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The Nasal Dorsum

Residual dorsal or dorsolateral hump- another common postoperative dorsal deformity is a residual hump and these can be especially bothersome and may require secondary correction. Although inadequate hump reduction is always possible, it can also be likely formed from calcium deposits and may also be secondary to bone dust or neocartilage formation. But another reason may be to blame—when performing dorsal reduction, most surgeons first shave or resect excess dorsal septum and upper laterals with a scalpel and then reduce the bony dorsum using a rasp. Frequently, later in the procedure, further touch-up rasping may be necessary on the dorsum. During cartilaginous scalpel reduction of the dorsum the upper laterals beneath the nasal bones are not resected. Rasping of the bony dorsum unroofs the underlying upper lateral cartilage and frequently allows a small area of the upper laterals to protrude slightly above the dorsal line. This needs to be then resected again after the rasping with a scalpel or fomon scissors. Additionally, slight edema that occur early intraoperatively (or local anesthetic injected into the overlying envelope) can easily mask these slight protrusions, which become apparent externally only after complete resolution of postoperative edema. The dorsum may appear perfectly smooth after initial reduction, but any further touch-up bony rasping done later in the procedure can allow cartilage underlying bone at the keystone to protrude. Prevention of residual dorsal or dorsolateral protrusions by always consciously checking the keystone area for cartilage protrusions under direct visualization after any rasping of the keystone area. Trimming small cartilaginous protrusions tangentially with a scalpel is the best way to reduce them.

The inverted v deformity-This deformity is visible in upper dorsum to middorsum and occurs with time after a rhinoplasty with posterior displacement or collapse of the nasal bones after osteotomy or from overreduction of dorsal upper laterals relative to dorsal septum. Nasal bone collapse occurs when nasal bones are highly mobile with lateral osteotomies which detach mucosa beneath osteotomy. This lacerated mucosa beneath osteotomy allows the base of the nasal bone to fall into the vestibule from lack of soft tissue support, and the dorsal height of the nasal bones decreases. As the dorsal nasal bones falls posteriorly, the attached upper lateral cartilages also displaces posteriorly, making the dorsal septum protrude. The dorsal septum alone defines the dorsum and protrudes, while the posteriorly displaced nasal bones and upper laterals form the inverted v with the apex towards the radix. This deformity occurs more commonly with endonasal rhinoplasty and rarely occurs with open rhinoplasty because with the open approach the nasal bones can be resuspended into dorsal perpendicular plate of the ethmoid or dorsal septum. Another cause of inverted v deformity is excessive trimming of the dorsal upper laterals, allowing the dorsal septum to protrude above the upper laterals. A very important intraoperative point Dr Sam Rizk has noted which leads to overresection of the upper lateral cartilages is that the retraction of the soft tissue envelope with an Aufricht to expose the nasal dorsum in rhinoplasty results in displacement of the upper laterals above the septum intraoperatively deceiving the surgeon into overresection. This retraction makes the upper lateral cartilages appear too high relative to the septum. If trimmed level with the septum with the envelope retracted significantly, the dorsal upper laterals fall posterior to the dorsal septum when retraction is removed resulting in an inverted v deformity. It is important to judge the relationship of the dorsal septum to the dorsal upper laterals with minimal retraction anteriorly on the soft tissue envelope to prevent overresection of the dorsal upper laterals according to Dr Sam Rizk, a new york rhinoplasty surgeon and double board certified facial plastic surgeon.

Defining the desired height of the dorsum- The ideal height of the dorsum depends on achievable tip projection off the facial plane and the desired relationship of the patient’s nasal dorsal profile to the tip projecting point. This relationship varies in male versus female rhinolasty patients according to Dr Sam Rizk, a new york city rhinoplasty specialist. The nasal profile relationship to the nasal tip can affect the masculinity or feminine character of the nose. For instance a supratip break is a feminine character to the nose but is not appropriate for a male nose. A supratip break can be created by either projecting or rotating nose more or by reducing the supratip area more. According to Dr Sam Rizk, adjusting the dorsal nasal profile requires not only an understanding of nasal surgical techniques and relationships of the various regions of the nose, but also requires an artistic understanding of the desired nasal and facial balance in that particular patient. Extensive preoperative discussions facilitated with computer imaging enables this understanding. Dr Sam Rizk does this with patient profiles and has a vision for each patient. Dr Rizk’s vision for the profile of the patient is then not only discussed but also demonstrated via computer imaging in the preoperative patient discussion. Dr Sam Rizk believes that each surgeon may have their own opinion as to the ideal profile and this is where variability in results may occur with equally qualified surgeons. Each surgeon incorporates his own vision and ideals of beauty to the patient creating differing results. This is one of the factors which makes each rhinoplasty surgeon different. Dr Sam Rizk likens this to purchasing different artworks from different artists. Dr Rizk further emphasizes that it is very important for patients to see examples of the rhinoplasty surgeon’s work to judge and decide on who to choose in order for the patient to not end up disappointed but choosing a surgeon who may be technically qualified but whose artistic vision may not match the patient’s. Dr Sam Rizk further points to the importance of comparing tip projection to the dorsal nasal profile line. Most surgeons think of tip projection as the furthermost tip defining point distance from the alar groove and although this is a correct definition, the tip projection needs to be compared to the dorsal nasal line to determine overprojection of the nasal tip, underprojection, and normal projection. Tip projection off the facial plane is one of the most critical anatomic parameters in rhinoplasty. Ideal tip projection off the facial plane depends on nasal length. The longer the nose, the more tip projection off the facial plane is desirable to maintain aesthetic balance. This relationship has been expressed by many surgeons in different ways. The most clinically practical methods of defining desired tip projection is understanding visual aesthetic judgment on how much tip projection off the facial plane is desirable to maintain aesthetic balance and adjusting the dorsum accordingly. Tip projection should be .67 of the dorsal lateral distance from nasofrontal angle to the tip of the nose (most projecting part) according to the methods of nasofacial relationship described by Byrd. Therefore, Dr Sam Rizk takes into account this important concept in planning his rhinoplasty surgery, specifically planning tip projection relative to the dorsal line in addition to tip projection off the facial plane during his preoperative assessment of the patient. This important relationship, Dr Sam Rizk points out, has a dramatic effect on the aesthetic appearance of the nose and is an important topic to discuss with the patient preoperatively. When the tip projection is above the dorsal line, a supratip break exists and the tip usually appears to have more definition in lateral view because it is set apart from the line of the dorsum. When the tip projection is even with the dorsal line, a supratip break is not present, but some patients prefer this type of relationship (especially male patients) and it is certainly aesthetically acceptable. If the tip projection is below the dorsal line, the tip appears to be hanging and creates an aesthetically unsatisfactory tip-dorsum relationship.

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