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.