The normal or “ideal” dorsum exhibits a smooth transition from the nasal radix to the nasal tip. In a male, this relationship is classically identified as a smooth line, whereas in a Caucasian female, the ideal dorsum lies 2 mm behind this line. Patients with deficiency of the nasal dorsum (low dorsum) lie behind this line.

In non-Caucasian patients, the ideal dorsum may be different, and patient preferences must be identified.

Dorsal deficiency can be congenital, genetic, traumatic, or a consequence of previous surgery. Some patients are born with a low dorsum, and many ethnicities have a naturally occurring low dorsum (eg, Asian ancestry).

Trauma to the nose can cause septal collapse resulting in a low dorsum or “saddle deformity.”

Previous over-resection of the nasal dorsum and aggressive septal surgery are the most common reasons for dorsal deficiency after rhinoplasty.

In cases where no prior surgery has been performed, the diagnosis is clear and based on physical examination. The patient is viewed on profile, and the ideal radix and tip are visualized. The dorsum is designed to fit these ideals.

If previous surgery has been performed, the rhinoplasty surgeon should be aware of the causes of a dorsal deficiency. Along with physical examination, photographs should always be taken and, again, the ideal radix and tip overlaid on the profile photograph. A complete internal speculum examination should be done to assess the presence and integrity of the nasal septum. Previous operative reports are desirable in diagnosis and should help guide the surgical plan.

CT scans are rarely indicated except in the presence of severe trauma or asymmetric developmental deviation of the nose (ADDN). CT scans are useful to assess the nasal bones, nasal septum, heights of the maxillae, and the presence of concha bullosa.

Theoretically hyaluronic acid fillers can be used as a temporary solution; however, the authors do not advocate this type of treatment. Results are marginal at best, and injections require a high level of accuracy and experience. Follow-up (repeat) treatments must be done at least twice per year.

The authors perform diced cartilage in fascia as the mainstay for dorsal augmentation whenever dorsal deficiency exists. Timing is dependent on patient age (patients should be older than 14 years old) and timing of previous operations. We advocate waiting at least 1 year from any prior nasal surgeries to perform secondary surgery.