Osteotomies are critical techniques in rhinoplasty. There are a variety of approaches, trajectories, and tools used with no widely standardized classification or nomenclature. Percutaneous osteotomies are gaining in popularity, and picture framing the nasomaxillary bone is crucial for predictable fracture and reproducible results. This is best accomplished with medial, lateral, and transverse osteotomies. Intermediate osteotomies are used less frequently, but provide more mobility. With a detailed understanding of anatomy and a thorough approach to nasal osteotomies, the contour and function of the bony vault can be reshaped with a successful outcome for both the surgeon and patient.
Key points
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A methodical preoperative evaluation is critical to understanding the cosmetic and functional concerns of the patient when planning for nasal osteotomies.
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An inconsistent variety of osteotomy nomenclature is used for osteotomy classification. However, the key concept of picture framing the nasomaxillary complex is critical to reproducible results.
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Perforating percutaneous osteotomies are gaining in popularity owing to the ease of access and reduction in postoperative edema and ecchymosis.
The osseous framework of the nose provides the structural foundation for both nasal shape and function. The paired nasal bones join the ascending (or frontal) process of the maxilla, defining the upper lateral sidewall and dorsal width in conjunction with the upper lateral cartilages. Superiorly, the nasal bones join the nasal part of the frontal bone, defining the nasion. Superolaterally, the frontal process of the maxilla joins the frontal bone, completing the bony nasal vault. These osseous structures are concealed by the overlying skin, soft tissue, and nasal mimetic musculature within the superficial musculoaponeurotic system. Alterations in the shape and orientation of the bony framework may be congenital or acquired in nature (ie, posttraumatic). However, these alterations can have significant cosmetic and functional impacts that can be concerning to the patient.
The approach to the surgical management of the bony nasal vault remains challenging and is frequently debated among rhinoplasty surgeons. As the osseous framework provides the foundation from which the remainder of the structural elements of the external nose are derived, operative management is complex and nuanced. To improve management and outcomes, it is imperative to follow a comprehensive and structured preoperative evaluation.
Evaluation of the bony nasal vault
Evaluation of the nasal framework starts with a comprehensive history. It is important to elicit the specific functional and/or cosmetic complaints of the patient. Use of a hand-held mirror can be beneficial as the patient describes their primary concerns. Prior history of trauma or past nasal surgery could suggest increased scar formation and adhesions, potential fracture lines, and possibly less structural tissue integrity in comparison with congenital cases. Past medical history is also important, because a history of autoimmune diseases affecting the nose, chronic steroid use, or cardiopulmonary disease among other findings may all affect the operative and anesthetic approach.
After eliciting a comprehensive history, a systematic physical examination is performed. Structurally, the nose can be divided horizontally into the osseous, cartilaginous, and lobular thirds roughly corresponding with the nasal bones, upper lateral cartilages, and lower lateral cartilages, respectively. Focusing on the upper third, evaluation should be performed from both the frontal and the lateral views. Palpation is critical to evaluate for bony step-offs, instability, and the thickness of nasal skin overlying the nasal bones. From a frontal view, nasal bone abnormalities can be categorized into deviations and width abnormalities of the vault. The nasal bones should project symmetrically along the sagittal midline. Prior trauma or congenital abnormalities can project the nasal root off the midline. When evaluating the bony width of the nose, the dorsal and ventral width must be evaluated. The dorsal width is defined by the nasal bones at the dorsal projection, helping to contour the brow–tip aesthetic line, while the ventral width is defined by the ascending process of the maxilla. Cochran and colleagues describe that the ventral width should be about 80% of the alar width in the ideal nose; however, this can vary based on gender and race. Notice should be made of a narrow dorsum, particularly as a result of prior osteotomies that may be causing functional obstruction. From the lateral view, one should evaluate the nasofrontal angle and the radix height. Classically, the ideal nasofrontal angle for the Caucasian male ranges from 115° to 130°, although this, too, can vary significantly based on gender and race. Again from the lateral view, evaluation for a dorsal hump is critical, because this is often a prominent cosmetic concern. The need to address a dorsal hump operatively is a key consideration in planning for potential osteotomies. The details of the nasal anatomy must be taken in the context of the facial profile, including forehead profile, dental occlusion, and chin projection.
Preoperative photography is an excellent, objective means to document findings regarding the bony nasal vault and to plan approaches for operative repair. Traditional facial plastic photography should be used, including the anteroposterior, oblique, and lateral views. Ideally, this should be performed in a photo studio with a lighting system to avoid shadows, and with reference to the horizontal Frankfort line. These photographs allow the surgeon to frame the discussion with the patient, and help to illustrate concerns that may be encountered. The photographs should be taken to the operating room to provide a reference for the operative plan.
The decision to proceed with rhinoplasty including osteotomies is a complex decision that requires a detailed understanding of the nasal anatomy and a comprehensive evaluation. Generally speaking, osteotomies are best suited for correction of a deviated dorsum, thinning of a broad nasal dorsum, or closing open roof deformities. Rarely, osteotomies can be used to widen an excessively thin dorsum from previous surgery. This review aims to highlight the critical considerations and components in nasal osteotomies.
Evaluation of the bony nasal vault
Evaluation of the nasal framework starts with a comprehensive history. It is important to elicit the specific functional and/or cosmetic complaints of the patient. Use of a hand-held mirror can be beneficial as the patient describes their primary concerns. Prior history of trauma or past nasal surgery could suggest increased scar formation and adhesions, potential fracture lines, and possibly less structural tissue integrity in comparison with congenital cases. Past medical history is also important, because a history of autoimmune diseases affecting the nose, chronic steroid use, or cardiopulmonary disease among other findings may all affect the operative and anesthetic approach.
After eliciting a comprehensive history, a systematic physical examination is performed. Structurally, the nose can be divided horizontally into the osseous, cartilaginous, and lobular thirds roughly corresponding with the nasal bones, upper lateral cartilages, and lower lateral cartilages, respectively. Focusing on the upper third, evaluation should be performed from both the frontal and the lateral views. Palpation is critical to evaluate for bony step-offs, instability, and the thickness of nasal skin overlying the nasal bones. From a frontal view, nasal bone abnormalities can be categorized into deviations and width abnormalities of the vault. The nasal bones should project symmetrically along the sagittal midline. Prior trauma or congenital abnormalities can project the nasal root off the midline. When evaluating the bony width of the nose, the dorsal and ventral width must be evaluated. The dorsal width is defined by the nasal bones at the dorsal projection, helping to contour the brow–tip aesthetic line, while the ventral width is defined by the ascending process of the maxilla. Cochran and colleagues describe that the ventral width should be about 80% of the alar width in the ideal nose; however, this can vary based on gender and race. Notice should be made of a narrow dorsum, particularly as a result of prior osteotomies that may be causing functional obstruction. From the lateral view, one should evaluate the nasofrontal angle and the radix height. Classically, the ideal nasofrontal angle for the Caucasian male ranges from 115° to 130°, although this, too, can vary significantly based on gender and race. Again from the lateral view, evaluation for a dorsal hump is critical, because this is often a prominent cosmetic concern. The need to address a dorsal hump operatively is a key consideration in planning for potential osteotomies. The details of the nasal anatomy must be taken in the context of the facial profile, including forehead profile, dental occlusion, and chin projection.
Preoperative photography is an excellent, objective means to document findings regarding the bony nasal vault and to plan approaches for operative repair. Traditional facial plastic photography should be used, including the anteroposterior, oblique, and lateral views. Ideally, this should be performed in a photo studio with a lighting system to avoid shadows, and with reference to the horizontal Frankfort line. These photographs allow the surgeon to frame the discussion with the patient, and help to illustrate concerns that may be encountered. The photographs should be taken to the operating room to provide a reference for the operative plan.
The decision to proceed with rhinoplasty including osteotomies is a complex decision that requires a detailed understanding of the nasal anatomy and a comprehensive evaluation. Generally speaking, osteotomies are best suited for correction of a deviated dorsum, thinning of a broad nasal dorsum, or closing open roof deformities. Rarely, osteotomies can be used to widen an excessively thin dorsum from previous surgery. This review aims to highlight the critical considerations and components in nasal osteotomies.
Perioperative considerations
Planning for rhinoplasty procedures in which osteotomies may be indicated is imperative. In addition to patient photography and a detailed discussion regarding desired outcomes, an appropriate anesthetic and operative setup are critical to success.
Anesthesia
Rhinoplasty procedures are performed under a wide array of anesthetic plans, including local anesthesia, sedation with local anesthetic, and general anesthesia. The choice of anesthesia is also related to overall patient comorbidities. For relatively straightforward soft tissue rhinoplasty procedures, some advocate for the use of local anesthetic and sedation over general anesthesia, citing less bleeding and postoperative pain. Sklar and colleagues describe performing approximately 80% of their rhinoplasty cases under local with sedation rather than general anesthesia, even when performing routine osteotomies and dorsal hump rasping. However, when cases are expected to take longer than 80 minutes, involve relatively complex structural reshaping, or patients who are not American Society of Anesthesiologists class I or II, they typically prefer general anesthesia. Although definitive data may be lacking, a systematic review and metaanalysis on the management of nasal bone fractures showed that general anesthesia was favored over local anesthesia (with or without sedation) for closed reduction of nasal bone fractures. The metaanalysis showed that trends for patient satisfaction with anesthesia, nasal function, and need for subsequent anesthesia all favored general anesthesia and there was a statistically significant improvement in cosmetic satisfaction when patients underwent general anesthesia. These data suggest that cosmetic outcomes when manipulating the bony vault could be improved under general anesthesia, but the data are far from definitive and the decision should be made on a case-by-case basis.
Adjunct Medications
A handful of adjunct medications have been studied in rhinoplasty to reduce bleeding or postoperative effects. Tuncel and colleagues found that the use of controlled hypotension intraoperatively with perioperative steroids significantly reduced intraoperative bleeding as well as postoperative edema and ecchymosis. Notably, a regimen of 3 doses of dexamethasone (at the start of the operation, at the time of the osteotomy, and 24 hours postoperatively) resulted in statistically less edema at postoperative days 5 and 7 compared with a single dose. A subsequent metaanalysis similarly demonstrated both edema and ecchymosis in rhinoplasty patients was significantly improved with perioperative steroids and that multiple steroid doses seemed to be superior. Ong and colleagues recently published a similar systematic review confirming the usefulness of steroids, as well as intraoperative hypotension, cooling, and postoperative head elevation in reducing postoperative complications. We routinely use perioperative steroids in rhinoplasty cases, as well as perioperative cooling and head elevation, particularly when osteotomies are planned.
More recently, the usefulness of desmopressin for hemostasis in rhinoplasty, particularly with osteotomies, has been described. Initially described in orthognathic surgery, Gruber and colleagues have more recently published on the benefits in nasal osteotomies. They recommend IV dosing of 0.1 μg/kg, typically giving a maximum of 3 doses intraoperatively to assist with bleeding and ecchymosis. Although data are sparse, there have been no reported thrombotic complications and it may offer hemostatic benefits beyond traditional local epinephrine.
Operative techniques
Although the indications and desired outcomes from nasal osteotomy are well-established, the nomenclature, approach, and technique for these osteotomies remains clouded with considerable confusion and debate. In general, an osteotomy is defined as a controlled fracture or cut in the bony pyramid of the nose. Traditionally, this has been performed with a “continuous” osteotomy—a controlled, continuous curvilinear cut (classically performed with a saw or osteotome) completely transecting the bone. More recently, “perforating” osteotomies have gained momentum. Perforating osteotomies are performed as a postage-stamp style of discrete, discontinuous small osteotomies (typically 2-3 mm) along the desired fracture line. The bone is then manually fractured along this line in a controlled fashion, theoretically reducing the soft tissue trauma and subsequent ecchymosis and edema. In an effort to standardize the nomenclature around osteotomies, we have classified osteotomies into 4 types: medial, lateral, transverse, and intermediate. The various approaches, techniques, and limited data supporting them are discussed for each.
The general principle of nasal osteotomies is to mobilize each nasomaxillary complex. This includes the nasal bone and a segment of the ascending process of the maxilla. It is important to note that lateral osteotomies are placed through the maxilla, rather than the nasal bone. This concept involves “picture framing” the bony dorsum to completely mobilize each half. The senior author generally approaches complete mobilization through a medial and lateral osteotomy, which is connected by a transverse osteotomy for full mobilization.
Medial Osteotomy
As the name suggests, the medial osteotomy is performed medially along the nasal bone, separating it from the septum and contralateral nasal bone. In general, this osteotomy is aligned primarily along the parasagittal plane, although a wide array of oblique angles and variations are described. Notably, much of the dissection and manipulation of the medial osteotomy is aided by digital palpation because visualization is limited with the open or endonasal approach.
Dorsal hump
A discussion regarding medial osteotomies should include dorsal hump reduction. In a significant portion of patients undergoing osteotomies, the reduction of the dorsal hump is often a key component in the reshaping of the osseous nasal vault. A dorsal hump is a prominence at or near the rhinion and can be bony and/or cartilaginous. There are multiple techniques described for managing a hump. Joseph and Skoog initially described the use of an osteotome to remove the medial nasal bones along with the dorsal septum and medial upper lateral cartilages. Given the inherent limitations in visualization, this en bloc technique can result in overresection or asymmetry. Therefore, conservative reduction is critical. Once the dorsal hump is excised, an open roof deformity is created. Careful planning must be performed before the bony cut in the dorsal nasal bones is performed. Detailed marking of the skin and the subsequent osteotomy trajectory can be beneficial in avoiding asymmetry. The brow–tip aesthetic lines follow along the contour of the dorsal bony width. This line, along with the projection of the nose from lateral view, can assist the surgeon in planning.
An alternative to the osteotome and en bloc excision of the dorsal nasal bones, many surgeons use a rasp to sequentially file the bony hump. With this approach, the cartilaginous portion is managed sharply. However, the bony dorsum is reduced with either a pull or push rasp. The key advantage of the rasp is the slower, controlled reduction of the bony hump. Frequent redraping of the soft tissue envelope allows the surgeon to gauge the degree of hump reduction that has been performed and evaluate for symmetry.
With either approach, complete removal of the dorsal hump simultaneously completes the medial osteotomy as the nasal bones are mobilized from the septum. Some authors promote extending an obliquely angled medial osteotomy from the hump reduction ; however, this is typically not necessary if combined with a complete lateral and transverse osteotomy, because the transverse osteotomy serves the same function.
The final point of discussion regarding hump reduction is the importance of an open roof deformity. After excising the dorsal hump, the dorsum is left with a flat and wide contour as the nasal bones are separated from the septum. This contour irregularity is referred to as an “open roof” deformity, and results in a prominent dorsal width if not corrected. Correction requires mobilization of the nasomaxillary bone complex and infracture to reduce the width.
Traditional medial osteotomy
If a dorsal hump reduction is not performed, a traditional medial osteotomy is typically required to separate the nasal bones from the septum. A wide array of medial osteotomy trajectories have been described, including fading, straight, and oblique variations. Gruber and colleagues described a wedge of thick, hypervascular bone along the medial, cephalad nasal bones. We prefer to avoid this bone with a gently fading medial osteotomy technique. With this technique, the osteotome is engaged in the caudal edge of the nasal bone adjacent to the septum. The osteotome is initially angled vertically then slowly directed approximately 15° lateral to the sagittal plane ( Fig. 1 A). It is important to note that the medial osteotomy primarily controls the dorsal width. The final consideration in the medial osteotomy is the length of the cut. As the osteotome is gently faded off the sagittal plane, it is imperative to complete the osteotomy before reaching the nasofrontal suture. If the osteotomy is extended through the nasofrontal suture, the thick cephalic bone fulcrums or “rocks” about the suture, resulting in lateralization of the cephalic segment with medialization of the caudal nasal bone. This complication, referred to as a rocker deformity, can be readily visualized through the thin dorsal skin. It can be corrected by performing a transverse osteotomy caudal to the nasofrontal suture line and the nasal bone can then be manipulated without fulcruming across the suture.
