Combined Nasal Osteotomies With Caudal Transverse Osteotomy and Their Effect on Dorsal Geometry

Combined Nasal Osteotomies With Caudal Transverse Osteotomy and Their Effect on Dorsal Geometry Abstract Background Congenital, traumatic, or developmental bony vault deformities may require additional interventions rather than classical osteotomies to correct the surface structure or angulations of the nasal bones in rhinoplasty. Objectives The aim of the study was to determine the effects of the additional osteotomies applied for the correction of the nasal vault asymmetries retrospectively. Methods Twenty-one patients among 512 primary rhinoplasty cases between 2011 and 2016 with bony vault asymmetries were included in the study. Three patients had bilateral convex, 6 patients had unilateral convex, and 7 patients had unilateral concave surface deformities. Five patients had concave deformity on one side and convex deformity on the other side. Double-layer lateral osteotomies and caudal transverse osteotomies were conducted for the correction of the severe surface anatomy deformities of the nasal bones. The caudal transverse osteotomy was delicately performed with a special osteotome, which was designed to protect inner periosteum and mucosa of the nasal bone, and to prevent uncontrolled fracture formation with thinned edge. Results Twenty patients (95.2%) had favorable results with restoration of a symmetric bony and cartilaginous nasal vault configuration. None of the bone fragments showed any rotation or malposition. One (4.8%) patient with a crooked nose had suboptimal dorsal geometry without requiring revisional surgery at the level of the cartilaginous nasal vault. Conclusions The author described the morphology, clinical relevance, and correction methods of the nasal vault and the changes that occur in this area during rhinoplasty in patients with concave, convex, or combined three-dimensional nasal bone deformities. Level of Evidence: 4 The dorsal aesthetic lines have been considered one of the most important components of the aesthetic perception in rhinoplasty. Restoration of the anatomy of the osseo-cartilaginous vault is essential for obtaining pleasing dorsal aesthetic lines and functional outcomes in rhinoplasty. One of the most consequential maneuvers in rhinoplasty is nasal bone osteotomy, the importance of which has not been sufficiently emphasized. An improper, and even a proper, osteotomy can result in some adverse effects, avoidance of which can make the rhinoplasty much more successful.1 One of the persistent problems with nasal bone osteotomies in patients with severe asymmetric bony vault is symmetric reduction of the width of the nasal dorsum. Various attempts to correct 3-dimensional deformities of the crooked nose may lead to iatrogenic impairment in nasal skeleton. In addition, an algorithm as to which osteotomy and what kind of osteotom to use has not been fully explored. A thorough understanding and development of the various osteotomy techniques will allow the surgeon to improve the overall contour and aesthetic features of the nose and its harmony with the face, while ensuring preservation of or improvement on the functional internal anatomy of the nasal airway. The bony nose is composed of two nasal bones that attach frontal bone at the nasion superiorly, lacrimal bone superolaterally, and frontal process of the maxilla inferolaterally. The bones are thickest at the nasofrontal junction and become weaker caudally. The bony edges of the pyriform aperture are the thinnest portion of the nasal bones.2 That is why the caudal portion of the nasal bone is more prone to fractures when compared to other sides. Fracture of the caudal portion may cause the deformity of the nasal bone at the trauma region; however, fracture of the cephalic portion of the nasal bone may also lead to more complex deformities, including crooked nose or leaning nose, which are caused by high-energy trauma. The etiology of the crooked nose may be congenital or acquired.3 There are certain differences between the traumatic deformity of adulthood and the developmental deformity, which occurs in trauma during childhood. Congenital, traumatic, or developmental bony vault deformities may require additional interventions rather than classical osteotomies to correct the surface structure or angulations of the nasal bones. METHODS This study retrospectively reviewed 21 patients among 512 primary cases between October 2011 and December 2016 with bony vault asymmetries following approval of Hacettepe University Non-Interventional Clinical Research Ethics Board (Approval Number: GO 16/472-50). All of the patients had previous trauma history to their nasal bones. The patients who had nasal deformities with nasal bone surface irregularities were included in the study. The patients who had previous nasal surgery such as rhinoplasty or excisional or reconstructional interventions of the soft tissue coverage of the nasal dorsum and who had the deformity at only cartilaginous vault level were excluded from the study. The deformities were caused by deviations of the bony vault toward one side of the nose, or they were the result of the width irregularities between the upper and middle one-thirds of the nose. All of the operations were performed by the same consultant plastic surgeon (E.K.). The results of the operations were evaluated according to the patient satisfaction with a satisfaction determination query. Inclusion criteria of the patients depend on the surface anatomy of the nasal bone deformities. All of the patients had a certain degree of concavity or convexities on one or both sides of the nasal bones. Three patients had bilateral convex, 6 patients had unilateral convex, and 7 patients had unilateral concave deformities. Five patients had concave deformity on one side and convex deformity on the other side (Figure 1). Figure 1. View largeDownload slide View largeDownload slide This 21-year-old man has severe 3-dimensional nasal bony vault deformity. (A) The topographic features of the nasal bone of the patient characterized by convex deformity on right side, however, concave deformity on the left side. (B) Cephalo-caudal concave deformity on the right side (yellow line) and cephalo-caudal convex deformity on the left side (red line) of the patient can be observed. (C) The nasal bone reveals antero-posterior concave deformity on the right side (yellow line) and antero-posterior convex deformity on the left side (red line) on the hemi-basilar view. (D) Photography of the external nose of the patient. (E, G, I) Preoperative and (F, H, J) 14-month postoperative photographs of the patient. Figure 1. View largeDownload slide View largeDownload slide This 21-year-old man has severe 3-dimensional nasal bony vault deformity. (A) The topographic features of the nasal bone of the patient characterized by convex deformity on right side, however, concave deformity on the left side. (B) Cephalo-caudal concave deformity on the right side (yellow line) and cephalo-caudal convex deformity on the left side (red line) of the patient can be observed. (C) The nasal bone reveals antero-posterior concave deformity on the right side (yellow line) and antero-posterior convex deformity on the left side (red line) on the hemi-basilar view. (D) Photography of the external nose of the patient. (E, G, I) Preoperative and (F, H, J) 14-month postoperative photographs of the patient. All of the patients operated with the open technique. After skin flap elevation, dissection of the dorsum of the nose was begun to perform subpericondrialy at the caudal edge of the upper lateral cartilages and extended subperiosteally at the level of the bony dorsum. The periosteal dissection was limited laterally at the level of the planned osteotomy line for the hump reduction, which means the periosteum over the nasal bone at the lateral nasal wall was kept attached to the nasal bone. Pericondrium of the upper lateral cartilage and periosteum of the nasal bones were elevated as a single unit, like a blanket, to cover the structures after dorsal restoration. Then the nasal bone and underling upper lateral cartilages were separated from each other with a sharp-edged frier dissector at the apex of the bony vaults without damaging the cartilages. The dissection between bone and upper lateral cartilages did not exceed down to the level of the planned osteotomy level of the hump reduction to prevent osteocartilaginous dislocation on the lateral nasal wall. After reduction of the bony humps with osteotomes, deformities of the lateral nasal wall geometry were corrected with additional osteotomies. Depending on the deformity present, several osteotomy combinations, including median osteotomy, transverse osteotomy, lateral osteotomy, double-layer lateral osteotomy, and caudal transverse osteotomy, were applied. Caudal transverse osteotomy was conducted to correct severe 3-dimensional concave or convex deformities of the nasal bone, which reveal not only antero-posterior but also cephalo-caudal bulging or depressions (Figure 2) (Video). Caudal transverse osteotomy was delicately performed with a special osteotome, which was designed to protect the inner periosteum and mucosa of the nasal bone, and to prevent uncontrolled fracture formation on the thinned edge (Figure 3). Figure 2. View largeDownload slide View largeDownload slide (A, C, E, G) A 25-year-old man with prominent bulging on the right nasal bone over the keystone area. Hump reduction, caudal transverse osteotomy, paramedian osteotomy, transverse osteotomy, and high-low-low lateral osteotomies were performed. Cephalic portion of the nasal bone after caudal transverse osteotomy was medialized; however, caudal portion was lateralized and slightly twisted to achieve plane lateral nasal wall (I). (B, D, F, H) Eighteen-month postoperative views reveal balanced nasal dorsal geometry and relatively plane morphology with subtle yet persistent prominence of caudal margin of the right nasal bone. These subtle problems can be solved with delicate planning considering the possible new localization of the angulated distal segments. Figure 2. View largeDownload slide View largeDownload slide (A, C, E, G) A 25-year-old man with prominent bulging on the right nasal bone over the keystone area. Hump reduction, caudal transverse osteotomy, paramedian osteotomy, transverse osteotomy, and high-low-low lateral osteotomies were performed. Cephalic portion of the nasal bone after caudal transverse osteotomy was medialized; however, caudal portion was lateralized and slightly twisted to achieve plane lateral nasal wall (I). (B, D, F, H) Eighteen-month postoperative views reveal balanced nasal dorsal geometry and relatively plane morphology with subtle yet persistent prominence of caudal margin of the right nasal bone. These subtle problems can be solved with delicate planning considering the possible new localization of the angulated distal segments. Figure 3. View largeDownload slide (A, B) A special osteotome was designed to be able to perform delicate caudal transverse osteotomy and to prevent uncontrolled fracture formation with thinned edge. Figure 3. View largeDownload slide (A, B) A special osteotome was designed to be able to perform delicate caudal transverse osteotomy and to prevent uncontrolled fracture formation with thinned edge. Video 1. Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy107 Video 1. Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy107 Close The caudal transverse osteotomy enhances the mobilization of the caudal and cephalic portions of the nasal bone segments in different vectors. For correction of the convex deformity of the nasal bone, the cephalic portion was moved medially and the caudal portion was moved laterally (Figure 2I). However, correction of the concave deformity of the nasal bones was also performed with caudal transverse osteotomy, and movement of the osteotomized segments was different. Neighboring edges of both cephalic and caudal segments of the nasal bones were moved laterally to flatten the concave surface. If the concave deformity imitated crock-like geometry, additional lateral osteotomies, which were the upper osteotomy line of the double-layer lateral osteotomy, were applied. The upper lines of the double-layer lateral osteotomies were designed to cross the caudal transverse osteotomy line at the deepest point of the concave bone. Then the corners of the bone segments at the crisscross area were protruded laterally to flatten the concave surface. When double-layer osteotomies are required, the higher osteotomy should be completed before the lower one. This maneuver is essential for preventing displacement of fragments over the lower osteotomy line. All of the mucosal sides of the caudal transverse osteotomy lines were inspected intraoperatively to determine mucosal tears, which may cause possible bony instabilities. All of the patients had septal deviations that required septoplasty. Septal deviations in 17 patients were corrected with submucous resection; however, septal deviations in 4 patients required horizontal mattress sutures in combination with septal cartilage scoring. All of the middle thirds of the noses were stabilized with fold-in spreader flaps; however, 3 patients with concave nasal bone surface deformities required additional spreader grafts on the concave sides. RESULTS A total of 21 patients between 18 and 33 years old (mean, 24.5 years) met the inclusion criteria. Twelve patients were male and 9 patients were female. The follow-up range was between 9 and 49 months (mean, 17 months). The percentage of patients who had favorable results with restoration of a symmetric bony and cartilaginous nasal vault configuration was 95.2% (Figure 4). Figure 4. View largeDownload slide (A, C, E) This 26-year-old man had a nasal fracture during childhood. Nasal bone of the patient was revealing concave surface deformity on the right and convex surface deformity on the left. (B, D, F) Thirty-month postoperative views of the patient after hump reduction, median, transverse, caudal transverse, and bilateral double-layer lateral osteotomies. The late results reveal balanced dorsal geometry with subtle persistent prominence of the caudal margin of the left nasal bone and deviation. Figure 4. View largeDownload slide (A, C, E) This 26-year-old man had a nasal fracture during childhood. Nasal bone of the patient was revealing concave surface deformity on the right and convex surface deformity on the left. (B, D, F) Thirty-month postoperative views of the patient after hump reduction, median, transverse, caudal transverse, and bilateral double-layer lateral osteotomies. The late results reveal balanced dorsal geometry with subtle persistent prominence of the caudal margin of the left nasal bone and deviation. Sufficient mobilization of the nasal bones was achieved in all patients. None of the osteotomy lines revealed an unexpected course during combined osteotomies, including caudal transverse osteotomy. Collapse or spicule formation of the nasal bone was not observed with combined osteotomies. None of the bone fragments showed any rotation or malposition. None of the caudal transverse osteotomy attempts resulted in nasal mucosal tears during the osteotomy course. All of the deformities, including bony deviation, surface irregularities of the lateral nasal bone, and asymmetries between right and left nasal bones, were corrected. One (4.8%) patient with a crooked nose had suboptimal dorsal geometry without requiring revisional surgery at the level of the cartilaginous nasal vault. The deformity of this particular patient was caused by the deformity of the upper lateral cartilage secondary to the previous trauma (Figure 5). Figure 5. View largeDownload slide View largeDownload slide (A, C, E, G) A 23-year-old woman with nasal deformity caused by nasal trauma. Aymmetric hump reduction, radix reduction, paramedian osteotomy, bilateral caudal transverse osteotomy, bilateral transverse osteotomy, and right double-layer lateral osteotomies were performed. (B, D, F, H) Two-year postoperative views reveal well-established bony vault and dorsal aesthetic lines. An acceptable and minor depression not at the level of the bony vault but around the right upper lateral cartilage can be observed (H). Figure 5. View largeDownload slide View largeDownload slide (A, C, E, G) A 23-year-old woman with nasal deformity caused by nasal trauma. Aymmetric hump reduction, radix reduction, paramedian osteotomy, bilateral caudal transverse osteotomy, bilateral transverse osteotomy, and right double-layer lateral osteotomies were performed. (B, D, F, H) Two-year postoperative views reveal well-established bony vault and dorsal aesthetic lines. An acceptable and minor depression not at the level of the bony vault but around the right upper lateral cartilage can be observed (H). DISCUSSION The aesthetic features of the nose require a delicate balance not only with the anatomy of the nose itself but also for its relationship with the face in rhinoplasty operations. One of the most consequential maneuvers in restoration of the harmony in rhinoplasty is nasal bone osteotomy. The lateral osteotomy technique evolved over several decades; however, the earliest technique was popularized by Josef who used a saw osteotomy method.4-6 From this evolution, two basic techniques for performing lateral osteotomies have evolved: continuous and perforating. The ideal lateral osteotomy should not only be precise, reproducible, safe, with maximum aesthetic and functional results, but also should limit postoperative sequela such as edema, ecchymosis, and nasal bone instability.7 Congenital, traumatic, or developmental bony vault deformities may require additional interventions rather than classical osteotomies to correct the surface structure or angulations of the nasal bones. The requirement of additional intervention was based on the nasal bone quality and geometry. All of the osteotomies performed in this study were continuous. Most of the patients had previous trauma, which causes severe angulations of the bony nasal vault and thickening of the nasal bone at the surrounding area of the fracture line. Other deformities were slope or bowl formation at the surface of the lateral nasal wall, which cannot be corrected with standard medialization after a classical lateral osteotomy. Application of the standard medialization of the concave bone would reveal insufficient mobilization at the keystone area or over-medialization at the cephalic portion above the keystone area. For the convex deformity of the nasal bone, this maneuver would also cause over-medialization at the keystone area, which may compromise quality of nasal airflow. To establish the collinear relationship with the nasal bone and upper lateral cartilage, the nasal bone geometry should be flattened. There have been many types of bone-cutting instruments and technologies described for rhinoplasty. They can be classified broadly into saws, osteotomes, chisels, shavers, rasps, bone-cutting forceps, rongeurs, oscillating saws, and piezoelectric scalpels.8-12 Each type of instrument has its own advantages under specific circumstances, although the final choice may depend on the surgeon’s experience. All of the maneuvers performed to cut the bones were performed with osteotomes in this particular study. After reduction of the bony humps with osteotomes, the deformities of the lateral nasal wall geometry were corrected with additional osteotomies, including double-layer lateral osteotomy, caudal transverse osteotomy, or a combination of them. Lateral osteotomes were used for the lateral osteotomy or double-layer lateral osteotomies, a chisel was used for the paramedian and transverse osteotomy, and a specially designed super-thinned edge chisel was used for the caudal transverse osteotomy. A thinned-edge osteotome was used for the prevention of the uncontrolled fracture during osteotomy of the weaker caudal portion of the nasal bone. Utilization of a thinned edge with a relatively blunt tip osteotome during caudal transverse osteotomy and designation of the osteotomy lines on the lateral nasal walls were the unique parts of the study. The caudal osteotomy lines were designed to be going through the most prominent point of the convex and the deepest point of the concave nasal bone deformities. If the deformity was severe, caudal transverse osteotomies were combined with the upper layer of the double-layer lateral osteotomy. Parkes et al addressed the problem of lateral nasal walls that are convex in the anteroposterior plane by introducing the double-lateral osteotomy, which consists of intermediate and lateral osteotomies.13 The authors emphasized that the intermediate osteotomy was “found to approximate the suture line between the maxilla and nasal bone.”13 Ghanaatpisheh et al also emphasized double-layer lateral osteotomy for narrowing the dorsum and correcting lateral wall convexity, designed in 3 levels: high, midlevel, and low.14 However, these osteotomies are effective in correcting the convex deformity in the anteroposterior plane, but they cannot be considered as a solution for the convex deformity in the cephalo-caudal plane. The caudal transverse osteotomy line was designed to be perpendicular to the upper layer of the double-layer lateral osteotomies to correct the 3-dimensional deformity of the nasal bone. This osteotomy enhances the mobilization of the caudal and cephalic portions of the nasal bone segments in different vectors. For the correction of the concave deformities of the nasal bone, the cephalic portion was moved laterally and the caudal portion was moved medially. However, convex deformities were corrected with medialization of the cephalic part and lateralization of the caudal part of the nasal bones. Sequencing the osteotomies plays a crucial role for preservation of the stability of the bony segments during performing combined osteotomies. After hump reduction, median osteotomies were performed. Then transverse and caudal transverse osteotomies were completed consecutively. Lateral osteotomies were performed after caudal transverse osteotomy. If double-layer lateral osteotomies were required, upper-level lateral osteotomies had priority when compared with lower-level lateral osteotomies. The correct strategy on sequencing would supply more control during the course of the osteotomies. Despite dramatic improvements in the dorsal nasal contours of the patients, some appear to have subtle yet persistent prominence of the caudal margin of the nasal bones (Figures 2 and 4). Another problem with deviated noses is persistent tilt of the cartilaginous vault. Suboptimal correction of the bony deviation may lead to cartilaginous tilt (Figure 5H). Difficulties in the prediction of new localization of the osteotomized segments from the 3-dimentional deformities may lead to these minor irregularities. These subtle problems can be solved with delicate planning by considering the possible new localization of the dorsal edge of the angulated distal segments before performing the osteotomy. The preservation of the stability of the fragmented nasal bone was the consequential maneuvers of these complex osteotomies. The periosteum provides support and nourishment to the underlying nasal bones.5 The periosteum over the lateral nasal wall was not dissected to preserve the soft tissue and nasal bone attachments, which is important to maintain the integrity and stability of the osteotomized bones. Another factor to keep osteotomized bones together was preservation of the mucosa and lateral extension of the upper lateral cartilage, underling the bone. Palhazi et al found lateral keystone areas in 24 heminoses (80%) and were highly variable in 15 fresh cadavers. When the lateral keystone area was present in the cadavers, the transition from dorsal keystone area to lateral keystone area corresponded to 1 of 3 patterns: continuous, stepped, or minimal joint.13 The continuous and stepped pattern extensions of the upper lateral cartilages may interfere with the caudal transverse osteotomy line. The preservation of the mucosa and continuous and stepped pattern extension of the upper lateral cartilages may also contribute to protection against medial collapse of the fragmented lateral nasal wall. That is why the double-layer lateral and caudal transverse osteotomies were performed with utmost care to be able to preserve the structures underling the nasal bone.15 Another sustentacular structure for the osteotomized segments is osteocartilagineous connections. The upper lateral cartilages attach the undersurfaces of the nasal bones and extend cephalically. Articulation and the relationship between upper lateral cartilages and nasal bones are vital to preserve lateral nasal wall integrity. Surgeons must take care to preserve the articulation of the nasal bones and upper lateral cartilages during dissection or rasping near the inferior edge of the nasal bones.5 Uncontrolled detachment of the nasal bone and upper lateral cartilages may cause inverted V deformity or step deformity on the lateral nasal wall. Precise maneuvers must be conducted during dissecting upper lateral cartilages from the nasal bone at the level of the dorsal portion, and the dissection should not be extended laterally to avoid detachment of the bone and the cartilage at the lateral nasal wall. The study has some limitations because of the varieties of the clinical situations, which prevents grouping or standardization of the patients. The retrospective design of the study and the lack of CT scans of all patients brought some additional limitations, such as difficulties to measure or analyze the depth or degree of the concave deformities on the nasal bone with objective methods. Another apparent limitation of the study is the small size of the series. The rarity of these complicated cases restrains the attainability of a large series. The authors described the morphology, clinical relevance, and correction methods of the nasal vault and the changes that occur in this area during rhinoplasty in patients with 3-dimensional nasal bone deformities. Principles for the safety of the combined osteotomies depend on limited dissection over the nasal bone and upper lateral cartilage, preservation of the nasal mucosa under the nasal bone, delicate fracturing of the distal bony segment, and supporting the inner surface with a silicon splint. CONCLUSIONS Correction of deformities of the nasal vault presents a challenge to the plastic surgeon. Achieving optimal aesthetic and functional results requires a comprehensive knowledge of not only the bony but also cartilaginous framework of the nose and its relationship with the overlying and underlying soft tissues. Suboptimal aesthetic results may occur when excessive or inadequate mobilization of the nasal bony framework is performed. Flattening and precise control of the slope of the nasal bone is facilitated with caudal transverse osteotomy. A specially designed thinned-edge osteotome enhances caudal transverse osteotomy. The combined and precisely pried nasal osteotomy technique represents an effective and logical approach for correcting concave or convex nasal bone deformities. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, or publication of this article. Funding The authors received no financial support for the research, authorship, or publication of this article. REFERENCES 1. Guyuron B . Variations in nasal osteotomy: consequences and technical nuances . In Hodgson S , Kuhn B , Mortimer A , eds. Rhinoplasty . China : Elsevier Saunders ; 2012;133-139 . 2. Harshbarger RJ , Sullivan PK . Lateral nasal osteotomies: implications of bony thickness on fracture patterns . Ann Plast Surg . 1999 ; 42 ( 4 ): 365 - 370 ; discussion 370. Google Scholar CrossRef Search ADS PubMed 3. Cerkes N . The crooked nose: principles of treatment . Aesthet Surg J . 2011 ; 31 ( 2 ): 241 - 257 . Google Scholar CrossRef Search ADS PubMed 4. Most SP , Murakami CS . A modern approach to nasal osteotomies . Facial Plast Surg Clin North Am . 2005 ; 13 ( 1 ): 85 - 92 . Google Scholar CrossRef Search ADS PubMed 5. Dobratz EJ , Hilger PA . Osteotomies . Clin Plast Surg . 2010 ; 37 ( 2 ): 301 - 311 . Google Scholar CrossRef Search ADS PubMed 6. Murakami CS , Larrabee WF . Comparison of osteotomy techniques in the treatment of nasal fractures . Facial Plast Surg . 1992 ; 8 ( 4 ): 209 - 219 . Google Scholar CrossRef Search ADS PubMed 7. Bloom JD , Immerman SB , Constantinides M . Osteotomies in the crooked nose . Facial Plast Surg . 2011 ; 27 ( 5 ): 456 - 466 . Google Scholar CrossRef Search ADS PubMed 8. Walter C . Septo-rhinoplasty: the correction of the bony parts of the nose . J Laryngol Otol . 1980 ; 94 ( 5 ): 475 - 484 . Google Scholar CrossRef Search ADS PubMed 9. Rubin FF . Reconstruction of bony nasal pyramid. Three new instruments . Arch Otolaryngol . 1968 ; 88 ( 3 ): 279 - 282 . Google Scholar CrossRef Search ADS PubMed 10. Goumain AJM . Cutting forceps for lateral osteotomy in rhinoplasty . Plast Reconstr Surg . 1973 ; 53 ( 3 ): 358 - 366 . Google Scholar CrossRef Search ADS 11. Avsar Y . The oscillating micro-saw: a safe and pliable instrument for transverse osteotomy in rhinoplasty . Aesthet Surg J . 2012 ; 32 ( 6 ): 700 - 708 . Google Scholar CrossRef Search ADS PubMed 12. Robiony M , Toro C , Costa F , Sembronio S , Polini F , Politi M . Piezosurgery: a new method for osteotomies in rhinoplasty . J Craniofac Surg . 2007 ; 18 ( 5 ): 1098 - 1100 . Google Scholar CrossRef Search ADS PubMed 13. Parkes ML , Kamer F , Morgan WR . Double lateral osteotomy in rhinoplasty . Arch Otolaryngol . 1977 ; 103 ( 6 ): 344 - 348 . Google Scholar CrossRef Search ADS PubMed 14. Ghanaatpisheh M , Sajjadian A , Daniel RK . Superior rhinoplasty outcomes with precise nasal osteotomy: an individualized approach for maintaining function and achieving aesthetic goals . Aesthet Surg J . 2015 ; 35 ( 1 ): 28 - 39 . Google Scholar CrossRef Search ADS PubMed 15. Palhazi P , Daniel RK , Kosins AM . The osseocartilaginous vault of the nose: anatomy and surgical observations . Aesthet Surg J . 2015 ; 35 ( 3 ): 242 - 251 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. 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Combined Nasal Osteotomies With Caudal Transverse Osteotomy and Their Effect on Dorsal Geometry

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Abstract

Abstract Background Congenital, traumatic, or developmental bony vault deformities may require additional interventions rather than classical osteotomies to correct the surface structure or angulations of the nasal bones in rhinoplasty. Objectives The aim of the study was to determine the effects of the additional osteotomies applied for the correction of the nasal vault asymmetries retrospectively. Methods Twenty-one patients among 512 primary rhinoplasty cases between 2011 and 2016 with bony vault asymmetries were included in the study. Three patients had bilateral convex, 6 patients had unilateral convex, and 7 patients had unilateral concave surface deformities. Five patients had concave deformity on one side and convex deformity on the other side. Double-layer lateral osteotomies and caudal transverse osteotomies were conducted for the correction of the severe surface anatomy deformities of the nasal bones. The caudal transverse osteotomy was delicately performed with a special osteotome, which was designed to protect inner periosteum and mucosa of the nasal bone, and to prevent uncontrolled fracture formation with thinned edge. Results Twenty patients (95.2%) had favorable results with restoration of a symmetric bony and cartilaginous nasal vault configuration. None of the bone fragments showed any rotation or malposition. One (4.8%) patient with a crooked nose had suboptimal dorsal geometry without requiring revisional surgery at the level of the cartilaginous nasal vault. Conclusions The author described the morphology, clinical relevance, and correction methods of the nasal vault and the changes that occur in this area during rhinoplasty in patients with concave, convex, or combined three-dimensional nasal bone deformities. Level of Evidence: 4 The dorsal aesthetic lines have been considered one of the most important components of the aesthetic perception in rhinoplasty. Restoration of the anatomy of the osseo-cartilaginous vault is essential for obtaining pleasing dorsal aesthetic lines and functional outcomes in rhinoplasty. One of the most consequential maneuvers in rhinoplasty is nasal bone osteotomy, the importance of which has not been sufficiently emphasized. An improper, and even a proper, osteotomy can result in some adverse effects, avoidance of which can make the rhinoplasty much more successful.1 One of the persistent problems with nasal bone osteotomies in patients with severe asymmetric bony vault is symmetric reduction of the width of the nasal dorsum. Various attempts to correct 3-dimensional deformities of the crooked nose may lead to iatrogenic impairment in nasal skeleton. In addition, an algorithm as to which osteotomy and what kind of osteotom to use has not been fully explored. A thorough understanding and development of the various osteotomy techniques will allow the surgeon to improve the overall contour and aesthetic features of the nose and its harmony with the face, while ensuring preservation of or improvement on the functional internal anatomy of the nasal airway. The bony nose is composed of two nasal bones that attach frontal bone at the nasion superiorly, lacrimal bone superolaterally, and frontal process of the maxilla inferolaterally. The bones are thickest at the nasofrontal junction and become weaker caudally. The bony edges of the pyriform aperture are the thinnest portion of the nasal bones.2 That is why the caudal portion of the nasal bone is more prone to fractures when compared to other sides. Fracture of the caudal portion may cause the deformity of the nasal bone at the trauma region; however, fracture of the cephalic portion of the nasal bone may also lead to more complex deformities, including crooked nose or leaning nose, which are caused by high-energy trauma. The etiology of the crooked nose may be congenital or acquired.3 There are certain differences between the traumatic deformity of adulthood and the developmental deformity, which occurs in trauma during childhood. Congenital, traumatic, or developmental bony vault deformities may require additional interventions rather than classical osteotomies to correct the surface structure or angulations of the nasal bones. METHODS This study retrospectively reviewed 21 patients among 512 primary cases between October 2011 and December 2016 with bony vault asymmetries following approval of Hacettepe University Non-Interventional Clinical Research Ethics Board (Approval Number: GO 16/472-50). All of the patients had previous trauma history to their nasal bones. The patients who had nasal deformities with nasal bone surface irregularities were included in the study. The patients who had previous nasal surgery such as rhinoplasty or excisional or reconstructional interventions of the soft tissue coverage of the nasal dorsum and who had the deformity at only cartilaginous vault level were excluded from the study. The deformities were caused by deviations of the bony vault toward one side of the nose, or they were the result of the width irregularities between the upper and middle one-thirds of the nose. All of the operations were performed by the same consultant plastic surgeon (E.K.). The results of the operations were evaluated according to the patient satisfaction with a satisfaction determination query. Inclusion criteria of the patients depend on the surface anatomy of the nasal bone deformities. All of the patients had a certain degree of concavity or convexities on one or both sides of the nasal bones. Three patients had bilateral convex, 6 patients had unilateral convex, and 7 patients had unilateral concave deformities. Five patients had concave deformity on one side and convex deformity on the other side (Figure 1). Figure 1. View largeDownload slide View largeDownload slide This 21-year-old man has severe 3-dimensional nasal bony vault deformity. (A) The topographic features of the nasal bone of the patient characterized by convex deformity on right side, however, concave deformity on the left side. (B) Cephalo-caudal concave deformity on the right side (yellow line) and cephalo-caudal convex deformity on the left side (red line) of the patient can be observed. (C) The nasal bone reveals antero-posterior concave deformity on the right side (yellow line) and antero-posterior convex deformity on the left side (red line) on the hemi-basilar view. (D) Photography of the external nose of the patient. (E, G, I) Preoperative and (F, H, J) 14-month postoperative photographs of the patient. Figure 1. View largeDownload slide View largeDownload slide This 21-year-old man has severe 3-dimensional nasal bony vault deformity. (A) The topographic features of the nasal bone of the patient characterized by convex deformity on right side, however, concave deformity on the left side. (B) Cephalo-caudal concave deformity on the right side (yellow line) and cephalo-caudal convex deformity on the left side (red line) of the patient can be observed. (C) The nasal bone reveals antero-posterior concave deformity on the right side (yellow line) and antero-posterior convex deformity on the left side (red line) on the hemi-basilar view. (D) Photography of the external nose of the patient. (E, G, I) Preoperative and (F, H, J) 14-month postoperative photographs of the patient. All of the patients operated with the open technique. After skin flap elevation, dissection of the dorsum of the nose was begun to perform subpericondrialy at the caudal edge of the upper lateral cartilages and extended subperiosteally at the level of the bony dorsum. The periosteal dissection was limited laterally at the level of the planned osteotomy line for the hump reduction, which means the periosteum over the nasal bone at the lateral nasal wall was kept attached to the nasal bone. Pericondrium of the upper lateral cartilage and periosteum of the nasal bones were elevated as a single unit, like a blanket, to cover the structures after dorsal restoration. Then the nasal bone and underling upper lateral cartilages were separated from each other with a sharp-edged frier dissector at the apex of the bony vaults without damaging the cartilages. The dissection between bone and upper lateral cartilages did not exceed down to the level of the planned osteotomy level of the hump reduction to prevent osteocartilaginous dislocation on the lateral nasal wall. After reduction of the bony humps with osteotomes, deformities of the lateral nasal wall geometry were corrected with additional osteotomies. Depending on the deformity present, several osteotomy combinations, including median osteotomy, transverse osteotomy, lateral osteotomy, double-layer lateral osteotomy, and caudal transverse osteotomy, were applied. Caudal transverse osteotomy was conducted to correct severe 3-dimensional concave or convex deformities of the nasal bone, which reveal not only antero-posterior but also cephalo-caudal bulging or depressions (Figure 2) (Video). Caudal transverse osteotomy was delicately performed with a special osteotome, which was designed to protect the inner periosteum and mucosa of the nasal bone, and to prevent uncontrolled fracture formation on the thinned edge (Figure 3). Figure 2. View largeDownload slide View largeDownload slide (A, C, E, G) A 25-year-old man with prominent bulging on the right nasal bone over the keystone area. Hump reduction, caudal transverse osteotomy, paramedian osteotomy, transverse osteotomy, and high-low-low lateral osteotomies were performed. Cephalic portion of the nasal bone after caudal transverse osteotomy was medialized; however, caudal portion was lateralized and slightly twisted to achieve plane lateral nasal wall (I). (B, D, F, H) Eighteen-month postoperative views reveal balanced nasal dorsal geometry and relatively plane morphology with subtle yet persistent prominence of caudal margin of the right nasal bone. These subtle problems can be solved with delicate planning considering the possible new localization of the angulated distal segments. Figure 2. View largeDownload slide View largeDownload slide (A, C, E, G) A 25-year-old man with prominent bulging on the right nasal bone over the keystone area. Hump reduction, caudal transverse osteotomy, paramedian osteotomy, transverse osteotomy, and high-low-low lateral osteotomies were performed. Cephalic portion of the nasal bone after caudal transverse osteotomy was medialized; however, caudal portion was lateralized and slightly twisted to achieve plane lateral nasal wall (I). (B, D, F, H) Eighteen-month postoperative views reveal balanced nasal dorsal geometry and relatively plane morphology with subtle yet persistent prominence of caudal margin of the right nasal bone. These subtle problems can be solved with delicate planning considering the possible new localization of the angulated distal segments. Figure 3. View largeDownload slide (A, B) A special osteotome was designed to be able to perform delicate caudal transverse osteotomy and to prevent uncontrolled fracture formation with thinned edge. Figure 3. View largeDownload slide (A, B) A special osteotome was designed to be able to perform delicate caudal transverse osteotomy and to prevent uncontrolled fracture formation with thinned edge. Video 1. Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy107 Video 1. Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy107 Close The caudal transverse osteotomy enhances the mobilization of the caudal and cephalic portions of the nasal bone segments in different vectors. For correction of the convex deformity of the nasal bone, the cephalic portion was moved medially and the caudal portion was moved laterally (Figure 2I). However, correction of the concave deformity of the nasal bones was also performed with caudal transverse osteotomy, and movement of the osteotomized segments was different. Neighboring edges of both cephalic and caudal segments of the nasal bones were moved laterally to flatten the concave surface. If the concave deformity imitated crock-like geometry, additional lateral osteotomies, which were the upper osteotomy line of the double-layer lateral osteotomy, were applied. The upper lines of the double-layer lateral osteotomies were designed to cross the caudal transverse osteotomy line at the deepest point of the concave bone. Then the corners of the bone segments at the crisscross area were protruded laterally to flatten the concave surface. When double-layer osteotomies are required, the higher osteotomy should be completed before the lower one. This maneuver is essential for preventing displacement of fragments over the lower osteotomy line. All of the mucosal sides of the caudal transverse osteotomy lines were inspected intraoperatively to determine mucosal tears, which may cause possible bony instabilities. All of the patients had septal deviations that required septoplasty. Septal deviations in 17 patients were corrected with submucous resection; however, septal deviations in 4 patients required horizontal mattress sutures in combination with septal cartilage scoring. All of the middle thirds of the noses were stabilized with fold-in spreader flaps; however, 3 patients with concave nasal bone surface deformities required additional spreader grafts on the concave sides. RESULTS A total of 21 patients between 18 and 33 years old (mean, 24.5 years) met the inclusion criteria. Twelve patients were male and 9 patients were female. The follow-up range was between 9 and 49 months (mean, 17 months). The percentage of patients who had favorable results with restoration of a symmetric bony and cartilaginous nasal vault configuration was 95.2% (Figure 4). Figure 4. View largeDownload slide (A, C, E) This 26-year-old man had a nasal fracture during childhood. Nasal bone of the patient was revealing concave surface deformity on the right and convex surface deformity on the left. (B, D, F) Thirty-month postoperative views of the patient after hump reduction, median, transverse, caudal transverse, and bilateral double-layer lateral osteotomies. The late results reveal balanced dorsal geometry with subtle persistent prominence of the caudal margin of the left nasal bone and deviation. Figure 4. View largeDownload slide (A, C, E) This 26-year-old man had a nasal fracture during childhood. Nasal bone of the patient was revealing concave surface deformity on the right and convex surface deformity on the left. (B, D, F) Thirty-month postoperative views of the patient after hump reduction, median, transverse, caudal transverse, and bilateral double-layer lateral osteotomies. The late results reveal balanced dorsal geometry with subtle persistent prominence of the caudal margin of the left nasal bone and deviation. Sufficient mobilization of the nasal bones was achieved in all patients. None of the osteotomy lines revealed an unexpected course during combined osteotomies, including caudal transverse osteotomy. Collapse or spicule formation of the nasal bone was not observed with combined osteotomies. None of the bone fragments showed any rotation or malposition. None of the caudal transverse osteotomy attempts resulted in nasal mucosal tears during the osteotomy course. All of the deformities, including bony deviation, surface irregularities of the lateral nasal bone, and asymmetries between right and left nasal bones, were corrected. One (4.8%) patient with a crooked nose had suboptimal dorsal geometry without requiring revisional surgery at the level of the cartilaginous nasal vault. The deformity of this particular patient was caused by the deformity of the upper lateral cartilage secondary to the previous trauma (Figure 5). Figure 5. View largeDownload slide View largeDownload slide (A, C, E, G) A 23-year-old woman with nasal deformity caused by nasal trauma. Aymmetric hump reduction, radix reduction, paramedian osteotomy, bilateral caudal transverse osteotomy, bilateral transverse osteotomy, and right double-layer lateral osteotomies were performed. (B, D, F, H) Two-year postoperative views reveal well-established bony vault and dorsal aesthetic lines. An acceptable and minor depression not at the level of the bony vault but around the right upper lateral cartilage can be observed (H). Figure 5. View largeDownload slide View largeDownload slide (A, C, E, G) A 23-year-old woman with nasal deformity caused by nasal trauma. Aymmetric hump reduction, radix reduction, paramedian osteotomy, bilateral caudal transverse osteotomy, bilateral transverse osteotomy, and right double-layer lateral osteotomies were performed. (B, D, F, H) Two-year postoperative views reveal well-established bony vault and dorsal aesthetic lines. An acceptable and minor depression not at the level of the bony vault but around the right upper lateral cartilage can be observed (H). DISCUSSION The aesthetic features of the nose require a delicate balance not only with the anatomy of the nose itself but also for its relationship with the face in rhinoplasty operations. One of the most consequential maneuvers in restoration of the harmony in rhinoplasty is nasal bone osteotomy. The lateral osteotomy technique evolved over several decades; however, the earliest technique was popularized by Josef who used a saw osteotomy method.4-6 From this evolution, two basic techniques for performing lateral osteotomies have evolved: continuous and perforating. The ideal lateral osteotomy should not only be precise, reproducible, safe, with maximum aesthetic and functional results, but also should limit postoperative sequela such as edema, ecchymosis, and nasal bone instability.7 Congenital, traumatic, or developmental bony vault deformities may require additional interventions rather than classical osteotomies to correct the surface structure or angulations of the nasal bones. The requirement of additional intervention was based on the nasal bone quality and geometry. All of the osteotomies performed in this study were continuous. Most of the patients had previous trauma, which causes severe angulations of the bony nasal vault and thickening of the nasal bone at the surrounding area of the fracture line. Other deformities were slope or bowl formation at the surface of the lateral nasal wall, which cannot be corrected with standard medialization after a classical lateral osteotomy. Application of the standard medialization of the concave bone would reveal insufficient mobilization at the keystone area or over-medialization at the cephalic portion above the keystone area. For the convex deformity of the nasal bone, this maneuver would also cause over-medialization at the keystone area, which may compromise quality of nasal airflow. To establish the collinear relationship with the nasal bone and upper lateral cartilage, the nasal bone geometry should be flattened. There have been many types of bone-cutting instruments and technologies described for rhinoplasty. They can be classified broadly into saws, osteotomes, chisels, shavers, rasps, bone-cutting forceps, rongeurs, oscillating saws, and piezoelectric scalpels.8-12 Each type of instrument has its own advantages under specific circumstances, although the final choice may depend on the surgeon’s experience. All of the maneuvers performed to cut the bones were performed with osteotomes in this particular study. After reduction of the bony humps with osteotomes, the deformities of the lateral nasal wall geometry were corrected with additional osteotomies, including double-layer lateral osteotomy, caudal transverse osteotomy, or a combination of them. Lateral osteotomes were used for the lateral osteotomy or double-layer lateral osteotomies, a chisel was used for the paramedian and transverse osteotomy, and a specially designed super-thinned edge chisel was used for the caudal transverse osteotomy. A thinned-edge osteotome was used for the prevention of the uncontrolled fracture during osteotomy of the weaker caudal portion of the nasal bone. Utilization of a thinned edge with a relatively blunt tip osteotome during caudal transverse osteotomy and designation of the osteotomy lines on the lateral nasal walls were the unique parts of the study. The caudal osteotomy lines were designed to be going through the most prominent point of the convex and the deepest point of the concave nasal bone deformities. If the deformity was severe, caudal transverse osteotomies were combined with the upper layer of the double-layer lateral osteotomy. Parkes et al addressed the problem of lateral nasal walls that are convex in the anteroposterior plane by introducing the double-lateral osteotomy, which consists of intermediate and lateral osteotomies.13 The authors emphasized that the intermediate osteotomy was “found to approximate the suture line between the maxilla and nasal bone.”13 Ghanaatpisheh et al also emphasized double-layer lateral osteotomy for narrowing the dorsum and correcting lateral wall convexity, designed in 3 levels: high, midlevel, and low.14 However, these osteotomies are effective in correcting the convex deformity in the anteroposterior plane, but they cannot be considered as a solution for the convex deformity in the cephalo-caudal plane. The caudal transverse osteotomy line was designed to be perpendicular to the upper layer of the double-layer lateral osteotomies to correct the 3-dimensional deformity of the nasal bone. This osteotomy enhances the mobilization of the caudal and cephalic portions of the nasal bone segments in different vectors. For the correction of the concave deformities of the nasal bone, the cephalic portion was moved laterally and the caudal portion was moved medially. However, convex deformities were corrected with medialization of the cephalic part and lateralization of the caudal part of the nasal bones. Sequencing the osteotomies plays a crucial role for preservation of the stability of the bony segments during performing combined osteotomies. After hump reduction, median osteotomies were performed. Then transverse and caudal transverse osteotomies were completed consecutively. Lateral osteotomies were performed after caudal transverse osteotomy. If double-layer lateral osteotomies were required, upper-level lateral osteotomies had priority when compared with lower-level lateral osteotomies. The correct strategy on sequencing would supply more control during the course of the osteotomies. Despite dramatic improvements in the dorsal nasal contours of the patients, some appear to have subtle yet persistent prominence of the caudal margin of the nasal bones (Figures 2 and 4). Another problem with deviated noses is persistent tilt of the cartilaginous vault. Suboptimal correction of the bony deviation may lead to cartilaginous tilt (Figure 5H). Difficulties in the prediction of new localization of the osteotomized segments from the 3-dimentional deformities may lead to these minor irregularities. These subtle problems can be solved with delicate planning by considering the possible new localization of the dorsal edge of the angulated distal segments before performing the osteotomy. The preservation of the stability of the fragmented nasal bone was the consequential maneuvers of these complex osteotomies. The periosteum provides support and nourishment to the underlying nasal bones.5 The periosteum over the lateral nasal wall was not dissected to preserve the soft tissue and nasal bone attachments, which is important to maintain the integrity and stability of the osteotomized bones. Another factor to keep osteotomized bones together was preservation of the mucosa and lateral extension of the upper lateral cartilage, underling the bone. Palhazi et al found lateral keystone areas in 24 heminoses (80%) and were highly variable in 15 fresh cadavers. When the lateral keystone area was present in the cadavers, the transition from dorsal keystone area to lateral keystone area corresponded to 1 of 3 patterns: continuous, stepped, or minimal joint.13 The continuous and stepped pattern extensions of the upper lateral cartilages may interfere with the caudal transverse osteotomy line. The preservation of the mucosa and continuous and stepped pattern extension of the upper lateral cartilages may also contribute to protection against medial collapse of the fragmented lateral nasal wall. That is why the double-layer lateral and caudal transverse osteotomies were performed with utmost care to be able to preserve the structures underling the nasal bone.15 Another sustentacular structure for the osteotomized segments is osteocartilagineous connections. The upper lateral cartilages attach the undersurfaces of the nasal bones and extend cephalically. Articulation and the relationship between upper lateral cartilages and nasal bones are vital to preserve lateral nasal wall integrity. Surgeons must take care to preserve the articulation of the nasal bones and upper lateral cartilages during dissection or rasping near the inferior edge of the nasal bones.5 Uncontrolled detachment of the nasal bone and upper lateral cartilages may cause inverted V deformity or step deformity on the lateral nasal wall. Precise maneuvers must be conducted during dissecting upper lateral cartilages from the nasal bone at the level of the dorsal portion, and the dissection should not be extended laterally to avoid detachment of the bone and the cartilage at the lateral nasal wall. The study has some limitations because of the varieties of the clinical situations, which prevents grouping or standardization of the patients. The retrospective design of the study and the lack of CT scans of all patients brought some additional limitations, such as difficulties to measure or analyze the depth or degree of the concave deformities on the nasal bone with objective methods. Another apparent limitation of the study is the small size of the series. The rarity of these complicated cases restrains the attainability of a large series. The authors described the morphology, clinical relevance, and correction methods of the nasal vault and the changes that occur in this area during rhinoplasty in patients with 3-dimensional nasal bone deformities. Principles for the safety of the combined osteotomies depend on limited dissection over the nasal bone and upper lateral cartilage, preservation of the nasal mucosa under the nasal bone, delicate fracturing of the distal bony segment, and supporting the inner surface with a silicon splint. CONCLUSIONS Correction of deformities of the nasal vault presents a challenge to the plastic surgeon. Achieving optimal aesthetic and functional results requires a comprehensive knowledge of not only the bony but also cartilaginous framework of the nose and its relationship with the overlying and underlying soft tissues. Suboptimal aesthetic results may occur when excessive or inadequate mobilization of the nasal bony framework is performed. Flattening and precise control of the slope of the nasal bone is facilitated with caudal transverse osteotomy. A specially designed thinned-edge osteotome enhances caudal transverse osteotomy. The combined and precisely pried nasal osteotomy technique represents an effective and logical approach for correcting concave or convex nasal bone deformities. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, or publication of this article. Funding The authors received no financial support for the research, authorship, or publication of this article. REFERENCES 1. Guyuron B . Variations in nasal osteotomy: consequences and technical nuances . In Hodgson S , Kuhn B , Mortimer A , eds. Rhinoplasty . China : Elsevier Saunders ; 2012;133-139 . 2. Harshbarger RJ , Sullivan PK . Lateral nasal osteotomies: implications of bony thickness on fracture patterns . Ann Plast Surg . 1999 ; 42 ( 4 ): 365 - 370 ; discussion 370. Google Scholar CrossRef Search ADS PubMed 3. Cerkes N . The crooked nose: principles of treatment . Aesthet Surg J . 2011 ; 31 ( 2 ): 241 - 257 . Google Scholar CrossRef Search ADS PubMed 4. Most SP , Murakami CS . A modern approach to nasal osteotomies . Facial Plast Surg Clin North Am . 2005 ; 13 ( 1 ): 85 - 92 . Google Scholar CrossRef Search ADS PubMed 5. Dobratz EJ , Hilger PA . Osteotomies . Clin Plast Surg . 2010 ; 37 ( 2 ): 301 - 311 . Google Scholar CrossRef Search ADS PubMed 6. Murakami CS , Larrabee WF . Comparison of osteotomy techniques in the treatment of nasal fractures . Facial Plast Surg . 1992 ; 8 ( 4 ): 209 - 219 . Google Scholar CrossRef Search ADS PubMed 7. Bloom JD , Immerman SB , Constantinides M . Osteotomies in the crooked nose . Facial Plast Surg . 2011 ; 27 ( 5 ): 456 - 466 . Google Scholar CrossRef Search ADS PubMed 8. Walter C . Septo-rhinoplasty: the correction of the bony parts of the nose . J Laryngol Otol . 1980 ; 94 ( 5 ): 475 - 484 . Google Scholar CrossRef Search ADS PubMed 9. Rubin FF . Reconstruction of bony nasal pyramid. Three new instruments . Arch Otolaryngol . 1968 ; 88 ( 3 ): 279 - 282 . Google Scholar CrossRef Search ADS PubMed 10. Goumain AJM . Cutting forceps for lateral osteotomy in rhinoplasty . Plast Reconstr Surg . 1973 ; 53 ( 3 ): 358 - 366 . Google Scholar CrossRef Search ADS 11. Avsar Y . The oscillating micro-saw: a safe and pliable instrument for transverse osteotomy in rhinoplasty . Aesthet Surg J . 2012 ; 32 ( 6 ): 700 - 708 . Google Scholar CrossRef Search ADS PubMed 12. Robiony M , Toro C , Costa F , Sembronio S , Polini F , Politi M . Piezosurgery: a new method for osteotomies in rhinoplasty . J Craniofac Surg . 2007 ; 18 ( 5 ): 1098 - 1100 . Google Scholar CrossRef Search ADS PubMed 13. Parkes ML , Kamer F , Morgan WR . Double lateral osteotomy in rhinoplasty . Arch Otolaryngol . 1977 ; 103 ( 6 ): 344 - 348 . Google Scholar CrossRef Search ADS PubMed 14. Ghanaatpisheh M , Sajjadian A , Daniel RK . Superior rhinoplasty outcomes with precise nasal osteotomy: an individualized approach for maintaining function and achieving aesthetic goals . Aesthet Surg J . 2015 ; 35 ( 1 ): 28 - 39 . Google Scholar CrossRef Search ADS PubMed 15. Palhazi P , Daniel RK , Kosins AM . The osseocartilaginous vault of the nose: anatomy and surgical observations . Aesthet Surg J . 2015 ; 35 ( 3 ): 242 - 251 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Aesthetic Surgery JournalOxford University Press

Published: May 8, 2018

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