Component Hump Reduction With Midvault Reconstruction

The Problem

The dorsal hump is the most common complaint in patients presenting for cosmetic rhinoplasty. Mastering this technique, its pitfalls, and its functional implications is essential for the surgeon wanting to build a successful rhinoplasty practice.

The Background

The dorsal hump may be osseous, cartilaginous, or osteocartilaginous. It may be associated with a deviation in the dorsum, in which case the nasal bones will be intrinsically asymmetric, and the dorsal septum will be deviated as well.

The hump may be removed using an open or closed surgical technique, to the preference and comfort of the surgeon. The dorsal hump may be removed using an incremental technique, using a combination of rasps for the bony portion, and a scalpel or dorsal scissors for the cartilaginous portion. It may also be removed en bloc using a scalpel or dorsal scissors for the cartilaginous section and a Rubin osteotome for the bony portion. Finally, piezoelectric surgery may be used for the bony component, followed by sharp removal of the cartilaginous portion.

An important consideration is the preservation of the midvault of the nose, which corresponds to the area of the internal nasal valve, and is anatomically defined by the junction of the upper lateral cartilages (ULCs) to the dorsal septum. This is generally recommended when at least 2 mm of dorsal hump is removed. Two strategies may be employed: autospreaders or spreader grafts. Autospreaders, or spreader flaps, consist of turning in the dorsal portion of the ULCs and suturing them to the cartilaginous dorsum, after scoring or cutting the spreader flap area. Some surgeons do not score or cut the cartilages. Spreader grafts consist of cartilage that is harvested from the septum, ULCs, concha, or rib. They generally measure 2 to 3 cm long by 2 to 3 mm wide and are sutured to the dorsal septum. An important technical pearl is that the suturing of the spreader flaps or grafts should be performed caudally along the dorsal septum to prevent an unnatural appearance at the transition area between the nasal bones and ULCs.

Following hump reduction, osteotomies should be performed in order to close the open-roof deformity, narrow the nasal bony width, or correct deviations in the nasal dorsum. Osteotomies should result in a mobile nasal bone that can then be repositioned accordingly. If piezosurgery is not used, minimal lateral undermining at the level of the dorsum should be performed to preserve the support of the nasal bones and prevent their collapse into the airway. Lateral osteotomies usually follow a pattern of high-low-high, and sometimes low-low-high in the case of a wide nasal base width. They should be connected to the medial osteotomies, via greenstick fracture or transverse osteotomies. Bony hump reduction already is responsible for part of the medial osteotomies. Sometimes these might not be necessary, although we find them necessary in most cases with shortened length.

When dealing with a deviated nose, osteotomies may be performed in an “open-book” fashion, starting on the most deviated side, in the following order: lateral, paramedian, paramedian, lateral. Intrinsic deviations in the dorsal septum sometimes cannot be corrected only using osteotomies, and a combination of a clocking suture, which represents an asymmetric horizontal mattress suture placed cephalically on a ULC and spanning towards the caudal dorsal septum in order to straighten the septum. Sometimes, an asymmetrically placed spreader graft sutured to the dorsal septum on the side opposite the deviation may act as a dorsal septal replacement graft. Onlay camouflage grafts using crushed cartilage or diced cartilage, with or without temporalis fascia or fibrin glue, may be placed on the contralateral side in very deviated noses. Most of these cases require osteotomies, although minimal (less than 1–2 mm) humps may be addressed without osteotomies when the bony roof is not “uncapped” without exposure of the underlying ULCs.

All cases require diligent history, physical examination, standardized photography, and evaluation using patient-reported outcome measures such as the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) for proper documentation, evaluation, and follow-up.