How Does a Surgeon Decide if Your Nose Needs to Be Broken or Not for Rhinoplasty?

First of all, "breaking the bones" seems to give patients an image of some sort of club or baseball-bat-like device used by surgeons to break the nasal bones. Far from this, we use small, sharp tools called osteotomes (like a tiny chisel, often with a lip or "guard" to keep it in exact position) to make slits in the eggshell-thin nasal bones, which allows surgeons to "infracture" or narrow these  bones.

This narrowing is done for excessively wide upper nasal structures, or to restore the normal nasal pyramid after removal of a prominent hump.

Nasal osteotomies are not needed when the nose has a normal width in the upper third, or no hump to reduce. If a hump is reduced without concomitant osteotomies, an "open-roof" deformity is created, and this will require re-operation to "fix."

"Breaking the bones" during rhinoplasty is necessary in most cases to give the refinement that patients ask for, and although some bruising is inevitable when this is done, "avoiding" the nasal osteotomies in cases where it should have been done is NOT a plus, it is a high (or guaranteed) risk of needing re-operation. Bruising resolves, but bad rhinoplasties require revision!

Thank you for the question. Based on the frequency with which I am asked this question in consultation, concern over the the idea of "breaking the nasal bones" is almost ubiquitous in patients considering Rhinoplasty.  In surgical terms, we refer to this concept as osteotomies, or cuts in the nasal bones, which are performed with very sharp specialized instruments.  Osteotomies are utilized most particularly in three circumstances: i) when the nasal bones are crooked, ii) when a dorsal hump is removed (removing a hump often leads to a flat surface on the dorsum which must be narrowed), iii) a wide nasal dorsum for purposes of narrowing.  Under anesthesia, a patient will not be aware if osteotomies were or were not performed (in skilled hands).  The amount of swelling and/or bruising after the procedure has postoperatively correlates with how smoothly the osteotomies were performed.  In more experienced hands, the procedure is performed quickly and deftly, causing less swelling. Because the nasal bones require 6 weeks for fibrous healing to set in place, blunt trauma to the nose is to be avoided in order to minimize risk of displacement.

Breaking the nose is technically called an osteotomy and refers to a very precise cut in the bone made by your surgeon for several reasons:1) To straighten a crooked nose2) To narrow a nose3) To close what is called an open roof that may occur when a large hump is removed.It is not always necessary to perform an osteotomy and this is decided on a case by case basis.

Whether nasal bones need to be broken, depends on the size of the dorsal hump being removed.  A very small hump can be just rasped and no breaking of the nasal bones is necessary.  If there is a large hump that is removed, it will result in a flat top or open roof deformity of the nose, which must be closed with osteotomies.  

This is a question that is not easily answered. First, it is important to understand that a rhinoplasty does not involve 'breaking' the bones; rather, there are precise cuts made in the bone so that the bones can be repositioned. If done correctly, it is a very precise and controlled process. Deciding who needs osteotomies is not always straightforward, but in general, if the upper (bony) portion of the nose is crooked, asymmetric, or requires narrowing, then osteotomies are often useful.

Rhinoplasty always involves (among other things) moving, removing and repositioning of the nasal bones. This is sometimes referred to by lay people as "breaking" the bone. Actually, it is done delicately with special instruments that alolw accurate sculpting and optimal healing.

This is probably the most common misconception about rhinoplasty surgery.  Most rhinoplasty surgery involves cutting the bones.  This is done with specially designed instruments including what the average person would call a chisel.  But, just like you wouldn't say that a carpenter breaks wood (at least not a good one!), you shouldn't think of a rhinoplasty surgeon as someone who breaks noses.

In short, any rhinoplasty that hopes to make the upper half of the nose smaller is going to need cuts in the bone.  The most common rhinoplasty surgery request is hump removal, and that just about always requires bone cuts.  Cutting the bones is also necessary to narrow the upper nose with or without hump removal or to move the upper half of the nose left or right as in a crooked nose.

Nasal anatomy is fairly complex and very inter-related.  Because of this, rhinoplasty surgery is not simple, and thus is very interesting to those surgeons who enjoy it.  For these reasons, there is no simple answer to your question, but I'll give a few scenarios that are easy to understand:


If you have a crooked nose and the nasal bones contribute to the nose being crooked, they might need to be broken to be repositioned and straightened.

If you have a large hump, the bones might need to be moved together after reducing the hump to prevent the bridge from becoming too wide.  (Think about removing the top of a pyramid - the lower level is wider.)

Sometimes after reducing a hump, an open roof can be felt (where the skin buckles into a gap between the bone edges and the septum), and osteotomies are needed to close the gap.



Oh, saying that the bones are "broken" is a layman's way of describing the procedure.  Actually, the path of the break is carefully created using a sharp metal chisel (called an osteotome), and then the bone segment is moved into the desired position.  A greenstick fracture is often intentionally created to hinge the bone in the correct position.

Best regards,
Dr.B

Usually the surgeon will decide to perform carefully controlled microfractures called osteotomies if the bony pyramid is wide or crooked, or otherwise would not be proportionate to the lower cartilaginous pyramid after reshaping this area when performing rhinoplasty. This can and should be discussed as part of the consultation; many times the desired result can be achieved without the need for these "fractures".

The components addressed in an aesthetic rhinoplasty are usually the hump, the tip, and the nasal bones. The goal is to make all three look natural and congruent. In general, the larger the hump, the higher the chance the bones will need to be moved inward to match the new dorsum. Not doing so would produce a flattened and "wide" appearance that would not be pleasing to the eye.