Rhinoplasty, Nasal Hump Treatment & Management

Dorsal hump excision can be accomplished through a closed or open rhinoplasty technique. The surgical approach chosen depends on the etiology of the nasal hump and other rhinoplasty maneuvers incorporated into the procedure.

Once the patient and surgeon come to a mutual understanding that corrective surgery is desirable and that realistic expectations can be met, the surgical procedures, potential complications, and limitations of the surgery are discussed. Specific details are emphasized, including methods of anesthesia, financial aspects, timing, and frequency of postoperative visits, and specific postoperative instructions. At an appropriate time prior to surgery, the patient is instructed to cease any medication or herbs with anticoagulant effects.

The procedure can be performed under general or local anesthesia. In either case, local anesthesia is injected via an intercartilaginous approach to infiltrate the lateral nasal walls. If septal and tip work are also to be performed, the septum is infiltrated, and a small amount of anesthetic is placed between the domes and subcutaneously in the columella. In delivery or open rhinoplasty approaches, injections are made in the marginal incisions. Injections are not made in the nasal dorsum to prevent any distortion. Generally, less than 8 mL of local anesthetic is required.

Surgical access can be obtained using multiple rhinoplasty approaches, including nondelivery, delivery, and open techniques, depending on the other rhinoplasty maneuvers to be performed. Access is obtained through intercartilaginous and marginal incisions in delivery approaches and through an intracartilaginous or intercartilaginous incision in nondelivery approaches. In the external rhinoplasty approach, exposure of the dorsum is achieved via marginal incisions combined with a midcolumellar incision.

In all surgical approaches, the flap is elevated in a relatively avascular plane immediately adjacent to the underlying cartilages. Over the dorsum, the periosteum overlying the nasal bones is incised and elevated in continuity with the skin–soft tissue envelope centrally. To preserve periosteal attachments and nasal bone stability, the periosteum is left intact on the nasal bones laterally.

The dorsum is then carefully evaluated. Most dorsal humps consist primarily of cartilage with a bony component. Hump excision can be performed using various techniques. Rasping alone can be used to address small bony humps. Larger dorsal humps are usually excised using a Rubin osteotome or a combination of sharp excision of the cartilaginous hump (with a knife blade or scissors) and an osteotome to remove the bony and cartilaginous hump in continuity. Powered instrumentation has also been described for bony hump removal.

To prevent blunting of the angle, dorsal hump reduction is carried to the nasofrontal angle. When excising a large dorsal hump, mucoperichondrium must not be excised with the cartilaginous hump. The elevation of the mucoperichondrium off the undersurface of the medial upper lateral crura and dorsal septum or the separation of the upper lateral crura from the septum can facilitate this. If necessary, the upper lateral cartilages are trimmed to lie flush with the nasal dorsum. After excision of the cartilaginous hump, the nasal tip is depressed to ensure that the anterior septal angle is not visible. This maneuver reduces the risk of polly beak formation if postoperative loss of tip projection is present.

The presence of a deep nasofrontal angle is best addressed by nasofrontal augmentation combined with conservative hump resection. Nasofrontal augmentation can be accomplished with autogenous cartilage grafts or alloplastic material. Deepening of the nasofrontal angle is more technically difficult. The skin–soft tissue envelope is thick in the region of the nasion and may tend to bridge over the concavity in this area and blunt the underlying skeletal changes. Guyuron has estimated that approximately 25% of skeletal modifications are visible externally in soft tissue changes.^[1] Because of this tendency, overcorrection is necessary in this area. Deepening of the nasofrontal angle can be accomplished with rasps, osteotomes, or powered instrumentation.

After hump excision, the patient is generally left with an open roof deformity. Rasps are then used to smooth the bony margins. All bone fragments should be carefully removed. The dorsum is carefully evaluated, both internally and externally, to assess if any additional hump removal or smoothing with the rasp is indicated.^[2] The dorsal profile should be evaluated externally both visually and by palpation. The gloved finger is moistened to allow improved tactile sensation to assess for any irregularities or asymmetries. The skin over the dorsum is pressed down to reduce edema and allow better assessment of the dorsal profile obtained. This careful evaluation allows further fine-tuning to be performed, if necessary.

Osteotomies are required to close the open roof and reestablish the bony nasal pyramid as depicted in the image below. However, in the excision of a very small hump, osteotomies may not be required if narrowing of the upper third of the nose is not desired. Medial osteotomies can be performed to create a line for a controlled back fracture. Medial osteotomies may not be necessary if a large dorsal hump resection has been performed that leaves an open roof deformity. Medial osteotomies are performed by placing the osteotome at the junction of the nasal bone and septum and fading the osteotomy line obliquely in a lateral direction while avoiding the thick bone of the nasofrontal region.

Intermediate osteotomies are performed when excessive convexity or concavity of the nasal bone is observed in a severely deviated bony nasal vault. This procedure allows recontouring, as well as repositioning of the nasal bone, and is most effective in persons with overly convex nasal bones. The intermediate osteotomy is performed before the lateral osteotomies while the nasal bone still has some stability. A transcutaneous osteotomy with a 2-mm osteotome may be necessary to complete the osteotomy.

Lateral osteotomies can be performed various ways; namely, low-low, low-high, or high-low-high (curved) techniques. The high-low-high osteotomy leaves a triangle of bone intact at the pyriform aperture, which allows mobility of the lateral nasal wall without disrupting the lateral suspensory ligaments and prevents medialization of the inferior turbinate to minimize any nasal airway compromise.

An incision is made onto the pyriform aperture above the inferior turbinate. A subperiosteal tunnel can be elevated along the osteotomy tract to preserve the perichondrium. The osteotome is then seated on the bone 3-4 mm above the pyriform aperture, advanced down onto the face of the maxilla, and then angled toward a point medial to the inner canthus. The nondominant hand is constantly assessing the position of the osteotome. The osteotome is then rotated medially to complete the back fracture and to medialize the nasal bone. If the back fracture is incomplete, pressure can be applied to the nasal bone. To avoid a greenstick fracture, a 2-mm transcutaneous osteotomy can be performed to complete the fracture.

If true medialization of the nasal base is required in a nose with a wide upper and middle vault, then low-low osteotomies may be indicated. Low-high osteotomies may be used in patients with wide nasal bases with adequate nasal airways that can tolerate some narrowing. Perforating osteotomies can be performed via either a percutaneous or a transnasal approach, theoretically increasing stability by preserving a bridge of periosteum between osteotomy sites.

In performing osteotomies, the thicker bone of the nasofrontal region should be avoided. Back fracture in this region can result in a rocker deformity, in which the superior aspect of the bony segment moves laterally because of the fulcrum effect when the lateral nasal wall is moved medially. This deformity can be corrected by performing a percutaneous transverse osteotomy to complete the back fracture in the appropriate position.

After the rhinoplasty is complete, a nasal dressing, which consists of adhesive, careful taping, and a nasal splint, is applied.

The nasal splint is removed one week after surgery, and the nose is retaped using adhesive. One week later, the tape is removed, and the patient begins daily taping of the nose for the next several weeks. This taping is performed for at least 2 more weeks after the surgery or for longer if the edema is significant. Taping of the nose is an important postoperative measure because it helps eliminate the dead space between the nasal skeleton and the skin–soft tissue envelope and allows for optimal redraping.

Long-term monitoring is needed to evaluate results. Generally, patients should be monitored for one year before considering revision surgery. This monitoring period allows time for healing, scar maturation, and skin–soft tissue envelope redraping. However, subtle changes of healing and scar maturation, which can affect nasal contour and shape for years, continue to occur.

Early and late complications

Early postoperative complications include hemorrhage, edema, and ecchymosis. Hemorrhage is best treated by avoiding predisposing factors. All medications or herbs with anticoagulant effects should be avoided prior to surgery. Salicylates, in particular, should be stopped a full 10-14 days prior to surgery. A history of excess bleeding or bruising with mild trauma or a significant family history of bleeding problems warrants a preoperative hematologic evaluation.

Edema and ecchymosis occur commonly with rhinoplasty to varying degrees, depending on the patient and procedures performed. Ecchymosis generally resolves in 2-4 weeks but can be persistent for months in some patients, particularly those of Mediterranean heritage. Edema resolves more slowly over a period of months.

Fortunately, infection is a rare complication. Periostitis can occur along fracture or osteotomy lines and generally resolves with antibiotic therapy. Bone dust or fragments should be carefully removed to minimize this problem. Occasionally, callus formation at the site of bony hump removal or osteotomy sites can occur.

Osteotomy complications

Open roof deformity is primarily an issue in the following types of patients:

• Those who require removal of large wide humps and have thick nasal bones
• Those who have high thin humps where flattening and widening of the dorsum tends to occur postoperatively rather than the normal roundness
• Those who have strong dorsal humps with a deviated septum, which must be corrected to allow infracture

Stair-step deformity results when the lateral osteotomy is placed too high. Greenstick fractures due to an incomplete superior fracture at the nasal root can result in lateralization of the nasal bones with time. A rocker deformity can result when the back fracture takes place through the thicker bone of the nasofrontal region. A fulcrum effect results in lateralization of the superior aspect of the bony segment when the lateral nasal wall is moved medially. Correction requires an additional osteotomy in the appropriate back fracture location.

In patients with short nasal bones, lateral osteotomy and infracture to close an open roof deformity can result in the collapse of the middle nasal vault. If this collapse is a concern, spreader grafts can be placed between the septum and the upper lateral cartilages to support the internal nasal valve and to prevent the medial collapse of the upper lateral cartilages.

Overresection or underresection

Saddle-nose deformity can result from overresection of the nasal dorsum. This can be corrected with dorsal augmentation with autogenous cartilage or bone grafting, depending on the severity of the deformity. Alloplastic materials can also be used.

Polly beak deformity can result from insufficient lowering of the dorsal septum as part of the dorsal hump resection. Insufficient trimming of the upper lateral cartilages to lie flush with the dorsal septum can also result in this deformity.

In dorsal hump resection, the surgeon should be conservative, as overresection is a more difficult problem to correct than underresection. If a slight dorsal prominence remains because of failure of adequate skin–soft tissue envelope redrapage or underresection, correction can be achieved readily via conservative reexcision (cartilage) or refinement with rasping (bone) at the time of revision surgery.

However, a high dorsum and slight prominence conveys a natural, unoperated look and can be a desirable outcome, particularly in the noses of men and individuals of certain ethnicities. This outcome is in contrast to the scooped-out appearance of an overresected dorsum, which can be a telltale sign of surgery.

Dorsal hump resection can be a very satisfying operation for both patient and surgeon. Conservative resection of bone and cartilage can translate into a significant effect on nasal contour and character. In patients with very large humps, results may be limited by the ability of the skin–soft tissue envelope to redrape over a significant skeletal reduction. Overall, most patients are satisfied with the outcome of rhinoplasty surgery, and revision rates are low.

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article, Broken Nose.

Although the general principles and techniques of dorsal hump reduction remain essentially the same, instrumentation has continually evolved. In recent years, powered instrumentation for the nasal dorsum has become available. Proponents of this technology note the advantages of increased precision and less soft tissue trauma. Traditional instruments such as rasps and osteotomes, particularly in experienced hands, accomplish the same end and remain the standard of care. However, powered instrumentation may have an advantage in challenging areas such as the nasofrontal angle.