So many Rhinoplasty techniques out there--choice depends on your anatomy and goals
It can be confusing for a patient seeking rhinoplasty. So many methods and opinions exist which may vary surgeon to surgeon (as you discovered). Sounds like your goals are: to narrow the bones, lower the hump on the bridge, refine the tip, and narrow the nostrils. These are common goals but the appropriate techniques to use would depend on certain features of your anatomy. Without seeing pictures and having the luxury of a physical examination, it is tough to provide details about a plan.
However, one useful bit of information I can provide has to do with skin thickness. Generally, rhinoplasty is an operation in which we change the form of the bone and cartilage of the nose. Once this is done, the skin then has to drape cleanly onto this altered infrastructure in order for there to be an overall positive change in appearance afterward. Before surgery, each nose has the exact right amount of skin for the infrastructure beneath, like a glove fitting a hand.
After surgery in which there is reduction, narrowing, or lowering of this infrastructure, there is too much skin. If you have thin skin, the skin envelope can contract and shrink somewhat so that clean draping will occur. If you have thick skin, however, the skin cannot shrink that much and you may end up with a permanent relative excess of skin. This may lead to thickening of the skin and an appearance of skin fullness or bulging, sometimes called a polybeak deformity. If you have thick skin and want to look narrower or more refined, it may require building up some areas of the nose so that the infrastructure pushes into the thick skin envelope to create a more narrow and refined appearance.
This issue with the skin thickness is just one of many considerations with regard to which techniques are best for any given rhinoplasty. Though forums like this are helpful to provide information, they cannot replace a thorough evaluation with an experienced rhinoplasty surgeon so that all of these issues can be explored.
Rhinoplasty is a complex and difficult operation. Like many problems that are complex, there are many ways to approach solving the problem. It is not unusual to get different answers to specific maneuvers that will be done to improve the nasal appearance. The approaches are frequently influenced by what the surgeon is comfortable with and what they have had good results with in the past. Regarding osteotomies, they can be used to narrow the upper and mid thirds of the nose. If more than a very small dorsal hump is removed, they will likely be required anyway to prevent a wide, flat appearance to the bridge area. Without photos or an in-person exam, its difficult to comment more specifically.
Osteotomies will narrow a wide nasal bridge
Osteotomies are performed to narrow wide nasal bridges. Osteotomies are also done when a large hump has been removed from the nose and the surgeon needs to close the open roof deformity. If not, the nose bridge will be square and the patient will have a flattop nose after a hump reduction. Both medial and lateral osteotomies of nasal bones are usually performed to straighten and realign the nasal pyramid on the nose that has been broken or fractured.
Rasping is a technique used to remove excess bone or cartilage. How much is removed from the bone will determine if osteomoties are necessary. You want to maintain continuity of the bones after surgery. Therefore, if a significant amount of bone is removed, it will be necessary to do the osteotomies to move the nasal bones to maintain continuity between them and the surrounding bones. This will heal like any fracture. You have done your homework; now decide what you want to change and select the surgeon you want to do your work.
Rasping of a dorsal hump is very common. When this is performed, usually you get an "open roof" which is a flattening and a wider appearance of the upper 1/3 of the nose. The osteotomies close this "open roof" and allow you to have a narrower look to your nose. So when it appears very flat after rasping, osteotomies are necessary. The bones are not usually cut all the way, but are allowed to "greenstick" or incompletely break so they narrow but still stay attached.
Rhinoplasty Osteotomies, When is Rasping Enough?
Lot's of questions, lot's of consults, that's good.
Rasping is a method to reduce nasal bone height in a graduated fashion. The nasal dorsum may be reduced either with rasping or by using a chisel.
Osteotomies are performed to narrow the upper 1/3 of the nose (the boney portion), and/or to close the "open roof" that is left when a large dorsal hump of bone is removed.
The cut bones reattach very near to where they were cut, they are just angled more toward the dorsum of the nose (inward) to meet in the midline.
With regard to choosing your rhinoplasty surgeon, make sure that you know what bothers you, as well as what you want and what you will be satisfied with. Then listen to the surgeons and make sure that they understand and can deliver what you desire.
Good luck and be well.
Osteotomies in rhinoplasty
There are many components to rhinoplasty, as well as different methods of doing it. Open vs. closed approach is sometimes just a surgeon's preference. You can ask your doctors whether they do both approaches, and how often, and most importanly see their results and make sure you like them. Sounds like you are getting enough information.
Osteotomy is a fancy word for cutting the bones. You mention that your "front profile" has "fatty bone". I presume it means your nose is wide on the front view. To narrow it, we always have to do osteotomies, Usually as least one on each side. Nasal bones are thin enough that, to narrow the nose, you have to make that cut, and bring them closer together.
Rasping is usually done at the top, to take down the hump, and smooth it down. Sometimes we do osteotomies on the top as well, if the nose is too wide, or the hump is too large.
I would go back for a second consult, ask to see some rhinoplasty results that are close to your nasal shape, and had similar procedures done. Make sure the doctor is well versed in all different aspects of rhinoplasty procedure. Ask to talk to some of the previous patients, we often recommend our patients do that.
Rhinoplasty and The Bones
Rasping is what is done to take down the bony hump. Osteotomy is completely separate procedure and the other doctors probably failed to mention it. The breaking of the nose at the base where it meets your face of cheeks is commonly necessary when a hump is taken down. It may not be necessary when the hump is very small, but more often it is required. What the rasping does is given you what is called an open roof.
If you imagine a triangular roof on top of a house. If you take down the point your will left with an opening in the roof with the two sides of the roof coming up but not converging. That is what happens after rasping. Now what needs to be done is to close that open roof by doing an osteotomy at the base to bring together the sides again so that you have a continuity in the roof. Hope that gives you the picture.
Cutting bone during Rhinoplasty
Interesting set of opinions demonstrating that rhinoplasty is perhaps the trickiest operation is all of aesthetic surgery. In general (and without the benefit of your picture) the base of the nasal pyramid should sit within a line drawn from the inside of the eyelid to the corner of the mouth. The width of the pyramid is established by the relationship of the bones of the nose merging with the cheek bone. If the pyramid is too wide, an instrument called an osteotome is used to cut the bond and move it inwards.
The decision to or not to do an osteotomy depends on all the other relationships of the nose to the face. I find video imaging extremely useful both for the patient and me in determining choices such as these.
Doing a rhinoplasty open or closed is a personal decision for the surgeon. I almost always do them open (although early in my career I did all of them closed). I have found, though, that even in noses that are outwardly symmetrical, when exposed by the open technique, actual asymmetries are discovered that were not expected. But this is just one surgeon's opinion.