Cartilaginous Hump Research Articles

Risks and complications in rhinoplasty. A comparative study in structural vs preservation rhinoplasty

Introduction. Rhinoseptoplasty is considered the most challenging operation because many techniques have to be taken into consideration to achieve an optimal aesthetic and functional results. Rhinoseptoplasty techniques have been perfected over time, following two main surgical approaches: structural rhinoplasty (resection/ reconstruction) and conservative (preservation rhinoplasty). Methods. The authors present the risks and complications in a comparative study of 100 cases with patients in primary rhinoseptoplasty performed between 2019-2021: 50 cases in Structural Rhinoplasty and 50 cases in Preservation Rhinoplasty. The study presents two surgical concepts of rhinoplasty regarding the main advantages, disadvantages and indications of each type of rhinoseptoplasty surgery. Results and conclusions. Complications post-rhinoseptoplasty can be considered as perioperative, functional, anatomic (aesthetic) and psyhological. In this study 10 cases (10%) of primary rhinoplasty required revision surgery. The most frequent postoperative deformity is the “pollybeak” when a deep naso-frontal angle, cartilaginous hump and reduced tip projection are present preoperatively. The pollybeak was the indication in 4 cases (40%) of all revision rhinoplasties. Other frequent postoperative deformities are: wide nasal tip, retractions of the columella base and irregularities of the nasal dorsum. These deformities are very often combined and caused by a loss of septal support. Septorhinoplasty is a difficult procedure and the surgeon must have accurate anatomical knowledge and rich clinical experience. The risks for rhinoplasty-complications can be reduced with increasing experience. It is very important to make distinction between complication and mistake.

Dorsal Preservation Surgery: A Novel Modification for Dorsal Shaping and Hump Reduction.

A new technique for dorsal preservation rhinoplasty that minimizes recurrent hump deformity is introduced. The authors sought to present a novel dorsal roof flap (DRF) technique for modifying the nasal hump and dorsum while reducing morbidity. Twenty-two primary and 3 secondary rhinoplasty patients had 1 of 2 types of nasal DRF depending on hump composition. A triangular roof flap was created utilizing 2 incisions from W-point to lateral Keystone junction in cartilaginous humps (cartilaginous DRF) and to the nasion in osseocartilaginous humps (osseocartilaginous DRF). Then, septal strip excisions were conducted to lower the profile followed by nasal base narrowing. The DRF was then lowered to the desired profile line, any excess lateral wall height trimmed, and the DRF sutured to the upper lateral cartilages. Preoperative and postoperative nasolabial and nasoglabellar angles were measured on the photos. Mean follow-up was 10.3 (standard deviation, 4.41) months (range, 6-20 months). A total 22 humps were V-shape and 3 were S-shape. The composition of the hump was cartilaginous in 5 cases, bone in 7 cases, and combined in 13 cases. A cartilaginous DRF was utilized for the 5 cases with a cartilaginous hump and osseocartilaginous DRF was employed in the other 20 cases. There were no complications observed in the follow-up period and thus no revisions. The DRF technique allows preservation of the nasal dorsum and elimination of the dorsal hump while minimizing hump recurrence.

Special Consideration in the Management of Hump Noses in Asians.

Although not as prevalent as in Caucasian rhinoplasty, correction of a hump nose also poses a significant problem for East Asian rhinoplasty. The hump noses in East Asians can be classified as generalized humps, isolated humps, and relative humps with a low tip. Appropriate management of the Asian hump nose demands a good understanding of the anatomical characteristics unique to East Asians. As the East Asians generally prefer to have a nose with a prominent tip and well-augmented nasal dorsum, the concept of redistribution is significant in managing convex dorsum of the East Asians. Hump reduction should be done in a conservative and incremental manner, including careful removal of the bony cap and cartilaginous hump. Tip augmentation using a septal extension graft is an essential maneuver to achieve an aesthetically pleasing tip height, which has a tremendous impact on the overall aesthetic outcome. Midvault reconstruction, dorsal augmentation, and camouflage are additional key elements for the success of the operation. Complications such as undercorrection and dorsal irregularities are not uncommon, requiring surgeons to take utmost care to address them.

Endoscopic "Quick" Septoplasty in Preservation Rhinoplasty.

Preservation rhinoplasty (PR) is revolutionizing rhinoplasty surgery, based on new anatomical studies, advanced tip suture techniques, and refinement of surgical techniques. Septal surgery is a fundamental preparatory stage during PR, especially for the dorsal preservation let/push-down procedure. To increase the predictability of the septoplasty aesthetic effects on the nasal dorsum and further extend the principles of PR to septal surgery, we applied the endoscopic technology to the "quick" septoplasty technique we had already developed in the past decades. One hundred sixty-six patients (41 males, 125 females; mean age, 39.7 years; age range, 18-61 years) were submitted to endoscopic "quick" septoplasty for septal deviation during PR procedure. Preoperative evaluation of the nasal dorsum included external examinations of the size, shape, and orientation of the dorsum. Anterior active rhinomanometry was performed in all patients to determine nasal flow resistance preoperatively and 6 months after surgery. Preoperative and postoperative patients' scores on the Nasal Obstruction Septoplasty Effectiveness questionnaire were compared to assess the improvement of nasal symptoms after surgery. The duration of the septoplasty procedure was measured for all the patients. Standard nasal photographic assessment was performed before and 6 months after surgery. Postoperatively, 98.8% of our patients displayed an improvement of their nasal breathing function. No complication in terms of septal perforation, nasal infection, or bleeding was noticed. No case of turbinoseptal synechiae or cerebrospinal fluid leak was recorded. The dorsum preservation rhinoplasty procedure was successfully completed in all patients. The mean septoplasty operative time, excluding local anesthesia injection and other surgical procedures associated with septal surgery such as turbinoplasty and rhinoplasty, was 11.41 ± 6.23 minutes (range, 9-31 minutes). Our results show that a short surgical time is needed to perform the proposed endoscopic septoplasty procedure. Such a short operative time allows the physician to both correct septal deviations quickly and correct/reduce the cartilaginous hump, thus representing a fundamental element of PR. In addition, the minimal tissue dissection reduces intraoperative nasal edema, favoring intraoperative aesthetic evaluation.

The Aesthetic and Functional Roles of Spreader Flap in Primary Rhinoplasty

Dorsal hump resection was considered as the most ordinary part of rhinoplasty. It is obviously noticed that when a humpectomy is performed in a primary rhinoplasty, some surgeons underestimate the middle third (internal valve) reconstruction resulting in an inverted-V deformity. Although spreader graft is the gold standard for middle vault reconstruction, attention is turned to returning a portion of the hump following dorsal reduction in an attempt to reconstruct the middle vault. The aim of this study is to evaluate the use of spreader flap in primary rhinoplasties. This study included 40 patients classified into 3 groups as follows: (1) type I—mild cartilaginous hump, (2) type II—moderate cartilaginous hump, and (3) type III—huge cartilaginous hump. The results are satisfactory in most cases regarding the aesthetic and functional outcomes. Using auto-spreader flaps is shown to be simple, reproducible, and effective in shaping the midvault while keeping the internal valve intact.

Options for Middle Vault and Dorsum Restoration after Hump Removal in Primary Rhinoplasty.

Prevention of unfavorable sequelae following humpectomy in reduction rhinoplasty by restoration of the middle nasal vault complex today has become imperative in the majority of patients with perhaps the exception of small humps. In general, the techniques used for preservation and reconstruction of these important anatomical structures can be divided into two main categories: spreader graft and spreader flap techniques. Oversimplified spreader graft techniques require donor cartilage, whereas spreader flap techniques use the excess height of the medial portion of the upper lateral cartilages in patients with a cartilaginous hump. In principle, both donor cartilage and preserved upper lateral cartilages usually are positioned along both sides of the dorsal septum to provide natural and harmonious contours as well as to avoid functional impairment (valve collapse). However, the considerable number of publications on this topic attests to existing downsides of both surgical principles. To overcome these shortcomings, we illustrate additional modifications in the application of spreader grafts as well as spreader flaps. However, the main goal of this article is to provide an algorithm helping to decide which technique is best suited to meet the requirements of each individual patient.

Commentary on: The Osseocartilaginous Vault of the Nose: Anatomy and Surgical Observations.

The study by Palhazi, Daniel, and Kosins is a thorough anatomical and clinical analysis of the osseocartilaginous vault of the nose. The authors begin the article with some of the finest anatomical dissections of the nose currently in the literature. Their photography and measurements provide a high level of detail. On the basis of the data they collected in the cadaver laboratory, they were able to draw evidence-based conclusions with substantial clinical implications for humpectomy—a persistent problem for many surgeons. For example, they clearly show that whereas the shape of the hump is determined largely by the cartilaginous component prehumpectomy, the sides of the resultant nasal bones, posthumpectomy, determine the dorsal aesthetic lines. This anatomic finding reinforces the need to fashion the bones as much as or more than the cartilages to create the desired dorsal aesthetic lines. They also introduce the concept that the bony component of the dorsal hump should be thought of as a “cap” covering the cephalic part of the cartilaginous hump. They make the case that this cap can be removed easily enough with a rasp, although they indicate later in the paper that they occasionally use a power tool. This description is, perhaps, the single most important practical contribution from their anatomic studies. It provides encouragement for the beginning rhinoplasty surgeon to duplicate this seemingly atraumatic technique …

Upper Lateral Cartilage Fold-in Flap: A Combined Spreader and/or Splay Graft Effect Without Cartilage Grafts

Dorsal hump reduction almost always breaks the internal nasal valve and nasal obstruction is likely to occur postoperatively, unless reconstructed. One hundred eighty patients were operated using both open and closed rhinoplasty approaches. Upper lateral cartilages were meticulously separated from their junction with septum. Following bony and septal cartilaginous hump removal, upper lateral cartilages were folded inward. Either transcartilaginous horizontal mattress/simple sutures or perichondrial sutures were used depending of the desired width of the middle vault and the necessity for a splay-graft effect. In 7 patients unilateral, and in 1 patient bilateral, nasal synechia occurred and they were all treated under local anesthesia. All patients but 9 stated significantly improved nasal breathing. There was no inverted-V deformity or middle-vault narrowing observed. This technique is simple and physiologic, might be applicable for almost all primary rhinoplasty patients. Although it is possible with closed rhinoplasty approaches, it is easier with an open approach.

Nasal hump removal in Asians

Conclusion. When performing nasal hump reduction in Asians, the amount of hump resection should be tailored based on the predicted amount of dorsal augmentation and tip projection needed. Common complications of hump removal can be prevented by conservative hump removal and efficient use of spreader graft or camouflage cartilage grafts. Objectives. The authors present surgical features and results of nasal hump reduction in 51 Asian patients. Subjects and methods. Fifty-one consecutive patients who underwent nasal hump reduction were analyzed retrospectively. Characteristics of the nose accompanying the hump, approaches and techniques used, combined procedures, results and complications were evaluated. Preoperative and postoperative standardized photographs of the face were evaluated to judge objectively the aesthetic outcomes of the surgery. Results. The most frequent aesthetic characteristic accompanying the hump nose was a relatively low nasal dorsum and tip projection compared to the ideal Asian aesthetic norms. An endonasal approach was used for 22 patients (43%) and an external approach for 29 patients (57%). En bloc resection of the bony and cartilaginous hump, followed by rasping was the most commonly used methods for hump resection. Combined procedures included septoplasty (89%), dorsal augmentation with cartilage graft (73%), lateral osteotomy (69%), nasal tip surgery (49%) and spreader graft (39%). Objective evaluation showed complete correction of the hump in 70%, slight under-correction in 26%, and persistent hump (although less than preoperative) in 4%. Complications such as “inverted V” deformity, saddle nose, and nasal obstruction were not encountered.

Recycling the distal dorsum as a sheen graft

Background: Surgeons performing rhinoplasty are increasingly faced with secondary procedures in graft-depleted patients. Objective: A method is described for recycling resected distal dorsum as a Sheen tip graft. Methods: Each of 16 primary rhinoplasty patients was treated with a Sheen graft to the nasal tip harvested from the distal cartilaginous dorsum; the dorsal cartilaginous hump was removed without dorsal mucosal disruption. Intact dorsal vestibular mucosa acts as a mucosal spreader graft by adding width between the dorsum and the resected upper lateral cartilages. The hump must be large enough that resection of the distal dorsum will not result in overresection of the midvault. Results: Postoperative photographic analysis of each of the 16 patients after 1 to 5 years of follow-up shows increased nasal tip projection, establishment of a tip-defining point, and a double break (a supratip and infralobular break). No graft absorption was clinically noted. Conclusions: Recycling of the distal dorsum as a Sheen graft in selected patients results in an aesthetic contour. This method limits surgical dissection to a single donor area, saves time, preserves the septum, avoids potential septal perforation or hematoma, and decreases hemorrhage and edema.

Treatment of the Nasal Hump with Preservation of the Cartilaginous Framework

Classically, nasal hump reduction is based on the partial resection of the cartilages and bones of the nose, as it was described by Joseph almost a century ago. The cartilaginous portion of the hump consists of a single unity formed by the two upper lateral cartilages and the septal cartilage. During hump reduction in the classic rhinoplasty, this structure is slashed in three pieces, which is the main cause of irregularities, shadows, and pinchings over the long-term results. Late follow-ups of the classical hump removal often show an inverted V-shaped shadow on the dorsum secondary to the destruction of the osseous-cartilaginous transition. The angle and relation between the septal and upper lateral cartilages are reduced, which may compromise the functional aspect. The destruction of the unique anatomy of the cartilaginous hump is one of the main causes of this functional and aesthetic sequela. Here, we present a technique that preserves the cartilaginous framework of the nasal hump by lowering it through the resection of a strip of septum, avoiding the problems described above.

Treatment of the Nasal Hump with Preservation of the Cartilaginous Framework

Classically, nasal hump reduction is based on the partial resection of the cartilages and bones of the nose, as it was described by Joseph almost a century ago. The cartilaginous portion of the hump consists of a single unity formed by the two upper lateral cartilages and the septal cartilage. During hump reduction in the classic rhinoplasty, this structure is slashed in three pieces, which is the main cause of irregularities, shadows, and pinchings over the long-term results. Late follow-ups of the classical hump removal often show an inverted V-shaped shadow on the dorsum secondary to the destruction of the osseous-cartilaginous transition. The angle and relation between the septal and upper lateral cartilages are reduced, which may compromise the functional aspect. The destruction of the unique anatomy of the cartilaginous hump is one of the main causes of this functional and aesthetic sequela. Here, we present a technique that preserves the cartilaginous framework of the nasal hump by lowering it through the resection of a strip of septum, avoiding the problems described above.

A new tool for cartilaginous hump reduction

A simple and cheaply made instrument is described which aids accurate reduction of the cartilaginous hump in aesthetic rhinoplasty.

Postoperative Sequelae and Complications of Rhinoplasty

This article has overviewed complications of rhinoplasty. Generally, these complications fall into two categories: aesthetic (that is, cosmetic sequelae that may require a revision rhinoplasty) and nonaesthetic. Of the nonaesthetic complications, infection has the widest span of severity. A localized Staphylococcus aureus abscess or Pseudomonas infection of the nose may occur postoperatively. Owing to the proximity of the nose to the cranium, a cavernous sinus thrombosis or basilar meningitis may result. Postoperative toxic-shock syndrome is a rare occurrence that surgeons should be aware of; most cases have occurred with the presence of nasal packing, but a case using only plastic nasal splints has been reported also. Bacteremia seems to be uncommon during rhinoplasty. Infection after rhinoplasty is generally much less frequent than one would expect from an operation in an unsterile field. Antibiotics are frequently utilized electively. Postoperative nasal-periorbital edema and ecchymosis are regarded as unavoidable but may be lessened significantly by postoperative head elevation and cold packs. The possibility of postoperative bleeding must be evaluated by the surgeon preoperatively. This sequela usually occurs either within 72 hours postoperatively or at around 10 days postoperatively. Many different causes exist for chronic postoperative nasal obstruction, from poorly supported nasal valves closing upon inspiration to an enhanced allergic rhinitis leading to chronic nasal mucosal edema. The latter may be treated by injection of steroid into the turbinates. Among aesthetic complications, supratip prominence, saddle deformity, and persistent hump are among the more commonly reported. Supratip prominence--"polly-beak"--can be caused by inadequate reduction of tip cartilaginous or soft-tissue elements, especially in relation to the reduction of the dorsum. An over-reduced dorsum will leave an otherwise normal nasal tip with a relative prominence. An accumulation of blood or a mucous cyst occurring under the skin of the tip will produce a prominence. Poor tip projection, tip ptosis, and alar collapse are the result of overreduction of tip elements. A dislocated alar cartilage can appear as an asymmetric nasal bossa. Saddle-nose deformity occurs after overaggressive bony and/or cartilaginous hump removal. Infractured nasal bones that subsequently drop into the piriform aperture can create a bony saddle. Persistent hump is due to inadequate reduction of a bony or cartilaginous hump. If the septal cartilage reduction is disproportionate to the bony septum reduction, the appearance of either a hump or a saddle is possible.(ABSTRACT TRUNCATED AT 400 WORDS)

Tip graft from the cartilaginous dorsum in rhinoplasty.

A cartilage graft from the cartilaginous hump can be used in primary rhinoplasty for nasal tip projection. This technique has now been used for two years without complications in 35 patients with similar nose deformities, which included an inadequately projected tip and a high dorsal line. These grafts have proved to be another easy way to get an adequate tip projection in primary rhinoplasty.

Anatomy of the Nasal Hump

Histologic studies were performed on the cartilaginous nasal hump in 10 cadavers (newborn to age 80) and 10 clinical patients. In all sections, the upper two-thirds of the nasal cartilaginous hump is a fused unit between the upper lateral cartilages and the septum. This fused unit is permanently altered when the hump is removed.

Otolaryngologic plastic surgery 1964.

DURING 1964 there was a continuation of interest in plastic surgery by otolaryngologists reflecting the paternal role of our specialty in the birth of plastic surgery. The American Academy of Ophthalmology and Otolaryngology devoted the last afternoon of its 1964 meeting to a symposium^1-8on corrective rhinoplasty surgery. Becker¹pointed out that mastering the surgical technique of rhinoplasty does not necessarily produce a good result. He stated that the operator must have an artistic concept, understand the anatomical relations of the nasal structures, and know the degree of postoperative thickening and relaxation of tissues which can be expected under various conditions. This last point was exemplified by a question circularized by the International Correspondence Society.⁹Twelve well-known rhinoplasty surgeons were asked to calculate the amount of cartilaginous dorsum lowering necessary to prevent polly-beak formation (low cartilaginous hump). None of the surgeons had a definite formula other than