For the vast majority of patients, their top three complaints in order of importance are a “bump” on profile, a lack of tip definition, and a wide nose. Two of these three problems are associated with the dorsum, especially when a “balanced approach” is employed. Anatomically and embryologically, the bony vault and cartilaginous vault are fused into a single entity—the osseocartilaginous vault (OC). During the past 5 years, major changes in surgical techniques have dramatically changed our approach to hump reduction, mid-vault reconstruction, and osteotomies. We strongly advocate rasping off the bony cap to expose the intact underlying cartilaginous vault. Next, the upper lateral cartilages (ULCs) are split off from the anterior septum and reserved for possible spreader flaps. Then, the dorsal profile is lowered by resection of the anterior dorsal septum using scissors. Many types of osteotomies are available, including lateral, medial, and intermediate. The recent introduction of piezoelectric instrumentation (PEI), with its extensive exposure and precise cuts, has led to greater precision in bony vault management. Once the bones have been mobilized, the surgeon must reconstruct the mid vault, using either spreader grafts or spreader flaps. When dorsal augmentation is required, it can be done using autogenous tissue with diced cartilage in fascia (DC-F), which is our preferred technique. Ultimately, the major advances in how we approach the dorsum have resulted in improved aesthetic and functional results.
Osseocartilaginous vault Mid-vault Bony cap Spreader grafts Spreader flaps
This is a preview of subscription content, log in to check access.
Anderson JG, Laney TJ. Combined orthognathic and facial aesthetic surgery with case reports. J Tenn Dent Assoc. 2002;82:52–7.PubMedGoogle Scholar
Becker DG, Toriumi DM, Gross CW, Tardy ME Jr. Powered instrumentation for dorsal reduction. Facial Plast Surg. 1997;13:291–7.CrossRefPubMedGoogle Scholar
Davis RE, Raval J. Powered instrumentation for nasal bone reduction: advantages and indications. Arch Facial Plast Surg. 2003;5:384–91.CrossRefPubMedGoogle Scholar
Ellis DA, Gilbert RW. Analysis and correction of the crooked nose. J Otolaryngol. 1991;20:14–8.PubMedGoogle Scholar
Gerbault O, Daniel RK, Kosins AM. The role of piezoelectric instrumentation in rhinoplasty surgery. Aesthet Surg J. 2016;36:21–34.CrossRefPubMedGoogle Scholar
Ghanaatpisheh M, Sajjadian A, Daniel RK. Superior rhinoplasty outcomes with precise nasal osteotomy: an individualized approach for maintaining function and achieving aesthetic goals. Aesthet Surg J. 2015;35:28–39.CrossRefPubMedGoogle Scholar