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

Operative Technique

The open approach or more often the closed approach was employed depending on the additional maneuvers that were necessary. Local anesthesia with xylocaine 2% and adrenaline 1:200,000 was injected in the columella, intercartilaginous region on both sides, over the dorsum, and in the caudal septum. An intercartilaginous–hemitransfixion incision exposed the anterior septal angle, the cartilaginous septum, and gave adequate access to the ipsilateral lateral crus of the lower lateral cartilage and the nasal dorsum. Any septal modifications and most tip contouring maneuvers would be completed at this stage. This sequence permitted a good appreciation of the size of the hump to be resected to achieve a balanced tip–dorsum relationship. The submuscular aponeurotic system dissection continued up to the root of the nose and laterally over the attachment of the upper lateral cartilages (ULs) to the dorsal septum. The osseocartilaginous dorsum was freed from the underlying mucoperichondrium and mucoperiosteum. Extramucosal dissection, however, was not feasible in some noses with a large hump. One or 2 Aufricht retractors were used to elevate the dorsal soft tissues. The hump was resected in 1 piece (Fig. 1). A scalpel no. 11 was used to separate the cartilaginous part of the hump starting from the bony-cartilaginous junction and proceeding caudally. The osseous part was divided with a Rubin straight osteotome. A greater bony segment would be resected if deepening of a blunt nasofrontal angle was necessary. The hump was first denuded from any underlying soft tissues including the septal remnant and then reduced to the desired size (Figs. 2–6). For the cartilaginous part, a scalpel no. 15 was used, and for the bony part, a bone rongeur or a diamond drill was used (specifically in thin-skinned noses where irregularities would be more evident) (Fig. 4). With the aid of a morselizer, the osseocartilaginous junction of the new hump would be crushed before reinsertion (Fig. 5). This maneuver also provided a desirable flattening of the hump. With the dorsal soft tissues retracted, 2 nonabsorbable monofilament synthetic 5.0 sutures were passed through the corresponding medial edges of the upper laterals (1 at the cephalic end and 1 at the caudal end) (Fig. 7). At this point, the paramedian and percutaneous transverse and lateral osteotomies would take place. No osteotomies were performed in cases with a narrow nasal bridge. Silicon nasal splints would then be sutured on either side of the septum, if a septoplasty had been performed, to stabilize the septum and prevent collapse of the hump. The hump was then placed into position under the arch created by the sutures and the latter were tightened (Fig. 8). The ULs would thus stay lateral to the hump, and any inward movement would be prevented. A suture between the hump and the anterior septal angle would also prevent caudal dislocation of the hump. If a septoplasty was necessary, this could theoretically lead to collapse of the autograft because of an unstable dorsal septum. We stabilized the septum with the insertion of 2 nasal splints before the reinsertion of the autograft. This created a more stable basis for the autograft to rest on during the initial healing period. If interdomal sutures were deemed necessary, they would be performed at this stage. Earlier placement would narrow the space for inserting the modified hump. A light absorbable packing was inserted and patients were discharged home the first postoperative day. Follow-up for review was arranged after 1 week to remove the cast and then in the first, sixth, and twelfth months. Two relevant clinical cases are presented (Figs. 9–11).

Figure 1.

Hump resection.

Figure 2.

Resection of underlying mucosa and septal remnant from the hump.

Figure 3.

Trimming of hump edges with a rongeur to the appropriate shape.

Figure 4.

A diamond burr is used to taper the edges of the hump in thin-skinned patients.

Figure 5.

A morselizer flattens the hump.

Figure 6.

The appropriately sized hump is reinserted.

Figure 7.

Endoscopic view of the suture placement through an openapproach rhinoplasty. Nonabsorbable sutures are passed through the medial edges of the upper lateral cartilages.

Figure 8.

The modified hump is reinserted between the upper lateral cartilages and the knots tightened. The final position of the hump and sutures is shown.

Figure 9.

A, A 29-year-old female patient with a moderate hump and a low radix. Anterior preoperative view. B, Postoperative anterior view after hump reduction and reinsertion through a closed approach. C, Preoperative lateral view. D, Postoperative lateral view. Trimming of the lower lateral cartilages was achieved through bilateral intracartilaginous incisions, which resulted in increased tip rotation. The reinserted hump provided a stable and smooth profile.

Figure 10.

A, Preoperative left oblique view. B, Postoperative left oblique view. C, A 32-year-old female patient with a straight mild hump and low radix. Preoperative anterior view. D, Postoperative anterior view after hump resection, modification, and reinsertion through a closed approach. Reinsertion of the modified hump resulted in a narrower but still functional nasal dorsum.

Figure 11.

A, Preoperative left lateral view. B, Postoperative left lateral view. A straight and balanced profile is achieved. C, Preoperative right oblique view. D, Postoperative right oblique view.

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