Dorsal hump modification is a commonly performed procedure in most rhinoplasties. Specifically, hump reductions play a significant role in aesthetic rhinoplasty when the surgeon and patient wish to have a “smaller” and less projected nasal complex. There are several techniques available in order to perform a hump reduction. The purpose of this article is to review some of the surgical options available for dorsal hump reduction and management of the dorsum following this procedure.
Key points
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Recognition of exact cause of a dorsal hump is critical; is it a nasal issue or a maxillary issue?
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Completion of all necessary steps in order to reduce a bony hump is very important.
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Addressing the nose following a large hump removal is imperative and must be adhered to.
Introduction
Nasal hump reduction is a commonly performed procedure in most rhinoplasties, especially in Caucasian rhinoplasty whereby overprojection of the nasal complex might be a cosmetic concern. Achieving smooth dorsal lines, a balanced nose shape, and an aesthetic transition from the nasal bridge toward the nasal tip are requirements for an ideal rhinoplasty outcome. The keystone area of the nose comprises the dorsal hump, the area where the nasal bones of the bony vault attach to the cartilaginous vault (dorsal septum and upper lateral cartilages). This osseocartilaginous junction corresponds to the rhinion anatomically. There are multiple issues that can create a true dorsal hump, or give the “illusion” of an existence of a dorsal hump. Essentially, a dorsal hump is made up of overprojected upper lateral cartilages, tall nasal bones, an overprojected dorsal septum, or a combination of the above. In this article, a brief overview of the causation of dorsal hump is presented followed by surgical options available to address this deformity. Management of the nasal dorsum following hump reduction is also highlighted.
Assessment
It is the authors’ opinion that 3 distinct areas must be assessed when examining the nose from a profile view. These areas include the radix, middorsum, and the nasal tip. All 3 areas can, either independently or collectively, contribute to an actual dorsal hump or create an “illusion” of a dorsal hump.
Although there are multiple measurements, angles, and assessment tools for analyzing the objective size of an ideal nose, there is no substitute for experience and an aesthetic sense. A low radix can certainly contribute to the creation of a “pseudo-hump” as well as an underprojected or ptotic nasal tip. This is certainly highlighted when evaluating a patient for a maxillary orthognathic surgery. Patients’ noses with anterior-posterior vector deficiency of the maxilla have the appearance of a large dorsal hump because of underprojection of the nasal tip. On correction of the nasal tip by advancing the anterior nasal spine during a maxillary osteotomy, the “pseudo-hump” disappears ( Figs. 1 and 2 ). Oftentimes, dorsal augmentation, or appropriate tip support, as opposed to dorsal hump reduction, is what is actually necessary for some patients with a low radix or an underprojected nasal tip ( Fig. 3 ).
The middorsum certainly is the main area of focus during the examination of the nose in profile. An appropriate assessment of the size of the hump and its components is critical in the preoperative period. Dorsal humps come in a variety of sizes and shapes and as aforementioned are made up of cartilage (dorsal septal cartilage, upper lateral cartilages) as well as bone (nasal bones) ( Fig. 4 ). Typically, there is a lateral bony extension along the dorsal sidewalls that must also be accounted for during surgery.
Surgical Considerations
Hump removal can be performed via the open structure technique (preferred method of the authors) or via the endonasal closed technique. Before the actual hump reduction, the surgeon must decide how much of the dorsum to remove and whether to proceed with the hump reduction before or following harvesting of the septum. The actual amount of the hump reduction is really an aesthetic assessment; assuming the radix and nasal tip are supported appropriately and of adequate size, a few millimeters reduction is all that is typically necessary. Undercorrection/overcorrection of the hump can lead to deformities that would later require a revision rhinoplasty. Imbalance between resection of cartilaginous part of the hump and the bony part may lead to a “pollybeak deformity.” It is imperative to account for the amount of hump reduction when deciding to preserve a 10-mm “L”-strut of the membranous septum. If the surgeon leaves a 10-mm L-strut and then proceeds with a 4-mm hump reduction, the remaining strut may no longer be 10 mm (as the dorsal septum usually contributes to the hump), and this could certainly lead to collapse of the midvault. For this reason, the authors’ preference is to always reduce the hump before any septal harvest. The authors elevate the nasal mucosa off the underside of the dorsal hump (underside of upper lateral cartilages and dorsal septum) before its resection, as it is routinely performed during a septoplasty but without actually removing the septum. Once the ideal dorsal lines have been created, then the septal harvest is begun.
Surgical Options
After appropriate exposure, the hump is visualized (via open technique), and a decision must be made regarding its management. Regardless of the technique used, it is important to reconstruct the keystone area after major hump reduction (see later discussion). A variety of options exist for management of a dorsal hump, including the following:
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Hand-held rasps
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Rotary instrument
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Traditional drills versus ultrasound drills (Piezo)
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Blade and double-guarded osteotome
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Push-down technique (keystone preservation technique)
Small, cartilaginous humps can easily be addressed using rasps. Rasps should be used in a pulling motion and should proceed from the most coarse to the most fine working ends ( Fig. 5 ). Use of a rasp alone may lead to formation of some irregularities of the dorsum; therefore, it is important to redrape the soft tissue frequently to ensure proper reduction and avoidance of overresection.
