Reinserting the Hump in Primary Rhinoplasty

The Gain Is Three-Fold

Jannis Constantinidis, PhD; Georgios Fyrmpas, MSc, PhD

Disclosures

Plast Reconstr Surg Glob Open. 2016;4(10):e1021 

In This Article

Abstract and Introduction

Abstract

Background: Hump reduction in aesthetic rhinoplasty destabilizes the middle vault. Secondary maneuvers are necessary to avoid the long-term functional and aesthetic sequelae of middle vault collapse. We describe a new technique of reinserting the resected hump that combines (a) placement of the modified hump between the upper laterals and (b) bridging sutures between the upper laterals.

Methods: Retrospective review of patients undergoing primary aesthetic rhinoplasty with hump resection.

Results: Sixty-two patients, 46 with a straight and 16 with a deviated nose, enrolled. Twenty-three patients were operated through an open approach and 39 through a closed approach. Osteotomies were necessary in 56 patients. Mean follow-up was 13 months (range, 9–16 mo). A satisfactory result was achieved in all but 3 patients who had visible irregularities. Two of them required minimal rasping under local anesthesia and the third patient refused any further treatment.

Conclusions: Our modification of Skoog's original technique has certain advantages: the hump acts as a spreader and onlay graft, which preserves the natural dorsal lines. The sutures increase the nasal valve angle while preventing displacement of the reinserted hump. Indications include a straight or mildly deviated nose, a long thin-skinned nose with short nasal bones. The technique is also feasible through the closed or open approach and offers a valuable alternative to spreader grafts or flaps.

Introduction

Modification of the nasal profile is one of the most common components in primary aesthetic rhinoplasty. Reduction of an osseocartilaginous hump often leads to an open roof deformity, which is traditionally treated with medialization osteotomies. The ensuing narrowing of the airway at the level of the middle vault may become manifest years postoperatively. A number of solutions have been proposed to tackle both the functional and aesthetic sequelae of the hump resection. The workhorse in middle vault reconstruction is the spreader grafts popularized by Sheen.[1] Dorsal onlay grafts,[2] the push-down–let-down technique,[3] and the spreader flaps[4] are some alternatives. Hump reinsertion was initially proposed by Cottle[5] in 1954 and further developed by Skoog[6] in 1966. The original technique involved hump resection through a transcartilaginous approach, reduction of the hump, and reinsertion of it as an autologous graft. Stabilization of the graft to the anterior septum with an absorbable suture was necessary in some cases. A smooth, stable dorsum, a supported internal nasal valve, sparing of valuable septal cartilage, and short operative time are some of the advantages. The main disadvantage is graft visibility or palpability due to inadequate reduction or displacement. Despite the promising results, only a few surgeons still utilize this technique and its modifications. In this study, we describe a new modification of the Skoog's technique, which combines the modified hump with flaring sutures. The new complex serves 3 functions: that of a dorsal onlay graft, a spreader graft, and a flaring suture.

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