Hump Reduction Research Articles

Nasal bone length in Saudi rhinoplasty: a clinical-radiological study

BACKGROUND AND OBJECTIVESHump reduction in the presence of short nasal bones can result in significant esthetic and/or functional problems in patients seeking rhinoplasty in the Middle East. The aims of this study were to determine the mean length of nasal bones, amount of nasal dorsum it forms in relation to the whole nose, and incidence of short nasal bones in the Middle Eastern population.DESIGN AND SETTINGSA prospective study that has been carried out in a tertiary care hospital.PATIENTS AND METHODSA total of 154 patients (80 females and 74 males) who were scheduled for computed tomography scan for the paranasal sinuses were included in the study. The inclusion criteria were adults with no history of facial/nasal trauma, sinus space occupying lesions, or surgery.RESULTSIn males, the mean clinical nasal bone length was 19.59 mm and the mean radiological nasal bone length was 24.96 mm. In females, the mean clinical nasal bone length was 18.17 mm and the mean radiological bone length was 22.82 mm.CONCLUSIONThe bony vault represents 44.2% of the female nose and 44.3% of the male nose. In the present study, no patients displayed a short nasal bone that was less than one-third of the whole nasal length.

Role of Upper Lateral Cartilage Tension Spanning Suture in Restoring the Dorsal Aesthetic Lines in Rhinoplasty

Dorsal hump reduction can lead to significant aesthetic and functional deformities with distortion of the dorsal aesthetic lines without first preserving and subsequently restoring proper position of the upper lateral cartilages. The senior author (R.J.R.) previously described the component dorsal hump reduction to preserve the integrity of the upper lateral cartilages, thereby avoiding routine use of spreader grafts. In this study, the authors introduce an efficient and reproducible technique they call the upper lateral cartilage tension spanning suture to reconstitute the upper lateral cartilages into anatomical position. The authors have found this technique to consistently achieve smooth and symmetric contour to the nasal dorsum and pleasing dorsal aesthetic lines.

No Osteotomy Rhinoplasty: Indications and Surgical Details

Lateral osteotomy is a particular step in rhinoplasty that aims to close an open roof deformity after hump reduction, narrow the lateral walls of the nose, and symmetrically align the nasal bony framework in cases with asymmetry. When the only reason for performing lateral osteotomy is to close an open roof, this can be avoided by using auto spreader flaps. In component hump reduction, the entire length of the upper lateral cartilage is preserved, including the portion under the nasal bone bilaterally. The basic principles involve suturing the flaps in the midline with a modified technique and supporting the lateral nasal walls with onlay cartilage grafts. This method was used for 34 patients. The lack of lateral wall support was obvious in one of the patients. With precise indications and a well-designed surgery, can be achieved. Further studies with more patients and a longer follow-up period are needed to determine the accuracy of this philosophy. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Concurrent Elevation of the Upper Lateral Cartilage Perichondrium and Nasal Bone Periosteum for Management of Dorsum

A meticulous nasal dorsal dissection is an indispensable tool for a successful rhinoplasty. To achieve an aesthetically pleasing dorsum, fine dissection of the upper lateral cartilages (ULC), nasal bones, and keystone area is crucial. In this Featured Operative Technique article, the author describes a different concept of nasal dorsal skeletonization: the perichondro-periosteal flap technique. This technique has several advantages in restoring the nasal dorsum after hump reduction. Namely, the preparation and protection of the perichondrium and the periosteum of the nasal dorsum as a single entity allows a healthier, separate-layer closure over the osseocartilaginous dorsum.

Osteotomies in rhinoplasty surgery

To review the current literature on nasal osteotomies with an emphasis on new techniques as well as evaluations of existing procedures. Powered instrumentation has seen greater use and is felt to offer an improvement by some over more traditional methods. The enbloc osteotomy may be an alternative procedure to straighten a deviated bony dorsum that does not require hump reduction. Osteotomy sequence can have a significant effect on final outcomes. Comparisons of continuous vs. perforating osteotomy shows only a difference in ecchymosis and edema rather than effectiveness. The often frustrating and inconsistent nasal osteotomy has been carefully scrutinized by many surgeons over the years. Evolutionary improvements have been developed that may reduce outcome variability and enhance reliability.

The Nasal Keystone Region

The Nasal Keystone Region

The Use of Short Spreader Grafts in Rhinoplasty for Patients with Thick Nasal Skin

Thick nasal skin presents a challenge in rhinoplasty. Conventional spreader grafts in patients with thick nasal skin may result in an undesirable widening of the lower half of the nose where the nasal skin is thick. The use of short spreader grafts was evaluated in patients with thick nasal skin. For this study, 32 patients underwent closed rhinoplasty in which short spreader grafts were used. The spreader graft was 1 to 2 cm long and extended only to the transition of thin and thick nasal skin. The patients were followed for more than 1 year postoperatively. Aesthetic improvement was observed in all the patients. Nasal airway patency was improved or maintained in 94 % of the patients. Short spreader grafts effectively restore or maintain the internal nasal valve area after dorsal hump reduction while allowing for more aggressive narrowing of the lower part of the nose where nasal skin is thick. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Techniken der Nasenrückenkorrektur

Correction of the nasal dorsum ranks among the most common surgical procedures in rhinoplasty. Due to the involvement of nasal support structures such as septolateral cartilage and the K and scroll areas, these procedures have both aesthetic and functional impacts. In addition to spreader grafts and spreader flaps, the most important surgical methods currently include the split hump reduction technique, cartilage-fascia transplants and cartilage grafts from rib and ear. In addition to serving to correct deformities, the techniques described here help prevent complications such as inverted V, hourglass and saddle nose deformities, as well as nasal valve stenosis. The basic operative principle calls for reinforcement and reconstruction of the anatomical support structures, while avoiding overresection and mucosal lacerations.

The carbon brace

BackgroundThe CMCR brace (Corset MonocoqueCarbone respectant la Respiration –which means Monoshell Carbon Brace respecting Breathing) is an innovative brace, used in orthopaedic treatment for progressive thoracic, thoraco-lumbar or combined scoliosis, whatever their etiology. It can be used at the very young age without disrupting the chest growth, but should be kept for reducible scoliosis in older teenagers.Brace description and principlesThe CMCR brace is monoshell while retaining the corrective principle of the polyvalve Lyon brace with one or two supports (brace “pads”) located on hump(s).In contrast to Lyon brace made of plexidur and structured by metal reinforcement with adjustable but fixed localized supports, the CMCR brace is made of polyethylene and carbon with adjustable and mobile supports. This mobility provides a permanent pressure, which varies depending on ribs and spine movements.The correction is obtained without spinal extension so that each respiratory movement takes part in a gradual return to dorsal kyphosis.ResultsResults were presented in two published analysis:• In the first retrospective study about 115 patients, French-published in the Annals of Physical Medicine and Rehabilitation (2005), the CMCR brace stabilized moderate scoliosis, decreased the vital capacity (VC) of 13% compared to the VC without brace, and did not have sufficient impact on the hump reduction. Treatment had better results when started at Risser 3 or 4 than Risser 0, 1, 2. The brace was then modified to increase the dorsal pad pressure and the location of correction forces was defined more precisely through the use of 3D analysis.• The second study published in Scoliosis (2011) mainly focused on the impact on VC at brace setting up and followed a cohort of 90 patients treated with CMCR. Girls as well as boys increased VC during treatment, and at brace definitive removal, VC had increased of 21% from the initial value, whereas the theoretical VC at the same time rose by 18%.The difference between the time where the child actually wears its brace and the time asked by the clinician for the brace to be worn is only 1 hour, which means that this brace is accepted by teenagers.ConclusionsOrthopaedic treatment is still a heavy treatment for teenagers in growth period. This orthosis is designed to partly maintain spine and chest mobility. We hope so to have part in improving life conditions of these teenagers, compared to those treated with rigid braces.

The Role of Upper Lateral Cartilage in Correcting Dorsal Irregularities: Section 2. The Suture Bridging Cephalic Extension of Upper Lateral Cartilages

Dorsal irregularity after hump reduction is one of the most annoying problems in aesthetic nasal surgery. Spreader grafts, cartilaginous autogenous thin (CATS) grafts, Skoog-type dorsal grafts, cartilage grafts, bone grafts, fascia grafts, dermal grafts and nonbiologic products such as silicon and polytetrafluoroethylene are used to overcome this problem. In cases managed with spreader flaps rather than graft procedures, problems may persist in the area of the nasal bones, whereas irregularities in the cartilage dorsum can be minimized. More specifically, the surgically treated surface of the dorsum's upper third and the rhinion area [nasal bone and upper lateral cartilage (ULC) junction], which has the thinnest nasal soft tissue, present the greatest challenge for hiding irregularities and call for special attention. The ULC has a cephalic extension with varying lengths under the nasal bone. When these pieces of cartilage are protected during hump excision and sutured to each other, a strong, smooth, and a single-unit structure can be obtained. This technique was applied to 76 patients between 2009 and 2010. Manual examination during the postoperative period showed no irregularities in 60 patients. In the remaining 16 patients, minimal irregularities in the bony region were encountered. In 4 of these patients, the irregularities were visible in the profile view, and in the remaining 12 patients, they were felt only by manual examination. The bridging suture technique using cephalic extensions of the ULC is an improvement of the spreader flap technique to obtain a straight, smooth, and single-unit dorsum in rhinoplasty patients. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Nasal obstruction following septorhinoplasty: how well does acoustic rhinometry work?

Septorhinoplasty aims to improve not only the esthetic appearance but also breathing function of the nose. Although the esthetic improvement can be judged by the patient and the surgeon easily, evaluation of nasal breathing is more complicated. Besides the subjective symptom scores given by the patient, some objective methods have been developed. One of the most widely used of these objective methods is acoustic rhinometry, which gives valuable information about the cross-sectional areas and volumes of the nasal airway as a function of distance from the nostril. Since the introduction of acoustic rhinometry, many papers were reported regarding its efficiency with some conflicting conclusions. Septorhinoplasty has the potential to narrow the nasal airway, especially if it includes lateral osteotomies and hump reduction. We aimed to evaluate the role of rhinoplasty on nasal obstruction with the help of subjective symptom scores and acoustic rhinometry. The study consisted of 26 patients who underwent septorhinoplasty. Before and after surgery, the symptom scores and findings of acoustic rhinometry were collected both before and after decongestion of the nasal mucosa. Symptom scores decreased on both sides, which were statistically significant (p < 0.05), however, the changes in cross-sectional areas of the nasal airway were not statistically significant (p > 0.05). The correlation between the symptom scores and acoustic rhinometry findings was not significant for all levels. The effect of septorhinoplasty on nasal airway and some important maneuvers to protect against nasal obstruction are discussed.

Spontaneous lumbar curve correction in selective anterior instrumentation and fusion of idiopathic thoracic scoliosis of Lenke type C

Posterior pedicle screw instrumented correction and fusion have become the gold standard in the surgical treatment of thoracic scoliosis. However, in thoracic Lenke type C curves selective posterior fusion of the thoracic curve may lead to spinal imbalance. The aim of the study was to analyse the radiological results of selective anterior thoracic fusion using a standard open dual rod technique with special respect to spontaneous lumbar curve correction (SLCC). Twenty-eight patients (26 patients with Lenke 1C and 2 patients with Lenke 2C curves) with an average age of 15 years were surgically treated with an anterior dual rod system through a standard open double thoracotomy approach. Average clinical and radiological follow-up was 4 years (24-84 months). Fusion was carried out mostly from end-to-end vertebra. The primary curve was corrected from 61.6° (average correction on reverse bending films 42.9 %) to 27.1° (56.0 % correction) with an average loss of correction of 2.2°. The secondary lumbar curve measured 47.7° preoperatively (40-56°, average correction on reverse bending films 66.2 %) and corrected spontaneously to 30.1° (36 % SLCC) and remained stable without any cases of deterioration or decompensation during follow-up. Lumbar apical vertebral translation increased minimally by an average of 4 mm directly, postoperatively, and returned to an average of preoperative values during follow-up. All but two curves remained as type C lumbar modifier at follow-up. Preoperatively, three patients showed a marked coronal imbalance of more than 3 cm (all left, average 4.0 cm); at follow-up, two patients were still out of balance by more than 3 cm (all to the left, average 3.4 cm). Preoperatively, a marked shoulder imbalance of more than 1.0 cm was found in 11 patients; this was corrected in all patients to <1.0 cm at follow-up. The apical vertebral rotation measured according to Perdriolle was corrected from 23.5° to 15.0° in the thoracic spine (36.2 % correction) with an average clinical reduction of the rib hump of 63.2 %. In the lumbar spine, there was no relevant radiological derotation; however, clinically, the lumbar hump corrected spontaneously by 44.3 %. Thoracic kyphosis measured 28.5° preoperatively and 32.3° at follow-up. All six patients with a preoperative hypokyphosis (<20°) of an average of 9.5° were successfully corrected to an average thoracic kyphosis of 23.8° at follow-up. There were no cases of junctional thoracolumbar kyphosis. There were neither reoperations nor implant failures with pseudarthrosis. Selective anterior correction and fusion in primary thoracic curves with lumbar modifier type Lenke C resulted in a reliable and satisfactory SLCC. Advantages of anterior versus posterior techniques are the true segmental derotation with excellent rib hump correction and a superior restoration of thoracic kyphosis.

A New Instrument for Rhinoplasty: The Osteotome With Protector and Internal Guide

Rhinoplasty is a surgical procedure that demands a high level of intraoperative precision as well as maximum vigilance and control. Hump reduction is the most common maneuver in aesthetic rhinoplasty, but it is also the most sophisticated, dangerous, and difficult to learn. In this article, the authors describe the application of an osteotome with a protector and internal guide, which aids in achieving the necessary accuracy for hump reduction in safe, easy, and gentle manner.

CONTROLLING AESTHETICS OF THE NASAL DORSUM: ROLE OF OSSEOUS AND CARTILAGE GRAFTS

Aesthetic rhinoplasty is a popular procedure in the cosmetic surgery spectrum, often positively transforming facial balance and, with concomitant septal surgery, providing an opportunity to improve nasal airways. Dorsal hump reduction, correction of asymmetries and tip contouring are commonly undertaken. Rhinoplasty is usually performed as an isolated procedure, but can be combined with orthognathic surgery to enhance the overall result. However, more complicated deformities present the clinician with a greater challenge.

Dorsal Aesthetic Lines in Rhinoplasty: A Quantitative Outcome-Based Assessment of the Component Dorsal Reduction Technique

Preservation or reconstruction of the middle nasal vault structure and internal nasal valve after dorsal reduction is challenging. The purpose of this study was to retrospectively analyze a series of 100 consecutive rhinoplasty cases with respect to preservation or restoration of the dorsal nasal lines following component dorsal reduction. A new quantitative mathematical application for subject digital images was performed. Medical information and digital images were obtained from 100 consecutive primary rhinoplasty patients from one author (R.J.R.) with University of Texas Southwestern Medical Center Institutional Review Board consent. All postoperative subject digital images were taken at more than 1-year follow-up. Preoperative and postoperative digital images of the dorsal nasal aesthetic lines were analyzed using a software application that quantitated various facial anatomical features compared with landmark measurements unique for each subject (pupil-to-pupil distance). Dorsal line symmetry, nose width, and variation of deformities on each side of the face were determined. Mean subject dorsal line symmetry was 68 percent preoperatively and 94 percent postoperatively. Only 32.5 percent of dorsal lines were harmonious preoperatively, whereas 97 percent of dorsal lines were harmonious postoperatively. Identification of dorsal lines postoperatively versus preoperatively was similar in 74.6 percent, improved in 15.7 percent, and decreased in 9.7 percent. Nasal width lines were similar in 36 subjects, 21 subjects had wider nasal width lines, and 43 subjects had narrower width lines after surgery. Component dorsal hump reduction procedures result in reliable and reproducible clinical outcomes. Quantitative assessments provide evidence that improved and harmonious curves of dorsal aesthetic lines are achievable. Therapeutic, IV.(Figure is included in full-text article.).

Management of the Nasal Dorsum

Profile alignment, including nasal dorsal reduction, is one of the most common maneuvers in aesthetic rhinoplasty. Techniques often include cartilaginous excision and bony hump reduction with a chisel or a rasp. Cartilaginous nasal vault excision can result in separation of the junction between the upper lateral cartilages and the dorsal septum. This separation can cause an inferior-medial repositioning of the upper lateral cartilages and overall weakening of middle vault infrastructure. Furthermore, surgical interruption of this key region can also damage the internal nasal valve configuration and function and create static and dynamic airway obstruction. This article outlines the anatomy and function of the middle nasal vault and internal nasal valve. In addition, it provides an overview of aesthetic complications of dorsal hump removal including inverted-V deformity, saddle nose deformity, hourglass deformity, and their functional consequences. Preoperative individual risk factors for middle-third deformities are mentioned. Preventive and corrective surgical techniques including cartilage grafting and reconstructive sutures are also detailed.

Quantifying the Sharpness of Osteotomes for Dorsal Hump Reduction

To assess the relative sharpness of osteotomes after multiple uses, routine maintenance, and sharpening. This prospective clinical study and mechanical model quantified the relative sharpness of identical osteotomes at baseline; after 3, 6, and 9 uses; and after sharpening techniques compared with osteotomes from hospital central supply. The Instron universal tester developed a force-displacement curve as the osteotome blade cut a standardized suture. Force required to cut the suture is inversely proportional to osteotome sharpness. For osteotomes 1, 2, and 3, dullness occurred after 9 uses (4.836 lb; P < .001), 6 uses (4.431 lb; P < .005), and 3 uses (4.093 lb; P < .02), respectively. Osteotome 1 was professionally sharpened after 9 uses and retested (3.156 lb); results were similar to those for an osteotome used 6 times (3.160 lb). Additional sharpening showed significantly poorer performance (7.737 lb; P < .001 at baseline and after 9 uses). Osteotome 3 was hand sharpened after 6 uses and retested (7.750 lb; baseline P < .001). Two osteotomes from central supply required almost twice the cutting force relative to the senior author's osteotomes. Although osteotome performance decreased significantly over time, professional sharpening only achieved results similar to an osteotome used 3 to 6 times. Further resharpening seems detrimental to performance. Surgeons may want to consider osteotomes disposable instruments.

Quantifying the Sharpness of Osteotomes for Dorsal Hump Reduction

To assess the relative sharpness of osteotomes after multiple uses, routine maintenance, and sharpening. This prospective clinical study and mechanical model quantified the relative sharpness of identical osteotomes at baseline; after 3, 6, and 9 uses; and after sharpening techniques compared with osteotomes from hospital central supply. The Instron universal tester developed a force-displacement curve as the osteotome blade cut a standardized suture. Force required to cut the suture is inversely proportional to osteotome sharpness. For osteotomes 1, 2, and 3, dullness occurred after 9 uses (4.836 lb; P < .001), 6 uses (4.431 lb; P < .005), and 3 uses (4.093 lb; P < .02), respectively. Osteotome 1 was professionally sharpened after 9 uses and retested (3.156 lb); results were similar to those for an osteotome used 6 times (3.160 lb). Additional sharpening showed significantly poorer performance (7.737 lb; P < .001 at baseline and after 9 uses). Osteotome 3 was hand sharpened after 6 uses and retested (7.750 lb; baseline P < .001). Two osteotomes from central supply required almost twice the cutting force relative to the senior author's osteotomes. Although osteotome performance decreased significantly over time, professional sharpening only achieved results similar to an osteotome used 3 to 6 times. Further resharpening seems detrimental to performance. Surgeons may want to consider osteotomes disposable instruments.

Fundamental Principles in Aesthetic Rhinoplasty

This review article will highlight several fundamental principles and advances in rhinoplasty. Nasal analysis has become more sophisticated and thorough in terms of breaking down the anomaly and identifying the anatomic etiology. Performing this analysis in a systematic manner each time helps refine these skills and is a prerequisite to sound surgical planning. Dorsal augmentation with alloplastic materials continue to be used but more conservatively and often mixed with autogenous grafts. Long term outcomes have also taught us much with regards to wound healing and soft tissue contracture. This is best demonstrated with a hump reduction where the progressive pinching at the middle vault creates both aesthetic and functional problems. Correcting the twisted nose is challenging and requires a more aggressive intervention than previously thought. Both cartilage and soft tissue appear to have a degree of memory that predispose to recurrent deviations. A complete structural breakdown and destabilization may be warranted before the nose is realigned. This must be followed by careful and meticulous restabilization. Tip refinement is a common request but no single maneuver can be universally applied; multiple techniques and grafts must be within the surgeon's armamentarium.

Sonic rhinoplasty: sculpting the nasal dorsum with the ultrasonic bone aspirator

Rhinoplasty often requires precise, graded bone removal without damage to surrounding nasal soft tissue and mucosa. Unfortunately, current techniques are associated with decreased visualization, heat generation, mechanical chatter, and lack of surgical precision with resultant soft tissue injury. We introduce a novel technique to sculpt the nasal dorsum in a precise fashion with the ultrasonic bone aspirator and delineate its advantages over conventional techniques. Retrospective chart review. The SONOPET ultrasonic bone aspirator (Mutoh Co., Ltd., Tokyo, Japan) utilizes ultrasonic waves to emulsify bone with concurrent irrigation and suction, enabling precise, graded bone removal under direct visualization without thermal or mechanical injury to the surrounding soft tissue or mucosa. We describe the application of this technology to dorsal hump reduction with early follow-up to 9 months. Successful reduction was determined by the senior author at postoperative follow-up appointments. Sixty patients underwent open rhinoplasty requiring dorsal reduction with the ultrasonic bone aspirator. No individuals experienced delayed healing, infection, scarring, or major complications. Five of 60 patients had minor post surgical irregularities, which included visible nasal dorsum deformity, palpable nasal deformity, under-resection of the dorsum, and asymmetry of the nasal dorsum. No postoperative open sky deformities, inverted "V" deformities, over-resected dorsums, or skin injuries were observed. Ultrasonic bone aspiration permits safe, precise, graded bone removal without damaging surrounding nasal soft tissue and mucosa. We introduce novel applications of the ultrasonic bone aspirator in dorsal reduction that provide significant advantages over conventional techniques.