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  • Doctor POV: Open Rhinoplasty (Part 4)
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What I'm going to demonstrate is the nasal hump removal. The nasal hump is
also known as a dorsal hump or a dorsal bump. Many patients think that this
is one of the easiest types of Rhionoplasty's. In fact removal of a dorsal
hump is not complicated, however there are differences in technique. I see
so many times patients that come in who tell me they went and saw a plastic
surgeon for a simple dorsal hump removal, but low and behold their nose has
ended up compromised and collapsed, with a ski slope, or even worse when
the plastic surgeon took it upon himself to modify the tip, shortened the
nose, rotate the nose and make lots of other changes that were not
discussed, nor planned with the patient pre-operatively.

So in fact dorsal hump removal can be argued that ti's very simple because
there is only cartilage and bone that needs to be modified. However the
proper technique for dorsal hump removal is as follows.

What you can see is a started with gentle rasping of the dorsal. Which
essentially is the bridge of the nose. Now what I'm doing is I'm having my
assistant retract each of the cartilages, the lower lateral cartilages
downwards, and with my instrument what I'm doing is creating an opening
between the upper lateral cartilage on the left side and the dorsal septum
also known as the top part of the septum, the right and the left upper
lateral cartilage come together with the dorsal septum to create the middle
part of the bridge of the nose.

The part which is cartiledgeous. Now many plastic surgeons tend to take a
chisel or osteotome and remove these three components, essentially the left
upper lateral cartilage, the dorsal septum and the right upper lateral
cartilage, together in one fowl swoop. Worse yet some classic surgeons
tends to take the same chisel and continue the osteotomy to remove the bony
part of the nasal hump as well. So everything gets removes in one fowl
swoop. This ends up often times over correcting or under correcting the
removal of the dorsal hump.

What you just saw was me separating each of the upper lateral cartilages,
from the dorsal septum. Now what I'm'' doing with my scalpel is very
carefully and meticulously removing a very small strip of the top part of
the septum. This type of segmental resection of a dorsal hump, ensures that
I do not over correct nor under correct the removal of the dorsal hump.

What we do is, I save every component that I remove from the nose in a
container with saline because often times recycling of material in a
Rhinoplasty is necessary. What I do is lay the skin back down and take
another look and not only look, but also feel and then I take my rasp which
is essentially a file and start filing down the nasal bones again.

We have a variety of rasp in our Rhinoplasty set from very course to very
smooth. I start with the more course rasp and work my way down to the
smoother rasps. For dorsal humps that are very large, I may use an
osteotome to take off a portion of the nasal bones to start with and then
start rasping, but for this patient the hump was not that large and rasping
is preferential.

After meticulous incremental step wise shaving and rasping, I take another
look and another feel. At this point since I'm wearing 2.5 magnification
loops, which on my surgical googles are essentially like wearing
microscopes, I can see every tiny little component. If there's a small
ridge after the slight elevation, I can see it like there and remove it and
save it for possible further use.

This type of incremental step wise, shaving and rasping allows for the
dorsal septal height to be taken down preferentially to the upper lateral
cartilages. What that means which is essentially a new concept in
Rhinoplasty, is that each of the upper lateral cartilages remain a little
bit higher than the dorsal septum. That's extremely important because the
upper lateral cartilages tend to scar down as the nose heals and while the
nose can look perfectly fine at one week or at one month, or even at one
year, down the line, one of the telltale signs of a Rhinoplasty, which is
called an inverted bee deformity can form. An inverted bee deformity is a
situation where a shadow, like an upside down V forms at the junction of
the cartilaginous part of the bridge and the bony part of the bridge.

Now what's happened is the cartilage which is weaker and more under the
influence of scar tissue manipulation and healing tends to scar down and
heals in a position that's not favorable. So this type of segmental
resection of the nasal hump, back and forth, back and forth with very fine
meticulous moves allows me to be able to get the dorsal contour perfectly
the way I want it….

Doctor POV: Open Rhinoplasty (Part 4)

Dr. Shervin Naderi demonstrates the removal of a dorsal hump, discussing several common techniques doctors may use to achieve the desired look.