Minimizing nasal dorsum complications

Sharp osteotomes are essential to provide for a clean, precise bony hump excision. When the osteotome is dull, the chance of an asymmetric resection or overresection of the bony hump increases. Some surgeons have at least

Fig. 1. Overresection of the nasal tip cartilages in this patient resulted in predictable, unfavorable changes. (Copyright© Daniel Becker, MD)

two sets of osteotomes and rotate themdone set is always out, being sharpened. Other surgeons sharpen their osteotomes manually, with a sharpening stone, during each case. Both approaches are effective.

An anatomic approach is preferable. Detailed anatomic nasal analysis should guide surgery. When undertaking a hump reduction, the surgeon

Fig. 2. Alar batten grafts may be placed via an external rhinoplasty approach or into a precise pocket made through an endonasal incision as shown here. This graft is nonanatomic and typically is placed caudal to the lateral crura, where there is maximal collapse of the lateral nasal wall and supra-alar pinching. For maximal support, the alar batten graft should extend over the bone of the piriform aperture. (Copyright© Daniel Becker, MD)

Fig. 3. Composite grafts are useful in the treatment of severe alar retraction. (Copyright© Daniel Becker, MD)

should examine the excised tissue, assessing its symmetry, and whether it was the desired excision. If the bony dorsum is rasped, this would not be possible ( Fig. 4 ). Similar anatomic examination of the remaining cartilaginous and bony nasal dorsum also must be undertaken. It is expected that additional, calibrated refinement would be needed and should be undertaken with dogmatic adherence to the anatomic examination. Preoperative markings on the skin may be helpful to some surgeons for hump reduction and for osteotomies. Persistent irregularities of the bony dorsum may be addressed by rasping. The powered rasp is preferable to manual rasping in this situation ( Fig. 5 ) [28,29].

Fig. 4. En bloc resection of the nasal hump allows careful anatomic examination as the surgeon assesses the need for additional, calibrated refinements of the nasal dorsum. (Copyright©� Daniel Becker, MD)

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