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Comprehensive Report: Nasal Bone Intervention Techniques in Aesthetic Rhinoplasty

I. Introduction

Nasal bone manipulation is a critical component of modern aesthetic rhinoplasty, especially in structural nose surgeries. It addresses dorsal hump deformities, bony deviations, and base width modifications. Precise osteotomy techniques, combined with appropriate grafting and fixation, are essential to achieve symmetrical, functional, and natural-looking outcomes.

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II. Relevant Nasal Bone Anatomy

Understanding the bony anatomy of the nose is fundamental to planning and executing safe osteotomies:

• Nasal bones: paired and form the upper one-third of the nasal dorsum.
• Frontal processes of the maxilla: articulate laterally with the nasal bones.
• Nasofrontal suture, piriform aperture, and keystone area are key landmarks.
• Important soft tissue attachments and neurovascular structures (e.g., angular vessels) must be preserved during dissection.

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III. Classification of Nasal Bone Deformities

• Dorsal Hump: Caused by overgrowth of nasal bone and septal cartilage.
• Deviated Nasal Pyramid: Congenital or post-traumatic displacement.
• Flat Dorsum: Under-projected nasal bridge, often in Asian or African patients.
• Open Roof Deformity: A result of dorsal hump removal without proper lateral osteotomies.

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IV. Indications and Contraindications

Indications:

• Prominent dorsal hump
• Deviated nasal bones or asymmetrical pyramid
• Wide bony base
• Structural support for implant-based or autologous augmentation

Contraindications:

• Active local infection
• Uncontrolled bleeding disorders
• Poor general anesthesia tolerance
• Severe psychiatric disorders (e.g., BDD)

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V. Surgical Techniques of Bony Nasal Interventions

1. Dorsal Hump Reduction

• Performed with rasps, osteotomes, or piezoelectric devices.
• Precise layer-by-layer removal minimizes over-resection and maintains smooth contours.

2. Medial Osteotomy

• Indicated in wide nasal bones or midline deviations.
• Performed through an endonasal approach using guarded osteotomes.
• Enables midline repositioning and symmetrical narrowing.

3. Lateral Osteotomy

• Purpose: to close open roof deformity and reduce nasal base width.
• Techniques:
  • Internal (endonasal): More commonly used; hides scars.
  • External (percutaneous): Used selectively for better visibility or control.
• Patterns:
  • Continuous or perforated type
  • Low-to-low, low-to-high, or double-level depending on nasal width and anatomy.

4. Intermediate Osteotomy

• Rarely used; indicated for high septal deviations.
• Improves dorsal aesthetic lines in complex nasal pyramid cases.

5. Piezoelectric Osteotomy

• High precision and safety
• Reduces trauma to soft tissues, mucosa, and vessels
• Ideal for revision cases or thin-skinned patients

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VI. Adjunctive Techniques

Spreader Grafts:

• Inserted between upper lateral cartilages and septum to restore internal valve angle and prevent inverted-V deformity post-hump reduction.

Nasal Dorsum Grafts:

• Autologous (e.g., septal, conchal, rib cartilage) or alloplastic (e.g., ePTFE, silicone) materials.
• Restore dorsal height or camouflage post-osteotomy irregularities.

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VII. Complications and Management

Complication	Common Causes	Management
Postoperative nasal deviation	Asymmetric osteotomy or incomplete cut	Early repositioning or revision surgery
Saddle nose deformity	Over-reduction of hump	Dorsal grafting
Epistaxis / hematoma	Mucosal injury, excessive manipulation	Tamponade, surgical evacuation
Nasal obstruction	Internal valve collapse, bony narrowing	Spreader graft or septoplasty
Bony irregularities	Incomplete rasping, rough edges	Camouflage graft or revision rasping

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VIII. Postoperative Care and Follow-Up

• External nasal splint: 5–7 days
• Ice compression and head elevation to reduce edema
• Avoid trauma or pressure on the nose for 4–6 weeks
• Clinical follow-up: 1 week, 1 month, 3 months, and 6 months
• Long-term outcome evaluation includes aesthetic satisfaction and airway function

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IX. Quantitative and Qualitative Outcome Evaluation

Quantitative:

• Dorsal height and width measurements
• Angles: Nasofrontal Angle (115–130°), Nasolabial Angle (90–110°)
• 3D morphometric comparison (pre-op vs. post-op)

Qualitative:

• Standardized pre- and postoperative photography
• Patient satisfaction using Visual Analog Scale (VAS)
• Airway patency via rhinomanometry if needed

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X. References

1. Daniel RK. Rhinoplasty: Nasal Surgery by the Masters. Springer, 2018.
2. Gunter JP, Rohrich RJ. Dallas Rhinoplasty: Nasal Surgery by the Masters. Thieme, 2021.
3. Gerbault O, et al. “Piezoelectric Surgery in Rhinoplasty,” Aesthetic Surgery Journal, 2022.
4. Saban Y. “Advancements in Lateral Osteotomy,” Facial Plastic Surgery Clinics of North America, 2023.
5. Toriumi DM. “Management of Bony Vault Deformities,” Clinics in Plastic Surgery, 2020.

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