**9. Hump modification**

The dorsal hump is a complex anatomic component of the nose. The nasal hump is formed by two upper lateral cartilages, the septal cartilage and two nasal bones. Dorsal modification is usually started with resection of excessive parts and in some cases augmentation of shallow and defective parts. Hump resection may be done in a way that all excessive parts are resected in one piece (composite resection) or in a way that each component is trimmed and resected separately in an incremental manner (component resection).

#### **9.1. Composite hump surgery**

When it is planned to remove a maximum of 2 or 3mm of dorsal hump, composite resection may be done. In this technique, cartilaginous part is cut by surgical knife and a hump osteotome is inserted beneath the cut cartilage and hump resection is continued with mallet strokes to cut the excessive bone; then the resected hump is simply removed (Figure 13).

#### **9.2. Salient points**

**1.** Integrity of the underlying mucous is crucial in internal nasal valve function so this technique is best preserved for minor resections and in case further resection is necessary component resection should be performed.

**2.** The resected hump is a potential graft material that may be used as a strut, tip graft or as an ideal material for dorsal augmentation. The resected hump is a potential graft material that may be used as a strut, tip ‐2

.graft or as an ideal material for dorsal augmentation

**Figure 13: Composite hump surgery**

**Component hump resection**

.conservatively

**Spreader grafts**

**Figure 13.** Composite hump surgery

#### **9.3. Component hump resection**

In this technique the upper lateral cartilages are precisely separated from the nasal septum and underlying mucosa, then excessive septal cartilage is trimmed until the ideal position is achieved. To adjust the bony part, a bone rasp or osteotome is used. In final steps excessive upper laterals may be trimmed very In this technique the upper lateral cartilages are precisely separated from the nasal septum and underlying mucosa, then excessive septal cartilage is trimmed until the ideal position is achieved. To adjust the bony part, a bone rasp or osteotome is used. In final steps excessive upper laterals may be trimmed very conservatively.

#### **9.4. Important points**

**Important points** In major hump resections (more than 3mm), the dorsal hump may be ‐1 reconstructed to avoid breathing problems and to provide a pleasant aesthetic brow line. A spreader graft is the gold standard with which to reconstruct the 1-In major hump resections (more than 3mm), the dorsal hump may be reconstructed to avoid breathing problems and to provide a pleasant aesthetic brow line. A spreader graft is the gold standard with which to reconstruct the internal nasal valve; additionally, autospreader grafts and splay grafts are also effective methods in indicated cases [23-24].

internal nasal valve; additionally, autospreader grafts and splay grafts are also

These cartilages are placed on both sides of nasal septum and fixed with 5‐0 PDS

#### .(effective methods in indicated cases (23‐24 **10. Basic grafting techniques in dorsal surgery**

#### **10.1. Spreader grafts**

Spreader grafts are two quadrangular pieces of cartilage (3mm in width and 20mm in length) that may be modified according to the patients' specific needs. Spreader grafts are two quadrangular pieces of cartilage (3mm in width and 20mm in length) that may be modified according to the patients' specific needs. These cartilages are placed on both sides of nasal septum and fixed with 5-0 PDS sutures. This grafting technique

**Basic grafting techniques in dorsal surgery**

will change the geometry of internal nasal valve and prevent internal nasal valve incompe‐ tency (Figure 14). [25-27].

**Figure 14.** Spreader grafts.

**2.** The resected hump is a potential graft material that may be used as a strut, tip graft or as

.graft or as an ideal material for dorsal augmentation

**Figure 13: Composite hump surgery**

.(effective methods in indicated cases (23‐24

**Basic grafting techniques in dorsal surgery**

**Component hump resection**

.conservatively

**Important points**

**Spreader grafts**

The resected hump is a potential graft material that may be used as a strut, tip ‐2

In this technique the upper lateral cartilages are precisely separated from the nasal septum and underlying mucosa, then excessive septal cartilage is trimmed until the ideal position is achieved. To adjust the bony part, a bone rasp or osteotome is used. In final steps excessive upper laterals may be trimmed very

In this technique the upper lateral cartilages are precisely separated from the nasal septum and underlying mucosa, then excessive septal cartilage is trimmed until the ideal position is achieved. To adjust the bony part, a bone rasp or osteotome is used. In final steps excessive

1-In major hump resections (more than 3mm), the dorsal hump may be reconstructed to avoid breathing problems and to provide a pleasant aesthetic brow line. A spreader graft is the gold standard with which to reconstruct the internal nasal valve; additionally, autospreader grafts

In major hump resections (more than 3mm), the dorsal hump may be ‐1 reconstructed to avoid breathing problems and to provide a pleasant aesthetic brow line. A spreader graft is the gold standard with which to reconstruct the internal nasal valve; additionally, autospreader grafts and splay grafts are also

and splay grafts are also effective methods in indicated cases [23-24].

**10. Basic grafting techniques in dorsal surgery**

Spreader grafts are two quadrangular pieces of cartilage (3mm in width and 20mm in length) that may be modified according to the patients' specific needs. These cartilages are placed on both sides of nasal septum and fixed with 5‐0 PDS

Spreader grafts are two quadrangular pieces of cartilage (3mm in width and 20mm in length) that may be modified according to the patients' specific needs. These cartilages are placed on both sides of nasal septum and fixed with 5-0 PDS sutures. This grafting technique

an ideal material for dorsal augmentation.

760 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 13.** Composite hump surgery

**9.4. Important points**

**10.1. Spreader grafts**

**9.3. Component hump resection**

upper laterals may be trimmed very conservatively.

#### **10.2. Crushed cartilage**

Crushed cartilage is an ideal augmentation material that may be precisely added to defective dorsal segments and cover irregularities.

#### **10.3. Temporalis fascia**

Temporalis fascia is a soft smooth graft material that is frequently reported to be used in augmentation rhinoplasty. This graft easily blends-in with normal nasal tissues and does not make shadows or visible borders. To harvest temporalis fascia a 5cm curvilinear incision is made on the posterior hairline. With upward and anterior subcutaneous dissection, ideal access to temporalis fascia is obtained then adequate fascia is harvested and placed in the recipient site in the nose. This approach provides ideal access to the area. A direct incision in hair-bearing areas of the temporalis area is also frequently used.

#### **10.4. Lateral osteotomy**

Lateral osteotomy is generally done to narrow a wide bony vault and/or to close an open roof deformity. This is beneficial to reshape a malformed bony vault (like traumatic noses).Lateral osteotomy may be done by two main options; external perforating osteotomy or internal continuous osteotomy. Both techniques have their own advantages and disadvantages; the literature has shown that both work well in the hands of skilled and trained surgeons.

#### **10.5. External perforating osteotomy**

The osteotomy line is planned and marked over the skin. A small stab incision is made on the nasal skin, midway of the bony vault; then a 2mm osteotome is inserted through the incision line. Using sweeping movements of the osteotome it finds its proper place at the beginning of marked osteotomy line under the periosteum of the bony vault. Then, with mallet strokes the osteotomy is started. After performing one osteotomy site, the osteotome is gently pulled out of the bone in a way that it stays inside the skin incision and is guided in the planned osteotomy line and the next osteotomy site is done adjacent to first one. In this way several osteotomy holes are made along the planned line. Then a gentle finger pressure is applied over the bony vault and the osteotomized bony segment is moved medially. Gauze soaked in cold serum is pressed over the osteotomy region and held for a few minutes to control bleeding and edema (Figure 15).

**Figure 15.** External perforating osteotomy

#### **10.6. Internal continuous osteotomy**

A 3 to 4mm guided osteotomy is usually used in this method of osteotomy. First a nasal speculum is used to find the best place in pyriform aperture. A small 5 mm incision is done. Then the osteotome is inserted inside the incision in a way that the guide stays laterally and blade medially toward the nostrils. With mallet strokes, the osteotomy is started and continues toward the medial canthus in the planned line. Then gentle finger pressure is applied to medialize the bony segment. The same procedure is done on the other side and gauze is pressed over the bony nasal vault and held for few minutes to control the bleeding and edema.

#### **10.7. Salient points**

continuous osteotomy. Both techniques have their own advantages and disadvantages; the literature has shown that both work well in the hands of skilled and trained surgeons.

The osteotomy line is planned and marked over the skin. A small stab incision is made on the nasal skin, midway of the bony vault; then a 2mm osteotome is inserted through the incision line. Using sweeping movements of the osteotome it finds its proper place at the beginning of marked osteotomy line under the periosteum of the bony vault. Then, with mallet strokes the osteotomy is started. After performing one osteotomy site, the osteotome is gently pulled out of the bone in a way that it stays inside the skin incision and is guided in the planned osteotomy line and the next osteotomy site is done adjacent to first one. In this way several osteotomy holes are made along the planned line. Then a gentle finger pressure is applied over the bony vault and the osteotomized bony segment is moved medially. Gauze soaked in cold serum is pressed over the osteotomy region and held for a few minutes to control bleeding and edema

**10.5. External perforating osteotomy**

762 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 15.** External perforating osteotomy

(Figure 15).

