This article discusses the technique for planning, executing, and troubleshooting dorsal hump reduction for the cosmetic rhinoplasty patient. Details of the discussion include the necessary elements of the preoperative consultation with the patient, the specific instruments used to effectively and reproducibly create osteotomies, the anatomic and patient variables that require special attention, and the necessary measures to guard against potential complications.
Key points
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Consider the relationship of the nose to the other elements of the facial profile when planning dorsal hump takedown.
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Be prepared to use temporalis fascia for disguising osteotomy sites and nasal dorsal contour irregularities in thin-skinned patients.
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Preventatively address issues with post-hump-takedown middle nasal vault collapse with the use of spreader grafts.
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An onlay graft can be used to disguise the hump accentuation caused by a deep radix.
Introduction
Western ideals of nasal beauty have evolved around the leptorrhine nose, which consists of a thinner dorsum and more slender nostrils than the other 2 general nasal types, platyrrhine (broad) and mesorrhine (intermediate). Among leptorrhine noses, the Greek subtype (straight profile) has persisted as the most esthetically desirable variant over the Roman (convex) or Armenoid (convex with ptotic tip) subtypes.
The reasons for the desirability of the Greek nasal type are most likely 3-fold: esthetic, cultural, and evolutionary. The esthetic harmony of the face is based on the concept of vertical facial fifths and horizontal facial thirds, first described by the ancient Greeks. This concept ascribes the face with the unique role of serving as a communication portal with the world and suggests that a balanced appearance will be best received by others. The cultural contribution to our beauty ideals stem from popular figures and messages in our given society, usually dictated by the dominant class. The fact that the Greeks were the first to describe the concept of facial harmony may not be entirely unrelated to why the Greek nose remains the preferred leptorrhine subtype. The evolutionary reasons for the development of a specific nasal esthetic are most likely related to a desire for highlighting the femininity or masculinity of a given subject, which conveys sexual attractiveness. Women generally have a lower nasal dorsum due to the absence of exposure to testosterone, which exerts anatomic influence over the development of masculine facial features such as a lower, more prominent brow, stronger jaw, and more prominent nasal dorsum. Given that the overwhelming majority of patients seeking rhinoplasty surgery have been women, it is no surprise that there has been an emphasis on feminizing the nose through dorsal hump reduction. For male patients, the driver to reduce a dorsal hump is likely more cultural. Men are faced with the decision of potentially increasing their attractiveness based on cultural norms, but must be cautious about the potential to sacrifice masculinity in the process.
Introduction
Western ideals of nasal beauty have evolved around the leptorrhine nose, which consists of a thinner dorsum and more slender nostrils than the other 2 general nasal types, platyrrhine (broad) and mesorrhine (intermediate). Among leptorrhine noses, the Greek subtype (straight profile) has persisted as the most esthetically desirable variant over the Roman (convex) or Armenoid (convex with ptotic tip) subtypes.
The reasons for the desirability of the Greek nasal type are most likely 3-fold: esthetic, cultural, and evolutionary. The esthetic harmony of the face is based on the concept of vertical facial fifths and horizontal facial thirds, first described by the ancient Greeks. This concept ascribes the face with the unique role of serving as a communication portal with the world and suggests that a balanced appearance will be best received by others. The cultural contribution to our beauty ideals stem from popular figures and messages in our given society, usually dictated by the dominant class. The fact that the Greeks were the first to describe the concept of facial harmony may not be entirely unrelated to why the Greek nose remains the preferred leptorrhine subtype. The evolutionary reasons for the development of a specific nasal esthetic are most likely related to a desire for highlighting the femininity or masculinity of a given subject, which conveys sexual attractiveness. Women generally have a lower nasal dorsum due to the absence of exposure to testosterone, which exerts anatomic influence over the development of masculine facial features such as a lower, more prominent brow, stronger jaw, and more prominent nasal dorsum. Given that the overwhelming majority of patients seeking rhinoplasty surgery have been women, it is no surprise that there has been an emphasis on feminizing the nose through dorsal hump reduction. For male patients, the driver to reduce a dorsal hump is likely more cultural. Men are faced with the decision of potentially increasing their attractiveness based on cultural norms, but must be cautious about the potential to sacrifice masculinity in the process.
Preoperative planning and preparation
Despite the relatively common desire of patients to reduce their prominent nasal dorsum, there are great variations in the anatomic specifics for each patient. Skin type and thickness, height and width of the hump, relationship of the dorsal hump to the other defining profile points, and the esthetic desires of the patient, including gender appropriateness, are all important variables to consider in the planning and execution of dorsal hump reduction.
Rhinoplasty surgeons must possess a mastery of the inherent nasal anatomy ( Fig. 1 ) as well as an ability to perform a comprehensive assessment of surrounding nasal structures in 3 dimensions. Ideal nasal and facial angles must be considered in the context of the overall facial profile, including forehead shape, nasofrontal angle, radix height, nasofrontal angle, supratip break, tip-defining points and projection, infratip break, nasolabial angle, length of upper lip, dental occlusion, and chin projection. A change to any one of the above regions may result in a relative change to the other sites as well. On anterior view, changes in the nasal dorsum will frequently lead to an altered appearance of the dorsal esthetic lines, which are one of the most important aspects of nasal beauty ( Fig. 2 ).
Taking all of these data points into consideration, the surgeon will identify a treatment plan that will most accurately execute the desired results.
Patient positioning
Positioning for rhinoplasty surgery should optimize unimpeded access to the patient for both physician and assistant. The patient’s airway should be established in such a way as to avoid distorting the lip anatomy and to avoid encroaching on the physician’s maneuverability. The authors recommend using an oral RAE endotracheal tube taped to the midline of the lower lip in order to accomplish the above. In cases where an external approach will be used, it is advisable to prepare the patient’s facial skin preoperatively with Betadine or another antiseptic solution. Draping should be performed in such a way as to include the patient’s entire facial profile, from the hairline superiorly to below the cervicomental angle inferiorly.
Procedural approach
Dorsal hump reduction is typically performed in combination with other nasal alterations. Although surgeon preference is variable for determining the order of the procedure, it is often appropriate to perform the tip refining steps of the procedure before executing the dorsal hump reduction. Tip refining can aid in ensuring proper harmony between the ultimate dorsal reduction and the overall nasal form and can be particularly important when caring for patients with saddle nose deformity who are also undergoing bony hump reduction ( Fig. 3 ).
Tip-refining aspects of the procedure should be completed based on preoperative planning for desired tip projection, rotation, and shape. Tip rotation can significantly alter the extent of dorsal hump modification and therefore must be considered carefully. Once this has been executed, the cartilaginous and bony dorsal hump are taken down. Conservative primary excision is advisable at the outset of the procedure because additional excision is always possible.
There are several different techniques for addressing the dorsal hump. Some authors recommend en-bloc reduction of the cartilaginous vault, whereas others advocate component reduction by first separating the upper lateral cartilages from the nasal septum in order to maintain the transverse portions of the upper lateral cartilages. Regardless, the cartilaginous portion of the hump is traditionally taken down sharply with a 15-blade or truncated 11-blade scalpel ( Fig. 4 ). Limiting the resection at the rhinion can help prevent a concave nasal profile, while placement of a radix graft can help disguise a hump in select patients by easing the transition from the nasal dorsum to frontal bone ( Fig. 5 ).
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