Commentary on: An Anatomic Analysis of the Bony Vault: From the Perspective of Osteotomy in Rhinoplasty.

Abstract

In “An Anatomic Analysis of the Bony Vault: From the Perspective of Osteotomy in Rhinoplasty,” Kim et al utilize imaging technology to describe bone thickness along the planned osteotomy path of a cohort of rhinoplasty patients.1 To quantify the bony vault (BV) thickness, they utilize 3-dimensional (3D) facial bone computed tomography (CT) scans. The authors’ goal in performing the study is to better describe the anatomy of the bony vault for optimization of surgical planning and osteotomies among rhinoplasty surgeons. We commend the authors on a well-done study in which a novel methodology is utilized to reinforce anatomical findings of previous studies and highlight the importance of a comprehensive anatomical understanding of the nose and skull when performing rhinoplasty surgery. The authors present a few notable results. First, although the majority of patients presenting for primary rhinoplasty had symmetric BVs (64.8%), a substantial portion were found to have asymmetric BVs (35.2%). With over a third of primary rhinoplasty patients presenting with asymmetry of their BV, we agree that rhinoplasty surgeons need to pay detailed attention to examining the bony vault during preoperative visits. As the authors correctly conclude, ignoring potential asymmetries and bony vault thickness variations in rhinoplasty patients may result in poor outcomes following rhinoplasty and osteotomy. Second, the authors found that BV is thickest at the middle level of the lateral osteotomy path. Third, the authors corroborate other studies that have found that male patients often have significantly thicker BVs than their female counterparts. Fourth, a major takeaway of this study is that the BV is thicker on the deviated side in patients with asymmetric BVs at almost all levels (except for the lower level of the lateral osteotomy path and the high level of the intermediate path); the authors found that asymmetric BVs are overall thicker than the mean thickness of the bones in a symmetric BV. Interestingly, they also found that in asymmetric BVs the bone contralateral to the deviated bone was thinner than that of the symmetric BV bone.