Hump Resection Research Articles

Intraoperative Measurement-Based Approach to Supratip Deformity in Open Structural Rhinoplasty.

Supratip deformity is one of the most common complications after open rhinoplasty. This study aimed to define a new risk scoring system for supratip deformity and determine the distances that should be left between the tip defining point (TDP) and anterior septal angle (ASA) to prevent it. Four hundred sixty-nine patients who underwent open rhinoplasty between 2018-2022 were included in this retrospective study. The patients were evaluated according to the risk scoring system consisting of four parameters (skin thickness, lower lateral cartilage anatomy, amount of hump resection, and soft tissue procedures). Because of the presence of supratip deformity at the postoperative 12th month, the patients were divided into two groups: (i) without supratip deformity (n = 418) and (ii) with supratip deformity (n = 51). Statistical inferences were made regarding the development of supratip deformity by evaluating the relationship between the risk scores and the intraoperative TDP-ASA distances. There was a significant difference between the groups in risk scores (P < 0.05). In cases with high-risk scores, it was calculated that the probability of developing supratip deformity decreased significantly when the TDP-ASA distance was above 7.5 mm and increased significantly when the TDP-ASA distance was below 6.5 mm. In cases with low-risk scores, it was found that the probability of developing supratip deformity was reduced considerably when the TDP-ASA distance was over 6.0 mm. The authors recommend keeping the TDP-ASA distance above 6.0 mm in low-risk patients and 7.5 mm in high-risk patients to avoid supratip deformity.

Comparison of Functional and Cosmetic Outcomes Between Dorsal Preservation and Spreader Flap Rhinoplasty: A Randomized Trial.

Preservation rhinoplasty is a novel and increasingly utilized method in nasal plastic surgery. The study aimed to compare the functional and aesthetic outcomes of dorsal preservation rhinoplasty, a new and interesting method, with conventional hump resection. A total of 84 rhinoplasty applicants were randomly assigned to 2 groups. The first group underwent convention dorsal hump resection with spreader flap midvault reconstruction and the second group underwent dorsal preservation rhinoplasty with the modified subdorsal strip method. Aesthetic and functional outcomes, including residual hump, nasal width, projection, and rotation, were evaluated after 1 year with the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS), visual analog scale (VAS), and image analysis. Eighty-four patients with a mean age of 30.96 ± 6.75 years were recruited, of whom 15 (17.6%) were male. There were no significant differences in confounding variables between the 2 groups. There were no significant differences in residual hump (P = .11), nasal width (P = .37), projection (P = .70), rotation (P = .79), VAS (P = .81), or SCHNOS (P = .90) between the 2 groups. Dorsal preservation rhinoplasty with the modified subdorsal strip method may have comparable aesthetic and functional outcomes to spreader flaps midvault reconstruction.

Evaluating the efficiency of endoscope-assisted septo-rhinoplasty via intranasal approach

Objective: To observe the functional and esthetic results of endoscope-assisted septo-rhinoplasty via intranasal approach. Methods: The clinical data of 12 patients with septal deviation and nasal deformity in the University of Hong Kong-Shenzhen Hospital from June 2021 to June 2022 were analyzed, including 8 males and 4 females, aging 28 to 58 years. All patients were operated under general anesthesia. The septal deviation was corrected by hemitransfixion incision, combined with intercartilaginous incision and other intranasal or extranasal incisions to perform osteotomy, hump resection and saddle nose correction. Patient satisfaction with postoperative functional and aesthetic improvements was assessed through Nasal Obstruction Symptom Evaluation (NOSE), Rhinoplasty Outcome Evaluation (ROE), and Visual Analogue Scale (VAS).SPSS 25 software was used for statistical analysis. Results: The correction of nasal septum deviation was satisfactory in all 12 patients. Nasal obstruction was relieved, with NOSE score and VAS score of nasal ventilation decreased [(21.67±10.30) vs (70.83±14.12), (1.83±1.03) vs (8.33±0.89), t value was 9.49 and 16.30, respectively, both P<0.05]. The nasal appearance of 10 patients with crooked nose deformity was improved, with ROE score and VAS score of nasal appearance increased [(21.30±2.31) vs (8.10±3.31), (8.90±0.99) vs (3.80±1.62), t value was -11.85 and -9.33, respectively, both P<0.05];The nasal vestibule morphology of 2 patients with abnormal nasal vestibule was improved. During the follow-up of 12 to 24 months, no postoperative complication such as nasal septum perforation, nasal cavity adhesion or nasal dorsal collapse occurred in all patients. Conclusion: Endoscope-assisted septo-rhinoplasty via intranasal approach can resolve both functional and esthetic problems at the same time, improving outcomes while reducing surgical trauma.

The Use of Posterior Auricular Fascia Graft (PAFG) for Slight Dorsal Augmentation and Irregular Dorsum Coverage in Primary and Revision Rhinoplasty: A Prospective Study

IntroductionAugmentation and coverage of irregularities of the nasal dorsum remain a challenge in rhinoplasty. Different techniques have been described in the current literature for this purpose. The aim of this study is to assess and illustrate the author experience and outcomes using the posterior auricular fascia graft (PAFG) for dorsal camouflage and augmentation in primary and revision rhinoplasty.Material and MethodsA prospective bicentric study was conducted, including patients with slight dorsal deficiencies and/or with dorsal irregularities following hump resection, trauma or previous rhinoplasty receiving PAFG to improve the rhinoplasty outcome. To objectively assess the graft resorption rate, MRI was performed 2 weeks and 18 months after surgery. To investigate patient satisfaction, the preoperative and 1-year postoperative scores obtained using the rhinoplasty outcomes evaluation (ROE) scale were compared. The scores following a normal distribution obtained for each patient were compared using a paired t-test.ResultsForty-five patients were enroled in this study. Average follow-up duration was 35.4 months. Patients’ age ranged from 17 to 57 years. No cases of infection or major graft resorption were observed. No postoperative scars were visible at the donor site. All patients were satisfied after surgery, and a statistically significant difference between pre- and postoperative scores (p<0.0001) was observed.ConclusionThis study showed that PAFG is a reliable technique for dorsal camouflage and slight augmentation in primary and revision rhinoplasty. The procedure is safe, easy and quick and only requires a small learning curve.Level of Evidence IIThis 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.

Matched Cohort Comparison of Dorsal Preservation and Conventional Hump Resection Rhinoplasty.

Structural preservation techniques (SPR) minimize disruption of the dorsal aesthetic lines, with potential aesthetic and functional benefits over conventional hump resection techniques (CHR). The goal of this study is to compare patient reported outcomes between these techniques. This study was a retrospective matched cohort analysis of patients undergoing rhinoplasty with dorsal hump reduction using patient-reported outcomes measures: Standardized Cosmesis and Health Nasal Outcomes Survey (obstructive: SCHNOS-O, cosmetic: SCHNOS-C) and visual analog scale (functional: VAS-F, cosmetic: VAS-C). A cohort of patients undergoing SPR were matched to a cohort undergoing CHR based on age, gender, and preoperative SCHNOS scores. Intraoperative techniques and patient-reported outcomes were compared between groups. There were no significant differences in the dorsal height between groups. While radix grafting was more common in SPR, dorsal onlay grafting and midvault reconstructive techniques (e.g. autospreader flaps) were more common in CHR. Within both groups, post-operative SCHNOS and VAS improved significantly at short- and long-term follow-up. There were no differences between SCHNOS or VAS scores preoperatively. Post-operative SCHNOS-O and SCHNOS-C scores were similar between groups at both short-term and long-term follow-up. Post-operative VAS-F scores were not different; however, VAS-C scores at short-term follow-up were statistically greater in the SPR group compared to the CHR group (8.92 vs 8.20, p = 0.03). At long-term follow-up, the difference was not significant. While there are theoretical functional and aesthetic benefits of SPR techniques, the patient reported benefits may be minimal when compared to CHR techniques with appropriate midvault reconstruction. 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 .

Inverted-V Deformity: An Anatomic Study.

The inverted-V deformity is an unwanted aesthetic consequence of dorsal hump resection. Despite their attachment to the nasal bones, the upper lateral cartilages (ULCs) can separate from the nasal bones, creating a step-off after cartilaginous dorsal hump removal. The mechanism of how the ULCs can separate from the nasal bones despite their attachment was studied to improve understanding of the inverted-V complication and its prevention. A dorsal hump resection (bony and cartilaginous) was performed on 12 fresh cadavers to observe the effect on the ULCs. As a secondary study, the effect of different preventative maneuvers was investigated. Cartilaginous dorsal resection destroys the spreader mechanism of the T-frame and impacts the stabilization of the ULCs, resulting in them becoming free-floating. This causes them to migrate in a posterior, medial, and cranial direction relative to the nasal bones. The dynamic attachment of the ULCs to the nasal bones is key in this mechanism and allows actual separation of the ULCs from the nasal bones to result in the inverted-V deformity. Caudal traction to the ULCs re-tensions these attachments, pulling the ULCs against the nasal bones again. This anatomic dissection study has established that the connection between the nasal dorsum and ULCs is not a static fusion but is dynamic. This attachment can be used in primary rhinoplasty to prevent inverted-V deformity by applying caudal traction to the ULCs when reconstructing the dorsum which will tension the ULCs toward the nasal bones.

Key stone plasty and asymmetric hump resection in crooked nose deformity

ObjectiveThe aim of this study is to propose a new approach in crooked nose deformity with key-stone plasty and asymmetric hump resection. MethodTwelve patients with crooked nose deformities were operated using the open rhinoplasty technique. Our method, unlike other methods, has two different steps. Following asymmetric hump resection, cartilaginous and osseous septum were cut separated at the key stone area or more caudally and fix the septum with sutures again by allowing them to slide over each other in a way that directs the septum to the midline. If there is an inability to reveal the septum, we apply a longer spreader graft to the cartilage septum side. ResultsThe mean ages were 27.4 years. The mean follow-up time of the patients was 19.1 months. No complications were observed due to this technique. This technique was effective in the treatment of all our patients with crooked nose deformities. ConclusionA novel surgical approach with key-stone plasty and asymmetric hump resection method was proposed in crooked nose deformity with a video animation.

Assessment of Functional Outcomes of an Autospreader Flap and Spreader Graft in Rhinoplasty.

Nasal obstruction after rhinoplasty occurs due to narrowing of the internal nasal valve. Narrowing is due to osteotomy performed to close the open roof of nose after dorsum hump resection. Spreader grafts and autospreader flaps are used to prevent such narrowing. in this study, we aimed to compare the effects of these 2 rhinoplasty techniques on olfactory function, nasal air passage opening, quality of life, and patient satisfaction. In this prospective study, 48 rhinoplasty patients were randomly divided into 2 groups according to graft technique used, either spreader graft or autospreader flap. These 2 groups were compared for patient satisfaction. The sinonasal outcome test-22, peak nasal flowmetry, and Connecticut Chemosensory Clinical Research Center test were applied to all patients before and 8 weeks after surgery. The study enrolled 48 patients. Nasal airflow increased in both groups postoperatively. in the preoperative and postoperative comparison of odor functions, postoperative odor functions were similar in both groups. In the autospreader flap group, the preoperative rhinoplasty outcome evaluation questionnaire score was 4.1 ± 2.2 versus 21.3 ± 2.6 in the third postoperative month. The preoperative rhinoplasty outcome evaluation score was 3.9 ± 2.1 in the spreader graft group and 19.7 ± 1.9 in the third postoperative month. In the present study, postoperative nasal airflow improved in the patients in both the spreader graft and autospreader flap groups. in the patient satisfaction surveys after rhinoplasty, the satisfaction of the patients in the autospreader flap group was higher than that of the patients in the spreader graft group.

Outcome after Dorsal Hump Resection versus Hump Remodeling and Re-insertion: A Randomized Controlled Trial

Outcome after Dorsal Hump Resection versus Hump Remodeling and Re-insertion: A Randomized Controlled Trial

Discussion: Narrowing and Operated Appearance of the Middle Nasal Third after Hump Resection without Middle Vault Reconstruction.

Discussion: Narrowing and Operated Appearance of the Middle Nasal Third after Hump Resection without Middle Vault Reconstruction.

Narrowing and Operated Appearance of the Middle Nasal Third after Hump Resection without Middle Vault Reconstruction.

Little is known about the incidence of narrowing and an operated appearance of the dorsum after hump resections if the dorsum is not reconstructed with spreader grafts or spreader flaps. Patients who had undergone a composite hump resection (n = 22) or a component hump resection (n = 25) were interviewed and photographed with a minimum follow-up of 12 months. Four expert rhinoplasty surgeons and four laypersons rated the appearance of the middle third of the dorsum on the preoperative and postoperative en face photographs. The quartile of the most surgical appearing outcomes was analyzed regarding potentially preventive surgical maneuvers. No patient was dissatisfied with the frontal view of the nose. Agreement between expert and lay raters (Kendall's coefficient of concordance) was 0.51 (p < 0.01) and 0.34 (p = 0.06) for appearance and 0.55 (p < 0.01) and 0.46 (p < 0.01) for width, respectively. Expert raters found that a surgical appearance of the dorsum had both increased and decreased after surgery, with an average increase of 0.27 ± 1.05 and 0.21 ± 1.18 points on a five-point Likert scale for composite and component resection, respectively. Pearson correlation between the degree of dorsal lowering and surgical appearance on the anterior view was 0.31 (p = 0.026). Reconstruction of the middle third could potentially have improved the outcome in 15 percent of the patients. Lowering of the dorsum without middle vault reconstruction on average increased an operated appearance to a small degree that was not noted by the patients. This effect was similar for composite and component hump resections. Therapeutic, III.

Spreader Flap versus Spreader Graft in Dorsal Reconstruction following Hump Resection in Primary Closed Rhinoplasty

Objectives: To evaluate outcome of spreader flaps versus the spreader grafts in reconstruction of the nasal dorsum after large hump resection. This includes both functional and aesthetic aspects.Patients and Methods: Thirty patients seeking rhinoplasty for dorsal nasal hump. All surgeries were done through the closed approach. Patients were randomly divided into two groups and accordingly to the modality of nasal dorsal reconstruction after hump resection. Group (A) patients were scheduled for reconstruction using spreader grafts while in Group (B) spreader flaps were used. Evaluation included functional and aesthetic considerations. Functional subjective evaluation was done by Nasal Obstruction Symptom Evaluation (NOSE) score and objective assessment by active anterior rhinomanometry (AAR). Aesthetic evaluation included patients’ assessment of their problem according to Visual Analogue scale (VAS) while objective evaluation was done based on a suggested scoring system designed by the authors using pre and post-operative photography. The evaluating surgeons were blinded regarding the vault reconstructive modality.Results: In both groups significant improvement in both functional and aesthetic outcome - after a minimum of three months follow up- when comparing the pre and postoperative data that was obtained. There was no statistically significant difference in outcome between both groups.Conclusion: The spreader flap is a good alternative to the spreader graft in nasal dorsal reconstruction after large hump resection giving similar positive results both functionally and aesthetically however, the authors find the autospreader flap more superior to spreader graft technique as it does not require cartilage harvest.

Combination of the Push-Down and Let-Down Techniques: Mix-Down Approaches

Rhinoplasty is one of the most widely conducted and challenging types of aesthetic surgical operations, and dorsal hump reduction is a commonly performed aesthetic surgery among Caucasian patients. Dorsal hump resection is traditionally conducted by removing the dorsal nasal bone and cartilage. The push-down and let-down techniques are used for dorsal preservation in dorsal hump reduction operations. Different patients require different approaches to achieve the best results in terms of aesthetic appearance and functionality. In the present research, the author describes two novel approaches that combine the push-down and let-down techniques for appropriate patients. The records of 45 patients (40 females and 5 males) were assessed, and those who were eligible for the present approaches were included. The author defined two approaches in which the push-down and let-down techniques were used simultaneously (mix-down methods). All patients included in the study completed the Rhinoplasty Outcome Evaluation (ROE) questionnaire before surgery and at their one-year follow-up appointment. The median ROE scores were 60.1 points before surgery and 92.2 points one year after surgery; this difference was statistically significant (p<0.001). The present study is the first to demonstrate the beneficial effects of combining the push-down and let-down techniques in a selected patient population. These new approaches will improve both cosmetic and functional outcomes and allow surgeons to choose the best option for patients who are eligible for these mix-down approaches. 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 .

Endoscopic Sphenopalatine Ganglion Block Efficacy in the Management of Periorbital Edema and Ecchymosis After Septorhinoplasty.

This study aims to evaluate the efficacy of sphenopalatine ganglion block (SPGB) on postoperative edema and ecchymosis for the patients undergoing septorhinoplasty (SRP). In the study, a total number of 55 participant patients (40% male and 60% female, aged between 18 and 42 years) undergoing hump resection and osteotomies were allocated into 2 groups. The SPGB (+) group consisted of 27 patients who underwent SPGB, while the SPGB (-) group consisted of 28 patients who underwent SRP without SPGB. On the first, third, and seventh postoperative days (POD1, POD3, POD7), the score marks of periorbital edema and ecchymosis of the patients were evaluated. Additionally, postoperative upper eyelid edema and upper eyelid ecchymosis as well as lower eyelid edema, and lower eyelid ecchymosis on POD1, POD3, POD7 were evaluated. A comparison with regard to intraoperative bleeding, surgical field, and operation time between the 2 groups was also conducted. Upper eyelid edema, upper eyelid ecchymosis, lower eyelid edema, lower eyelid ecchymosis on POD 1, 3, 7 were found to be significantly lower in SPGB (+) group in comparison to SPGB (-) group (P < 0.001). Intraoperative blood loss and surgical field were found to be significantly lower in SPGB group (+) than in SPGB (-) group (P < 0.00). The operation time was not found statistically significant between the 2 groups (P = 0.212). Sphenopalatine ganglion block is a safe and effective way of reducing postoperative edema and ecchymosis after SRP. Besides, it provides a better surgical field and reduced bleeding intraoperatively.

3D photogrammetric analysis in hump nose correction based on nasal tip projection without dorsal augmentation in Asian rhinoplasty

IntroductionHump nose in Asians should be managed differently in consideration of the lateral profile and the balance between the dorsal height and nasal tip projection. We suggest an alternative approach comprising mild rasping and nasal tip projection using a septal extension graft. Material and methodsIn this retrospective study, patients who underwent hump nose correction with rhinoplasty between March 2012 and July 2015 were recruited. Instead of applying conventional dorsal augmentation after humpectomy, our approach involved only smooth dorsal contouring in limited cases. 15 patients were evaluated, with surgical outcomes demonstrated using three-dimensional photogrammetry. ResultsOver the postoperative period, hump height decreased (pre 2.77 ± 2.07, post 0.31 ± 0.55, p = 0.001). Regarding the efficacy of tip projection, both nasal tip protrusion (pre 17.64 ± 4.82, post 20.46 ± 4.05, p = 0.001) and tip projection (pre 19.75 ± 4.26, post 21.83 ± 4.17, p = 0.023) were increased. The hump nose reduction ratio was 84.94% after 6 months and 76.47% after 1 year, whereas increases in nasal tip projection and dorsal augmentation were minimal, with ratios of 14.75% and 12.76%, respectively, after 6 months). ConclusionTherefore, creating a balance between the nasal tip and nasal dorsum in hump nose correction is more important than dorsal augmentation after hump resection in Asians.

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.

Impact of Dorsal Preservation Rhinoplasty Versus Dorsal Hump Resection on the Internal Nasal Valve: a Quantitative Radiological Study.

This study evaluates the impact of different hump takedown techniques, namely the conventional hump resection with midvault reconstruction, the push-down (PD) and the let-down (LD) procedures, on the INV dimensions. In this cadaveric study, six heads were divided randomly into either the conventional hump resection technique (Group A; n = 6 sides) or DPR techniques (n = 6 sides). This latter group was subdivided such that initially a PD procedure was performed (Group B; n = 6 sides), followed by a LD procedure on the same heads (Group C; n = 6 sides). A validated radiological method was used to measure the INV angle and cross-sectional area (CSA) in a modified coronal plane both pre- and post-procedurally. Group A did not show significant reduction in the INV angle nor in CSA (p = 0.068 and p = 0.156, respectively). In the push-down group (B), we observed a mean change of 2.05° in the angles and 0.3cm2 in the CSA (p = 0.0163 and p < 0.001, respectively). The LD group (C) did not show significant reduction in the INV angle nor in CSA (p = 0.437 and p = 0.331, respectively). Neither the conventional hump resection nor the LD DPR technique reduced the INV dimensions. However, the PD preservation technique significantly reduced the INV dimensions. 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.

Dorsal Hump Reduction Based on the New Ethmoidal Point Classification: A Clinical and Radiological Study of the Keystone Area in 138 Patients.

Hump resection often requires reorganization of the keystone area. The authors sought to describe the importance of the point where the perpendicular plate of ethmoid joins the septal cartilage (SC) and the nasal bones (NB) (Ethmoidal point [E-point]) for hump resection surgical planning. Measurements from mid-sagittal slices in nasal computed tomography scans taken in adult Caucasian patients between January 2015 and December 2018 were compared between patients seeking primary rhinoplasty due to a nasal hump and patients not seeking rhinoplasty (control group). Patients with previous nasal surgery or trauma, genetic or congenital facial disorders, and high septal deviation were excluded. The length of overlap between NB and SC was compared between the 2 groups. The location of the E-point in relation to the beginning of the nasal hump in the cephalocaudal direction was documented in the patients seeking rhinoplasty. The study population included 138 patients, 69 seeking and 69 not seeking rhinoplasty (96 females). The mean age was 32.9 years (range, 18-55 years). The length of overlap between NB and SC was similar between both groups (11.7 ± 3.3 vs 10.8 ± 3.3; P = 0.235). The E-point was located before the beginning of the nasal hump in 97% (67/69) of nasal hump patients, and it could be found a mean distance of 2.3 (±2.3) mm cephalic to the latter. As a rule, the perpendicular plate of the ethmoid does not contribute to the nasal hump; therefore, only in exceptional cases should this be addressed while performing dorsal reduction.

Lateral osteotomy plus hump resection vs hump re-modeling without lateral osteotomy: impact on frontal nasal view.

SUMMARYThis article reviews the personal experience and evolution of osteotomy approach in the last years of practice to obtain a natural appearance of the nasal pyramid in the frontal view. The aim is to analyse the long-term results after rhinoplasty on nasal width in two different cohorts of patients subjected to lateral osteotomy plus hump resection vs. hump re-modeling without lateral osteotomy considering the impact on frontal nasal view and how this relates to changes observed over time in the nasal width and contour. The study was carried out between January 2010 and December 2013, considering 42 patients undergoing primary rhinoplasty. Comparisons were made between the change in the dorsal width of the nasal pyramid at the level of the medial canthi, at the level of the inferior margin of the orbital rim, of ventral width of the nasal pyramid at the level of the medial canthi and at the level of the inferior margin of the orbital rim. In the first group, we found significant postoperative mean widening of the intercanthal dorsal width and narrowing of the ventral, while in the second group there was significant postoperative mean narrowing of the dorsal width both at level of the medial canthi and the anterior junction of the nasal bones. Our analysis seems to point out that dorsal grafting is useful for re-shaping the nasal profile with a persistent and harmonious correction of the dorsal frontal dimension of the nose. Simple hump removal/repositioning may be considered in selected instances to avoid lateral osteotomies. It also seems of paramount importance to tailor osteotomies according to nasal bone anatomy: large, strong and curved bones deserve aggressive narrowing by lateral and medial continuous osteotomies without periosteal elevation, although this approach may be insufficient to narrow the upper dorsal aspect of the nose.

A Practical Suggestion for Prepare Dorsal Onlay Graft.

Nowadays, rhinoplasty is one of the most popular surgical procedures. Dorsal contour irregularities caused by various maneuvers, such as hump resection, are a major concern in patients who have undergone rhinoplasty. The most common graft used in this case is dorsal onlay graft which is made from sliced and crushed cartilage. Ear, nose and throat specialists usually use Swester table (mayo desk) for preparing the graft, if there is no other steril metal instrument. Crushed cartilage is done on a sterile gauze or on the tables' cover, as a result cartilage may be contaminated with particules from the tables' cover and sterile gauze.The authors recommend using the steril pack of a new sterilized surgical instrument opened on the table for the slicing or crushing process. In this way, the cartilage can be spared from contamination and the loss of some cartilage to the table during slicing or crushing can be prevented.