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Nuances in component nasal hump reduction
Journal of Plastic, Reconstructive & Aesthetic Surgery (2018) 71, 178–184
Nuances in component nasal hump reduction Haneen Sadick a,*, Julian M. Rowe-Jones b, Holger G. Gassner c a
Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Mannheim, Medical Faculty of the University of Heidelberg, Theodor-Kutzer-Ufer, Mannheim 68135, Germany b Private Practice, The Nose Clinic, St Mary’s House, Guildford, Surrey, GU1 3PY & 152 Harley St, London W1G 7LH, UK c Finesse Center for Facial Plastic Surgery, Froehliche Tuerkenstrasse 8, Regensburg 94047, Germany Received 20 August 2017; accepted 4 October 2017
KEYWORDS Component hump reduction; Upper lateral cartilage; Cartilage preservation; Bony vault; Rhinoplasty
Summary Importance: Nasal hump reduction is a frequent manoeuvre in rhinoplasty. Over the last years, composite hump reduction has been advocated in favour of component hump reduction. The latter allows a more controlled and stepwise approach in reducing the nasal dorsum by deprojecting the cartilaginous dorsum separately from the bony dorsum. This approach also preserves the upper lateral cartilages (ULCs) and their mucosa. Objective: To analyse the intricacies of the anatomic transition zone between the ULCs, the rhinion and the nasal bones as they pertain to component hump reduction. Method: Anatomical dissections with five fresh cadaveric heads were performed in this study. The cephalic extension of the ULCs beneath the nasal bones was modified and measured after component hump reduction on both sides of the rhinion. Results: Central detachment of the ULCs from the bony dorsum and their release from the medial undersurface of the nasal bones allows for complete preservation of the ULCs. This is achieved by inferior-medial rotation of the cephalic ends of the ULCs against the septum. If not released completely during hump reduction, a substantial loss of the ULCs may be the consequence. Conclusions: The described manoeuvre allows the preservation of the cephalic components of the ULCs underneath the bony dorsum during component hump reduction. The result is a smoother transition line at the keystone area and along the entire bony-cartilaginous dorsum with a straighter aesthetic dorsal profile and oblique view. The present findings allowed us to present an operative algorithm with implementation into clinical practice. © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Parts of this study were presented at the Annual Meeting of the European Academy of Facial Plastic and Reconstructive Surgery in September 2016 in London, UK. * Corresponding author. Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Mannheim, Theodor-Kutzer-Ufer, Mannheim 68135, Germany. E-mail address: [email protected] (H. Sadick). https://doi.org/10.1016/j.bjps.2017.10.012 1748-6815/© 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Nuances in component nasal hump reduction
Introduction In many rhinoplasty procedures, reduction of the osseocartilaginous hump becomes an essential step during surgery. The anatomy of this region is complex, with many anatomical structures represented. Hump reduction, particularly if osteotomies are also performed, causes significant disruption that needs reconstruction. Possible sequelae include dorsal irregularities, inverted-V deformities or excessive narrowing of the middle vault. Anatomically, the bony vault is composed of the nasal bones. They attach superiorly to the frontal bone and laterally to the nasal process of the maxilla. Their inferior portion attaches to and overlaps the cephalic border of the upper lateral cartilages (ULCs).1 This is an important aspect the authors will reflect on later in more detail. The middle vault area consists of both the ULCs laterally and the septum medially. It provides a larger contribution to the dorsal hump than the paired nasal bones. The keystone area (K-area) marks the skeletal surface transition from the osseous to the cartilaginous dorsum. This specific area is characterised by its T-shaped contour and represents the widest part of the nasal dorsum. The ULCs join with the septum and form a ‘unified cartilaginous arch’, a term that has been coined by Rollin Daniel.2,3 Another anatomic key-point is the fact that the ULCs extend cranially beyond the K-area along the undersurface of the nasal bones.1,4,5 This underlap can vary between 4 and 14 mm in length and 3 and 9 mm in width.6 This anatomic peculiarity has an important impact on the stability of the bony vault and surgical interventions such as component hump reduction. Component hump reduction is nowadays the gold standard in nasal hump reduction. It has displaced composite hump reduction over the past few years and addresses the bony and the cartilaginous dorsum individually.7–9 This technique allows deprojection of the nasal hump in a more controlled and step-wise fashion. It describes the detachment of the ULCs from the septum at the cartilaginous dorsum before the septum is reduced. Bone reduction can be performed before or after this step. As a consequence, the horizontal component of each ULC is preserved. This facilitates maintenance of strength, stability, and width of the middle vault. The risk of a middle vault collapse or an inverted-V-deformity and the routine use of spreader grafts is minimised. This important aspect reflects the outstanding role in preserving the ULCs during hump reduction.10–12 Interestingly, many studies address the effect component hump reduction has on the cartilaginous dorsum in the middle vault area.13 The authors see the need to emphasise subtle nuances in component hump reduction that are not specifically addressed in the literature. These pertain especially to the relationship of the ULCs to the bony dorsum at the rhinion, namely the dorsal and lateral K-areas. The fact that a significant underlap of the ULCs under the nasal bones exists has not received widespread attention. The bony dorsum is a cap over the cartilaginous dorsum. The purpose of the present study was to analyse the transition of the ULCs to the bony dorsum and the septum during component hump reduction. The authors introduce an algorithm for reconstitution of the
179 bony-cartilaginous dorsum with refinements in component hump reduction.
Materials and method The present study was performed at the Division of Facial Plastic Surgery, Department of Otolaryngology, University Hospital of Mannheim and the Department of Anatomy, University of Regensburg, Germany. Data analysis and production of the manuscript was completed at the Division of Facial Plastic Surgery, Department of Otolaryngology, University Hospital of Mannheim, the Finesse Center for Facial Plastic Surgery in Regensburg, Germany, and the Nose Clinic, Guilford/London, UK. The study encompasses a human cadaver study on five fresh frozen cadaver heads with implementation of the anatomical findings into surgical practice. The authors describe a more detailed surgical algorithm in component hump reduction.
Anatomical study on human cadaver heads A total of five fresh frozen cadaver heads were used. Dissections were performed using headlight illumination and loupe magnification with standard instruments. Key findings and standardised surgical manoeuvres were documented using macrophotography with a Nikon D90 camera (Nikon Inc, Melville, New York), Sigma 17–70 mm, 1:2.8 Macro lens (Sigma Inc, Ronkonkoma, New York) and Sigma EM 140 iTTL macro ring light (Sigma Inc, Ronkonkoma, New York). The camera setting was as follows: aperture F18, shutter speed 1/60 s, ISO 200, white balance flash, manual focus and 70 mm focal length. All photographs were taken in the axial plane at an angle of 45° to the Frankfurt horizontal plane from below. Steps of dissection In all specimens, a midline incision was performed from the glabella to the nasal tip. The incision was carried along the columella and ended in the philtrum of the upper lip. The skin and soft tissue envelope was raised and dissected off the nose in the supraperichondrial plane on the cartilaginous dorsum and the subperiosteal plane on the bony dorsum to expose the underlying bony and cartilaginous structures. The ULCs and the adjacent septal cartilage were separated from the lower lateral cartilages (LLCs) by extending the intercartilaginious incisions into a transfixion incision. This exposed the inferior border of the ULCs and the septum. The underlying mucosa was then released from both the ULCs. In each cadaver head specimen, the bonycartilaginous hump was marked as a dotted line with a skin marker. The anterior border of the nasal bones was marked at the K-area using a 27-Gauge needle. Both the ULCs were then released from the septum in the subperichondrial plane, leaving a 1-mm gap between the ULCs and the septum (Figure 1a-b). From here on, the ULCs on both sides of the rhinion were dissected differently before performing component hump reduction. In all five cadaveric heads on each left side, the ULC was left attached to the nasal bone. On each right side, the medial aspect of the ULC was disarticulated from the
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Figure 1 (A) Exposure of the bony-cartilaginous dorsum after dissecting off the soft tissue envelope. Marking of the anterior border of the nasal bones at the K-area with a 27-gauge needle. Release of both the ULCs form the septum in the subperichondrial plane. (B) On the left side of the rhinion, the ULC is left attached to the nasal bone. On the right side of the rhinion, the medial aspect of the ULC is disarticulated from the nasal bone and dissected further cranially along its entire extent. The wooden stick indicates the gap between the ULC and the nasal bone on the right side of the rhinion. (C) Inferior-medial rotation of the detached right ULC towards the septum. The cranial part of the ULC turns into a transverse segment. The size of this segment correlates to the amount of hump reduction needed. (D) Situation after subsequent reduction of the bony-cartilaginous hump. On the right side of the rhinion, preservation of the entire ULC along the cartilaginous and bony vault area. Scoring of the remaining right ULC to be used as auto-spreader flap. On the left side of the rhinion, a substantial loss of the ULC cranial to the K-area.
nasal bone by sliding a No.15 scalpel blade or a Cottle elevator underneath the nasal bone. The dissection was then taken further cranially along the undersurface of the nasal bone up to the entire extent of the ULC. The amount of detachment of the medial segment of the ULC correlated to the amount of hump to be reduced (Figure 1c-d). Subsequently on both sides of the rhinion, the septum and the bony portions of the dorsal hump were resected using a No.11 scalpel blade and a 14-mm Rubin osteotome under direct vision. No further osteotomies were performed. The remaining ULCs were then scored along the line corresponding to the height of the dorsal septal resection line, folded over as an auto-spreader flap and secured to the lateral portion of the ULC with 5/0 monofilament nonabsorbable sutures. The anterior border of the nasal bones at the K-area was then marked again with a 27-gauge needle; the hump reduction was completed (Figure 1e-1f), and the degree of tissue gap between the septum and the lateral nasal bones along the bony vault area was documented as x. Study endpoints The study endpoint was to determine the amount of tissue gap due to a loss of bridging tissue between the septum and the lateral nasal bones along the bony vault area by comparing both sides of the rhinion. Therefore, digital photographs
were taken and transferred to Adobe Photoshop (Adobe photoshop CS5 extended, Version 12.0 × 64). The surface area of the ‘above-mentioned tissue gap’ on both sides of the rhinion was measured using Photoshop marking tools and compared.
Implementation of the surgical technique in clinical practice All surgeries were performed under general anaesthesia in patients with a moderate–to-severe dorsal hump. Local anaesthesia with 1% lidocaine and 1:1.000 adrenaline was used for vasoconstriction and hydrodissection. Standard rhinoplasty instruments were used. Either an open approach or an endonasal approach was used to raise the skin envelope and access the osseocartilaginous dorsum. From the findings of the anatomic study, a more detailed and nuanced approach to component hump reduction with specific focus on the bony vault area was defined (Figure 2a-d). Similar to the standard procedure of component hump reduction, the septal mucoperichondrium was first dissected bilaterally using a Cottle elevator. This was then followed by careful release of the ULCs from the junction with the dorsal septum in a subperichondrial plane. Great care was taken to
Nuances in component nasal hump reduction
181 medial aspects of the nasal bones. By sliding in the elevator further cranially underneath the nasal bones, the entire length of the ULCs was preserved along the bony vault area. This manoeuvre resulted in an inferior-medial rotation of the detached part of ULCs towards the septum, thus generating a transverse segment of up to 4 mm of the ULCs, which retained its original arch shape. The amount of detachment correlated with the amount of hump reduction needed. Because of the inferior-medial rotation towards the septum, no additional fold-in manoeuvre with a Brown-Adson forceps before hump reduction was required (Figure 2b). The next steps paralleled the standard procedures of component hump reduction. First the cartilaginous dorsum was reduced by taking down the septum with a No.11 scalpel blade. Then the bony dorsum was reduced with a 14-mm Rubin osteotome, taking care not to injure the preserved transverse segment of the ULCs beneath the nasal bones (Figure 2c). After hump reduction, the ULCs were realigned to the septum, either scored or unscored as an auto-spreader flap or after placement of an additional spreader graft (Figure 2d).
Results Anatomical dissections
Figure 2 A) Bilateral dissection of the septal mucoperichondrium with a Cottle elevator. B) Careful separation of the ULCs from the dorsal septum in a subperichondrial plane along the cartilaginous and bony vault area. C) Detachment of the ULCs from the medial aspect of the nasal bones at the K-area and the undersurface of the nasal bones. D) Reduction of the cartilaginous and bony dorsum while preserving the cranial segment of the ULCs in the bony vault area. E) Preservation of the entire length of the uncapped ULCs after hump reduction. F) Realignment of the ULCs with the septum as autospreader flaps.
preserve the integrity of the underlying mucoperichondrium of the ULCs to prevent the potential for late cicatricial narrowing of the internal nasal valve (Figure 2a). Other than in standard procedures for component hump reduction, the No.15 scalpel blade was now placed at the K-area to detach the ULCs from their attachments to the
The detachment of the right ULC from the medial aspect of the nasal bone resulted in a height difference of x to 2 mm between the right ULC and the bony dorsum at the K- area (Figure 3a). This manoeuvre helped spare the entire cranial segment of the right ULC. The ULC started to turn downwards with an inferior-medial rotation towards the septum. This generated a transverse segment of the cranial part of the ULC of up to 4 mm in the bony vault area (Figure 3b). After bony hump reduction, a substantial loss of the left ULC at the K-area and the bony vault area could be stated. The right ULC could be preserved in its entire length along the bony and middle vault area. On both sides of the rhinion, the amount of open roof resulting from the hump reduction was determined by measuring the gap between the remaining ULC and the septum in the bony vault area (Figure 3c). The average gap ratio between the right and the left ULC to the septum on both sides of the rhinion was 1:2 (Table 1). In all five cadaver head specimens on average, twice the amount of ULC was lost, if not detached, from the nasal bone and preserved in the bony vault area.
Surgical technique and algorithm defining the nuances in component hump reduction The algorithmical approach of dissection comprised 6 major steps that were as follows: 1) Separation of the ULCs from the dorsal septum in the subperichondrial plane 2) Additional separation of the ULCs from the junction with the dorsal septum beneath the nasal bones 3) In correlation with the amount of hump reduction required, defined detachment of the ULCs from the medial aspect of the nasal bones at the K-area and their undersurface
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Figure 3 A) Height difference of x to 2 mm between the right ULC and the bony dorsum at the K-area after detachment of the right ULC from the medial aspect of the nasal bone. B) Inferior-medial rotation of the entire cranial segment of the right ULC towards the septum. Generation of a transverse segment of the cranial part of the ULC of up to 4 mm along the bony vault area. C) On both sides of the rhinion, measurements of the tissue gap between the remaining ULC and the septum in the bony vault area after subsequent hump reduction.
Table 1 Measurement of the gap between the ULCs and the septum in the bony vault area after bony hump reduction. ULC on the right side of the rhinion initially detached from the K-area and the nasal bone; ULC on the left side of the rhinion initially left attached to the nasal bone before hump reduction. (n)
Right side (mm)
Left side (mm)
Ratio, right to left side
Specimen head 1 Specimen head 2 Specimen head 3 Specimen head 4 Specimen head 5
1 1 1.5 1 1.5
2 3 3 2 3
1:2 1:3 1:2 1:2 1:2
4) Reduction of the cartilaginous dorsum 5) Reduction of the bony dorsum while preserving the cranial segment of the ULCs in the bony vault area, comparable to an ‘uncapping’ of the ULCs with maintenance of the transverse segment of the ULCs at the bony vault area 6) Realignment of the ULCs with the septum with suture fixation as auto-spreader flaps or with additional spreader grafts Special focus was placed on steps 3 and 5 that deviated from the established standard of component hump reduction (Figure 4).
Discussion The standard procedure of component hump reduction, as described in the literature, relates to an individual reduction of each component of the nasal dorsum with maximised accuracy and control of resection.7 The ULCs are detached from the septum before the hump is resected. Interestingly, most of the reports refer to the separation of the ULCs from the septum only up to the K-area to spare the ULCs during
cartilaginous hump reduction. This manoeuvre is then followed by the bony hump resection. However, when it comes to the bony hump resection, literature reports on component hump reduction seem to neglect the presence of the ULCs in the bony vault area.7 In many cases, the subsequent reduction of the bony hump incurs a substantial loss of essential medial parts of the triangular cartilages. As a result, the absence of this bridging tissue between the septum and the lateral nasal bones along the bony vault area often necessitates further complex manoeuvres to close the gap. If the ULCs are not preserved meticulously between the lateral nasal bones, the absence of the bridging tissue may induce contour deficiencies, a substantial problem that cannot be solved by osteotomies. Osteotomies primarily narrow the bony dorsal aesthetic lines but do not close the ‘soft tissuecartilage’ gap in the bony vault area. This aspect reflects the possible limitations of conventional osteotomies. The authors believe that it is the preservation of the ULCs between the lateral nasal bones in the bony vault area that defines the contour of the nose, particularly in those cases with ‘parenthesis’-shaped bone edges after bone removal when osteotomies do not achieve straight, parallel and narrow bony dorsal aesthetic lines. The anatomical observations in this study could verify these findings, especially in those cases where the medial aspect of the ULCs was not detached from the nasal bones and thus not spared during component hump reduction. The key steps of dissection that mark the nuances in component hump reduction and differ from the standard procedure of component hump reduction focus mainly on the bony vault area. The aim is to preserve the ULCs cranially to the K-area underneath the nasal bones.14,15 This requires the detachment of the medial aspect of the ULCs from the nasal bones at the K-area and underneath the entire length of the nasal bones. The additional separation of the cephalic edge of the ULCs from the septum results in lowering of the detached cephalic part of the ULC with downward and inward rotation against the septum. The advantage is that a horizontal segment of the ULC similar to a ‘transversal shoulder’ can be preserved with a variable width of up to 3–4 mm, depending on the amount of hump reduction needed. This manoeuvre may be the subject of controversy.
Nuances in component nasal hump reduction
183 but they do not collapse into the nasal vestibulum completely. Two factors are responsible for this residual stability within the upper and middle vault area: first, the intentionally induced but rather defined and limited degree of height loss seen in the cephalic segment of the ULC correlates to the amount of hump to be resected.14,15 Second, the underlying mucoperichondrium of the ULC acts as an internal splint and mimics a hammock for the detached ‘transverse shoulder’ of the ULC.19 The main advantage of this key step of dissection is that the bony cap of the nasal hump is isolated and can be reduced without any injury to the underlying cartilaginous framework of the nose. This allows preservation of the natural T-bar of the ULCs and the septum as long as no additional cartilaginous hump reduction is needed.14 Moreover, no additional tissue gap between the septum and the lateral nasal bones is created, and the middle vault area has been left intact. In some cases, particularly those in whom only a small hump has been removed, osteotomies to close the ‘nasal roof top’ can be avoided. In the case of a separation of the ULCs from the septum, as performed in our anatomical dissections, the preserved cephalic edges of the ULCs can be easily realigned to the septum, thus re-establishing the ‘natural arch shape’ between the ULCs and the septum. The anatomical dissections in this study underlined the important role of the ULCs for the overall contour and aesthetic result in rhinoplasty, especially after hump reduction, because the ULCs not only define the middle third but also the upper third of the dorsal aesthetic lines. The authors employ this modified technique of component hump reduction routinely on all primary rhinoplasty cases that present with a dorsal hump. In techniques with non-powered instruments, this has become the standard method for dorsal hump reduction, with more accurate reconstruction of the middle and upper third of the nose. The authors believe that these modifications to component hump reduction have an important impact on the aesthetic outcome and surgical workflow.
Conclusion
Figure 4 A 28-year-old woman presented with a bonycartilaginous hump (preoperative pictures, left side). Thirteen months after component hump reduction with preservation of the ULCs along the bony and cartilaginous vault, with other procedures such as tip-plasty and osteotomies (postoperative pictures, right side). Postoperatively, the patient had no nasal airway obstruction. A smooth transition line at the K-area with a straight aesthetic dorsal profile could be achieved.
Some authors discourage from doing so and argue that the ULCs lose stability in the middle vault area.16–18 This argument calls for detailed analysis: anatomical dissections in 5/5 cadaveric heads showed that the ULCs lose height to the bony dorsum and rotate inferior-medially against the septum,
In this study, the authors present a more detailed approach to component hump reduction. The key steps of dissection that mark the differences to the previous standard technique of ‘component hump reduction’ mainly focus on the bony vault area. Prior to the bony hump reduction, the medial aspects of the ULCs are detached from the undersurface of the nasal bones at the K- area along their entire length. The detachment correlates to the amount of bony hump to be resected. This results in an intentional sagging of the medial aspect of the cranial border of the ULCs into the nasal vestibulum without collapsing totally. The ULCs remains attached to the lateral aspect of the nasal bones and to the piriform aperture at the lateral sidewalls. The cephalic components of the ULCs underneath the bony dorsum can be preserved more easily and allow a smoother transition line not only at the K-area but also along the entire bonycartilaginous dorsum. These refinements in component hump reduction, as presented in this study, may enhance a straighter appearance of the aesthetic dorsal profile. The need of grafting material to camouflage dorsal irregularities may be minimised.
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Conflict of interest None.
Funding None.
References 1. Tardy ME, Brown RJ. Surgical anatomy of the nose. New York: Raven Press; 1990. 2. Daniel RK, Letourneau A. Rhinoplasty: nasal anatomy. Ann Plast Surg 1988;20(1):5–13. 3. Daniel RK. The osseocartilaginous vault. In: Daniel RK, editor. Rhinoplasty. Boston: Little, Brown and Company; 1993:169– 214. 4. McKinney P, Johnson P, Walloch J. Anatomy of the nasal hump. Plast Reconstr Surg 1986;77:404. 5. Manavbasi YI, Kerem H, Basaran I. The role of upper lateral cartilage in correcting dorsal irregularities: section 2. The suture bridging cephalic extension of upper lateral cartilages. Aesthetic Plast Surg 2013;37:29–33. 6. Palhazi P, Daniel RK, Kosins AM. The osseocartilaginous vault of the nose: anatomy and surgical observations. Aesthetic Surg J 2015;35(3):242–51. 7. Rohrich RJ, Muzaffar AR, Janis JE. Component hump reduction: the importance of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg 2004;114:1298–308, discussion 13091312. 8. Halewyck S, Michel O, Daele J, Gordts F. A review of nasal hump reduction, with a particular emphasis on a comparison of component and composite removal. B-ENT 2010;6:41–8.
H. Sadick et al. 9. Lohuis PJFM, Faraj-Hakim S, Knobbe A, Duivesteijn W, Bran GM. Split hump technique for reduction of the overprojected nasal dorsum. Arch Facial Plast Surg 2012;14(5):346–53. 10. Roostaeian J, Unger JG, Lee MR, Geissler P, Rohrich RJ. Reconstitution of the nasal dorsum following component hump reduction in primary rhinoplasty. Plast Reconstr Surg 2014;133:509– 18. 11. Ozmen S, Ayhan S, Findikcioglu K, Kandal S, Atabay K. Upper lateral cartilage fold-in-flap: a combined spreader and/or splay graft effect without cartilage grafts. Ann Plast Surg 2008;61: 527–32. 12. Gruber RP, Perkins SW. Humpectomy and spreader flaps. Clin Plast Surg 2010;37:285–91. 13. Manavbasi YI, Basaran I. The role of upper lateral cartilage in dorsal reduction after hump excision: section 1. Spreader flap modification with asymmetric mattress suture and extension of the spreader effect by cartilage graft. Aesthetic Plast Surg 2011;35:487–93. 14. Gruber RP, Melkun ET, Woodward JF, Perkins SW. Dorsal reduction and spreader flaps. Aesthetic Surg J 2011;31(4):456–64. 15. Arslan E, Aksoy A. Upper lateral cartilage-sparing component dorsal hump reduction in primary rhinoplasty. Laryngoscope 2007;117:990–6. 16. Sharafi M, Jalessi M, Adamson P. Newly designed upper lateral cartilage flap for preventing depression of the keystone area in large-nose septorhinoplasty. JAMA Facial Plast Surg 2015;17(6): 399–404. 17. Gassner HG, Mueller-Vogt U, Strutz J, Kuehnel T. Nasal tip recontouring in primary rhinoplasty: the endonasal complete release approach. JAMA Facial Plast Surg 2013;15(1):11–16. 18. Gassner HG, Friedman O, Sherris DA, Kern EB. An alternative method of middle vault reconstruction. Arch Facial Plast Surg 2006;8(6):432–435. 19. Gerbault O, Daniel RK, Kosins AM. The role of piezoelectric instrumentation in rhinoplasty surgery. Aesthetic Surg J 2016; 36(1):21–34.
Nuances in component nasal hump reduction Haneen Sadick a,*, Julian M. Rowe-Jones b, Holger G. Gassner c a
Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Mannheim, Medical Faculty of the University of Heidelberg, Theodor-Kutzer-Ufer, Mannheim 68135, Germany b Private Practice, The Nose Clinic, St Mary’s House, Guildford, Surrey, GU1 3PY & 152 Harley St, London W1G 7LH, UK c Finesse Center for Facial Plastic Surgery, Froehliche Tuerkenstrasse 8, Regensburg 94047, Germany Received 20 August 2017; accepted 4 October 2017
KEYWORDS Component hump reduction; Upper lateral cartilage; Cartilage preservation; Bony vault; Rhinoplasty
Summary Importance: Nasal hump reduction is a frequent manoeuvre in rhinoplasty. Over the last years, composite hump reduction has been advocated in favour of component hump reduction. The latter allows a more controlled and stepwise approach in reducing the nasal dorsum by deprojecting the cartilaginous dorsum separately from the bony dorsum. This approach also preserves the upper lateral cartilages (ULCs) and their mucosa. Objective: To analyse the intricacies of the anatomic transition zone between the ULCs, the rhinion and the nasal bones as they pertain to component hump reduction. Method: Anatomical dissections with five fresh cadaveric heads were performed in this study. The cephalic extension of the ULCs beneath the nasal bones was modified and measured after component hump reduction on both sides of the rhinion. Results: Central detachment of the ULCs from the bony dorsum and their release from the medial undersurface of the nasal bones allows for complete preservation of the ULCs. This is achieved by inferior-medial rotation of the cephalic ends of the ULCs against the septum. If not released completely during hump reduction, a substantial loss of the ULCs may be the consequence. Conclusions: The described manoeuvre allows the preservation of the cephalic components of the ULCs underneath the bony dorsum during component hump reduction. The result is a smoother transition line at the keystone area and along the entire bony-cartilaginous dorsum with a straighter aesthetic dorsal profile and oblique view. The present findings allowed us to present an operative algorithm with implementation into clinical practice. © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Parts of this study were presented at the Annual Meeting of the European Academy of Facial Plastic and Reconstructive Surgery in September 2016 in London, UK. * Corresponding author. Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Mannheim, Theodor-Kutzer-Ufer, Mannheim 68135, Germany. E-mail address: [email protected] (H. Sadick). https://doi.org/10.1016/j.bjps.2017.10.012 1748-6815/© 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Nuances in component nasal hump reduction
Introduction In many rhinoplasty procedures, reduction of the osseocartilaginous hump becomes an essential step during surgery. The anatomy of this region is complex, with many anatomical structures represented. Hump reduction, particularly if osteotomies are also performed, causes significant disruption that needs reconstruction. Possible sequelae include dorsal irregularities, inverted-V deformities or excessive narrowing of the middle vault. Anatomically, the bony vault is composed of the nasal bones. They attach superiorly to the frontal bone and laterally to the nasal process of the maxilla. Their inferior portion attaches to and overlaps the cephalic border of the upper lateral cartilages (ULCs).1 This is an important aspect the authors will reflect on later in more detail. The middle vault area consists of both the ULCs laterally and the septum medially. It provides a larger contribution to the dorsal hump than the paired nasal bones. The keystone area (K-area) marks the skeletal surface transition from the osseous to the cartilaginous dorsum. This specific area is characterised by its T-shaped contour and represents the widest part of the nasal dorsum. The ULCs join with the septum and form a ‘unified cartilaginous arch’, a term that has been coined by Rollin Daniel.2,3 Another anatomic key-point is the fact that the ULCs extend cranially beyond the K-area along the undersurface of the nasal bones.1,4,5 This underlap can vary between 4 and 14 mm in length and 3 and 9 mm in width.6 This anatomic peculiarity has an important impact on the stability of the bony vault and surgical interventions such as component hump reduction. Component hump reduction is nowadays the gold standard in nasal hump reduction. It has displaced composite hump reduction over the past few years and addresses the bony and the cartilaginous dorsum individually.7–9 This technique allows deprojection of the nasal hump in a more controlled and step-wise fashion. It describes the detachment of the ULCs from the septum at the cartilaginous dorsum before the septum is reduced. Bone reduction can be performed before or after this step. As a consequence, the horizontal component of each ULC is preserved. This facilitates maintenance of strength, stability, and width of the middle vault. The risk of a middle vault collapse or an inverted-V-deformity and the routine use of spreader grafts is minimised. This important aspect reflects the outstanding role in preserving the ULCs during hump reduction.10–12 Interestingly, many studies address the effect component hump reduction has on the cartilaginous dorsum in the middle vault area.13 The authors see the need to emphasise subtle nuances in component hump reduction that are not specifically addressed in the literature. These pertain especially to the relationship of the ULCs to the bony dorsum at the rhinion, namely the dorsal and lateral K-areas. The fact that a significant underlap of the ULCs under the nasal bones exists has not received widespread attention. The bony dorsum is a cap over the cartilaginous dorsum. The purpose of the present study was to analyse the transition of the ULCs to the bony dorsum and the septum during component hump reduction. The authors introduce an algorithm for reconstitution of the
179 bony-cartilaginous dorsum with refinements in component hump reduction.
Materials and method The present study was performed at the Division of Facial Plastic Surgery, Department of Otolaryngology, University Hospital of Mannheim and the Department of Anatomy, University of Regensburg, Germany. Data analysis and production of the manuscript was completed at the Division of Facial Plastic Surgery, Department of Otolaryngology, University Hospital of Mannheim, the Finesse Center for Facial Plastic Surgery in Regensburg, Germany, and the Nose Clinic, Guilford/London, UK. The study encompasses a human cadaver study on five fresh frozen cadaver heads with implementation of the anatomical findings into surgical practice. The authors describe a more detailed surgical algorithm in component hump reduction.
Anatomical study on human cadaver heads A total of five fresh frozen cadaver heads were used. Dissections were performed using headlight illumination and loupe magnification with standard instruments. Key findings and standardised surgical manoeuvres were documented using macrophotography with a Nikon D90 camera (Nikon Inc, Melville, New York), Sigma 17–70 mm, 1:2.8 Macro lens (Sigma Inc, Ronkonkoma, New York) and Sigma EM 140 iTTL macro ring light (Sigma Inc, Ronkonkoma, New York). The camera setting was as follows: aperture F18, shutter speed 1/60 s, ISO 200, white balance flash, manual focus and 70 mm focal length. All photographs were taken in the axial plane at an angle of 45° to the Frankfurt horizontal plane from below. Steps of dissection In all specimens, a midline incision was performed from the glabella to the nasal tip. The incision was carried along the columella and ended in the philtrum of the upper lip. The skin and soft tissue envelope was raised and dissected off the nose in the supraperichondrial plane on the cartilaginous dorsum and the subperiosteal plane on the bony dorsum to expose the underlying bony and cartilaginous structures. The ULCs and the adjacent septal cartilage were separated from the lower lateral cartilages (LLCs) by extending the intercartilaginious incisions into a transfixion incision. This exposed the inferior border of the ULCs and the septum. The underlying mucosa was then released from both the ULCs. In each cadaver head specimen, the bonycartilaginous hump was marked as a dotted line with a skin marker. The anterior border of the nasal bones was marked at the K-area using a 27-Gauge needle. Both the ULCs were then released from the septum in the subperichondrial plane, leaving a 1-mm gap between the ULCs and the septum (Figure 1a-b). From here on, the ULCs on both sides of the rhinion were dissected differently before performing component hump reduction. In all five cadaveric heads on each left side, the ULC was left attached to the nasal bone. On each right side, the medial aspect of the ULC was disarticulated from the
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Figure 1 (A) Exposure of the bony-cartilaginous dorsum after dissecting off the soft tissue envelope. Marking of the anterior border of the nasal bones at the K-area with a 27-gauge needle. Release of both the ULCs form the septum in the subperichondrial plane. (B) On the left side of the rhinion, the ULC is left attached to the nasal bone. On the right side of the rhinion, the medial aspect of the ULC is disarticulated from the nasal bone and dissected further cranially along its entire extent. The wooden stick indicates the gap between the ULC and the nasal bone on the right side of the rhinion. (C) Inferior-medial rotation of the detached right ULC towards the septum. The cranial part of the ULC turns into a transverse segment. The size of this segment correlates to the amount of hump reduction needed. (D) Situation after subsequent reduction of the bony-cartilaginous hump. On the right side of the rhinion, preservation of the entire ULC along the cartilaginous and bony vault area. Scoring of the remaining right ULC to be used as auto-spreader flap. On the left side of the rhinion, a substantial loss of the ULC cranial to the K-area.
nasal bone by sliding a No.15 scalpel blade or a Cottle elevator underneath the nasal bone. The dissection was then taken further cranially along the undersurface of the nasal bone up to the entire extent of the ULC. The amount of detachment of the medial segment of the ULC correlated to the amount of hump to be reduced (Figure 1c-d). Subsequently on both sides of the rhinion, the septum and the bony portions of the dorsal hump were resected using a No.11 scalpel blade and a 14-mm Rubin osteotome under direct vision. No further osteotomies were performed. The remaining ULCs were then scored along the line corresponding to the height of the dorsal septal resection line, folded over as an auto-spreader flap and secured to the lateral portion of the ULC with 5/0 monofilament nonabsorbable sutures. The anterior border of the nasal bones at the K-area was then marked again with a 27-gauge needle; the hump reduction was completed (Figure 1e-1f), and the degree of tissue gap between the septum and the lateral nasal bones along the bony vault area was documented as x. Study endpoints The study endpoint was to determine the amount of tissue gap due to a loss of bridging tissue between the septum and the lateral nasal bones along the bony vault area by comparing both sides of the rhinion. Therefore, digital photographs
were taken and transferred to Adobe Photoshop (Adobe photoshop CS5 extended, Version 12.0 × 64). The surface area of the ‘above-mentioned tissue gap’ on both sides of the rhinion was measured using Photoshop marking tools and compared.
Implementation of the surgical technique in clinical practice All surgeries were performed under general anaesthesia in patients with a moderate–to-severe dorsal hump. Local anaesthesia with 1% lidocaine and 1:1.000 adrenaline was used for vasoconstriction and hydrodissection. Standard rhinoplasty instruments were used. Either an open approach or an endonasal approach was used to raise the skin envelope and access the osseocartilaginous dorsum. From the findings of the anatomic study, a more detailed and nuanced approach to component hump reduction with specific focus on the bony vault area was defined (Figure 2a-d). Similar to the standard procedure of component hump reduction, the septal mucoperichondrium was first dissected bilaterally using a Cottle elevator. This was then followed by careful release of the ULCs from the junction with the dorsal septum in a subperichondrial plane. Great care was taken to
Nuances in component nasal hump reduction
181 medial aspects of the nasal bones. By sliding in the elevator further cranially underneath the nasal bones, the entire length of the ULCs was preserved along the bony vault area. This manoeuvre resulted in an inferior-medial rotation of the detached part of ULCs towards the septum, thus generating a transverse segment of up to 4 mm of the ULCs, which retained its original arch shape. The amount of detachment correlated with the amount of hump reduction needed. Because of the inferior-medial rotation towards the septum, no additional fold-in manoeuvre with a Brown-Adson forceps before hump reduction was required (Figure 2b). The next steps paralleled the standard procedures of component hump reduction. First the cartilaginous dorsum was reduced by taking down the septum with a No.11 scalpel blade. Then the bony dorsum was reduced with a 14-mm Rubin osteotome, taking care not to injure the preserved transverse segment of the ULCs beneath the nasal bones (Figure 2c). After hump reduction, the ULCs were realigned to the septum, either scored or unscored as an auto-spreader flap or after placement of an additional spreader graft (Figure 2d).
Results Anatomical dissections
Figure 2 A) Bilateral dissection of the septal mucoperichondrium with a Cottle elevator. B) Careful separation of the ULCs from the dorsal septum in a subperichondrial plane along the cartilaginous and bony vault area. C) Detachment of the ULCs from the medial aspect of the nasal bones at the K-area and the undersurface of the nasal bones. D) Reduction of the cartilaginous and bony dorsum while preserving the cranial segment of the ULCs in the bony vault area. E) Preservation of the entire length of the uncapped ULCs after hump reduction. F) Realignment of the ULCs with the septum as autospreader flaps.
preserve the integrity of the underlying mucoperichondrium of the ULCs to prevent the potential for late cicatricial narrowing of the internal nasal valve (Figure 2a). Other than in standard procedures for component hump reduction, the No.15 scalpel blade was now placed at the K-area to detach the ULCs from their attachments to the
The detachment of the right ULC from the medial aspect of the nasal bone resulted in a height difference of x to 2 mm between the right ULC and the bony dorsum at the K- area (Figure 3a). This manoeuvre helped spare the entire cranial segment of the right ULC. The ULC started to turn downwards with an inferior-medial rotation towards the septum. This generated a transverse segment of the cranial part of the ULC of up to 4 mm in the bony vault area (Figure 3b). After bony hump reduction, a substantial loss of the left ULC at the K-area and the bony vault area could be stated. The right ULC could be preserved in its entire length along the bony and middle vault area. On both sides of the rhinion, the amount of open roof resulting from the hump reduction was determined by measuring the gap between the remaining ULC and the septum in the bony vault area (Figure 3c). The average gap ratio between the right and the left ULC to the septum on both sides of the rhinion was 1:2 (Table 1). In all five cadaver head specimens on average, twice the amount of ULC was lost, if not detached, from the nasal bone and preserved in the bony vault area.
Surgical technique and algorithm defining the nuances in component hump reduction The algorithmical approach of dissection comprised 6 major steps that were as follows: 1) Separation of the ULCs from the dorsal septum in the subperichondrial plane 2) Additional separation of the ULCs from the junction with the dorsal septum beneath the nasal bones 3) In correlation with the amount of hump reduction required, defined detachment of the ULCs from the medial aspect of the nasal bones at the K-area and their undersurface
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Figure 3 A) Height difference of x to 2 mm between the right ULC and the bony dorsum at the K-area after detachment of the right ULC from the medial aspect of the nasal bone. B) Inferior-medial rotation of the entire cranial segment of the right ULC towards the septum. Generation of a transverse segment of the cranial part of the ULC of up to 4 mm along the bony vault area. C) On both sides of the rhinion, measurements of the tissue gap between the remaining ULC and the septum in the bony vault area after subsequent hump reduction.
Table 1 Measurement of the gap between the ULCs and the septum in the bony vault area after bony hump reduction. ULC on the right side of the rhinion initially detached from the K-area and the nasal bone; ULC on the left side of the rhinion initially left attached to the nasal bone before hump reduction. (n)
Right side (mm)
Left side (mm)
Ratio, right to left side
Specimen head 1 Specimen head 2 Specimen head 3 Specimen head 4 Specimen head 5
1 1 1.5 1 1.5
2 3 3 2 3
1:2 1:3 1:2 1:2 1:2
4) Reduction of the cartilaginous dorsum 5) Reduction of the bony dorsum while preserving the cranial segment of the ULCs in the bony vault area, comparable to an ‘uncapping’ of the ULCs with maintenance of the transverse segment of the ULCs at the bony vault area 6) Realignment of the ULCs with the septum with suture fixation as auto-spreader flaps or with additional spreader grafts Special focus was placed on steps 3 and 5 that deviated from the established standard of component hump reduction (Figure 4).
Discussion The standard procedure of component hump reduction, as described in the literature, relates to an individual reduction of each component of the nasal dorsum with maximised accuracy and control of resection.7 The ULCs are detached from the septum before the hump is resected. Interestingly, most of the reports refer to the separation of the ULCs from the septum only up to the K-area to spare the ULCs during
cartilaginous hump reduction. This manoeuvre is then followed by the bony hump resection. However, when it comes to the bony hump resection, literature reports on component hump reduction seem to neglect the presence of the ULCs in the bony vault area.7 In many cases, the subsequent reduction of the bony hump incurs a substantial loss of essential medial parts of the triangular cartilages. As a result, the absence of this bridging tissue between the septum and the lateral nasal bones along the bony vault area often necessitates further complex manoeuvres to close the gap. If the ULCs are not preserved meticulously between the lateral nasal bones, the absence of the bridging tissue may induce contour deficiencies, a substantial problem that cannot be solved by osteotomies. Osteotomies primarily narrow the bony dorsal aesthetic lines but do not close the ‘soft tissuecartilage’ gap in the bony vault area. This aspect reflects the possible limitations of conventional osteotomies. The authors believe that it is the preservation of the ULCs between the lateral nasal bones in the bony vault area that defines the contour of the nose, particularly in those cases with ‘parenthesis’-shaped bone edges after bone removal when osteotomies do not achieve straight, parallel and narrow bony dorsal aesthetic lines. The anatomical observations in this study could verify these findings, especially in those cases where the medial aspect of the ULCs was not detached from the nasal bones and thus not spared during component hump reduction. The key steps of dissection that mark the nuances in component hump reduction and differ from the standard procedure of component hump reduction focus mainly on the bony vault area. The aim is to preserve the ULCs cranially to the K-area underneath the nasal bones.14,15 This requires the detachment of the medial aspect of the ULCs from the nasal bones at the K-area and underneath the entire length of the nasal bones. The additional separation of the cephalic edge of the ULCs from the septum results in lowering of the detached cephalic part of the ULC with downward and inward rotation against the septum. The advantage is that a horizontal segment of the ULC similar to a ‘transversal shoulder’ can be preserved with a variable width of up to 3–4 mm, depending on the amount of hump reduction needed. This manoeuvre may be the subject of controversy.
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183 but they do not collapse into the nasal vestibulum completely. Two factors are responsible for this residual stability within the upper and middle vault area: first, the intentionally induced but rather defined and limited degree of height loss seen in the cephalic segment of the ULC correlates to the amount of hump to be resected.14,15 Second, the underlying mucoperichondrium of the ULC acts as an internal splint and mimics a hammock for the detached ‘transverse shoulder’ of the ULC.19 The main advantage of this key step of dissection is that the bony cap of the nasal hump is isolated and can be reduced without any injury to the underlying cartilaginous framework of the nose. This allows preservation of the natural T-bar of the ULCs and the septum as long as no additional cartilaginous hump reduction is needed.14 Moreover, no additional tissue gap between the septum and the lateral nasal bones is created, and the middle vault area has been left intact. In some cases, particularly those in whom only a small hump has been removed, osteotomies to close the ‘nasal roof top’ can be avoided. In the case of a separation of the ULCs from the septum, as performed in our anatomical dissections, the preserved cephalic edges of the ULCs can be easily realigned to the septum, thus re-establishing the ‘natural arch shape’ between the ULCs and the septum. The anatomical dissections in this study underlined the important role of the ULCs for the overall contour and aesthetic result in rhinoplasty, especially after hump reduction, because the ULCs not only define the middle third but also the upper third of the dorsal aesthetic lines. The authors employ this modified technique of component hump reduction routinely on all primary rhinoplasty cases that present with a dorsal hump. In techniques with non-powered instruments, this has become the standard method for dorsal hump reduction, with more accurate reconstruction of the middle and upper third of the nose. The authors believe that these modifications to component hump reduction have an important impact on the aesthetic outcome and surgical workflow.
Conclusion
Figure 4 A 28-year-old woman presented with a bonycartilaginous hump (preoperative pictures, left side). Thirteen months after component hump reduction with preservation of the ULCs along the bony and cartilaginous vault, with other procedures such as tip-plasty and osteotomies (postoperative pictures, right side). Postoperatively, the patient had no nasal airway obstruction. A smooth transition line at the K-area with a straight aesthetic dorsal profile could be achieved.
Some authors discourage from doing so and argue that the ULCs lose stability in the middle vault area.16–18 This argument calls for detailed analysis: anatomical dissections in 5/5 cadaveric heads showed that the ULCs lose height to the bony dorsum and rotate inferior-medially against the septum,
In this study, the authors present a more detailed approach to component hump reduction. The key steps of dissection that mark the differences to the previous standard technique of ‘component hump reduction’ mainly focus on the bony vault area. Prior to the bony hump reduction, the medial aspects of the ULCs are detached from the undersurface of the nasal bones at the K- area along their entire length. The detachment correlates to the amount of bony hump to be resected. This results in an intentional sagging of the medial aspect of the cranial border of the ULCs into the nasal vestibulum without collapsing totally. The ULCs remains attached to the lateral aspect of the nasal bones and to the piriform aperture at the lateral sidewalls. The cephalic components of the ULCs underneath the bony dorsum can be preserved more easily and allow a smoother transition line not only at the K-area but also along the entire bonycartilaginous dorsum. These refinements in component hump reduction, as presented in this study, may enhance a straighter appearance of the aesthetic dorsal profile. The need of grafting material to camouflage dorsal irregularities may be minimised.
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Conflict of interest None.
Funding None.
References 1. Tardy ME, Brown RJ. Surgical anatomy of the nose. New York: Raven Press; 1990. 2. Daniel RK, Letourneau A. Rhinoplasty: nasal anatomy. Ann Plast Surg 1988;20(1):5–13. 3. Daniel RK. The osseocartilaginous vault. In: Daniel RK, editor. Rhinoplasty. Boston: Little, Brown and Company; 1993:169– 214. 4. McKinney P, Johnson P, Walloch J. Anatomy of the nasal hump. Plast Reconstr Surg 1986;77:404. 5. Manavbasi YI, Kerem H, Basaran I. The role of upper lateral cartilage in correcting dorsal irregularities: section 2. The suture bridging cephalic extension of upper lateral cartilages. Aesthetic Plast Surg 2013;37:29–33. 6. Palhazi P, Daniel RK, Kosins AM. The osseocartilaginous vault of the nose: anatomy and surgical observations. Aesthetic Surg J 2015;35(3):242–51. 7. Rohrich RJ, Muzaffar AR, Janis JE. Component hump reduction: the importance of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg 2004;114:1298–308, discussion 13091312. 8. Halewyck S, Michel O, Daele J, Gordts F. A review of nasal hump reduction, with a particular emphasis on a comparison of component and composite removal. B-ENT 2010;6:41–8.
H. Sadick et al. 9. Lohuis PJFM, Faraj-Hakim S, Knobbe A, Duivesteijn W, Bran GM. Split hump technique for reduction of the overprojected nasal dorsum. Arch Facial Plast Surg 2012;14(5):346–53. 10. Roostaeian J, Unger JG, Lee MR, Geissler P, Rohrich RJ. Reconstitution of the nasal dorsum following component hump reduction in primary rhinoplasty. Plast Reconstr Surg 2014;133:509– 18. 11. Ozmen S, Ayhan S, Findikcioglu K, Kandal S, Atabay K. Upper lateral cartilage fold-in-flap: a combined spreader and/or splay graft effect without cartilage grafts. Ann Plast Surg 2008;61: 527–32. 12. Gruber RP, Perkins SW. Humpectomy and spreader flaps. Clin Plast Surg 2010;37:285–91. 13. Manavbasi YI, Basaran I. The role of upper lateral cartilage in dorsal reduction after hump excision: section 1. Spreader flap modification with asymmetric mattress suture and extension of the spreader effect by cartilage graft. Aesthetic Plast Surg 2011;35:487–93. 14. Gruber RP, Melkun ET, Woodward JF, Perkins SW. Dorsal reduction and spreader flaps. Aesthetic Surg J 2011;31(4):456–64. 15. Arslan E, Aksoy A. Upper lateral cartilage-sparing component dorsal hump reduction in primary rhinoplasty. Laryngoscope 2007;117:990–6. 16. Sharafi M, Jalessi M, Adamson P. Newly designed upper lateral cartilage flap for preventing depression of the keystone area in large-nose septorhinoplasty. JAMA Facial Plast Surg 2015;17(6): 399–404. 17. Gassner HG, Mueller-Vogt U, Strutz J, Kuehnel T. Nasal tip recontouring in primary rhinoplasty: the endonasal complete release approach. JAMA Facial Plast Surg 2013;15(1):11–16. 18. Gassner HG, Friedman O, Sherris DA, Kern EB. An alternative method of middle vault reconstruction. Arch Facial Plast Surg 2006;8(6):432–435. 19. Gerbault O, Daniel RK, Kosins AM. The role of piezoelectric instrumentation in rhinoplasty surgery. Aesthetic Surg J 2016; 36(1):21–34.