HUMP REDUCTION UNDER DIRECT VISUALIZATION

Throughout the years, many surgeons have shown that the bony pyramid can be reliably reduced, repositioned, or augmented through an endonasal approach. Larrabee, however, reports that open rhinoplasty may allow more precise contour refining of the nasal dorsum.He explains that the incidence of profile irregularities may be reduced when procedures are performed via the open approach.10 Larrabee suggests that the benefits of increased exposure to the dorsum, available with the open rhinoplasty approach, should be exploited whenever possible.10 He points out that there is a tendency of some surgeons to treat the bony pyramid in an essentially closed fashion, even when using the open approach.10 In the experience of the senior author (D.G.B.), a closed approach has been reliable for addressing most bony profile problems. However, when performing an open rhinoplasty, the senior author now prefers to undertake hump reduction under direct visualization. With this open approach to the nasal dorsum and because of technical differences relating to the skin positioning, the rhinoplasty surgeon may require a different (i.e., narrower) osteotome from that which was previously used for "closed" hump reduction.

The senior author found that an 8-mm unguarded osteotome is preferable for most bony hump reductions when using an open approach (Figs. 1 and 2). Significantly wider osteotomes may be too wide and can cause injury to the skin–soft tissue envelope when using an open approach.

When the "closed" approach is used, the skin–soft tissue envelope is redraped into anatomic position before the hump excision, and awider osteotome can be accommodated. However, this additional width is not necessary for an open approach. The osteotome needs to be only as wide as the widest point of the hump resection, typically at the rhinion. When using an osteotome for dorsal hump excision under direct visualization, the 8-mm nonguarded osteotome provides a sharp cutting surface and precise size for this procedure. At times-when the patient has a very large hump -a wider osteotome may be preferable. This approach has been especially useful in revision patients where underresection or asymmetric resection has occurred (Figs. 3–6). It has been the senior author’s impression that the direct visualization afforded by this approach allows for more precision in these difficult revision situations.

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