Voted Top Rhinoplasty Doctor by Castle Connolly

The Nasal Dorsum

Primary versus secondary or revision rhinoplasty-the nasal dorsum issues that result in need for revisions. During rhinoplasty , septal surgeries, osteotomies and tip projection can affect the ideal or desired height of the dorsum, so it is important to delay final dorsum adjustments until the steps that may affect dorsal height are complete. During primary dorsum surgery, Dr Sam Rizk, prefers to slightly underreduce dorsum height, adjusting the final height of the dorsum during secondary dorsum surgery later in the rhinoplasty. After completing other modifications that can affect dorsal height (ie septal surgery), Dr Sam Rizk, a nyc rhinoplasty expert and double board certified facial plastic surgeon, performs final adjustments of the dorsum (ie fine tuning) during secondary dorsal modification. This is important because extensive septal surgery can decrease the support of the dorsal septum, allowing a slight sag of the remaining dorsal strut, decreasing dorsal height. When planning extensive septal surgery, it is important to initially underreduce the dorsum by at least 1-2mm. Many primary noses with a visible dorsal hump require only a 1-2mm dorsal reduction to remove the hump and create a straight dorsum of appropriate height and balance ideal tip projection. When planning an increase in tip projection, avoid dorsal overreduction during primary dorsum surgery to prevent inadequate dorsal height relative to the increased tip projection. On the same lines, when reducing tip projection off the facial plane, it is safe to perform relatively more dorsal reduction initially without risking inadequate dorsal height relative to the reduced tip projection. In either case, other factors can affect dorsal height during the rhinoplasty. Achieving perfect dorsal height and dorsal tip relationships is difficult for the most experienced rhinoplasty surgeon. The most important principle of dorsum surgery is to avoid overreduction, even if it means a relatively minor secondary procedure to lower the dorsum slightly. After overreduction, restoring dorsal height involves grafting, and grafting in the best of circumstances introduces several uncontrollable variables. Although adequate visualization of the dorsum is possible through both the open and closed rhinoplasty approaches, the open approach provides a wider field of view and perspective, which can also be achieved with the endoscopic high definition telescope visualization of the nasal dorsum, pioneered by Dr Sam Rizk. The increased visualization of the nasal dorsum and perspective increase accuracy and control of dorsum modification allows a more accurate rhinoplasty and decreases the need for a revision rhinoplasty.

Reduction of the dorsum-defining the goals. When planning dorsal modification, Dr Sam Rizk explains the first step in defining desired dorsum length and height is to determine final achievable tip projection. Measure existing tip projection on lateral images of the nose, and determine ideal tip projection by first defining desired nasal length. Having ideal tip projection, Dr Rizk decides whether this ideal projection is achievable given the clinical parameters, surgical experience, and available techniques. The surgeon can then determine final achievable tip projection. From the preoperative consultation, the surgeon should know whether the patient desires the tip projecting point even with or above the dorsal line of the nose. During planning, if the patient desires a supratip break (ie tip projecting point above the dorsal line of the nose), dorsal height must be slightly less than final achievable tip projection. If the patient desires no supratip break (ie tip projecting point level with the dorsal line), dorsal height is approximately the same as final achievable tip projection. Determing the desired relationship of the tip projecting point to the dorsum is important for several reasons. If, for example, a patient has an underprojecting tip but is willing to accept the tip level with the dorsum rather than insisting on a supratip break, this may be achievable without resorting to tip grafts and their inherent variables. Likewise, if a patient has an overprojectip tip, recession of the tip without undesirable tradeoffs may leave the tip above the existing dorsal line. If a supratip break is acceptable in this patient, dorsal augmentation is unnecessary. If the patient wants no supratiip break, further tip recession or dorsal augmentation would be necessary. Once the surgeon determines final achievable tip projection, then the surgeon can define the desired height of the dorsum. If dorsal height is excessive relative to the final desired tip projection, dorsal reduction is appropriate. If adequate or the same, no change or slight change is indicated in the dorsal height. If the dorsal height is deficient relative to the final achievable tip projection, the surgeon must decide whether to accept less tip projection or proceed with augmentation of the dorsum.

Lateral protrusions of the nasal dorsum-Dorsolateral protrusions or lateral humps protrude laterally and disrupt an ideally smooth dorsal aesthetic line. They occur most commonly in the rhinion or the junction of the bony and cartilaginous dorsum and can be bony, cartilaginous, or a combination of the two. Identifying lateral protrusions during the clinical examination and in preoperative photographs is important because small lateral protrusions are easily overlooked intraoperatively and create secondary deformities. In preoperative photographs, lateral protrusions (and especially differences in the protrusions on the two sides) are most apparent on oblique views but are also visible on anteroposterior and lateral views. If the lateral protrusion is primarily cartilaginous, remove it by a sharp, tangential shave resection using #15 or #11 blade though open or closed approaches. If the protrusion is bony, Dr Sam Rizk uses a micro-rasping powered tool to burr it down and remove it. After reducing a bony or combined bony-cartilaginous protrusion, carefully recheck for protruding cartilage uncovered as the nasal bone was rasped and shave it if present. Dr Rizk likes to address lateral protrusions before performing other dorsal modifications for many reasons. For one thing, they will not be overlooked as the surgery progresses and other major abnormalities are addressed. Also it is easier to shave tiny increments tangentially while all dorsum structures are stabilized. Once the dorsal upper laterals are mobilized, accurately and precisely reducing lateral protrusions is more difficult and it is much easier to overlook them entirely.

Dorsal reductions should be performed in steps. At primary dorsal reduction , the dorsal septum should be reduced less than desired amount, waiting until after septoplasty and osteotomies to perform the final reduction. Dr Sam Rizk, a ny rhinoplasty surgeon, emphasizes the need for a primary and secondary dorsal reduction after the osteotomies and septoplasty since the septum might settle down a few miliimeters after septoplasty. After appropriate reduction of the dorsal septum, Dr Sam Rizk will use a rasp or power burr to lower the bony dorsum (dorsal nasal bones and perpendicular plate of the ethmoid)-removing less than total amount desired. Rasps are sharp for maximal accuracy. Rasps have a tungsten carbide cutting inserts for sharpness. It is important to emphasize that the rasps limits the surgeon’s vision during the bony reduction which is a definite negative for Dr Rizk. This is why Dr Sam Rizk prefers the powered burr. Traditionally, surgeons perform rasping blind, redraping soft tissues to determine the adequacy of reduction when viewing it externally. Because rasps require manual power, performing small, accurate reductions is more difficult because the manual power required to move bone is often less than delicate. In addition, the surface areas of most rasps extends beyond the boundaries of the bony surfaces being treated, hence creating a lot of soft tissue trauma and possible inadvertent avulsions or abrasions to adjacent tissues and overlying skin. A small, properly selected and controlled electric power burr eliminates all these negatives.