–31.
13. Little JW. Applications of the classic dermal fat graft in primary and secondary facial rejuvenation. Plast Reconstr Surg. 2002;109(2):788–804.
14. Davis RE, Guida RA, Cook TA. Autologous free dermal fat graft. Reconstruction of facial contour defects. Arch Otolaryngol Head Neck Surg.
1995;121(1):95–100.
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© Springer Nature Singapore Pte Ltd. 2018
M. K. SUH, Atlas of Asian Rhinoplasty,
Mid-Vault Surgery: Hump Reduction
and Osteotomy
The vast majority of mid-vault surgeries consist of hump reduction and osteotomy. The frequency of hump nose reduction
has been increasing among Asian patients, for whom the operation varies significantly relative to Caucasian patients. In
Caucasian patients, the hump nose is characterized by excessive height of the dorsum on a long nose. In contrast, the Asian
hump nose is characterized by wide variations in radix height and nasal length, which calls for a wider spectrum of operative
options.
Osteotomy is performed to close the open roof after humpectomy, to decrease or increase the width of bony base, and to
correct deviations in the nasal bone. This chapter discusses operative techniques regarding hump reduction and osteotomy,
along with correction of wide nasal bone and hump nose correction in Asian patients.
Hump Reduction
Pathology of the Hump
Nasal hump is composed of cartilaginous hump and bony hump (Fig. 8.1). The cartilaginous component consists of the upper
lateral cartilage (ULC) and the dorsal septum. Whether the composition of nasal hump is more predominantly bony or carti-
laginous varies across individuals. The most frequent type is osteocartilaginous hump, which contains both cartilaginous and
bony components, with the cartilaginous portion usually larger than the bony portion of the hump. The next common type of
hump is that which is mainly composed of cartilaginous hump. Nasal hump containing only bony component is very rare
(Fig. 8.2).
8
Fig. 8.1 Components of nasal
hump. A nasal hump consists of
bony and cartilaginous components

210
a
b
c
d
Fig. 8.2 Types of nasal hump. Nasal humps can be classified into one of the four types. (a) The most common type is a hump with both the bony
and cartilaginous components. (b) The least common type is a hump that is composed mainly of bony component. (c) The second most common
type of hump is composed mainly of cartilaginous component. (d) A pseudohump results from a saddle in the dorsal septal cartilage
8 Mid-Vault Surgery: Hump Reduction and Osteotomy

211
Operative Techniques
The cartilaginous portion of the hump cannot be removed using a rasp or osteotome because of the inherent elasticity of the
cartilage. The best approach is direct resection of the cartilaginous hump using a No. 15 blade. The bony hump is removed
using an osteotome or rasp, or a combination thereof. In Asian patients, bony humps are removed using 6–8 mm osteotome.
Both manual rasp and powered rasp are useful for directly addressing small bony humps, but larger bony humps should first
be resected using an osteotome, with the rough edges refined with a rasp afterwards (Fig. 8.3).
a
b
Fig. 8.3 Instruments commonly used for hump
removal. (a) Rasping file. (b) Non-guarded
osteotome (left) and guarded osteotome (center and
right)
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212
Composite Resection
In the classic composite reduction, the cartilaginous hump (ULC and dorsal septum) and the bony hump are removed in one
piece. The cartilaginous component is removed using a sharp incision with a scalpel blade from the caudal margin of the
hump, and an osteotome is used to continue the division into the nasal bone using an osteotome (Fig. 8.4).
The composite resection includes excision of the transverse component of the ULCs, which triggers inferomedial reposi-
tioning of the ULCs, resulting in the narrowing of the cartilaginous mid-vault, inverted-V deformity, and internal valve insuf-
ficiency. The inverted-V deformity describes the inverted V-shaped indentation that forms between the caudal end of nasal
bones and the ULCs. This deformity can result from the collapse of ULCs against the septum. This deformity interrupts
dorsal aesthetic line, and also may cause difficulty in breathing (Fig. 8.5). This is because, while the inverted-V deformity
does not occur at the internal valve, chances are high that a patient with this deformity also has a narrow internal valve.
Additionally, composite resection is associated with high risk for mucosal injury (Fig. 8.6), which can cause internal valve
narrowing from mucosal scarring. Because of the problems associated with inverted-V deformity, component resection has
become preferable over the en bloc resection.
a
c
b
Fig. 8.4 Composite resection of the hump. (a) The cartilaginous portion of hump is excised using a scalpel blade. The resection is continued into
the bone using an osteotome. The hump is removed as a single piece. (b) A bony-cartilaginous hump resected en bloc via composite resection. (c)
Composite resection includes excision of the transverse component of the upper lateral cartilages, which triggers inferomedial repositioning of the
upper lateral cartilages, resulting in the inverted-V deformity and internal valve insufficiency
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213
Fig. 8.5 A patient with inverted-V deformity
Fig. 8.6 Composite resection of the hump can result in mucosal injury
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214
Component Resection
Component resection removes the dorsal septal hump and bony hump while preserving the ULCs. The technique preserves
the transverse portion of the upper lateral cartilage, which limits the medial movement and narrowing of the ULC, prevents
the 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 resection of the dorsal portion of septal cartilage
3. Resection of the bony hump
4. Evaluation for surface irregularity via digital palpation
5. Final shaping of the irregularity with rasping and blade
6. Re-approximation of the ULCs to the lowered dorsal septum, with or without spreader graft and osteotomies
a
b
c
d
Fig. 8.7 Component resection of the dorsal hump. (a) Detachment of the upper lateral cartilage from dorsal septum. (b) Resection of the dorsal
septal hump with blade. (c) Resection of the bony hump with osteotome. (d) Reattachment of upper lateral cartilage to the lowered dorsal
septum
8 Mid-Vault Surgery: Hump Reduction and Osteotomy

215
a
b
c
e
d
Fig. 8.8 Dorsal approach for the hump reduction. (a, b) The lower lateral cartilages are pulled caudally to expose the anterior septal angle. (c)
Dissection begins from the anterior septal angle to elevate the mucoperichondrial flaps from both sides of the dorsal septum. (d) The left upper
lateral cartilage is detached from the dorsal septum after elevating the left dorsal mucoperichondrial flap. (e) The right upper lateral cartilage is
detached from the dorsal septum
Division of the ULCs from the Dorsal Septum
To separate the ULCs away from the dorsal septum, the mucoperichondrial flap needs to be elevated from both sides of the
dorsal septum. If the hump reduction does not accompany any other septal correction surgery, then the dorsal septal mucop-
erichondrial elevation can be performed through the anterior septal angle (Fig. 8.8).
Hump Reduction

216
transverse wing
of dorsal septum
upper lateral
cartilage
Fig. 8.9 Transverse wing of the dorsal septal cartilage
a
b
Fig. 8.10 Preservation of the transverse wing in dorsal septal reduction. (a) Preservation of the transverse wing prevents mid-vault narrowing after
septal reduction. (b) If the transverse wing is resected along with the dorsal septum, the mid-vault will become narrower by the same width
In the keystone area, the dorsal septum and ULCs meet at right angles, but the angle between the two cartilages becomes
more acute in the caudal portion (Fig. 1.31). The transverse wing of dorsal septum is the widest at the keystone area (Fig. 8.9).
When detaching the ULC from the dorsal septum, the transverse wing should not be left on the dorsal septum but should be
attached to the ULC side. If the transverse wing is left with the dorsal septum, the resection of dorsal septum will result in
the loss of mid-vault width (Fig. 8.10). To keep the transverse wing in the ULC side, the blade or the D-knife should be ori-
ented not vertically but towards the midline when detaching the ULC from the dorsal septum (Fig. 8.11). Upon resection of
the dorsal septal hump, the transverse wing-ULC complex is repaired to the lowered dorsal septum.
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217
a
b
c
d
Fig. 8.11 Operative detail on preservation of transverse wing during septal hump reduction. (a) When detaching the ULCs from the dorsal sep-
tum, the edge of knife blade should not be oriented vertically but towards the midline. (b, c) The dorsal cartilage and ULCs are separated. The
transverse wing remains on the ULCs. (d) The transverse wing- ULC complexes are repaired to the lowered dorsal septum
Hump Reduction

218
Fig. 8.12 Detachment of the mucosa from the
undersurface of the nasal bone
With resection of large bony hump, the major concern is injury to the underlying mucosa. To prevent this complication,
the mucosa should be detached from the undersurface of the nasal bone. This is accomplished by gentle disarticulation of the
upper lateral cartilage from nasal bone using a periosteal elevator and by detaching the mucosa from the undersurface of the
nasal bone (Fig. 8.12). To minimize the risk of mucosal tearing, it is helpful to use local anesthetic injection for mucosal
inflation. Also, care should be taken not to cause injury in the keystone area.
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219
a
b
Fig. 8.13 Resection of the dorsal septal hump. (a) The ULC is separated from the dorsal septum. (b) The dorsal septal hump is resected with a
blade
Reduction of the Hump
The sequence of resection varies according to each surgeon. The author prefers resection of the cartilaginous part first and
bony portion second because most nasal hump has a larger cartilaginous component and because removal of the cartilaginous
hump affords a better view of the bony hump. This approach also allows firm placement of the osteotome from the distal end
of the bony hump.
Resection of the cartilaginous hump should be limited to the resection of the dorsal septum while preserving the upper
lateral cartilage. Using a No. 15 blade, the dorsal septal hump is incised through-and-through in the caudal-to- cephalic direc-
tion (Fig. 8.13). The height of dorsal septum is reset at the appropriate height, not by a single resection but by a series of small
stepwise conservative reductions. It is a safer approach to leave a bit of the cartilaginous hump, proceed with bony hump
reduction, and complete the cartilage resection to match the lowered bony dorsum.
There are two approaches to lowering the bony dorsum, depending on the size of the hump. A small hump can easily be
filed down using a bone rasp, which is a relatively easy and safe method. However, the bone should be filed down in a con-
servative, incremental way to avoid over-resection. Some surgeons remove larger bony humps using the rasp alone. However,
the author prefers removal of large portion of a bony hump first using an osteotome, with the bone rasp used to file down the
small amount of remaining bony hump. The reason for avoiding exclusive use of bone file for large bony humps is that vigor-
ous rasping is more likely to lead to periosteal injury and skin bruising. When filing down the bone, the rasp should be
cleaned frequently with a wire brush, and the operation field should be irrigated with saline to remove all the bony
fragments.
In patients with thin skin, the fine rasp should be used and the bony particles should be irrigated out of the space to mini-
mize the irregularities. If these precautions are not taken seriously, the thin skin may show even the most minor of underlying
irregularities. To avoid injury to the keystone area and septum, the rasping action should be performed in a slightly oblique
and caudal-to-cephalic direction (Fig. 8.14). At the time of rasping, the left thumb and middle finger should be placed on the
sides of nasal bone to palpate the hump and the head of the instrument to properly guide the rasping action and to avoid slip-
ping of the file (Fig. 8.15).
Osteotome can be difficult to use, and outcomes following osteotome vary widely depending on the experience of the
surgeon. To prepare for osteotomy of the nasal bone, the cartilaginous hump is excised using a No. 15 blade in the caudal-
to-cephalic direction. Once the way is clear, the osteotome is inserted below the elevated dorsal septal cartilage segment. The
bony and cartilaginous hump is resected in continuity (Fig. 8.16). The dorsal hump should be carefully resected with mucosa
left intact to avoid any communication between the nasal cavity and the operative space.
Hump Reduction

220
a
b
Fig. 8.14 Rasping of the bony hump should be performed in oblique directions
Fig. 8.15 Rasping of the bony hump
8 Mid-Vault Surgery: Hump Reduction and Osteotomy

221
a
b
c
Fig. 8.16 Resection of the bony hump using the osteotome. (a) Dorsal septal hump is being resected using a blade. (b) The osteotome is wedged
under the elevated dorsal septal cartilage and engaged into the nasal bone. (c) The resected bony and cartilaginous hump
Hump Reduction

222
Hump reduction should ideally be performed prior to submucosal resection (SMR) or harvest of septal cartilage graft. If
the septal cartilage is harvested before hump reduction, rasping or osteotome of the dorsal septum can injure the L-strut or
the keystone area. A dorsal L-strut of adequate width can only be guaranteed if the hump reduction is performed first and
septal cartilage graft harvest second.
Hump reduction can be tricky for a nasal hump with asymmetric nasal bone or deviated nasal bone. The hump reduction
should be asymmetric (Fig. 8.17). Less bone should be removed from the shorter side nasal. This allows for a more accurate
realignment of the osteotomized nasal bones along the midline.
The dorsal soft tissue is thicker over the nasion and supratip and is thinner over the rhinion, and this variation in soft- tissue
thickness should be an important consideration in hump reduction (Fig. 8.18). Straight-line resection of the bony and carti-
lage hump along the whole dorsum can result in depression externally. To obtain a smooth dorsal profile externally after
humpectomy, the bony-cartilaginous junction (rhinion), where the skin is thinnest, should be made slightly higher than the
more cephalic and caudal skeleton. In addition to the shape of bone and cartilage, hump nose correction should be performed
while evaluating the dorsal profile that includes the skin and soft tissue. Intraoperative edema can interfere with accurate
visual assessment of the dorsal height. As such, the dorsum should be evaluated by the palpation of the dorsum using the
index finger tip lubricated with normal saline.
correct
incorrect
Fig. 8.17 When resecting a hump in the asymmetric nasal bone or
deviated nasal bone, the resection should be asymmetric to restore sym-
metry to the nasal bone. Less bone should be removed from the shorter
nasal bone with greater gradient. This allows a more accurate alignment
of the nasal axis to midline after the osteotomy
thick
thin
thick
Fig. 8.18 Thickness of the nasal soft-tissue and skin envelope. The
nasal soft-tissue envelope is thinnest over the midportion of the
dorsum
8 Mid-Vault Surgery: Hump Reduction and Osteotomy

223
a
a’
b
c
Fig. 8.19 Repair of the ULCs to the lowered dorsal septum. (a) The height of dorsal septum became lower after septal hump resection. (b, c) The
edge of ULC is approximated to the lowered dorsal septum without inward folding of the cartilage edge
Restoration of the Upper Lateral Cartilages to Lowered Dorsal Septum
The open edges of the upper lateral cartilages should be repaired to the lowered dorsal septum with 5–0 PDS sutures
(Fig. 8.19).
There are two ways of mid-vault restoration, according to the suture placement. Upon resection of a large dorsal septal
hump, a length discrepancy may exist between the lowered dorsal septum and the edge of the upper lateral cartilage. Fixation
of the dorsal edge of the caudal border of upper lateral cartilage to the original location on the dorsal septum can become a
cause of contour irregularity. To prevent this issue, the upper lateral cartilage is pulled in the caudal direction and fixated onto
the septum. This usually translates into the caudal border of upper lateral cartilage being mobilized about 2–4 mm caudally
from its original position. The first suture is placed through the dorsal edge of both upper lateral cartilages and distal septum.
Afterwards, 2–3 additional sutures are placed proximally between the upper lateral cartilages and lowered dorsal septum.
Rohrich et al. refer to this as upper lateral cartilage tension-spanning suture (Fig. 8.20). This method of fixating upper lateral
cartilages to the dorsal septum under slight tension is especially useful for thin nasal skin and for large hump reduction,
where contour irregularity can be a problem.
Another method is to suture the upper lateral cartilage to the dorsal septum without any caudal advancement (Fig. 8.21).
This is indicated in patients with upper lateral cartilages that maintain a straight contour after being released from the septum
or in patients with small hump and strong cartilage.
The author does not favor the method in which the superior edge of upper lateral cartilage is in-folded into an autospreader
flap (Fig. 8.22) because this results in significantly more mid-vault narrowing than end-to-end restoration.
Hump Reduction

224
Fig. 8.20 Mid-vault
reconstruction using the upper
lateral cartilage tension-
spanning suture
Fig. 8.21 Mid-vault
restoration without the upper
lateral cartilage tension-
spanning suture
a
b
Fig. 8.22 Autospreader flap decreases the width of mid-vault much more than the direct repair of the ULC edges to the dorsal septum. (a)
Autospreader flap. (b) Direct repair of the ULC edges to the dorsal septum
8 Mid-Vault Surgery: Hump Reduction and Osteotomy

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Spreader Grafts
In most cases, spreader grafts are not needed after a component resection of the hump, with the following exceptions:
1. The possibility of inverted-V deformity cannot be excluded.
2. Presence of high dorsal septal deviation.
3. Presence, or possibility, of internal valve insufficiency.
4. The open roof cannot be closed by osteotomy after a large bony humpectomy.
5. Correction of narrow nose.
When it is difficult to decide whether a spreader graft is necessary or not, the safer option is to perform it. Septal cartilage
is the most ideal choice of graft source, due to shape and proximity, but auricular cartilage or costal cartilages can also be
used as necessary.
Spreader graft can be either a unilateral or a bilateral graft and should be placed from the keystone area to the distal dorsal
septum (Fig. 8.23).
In most situations, the spreader graft is placed at the same level as the height of the lowered dorsal septum. Closing the open
space in the bony roof or broad mid-vault can result in a rather flat dorsum. To avoid this problem, the spreader grafts should be
placed a little above the dorsal septum to create for a more rounded contour of the nasal dorsum. The spreader graft is first sutured
to the septum with 5–0 PDS, and then the upper lateral cartilages are secured onto the spreader graft-dorsal septal complex.
Fig. 8.23 Spreader grafts after dorsal hump reduction
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226
A straight dorsal line from side view is generally considered to be an ideal profile for a masculine face (Fig. 8.24). For this
reason, over-reduction of the nasal hump should be avoided in male patients in most situations.
Among female patients, a slightly curved nasal profile can appear very natural and is generally well accepted. In addition
to the lateral profile, the other important anatomic line is the dorsal aesthetic lines from the frontal view (Fig. 8.25). The dorsal
aesthetic lines originate on the supraorbital ridges and pass medially along the glabellar area to converge caudally at the medial
canthal ligaments. From there, the lines usually begin diverging at the keystone area and ultimately end at the tip-defining
points. This dorsal aesthetic line should be preserved or recreated with spreader grafts during hump nose surgery.
Fig. 8.24 Dorsal line on
profile view. In women, the
dorsal line is a smooth curve
that is slightly posterior to an
imaginary line drawn between
the radix and tip-defining
point. In men, the dorsal line
should be close to the straight
line for a masculine
appearance
Fig. 8.25 Dorsal aesthetic line
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227
Lateral Osteotomy After Hump Reduction
Resection of a large bony hump leaves a defect in the bony dorsum, which is referred to as an open roof (Fig. 8.26). Open
dorsal roof leaves visible and palpable bony ridges, with flattened or sunken appearance of the nasal dorsum between both
ridges. The open roof should be closed by medialization of the nasal bone after lateral osteotomy. If the first attempt at lateral
osteotomy is not successful in closing the roof, the osteotomy can be repeated, with the addition of medial or intermediate
osteotomy. If all else fails, the gap in the open roof needs to be filled in using either crushed or diced cartilage.
If a communication is discovered between the open roof and nasal cavity, filling the dead space with crushed cartilage can
assist in mucosal healing. In the presence of a mucosal injury, implants should not be used to close an open roof.
However, very small dorsal humps may not require osteotomies unless the narrowing of the bony base is required.
Lateral osteotomy is used not only to close an open dorsal roof but also to decrease the width of the bony nasal base. In case of
small hump reduction, lowered dorsum is proportional to the nasal bony base, and then bony base narrowing may not be required.
Reduction of large hump is often associated with a significant decrease in the height of the dorsum, which will make the nasal base
wider in comparison. In such cases, lateral osteotomy can be helpful in decreasing the width of the bony base and restoring the nasal
proportion. As the converse of this, dorsal augmentation can lead to the illusion of the bony base seeming narrower than it really is.
Lateral osteotomy will cause back fracture from the superolateral edge of open roof to the cephalic end of lateral osteot-
omy line. This back fracture usually follows the boundary between thick bone and thin bone (Fig. 8.27). If it does not occur
in the form of a complete greenstick fracture, a medial oblique osteotomy will need to be performed.
Intermediate osteotomy is appropriate, if the open roof is to be closed without decreasing the width of the bony base (Fig. 8.28).
Fig. 8.26 Open roof after bony hump reduction
Fig. 8.27 Lateral osteotomy to close the open roof
Fig. 8.28 Intermediate osteotomy to close the open roof in the
narrow nasal bony base. Intermediate osteotomy can close the
open roof without narrowing the bony base
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228
Complications of Hump Reduction
Early postoperative complications after hump reduction are hemorrhage, swelling, bruise, and infection. The risk of hemor-
rhage is minimized by avoiding the predisposing factors, such as aspirin, herb medication, and anticoagulants, which should
be discontinued for 2 weeks before an operation. All patients with a history suggestive of coagulation issues (easy bruising
or frequent mucosal bleeding) should undergo preoperative hematologic evaluation.
Soft-tissue edema and ecchymosis are fairly common after hump reduction. In most instances, these spontaneously
resolve in 2–3 weeks but can persist for months in some patients. As long as the ecchymosis is present, patients should be
instructed to use sunscreen.
Postoperative infection is very rare after hump reduction. However, prophylactic antibiotics is still recommended.
Occasionally, a bony callus may develop at the removed hump or at the osteotomy sites.
Complications related to the humpectomy and osteotomy to close the open roof are as follows.
Open-Roof Deformity
It is not rare to observe an open-roof deformity despite attempts at closing the roof with lateral osteotomy after a humpec-
tomy. This complication has several causes. It may be that the lateral osteotomy was not successful in closing the roof alto-
gether, or it may be that the roof was closed during the operation but was distracted from an incomplete greenstick fracture.
Other causes include high septal deviation and large hump with thick nasal bone.
Inverted-V Deformity
Post-humpectomy inverted-V deformity is caused by mid- vault narrowing (Fig. 8.5). This deformity is relatively rare for
component resections that preserve the upper lateral cartilage. However, component resection can still result in this defor-
mity from a great amount of nasal bone narrowing or from a resection of thick dorsal septum. If the deformity is likely,
spreader graft should be employed in a preventative effort.
Dorsal Irregularity
During dorsal hump resection, soft-tissue swelling can visually mask residual hump and irregularities of cartilage and bony
tissue. Throughout the operation, the hump should be palpated with saline-lubricated fingertip to evaluate for residual hump
and irregularities. Despite this, residual hump can become visible about the time postoperative edema subsides after a couple
of days (Fig. 8.29).
Fig. 8.29 Dorsal irregularity
after hump reduction
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229
Over-Resection
Whereas a minor over-resection of dorsal hump represents a mere irregularity, over-resection of the dorsal hump can result
in saddle nose deformity (Fig. 8.30). In most cases, such saddle nose can be corrected with dorsal augmentation using autog-
enous cartilage or alloplastic implants. However, severe saddle nose from an L-strut insufficiency will require L-strut recon-
struction with costal cartilage.
Fig. 8.30 A patient with sunken deformity from over-resection of dor-
sal hump
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230
Under-Resection
For either bony or cartilaginous hump, under-resection is much easier to address than over-resection. Because of this, a sur-
geon will benefit from having a conservative approach to operative management of nasal hump.
Pollybeak deformity is characterized by supratip fullness and bulging from profile view (Fig. 8.31). The deformity can
result from insufficient resection of the dorsal septum or from over-resection of bony hump. It can also be caused by exces-
sive scar formation at the supratip region after surgery, though this is relatively less frequent. The relative pollybeak can
result from tip drooping after surgery.
This deformity is more frequent in closed approach than in open approach. Detailed explanation for the correction of pol-
lybeak deformity is described in Chap. 16.
Fig. 8.31 Pollybeak deformity (supratip bulging) after dorsal hump
reduction. This deformity results from insufficient lowering of the dor-
sal septal hump
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231
Recurrence
A reappearance of nasal hump is most likely caused by inadequate resection of the nasal hump during the operation. This is
especially common for hump reduction performed using a rasp to remove both bony and cartilaginous hump. In such cases,
the bony hump is adequately addressed while the cartilaginous hump remains under-resected.
The following two precautions should be observed to minimize the risk of hump recurrence: meticulous resection of car-
tilage hump, copious irrigation to remove bony particles, and overlapping of paper taping when postoperative dressing.
Stair-Step Deformity
Stair-step deformity occurs along the lateral osteotomy line when the lateral osteotomy is placed too high.
Radix Deepening
While rare among Asian patients, overprojected radix is associated with aggressive countenance and gives the appearance of
hypotelorism (Fig. 8.32). In such patients, the radix needs to be deepened at the same time as the hump reduction. The opera-
tion is not an operation that is easy to perform. If the dorsal hump is very large, the hump resection should be performed first
to facilitate introduction of the electric burr for radix-deepening operation.
Radix deepening begins in the subperiosteal plane. In the radix area, the periosteum is elevated, after which guarded
electric burr is used to address the bone (Fig. 8.33). To avoid entering the frontal sinus, the movement of the burr tip should
be limited in the lateral direction (i.e., from side to side).
Fig. 8.32 Overprojected radix
Fig. 8.33 Guarded electric burr
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232
a
b
c
d
Fig. 8.34 Radix deepening. (a) The patient with overprojected radix and dorsal hump. (b) Postoperative view at 6 weeks after radix deepening,
hump reduction, and tip plasty using septal cartilage. (c) CT before operation. (d) CT after operation
It is easy to remove too much bone in a single swipe of the electric burr. As such, the handling of the burr should be delib-
erate, with the bone being removed in the smallest incremental portions allowed by the hand movement. Additionally, it is
important to minimize the contact between the burr tip and any soft tissue to decrease the chance of thermal injury. To mini-
mize thermal injury to the bone, saline irrigation should be used to quench the building heat in both the burr tip and the bone.
Thermal injury to the bone can cause postoperative seroma.
The skin and soft-tissue envelope are thick in the radix area and mask the underlying skeletal changes from radix-
deepening procedure. Therefore, overcorrection is often necessary to achieve the desired appearance of the radix (Fig. 8.34).
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233
Osteotomy
Nasal osteotomies are performed to reposition and reshape the nasal bone and have both functional and aesthetic applica-
tions. Nasal osteotomies are generally indicated for the following criteria:
1. To close an open roof after bony hump reduction
2. To decrease the width of a wide nasal bone
3. To increase the width of a narrow nasal bone
4. To correct the convex or concave bony deformities (including correction of deviated nasal bone)
There are many kinds of osteotomy techniques, including lateral osteotomy, medial osteotomy, intermediate osteotomy,
paramedian osteotomy, and transverse osteotomy. Osteotomy techniques vary according to surgeon preference, with consid-
erable debate and controversy across the aisle. In Asian patients, lateral osteotomy is the most commonly performed, fol-
lowed by medial osteotomy.
Types of Osteotomy
According to the characteristics of the bony division, nasal osteotomies can be classified into incomplete and complete
osteotomies.
Incomplete Osteotomy
Incomplete osteotomy refers to division of the bone which leaves a minimal amount of bony continuity left between the two
divided portions. An osteotomy designed to induce greenstick fracture is a good example of this.
Incomplete osteotomy results in a more stable skeletal frame and is associated with minimal risk for unwanted bony dis-
placement. If the greenstick fracture is not definite, the osteotomy can result in failed attempt at mobilization of the bone,
which is why this approach is considered to have lower long-term predictability.
There is a certain amount of controversy on whether the percutaneous perforating osteotomy is a type of incomplete oste-
otomy. Some have argued that the osteotomy creates a row of fenestration (postage stamp nature of osteotomy), which cre-
ates for a minimal bone continuity and meets the definition of incomplete osteotomy. Materially, however, the divided bones
in this case are held together by small periosteal bridges across the osteotomy line, which maintain the stability of bony
segment. Thus, the author finds this approach to represent a complete osteotomy with periosteal preservation.
Fact of the matter is that most osteotomies should not lead to incomplete fractures. The only example of incomplete oste-
otomy may be the greenstick back fracture formed as a result of a complete lateral osteotomy. In most cases, incomplete
osteotomies should be converted into complete osteotomies to increase long-term predictability.
Complete Osteotomy
A representative example of complete osteotomy is intranasal continuous osteotomy. The bone is completely divided without
any bridging continuity, which increases the long- term predictability of the operation. However, complete osteotomy does
create for unstable bony segments which may dislocate or collapse beyond what was intended by the surgeon. In order to
obtain stable osteotomy segments while achieving predictable outcomes, the surgeon should strive to obtain complete oste-
otomy while maintaining the periosteal integrity.
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234
Location of Osteotomy Line
Nasal bone osteotomy can be classified according to the location and orientation of the osteotomy, which are lateral osteot-
omy, medial osteotomy, intermediate osteotomy, transverse osteotomy, and midline vertical osteotomy (paramedian osteot-
omy) (Fig. 8.35).
Fig. 8.35 Types of nasal bone osteotomy. 1: lateral osteotomy, 2: intermediate osteotomy, 3: transverse osteotomy, 4: paramedian osteotomy, 5:
medial oblique osteotomy
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Approach
Lateral osteotomy is performed via intranasal and percutaneous approaches, depending on surgeon preference.
Intranasal Approach
The intranasal access is created via a small incision in the lateral wall of the nasal cavity. The osteotomy is performed using
a curved osteotome. The bony division is continuous and represents a complete osteotomy (Fig. 8.36).
b
Fig. 8.36 Intranasal continuous lateral osteotomy
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236
Percutaneous Approach
The percutaneous access to the nasal bone is made with a single-slit incision made at the midpoint of lateral osteotomy
line between the vestibule and medial canthus. Through this access, a sharp 2 mm osteotome is introduced. The osteotome
is swept up and down along the line of planned osteotomy, and the bone is perforated at 1–2 mm intervals to create a line
of perforation through the nasal bone. Once the perforations are complete, the bone is fractured using digital pressure
(Fig. 8.37).
FPO
b
a
Fig. 8.37 Percutaneous perforating lateral osteotomy. Percutaneous perforating osteotomy is performed using a 2 mm straight osteotome that is
introduced through a single-slit incision. Multiple perforations are created onto the nasal bone in a straight line. Once all of the perforations are
placed, the nasal bone is fractured by the application of digital pressure
8 Mid-Vault Surgery: Hump Reduction and Osteotomy