My son has a small dorsal hump on his nose. We consulted with a plastic surgeon and he stated he could file down the hump, and that he would then break the bones on either side of his nose to prevent the nose from looking too wide. His approach to breaking these bones is to make a small 1-2mm incision on the outside of the nose on both sides. He said this would cause minimal scarring. From what I researched the nasal bone breaking is usually done from the inside. What do you think of this approach?
Opinions on Breaking Nasal Bone Technique?
Doctor Answers 14
I prefer the external osteotomy.
While there is no specific approach that is "better," I tend to prefer the external osteotomy (a post-stamp perforation of the bones through a 2mm stab incision of the nasal skin).
Scarring from this approach is essentially a non-issue since they tend to heal with near invisibility. This approach minimizes bleeding and trauma to the delicate lining tissues of the nose. It also, in my opinion, maintains better stability of the nasal bones by tearing up less periosteum (the lining tissue of bone) on the bones' inner surface.
All the best,
Many options in rhinoplasty surgery
It never hurts to research your options and to ask probing questions. There are no absolutely right or wrong ways to perform any surgical procedure. If there was only one right way to do the surgery then everyone would do it the one 'right way'. There are several ways to perform a lateral osteotomy. I have found that the external approach is the least traumatic and most precise method. Others will, of course, debate this option. Precision, control and avoiding bruising are keys to a nice and predictable result. If you feel comfortable with your choice of a plastic surgeon then feel confident that he has selected the method that will be best in his experience.
Both techniques can be used.
The skill of the surgeon is more important than how he does the osteotomies. Having said that, in more than 30 years of rhinoplasty surgery, I have never found the need to make an exposed scar when I can do the same thing inside the nose without any chance of a noticeable scar.
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Techniques for osteotomies
There are many techniques used for osteotomies during rhinoplasty, and it really comes down to surgeon preference. While I prefer to use an internal approach, the external approach you are describing is well documented in the literature and is one of the standard techniques. (It is very direct and allows for good control of the osteotomy position.) I would not suggest that you attempt to coerce your surgeon to use some technique that they do not routinely use, as you may end up with a result that neither are happy with.
Percutaneous osteotomy great for gentle and accurate nasal bone fractures
What your surgeon is recommending is a percutaneous osteotomy. This is an excellent technique for making gentle and very accurate fractures in the lateral portion of the nasal bones. This would be a common technique used to narrow the bridge after a hump is reduced.
In some cases the osteotmies are performed from within then nose. It depends on the thickness of the bones and the degree of nasal bone movement required. Most Rhinoplasty specialists use various osteotomy techniques depending on the nature of the individual case.
Surgically Breaking the Nasal Bones -- Osteotomies
Different surgeons utilize different techiques, but one is not better than the other. The basic premise of surgically breaking the nasal bones (called osteotomies) is that a delicate instrument is used to cut the bones under the skin. The surgeon then repositions them to acheive the desired result.
Osteotomies are performed during rhinoplasty for several reasons.
- Narrowing a wide bridge (top of nose): One of the most common reasons for surgically breaking the nose is to narrow the bridge after removal of a dorsal hump. When a hump is removed, it leaves a gap along the top of the bridge. This gap needs to be closed so that there is not a depression on the top of the bridge (frequently called an open roof deformity)
- Narrowing a wide boney base (sides of nose): When the nose is wide where the nasal bones meet the cheek bones, osteotomies can be performed to narrow the width. This usually gives the bridge more definition from the front.
- Straightening a deviated or crooked nose: If the nasal bones are crooked, they can be repositioned to give the nose a straighter appearance.
Osteotomies usually increase the amount of bruising and swelling, but when performed correctly, can dramatically improve the appearance of the nose. Risks of osteotomies (if not performed correctly) include irregularity of the bone, palpable or visible boney ridges underneath the skin, crookedness of the bridge, nasal sidewall collapse.
No need for external incisions
The osteotomies are normally performed completely on the inside of the nose. There is no reason to make an external incision 2 mm on each side to narrow the sidewalls of the nose. If the bump is quite small on the bridge of the nose, no osteotomies need to be performed. If the bump is significant enough, osteotomies will be performed in most rhinoplasties. These are performed through an endonasal approach narrowing the nasal bones to give further fit and balance to the nose. If the bump is removed and causes a significant flattop nose deformity, then the osteotomies will need to be performed, all through an endonasal approach.
Breaking Nasal Bones
Internal and external techniques for fracturing the nasal bones are acceptable. Individual surgeons have their own preferences. Share your concerns with your docter. If you're still not satsified, get a second opinion.
External versus internal osteotomies
Breaking of the nasal bones is commonly done externally, although internal osteotomies are still preferred by some surgeons. I prefer external osteotomies as I feel they offer more precision and less bleeding and bruising than internal. Some surgeons may do both, but it is usually best to allow the surgeon to stay within his comfort zone - the procedure he performs most often will usually yield the best results in his hands.
Osteotomies in rhinoplasty
There are many ways to perform osteotomies. In fact, the way that your doctor describes is my preferred technique. In fact, I do it so frequently without any long term visible marks, that I usually forget to discuss the types of osteotomies with my patients. There have been a few studies that suggest that this approach causes less internal bleeding and tearing of the internal lining.