Surgical alteration of the bony pyramid is often anxiety-provoking for the prospective rhinoplasty patient. Just talking about “breaking” the bone in the middle of the face creates fear and apprehension. However, contemporary techniques, combined with sophisticated cutting instruments, intraoperative ice-water cooling, and postoperative mechanical cooling devices to minimize swelling and bruising, have greatly improved surgery of the bony vault. Yet despite technical advances, the most important factor is still a well-conceived and individualized treatment plan executed with meticulous precision and extreme care.

Our treatment philosophy seeks to create bone fragments that are as large as possible and to mobilize them completely so that it becomes much easier to mold a new bony pyramid. Typically this is done using parasagittal medial osteotomies, percutaneous transverse osteotomies, and percutaneous low-to-low lateral osteotomies (Fig. 9.1). By using a 2- or 3-mm osteotomies and the percutaneous technique for the transverse and lateral osteotomies, the blunt force energy is applied at right angles to the bone for more precise bone cut placement, and by using a mallet made from Teflon, the blunt force energy is dissipated like a shock absorber for less tissue trauma. Using this approach, we feel that we can avoid many of the complications resulting from unwanted bony comminution or misplaced bone cuts. We also use a single-access incision for each percutaneous osteotomy (Fig. 9.2). For the lateral osteotomy, the skin incision is placed at the junction of the caudal and medial thirds, and for the transverse osteotomy, the incision is placed at the junction of the central and middle thirds (Fig. 9.3). After inserting the osteotome, we also score the periosteum along the fracture line to displace blood vessels and minimize bleeding and to get a glas cutter effect (Fig. 9.4). Finally, in our practice we have not observed medial displacement of the inferior turbinate head with the low-to-low lateral osteotomy, and therefore we are not using a high-to-low-to-low technique for preserving Webster’s triangle.

When performing the parasagittal medial osteotomy (which is always performed first), we are occasionally confronted with the challenge of achieving straight and symmetrical osteotomy lines when the bony vault is asymmetrical (Fig. 9.5). When a large hump is first removed, a large open roof is produced, and medial osteotomies are unnecessary. But in cases with a small dorsal hump and thick dorsal bone, or in those without a dorsal hump, creation of symmetrical medial osteotomies is best achieved using the Lindemann fraise (Fig. 9.6). Using a power-driven Lindemann fraise, the parasagittal cuts are performed from the inside out and extend cephalically near the intercanthal line. In addition to parallel and straight bone cuts, the Lindemann osteotomies also remove the excess bone (Fig. 9.5) that prevents adequate narrowing of the bony vault. Low-to-low lateral osteotomies are performed next, and the procedure is then completed with transverse osteotomies to fully mobilize the bone fragments. Only in few cases do we perform an oblique osteotomy, which can also be performed with a Lindemann fraise (Fig. 9.7). Ice-water irrigation is then used to prevent bleeding and reduce swelling.

We apply ice water for some minutes, which helps to reduce bleeding and swelling. These techniques help to mobilize the nasal pyramid best, and from our point of view, this is the prerequisite for straightening or narrowing any disfiguration of the nasal pyramid.

Complete mobilization of the bony vault is a prerequisite for straightening and/or narrowing a misshapen bony nasal pyramid. However, aggressive skeletal mobilization also necessitates prolonged external splinting for a favorable surgical outcome. For most noses, 2 weeks of postoperative splinting is adequate, but for a very wide bony vault, we prefer 3 weeks of immobilization using a plaster of Paris splint extending onto the forehead and reinforced by a circular bandage to minimize movement from the mimetic musculature. Removal of the splint after 2 weeks in these cases may result in recurrence of a wide nose (Fig. 9.8).