Rhinoplasty Dr Bashar Bizrah Article on: Hump Removal

HUMP REMOVAL

“In the year 1896, there was a famous merchant in Berlin, who was easily recognized by his long humpy nose and a big moustache. The man came to Jacques Joseph asking him, “Do you think you can make my nose smaller?”, and Joseph replied, “Certainly”. A few weeks later, people in Berlin saw the merchant with his moustache, but his prominent nose was gone”. The instruments devised by Joseph, (the chisel, saws and retractors,) are still used today.

The patient with a hump, during his first consultation always requests a smaller nose. The clinical translation of this is a balanced nose; the patient means more definition, more refinement, symmetry, a straight nose and patent airways.

Hump removal is a vital step in rhinoplasty. The surgeon should take into consideration the patient’s height, age, race, origin and local social and traditional manners, for example, in the Gulf areas both males and females do not like retrousse dorsum, they prefer a straight or slightly higher profile, while women from Lebanon, Syria, Egypt and Europe like more tip projection.

TECHNIQUE

I. Cartilagenous hump removal

• Cartilagenous hump is incised as a single unit by using Fomon scissors or blade No. 11. (Fig. 17 -10)
• The scissors or blade is passed through all the three components of the cartilagenous hump: (Fig. 6 – 4 and Fig. 17 – 2)
  Left and right upper lateral cartilages and the septum.
• The superior septal angle:
  It is preferred in humpy and long noses to leave the superior septal angle intact until the end of the procedure, because these patients may have underprojected tip, short columella and short caudal septum. Therefore, in actual fact, in these situations, in order to achieve a balanced dorsum, the superior septal angle may need to be augmented with a suitable graft following tip plasty. If the superior septal angle is routinely lowered with the hump, it will cause supratip collapse and need extra augmentation procedures at the end of the operation.

II. Bony hump removal

• This may be removed on the conjunction with the cartilagenous component with an osteotome. (Fig. 6 – 5).

Fig. 6 - 1. (A,B,C) The new concept of rhinoplasty is balanced manoeuvres of reduction and augmentation. Supportive means should be considered in order to compensate for the loss of tip support caused by our routine incisions and excisions. In these cases the hump has been reduced and the tip has been augmented. This is in order to achieve straight, well oriented dorsum and adequate tip projection, definition and rotation.

Fig. 6- 2. (A,B,CJ Rhinoplasty is now transforming from an exercise in reduction to an operation of reorientation and preservation of structures. Hump has been reduced and tip plasty has been considered in order to achieve tip projection, definition and rotation.

• A rasp may be used for smaller humps. (Fig. 10 -11)
• Before the removal of any bony hump, elevate the periosteum with periosteum elevator.
• For a smaller hump start with a coarser rasp, then once the desirable hump has been removed, move to a more delicate rasp to smooth the bone. (Fig. 17 – 3)
• Direction during rasping should not be toward the nasion; rasping should be performed in an oblique and transverse manner across the nasal bone to avoid frontal oedema.
• For a larger hump remove with twelve or fifteen mm T-shape osteotome. The bony hump may be removed in conjunction with cartilagenous hump. (Fig. 6 – 6)
• Initial subtotal removal is recommended with osteotome, the remaining portion is removed by rasping. (Figs. 17 -10,11)
• Osteotomies are then performed in order to approximate nasal bones. (Fig. 6 – 7)
• Tip plasty:
  Maybe essential in order to obtain adequate tip projection, definition and rotation or to compensate for the loss of tip support caused by our routine incisions and excisions. The key manoeuvres are new dome creation, suture fixation, columellar strut and tip grafts or Bizrah’ s modified vertical dome division without delivery of lateral crus. (Reference should be made to chapter eight)

Hints

1. Hump removal is best performed after tip surgery, particularly in small and medium humps, while a large hump may be subtotally reduced before tip surgery at the beginning of the rhinoplasty procedure. Then accurate bone and cartilage alignment is made at the end of the procedure. (Fig. 6 – 3)
2. Do not overtake the hump, look at the tip, look at the nasion and supratip and then lower the nasal hump again if needed.
3. Skin and subcutaneous tissue covering the dorsum are thickest at the nasion and the supratip, therefore, when the hump removal is complete, the dorsum skeleton (bone and cartilage) should not be straight. The underlying skeleton must be adjusted accordingly. It is preferable to lower the septum and upper lateral cartilage very little below the level of the bony dorsum to avoid “pollybeak” deformity, as the skin and SMAS are thicker in the supratip area.
4. Finger test: The superior septal angle must not be visible when the tip of the nose is depressed. Pressure with the thumb in the nasolabial angle will show the excess cartilage in the supratip. This should be trimmed to avoid “pollybeak” deformity.

Fig. 6 - 3. Do not overtake the hump. At the beginning of the procedure, reduce the hump subtotally, then more reduction if needed is made at the end of the procedure after tip correction.

Fig. 6 - 4. The scissors is passed through all the three components of the cartilagenous hump, Leave the superior septa/ angle intact until the end of the procedure.

5. Causes of “pollybeak” deformity.
   • Excess supratip cartilage.
   • Poor tip elevation and rotation.
   • Injury to the SMAS layer of the supratip skin will lead to delayed scarring and fibrosis later.
   • Oversize supratip graft.
6. Visualize the dorsum at the end of hump removal, make sure all cut lines are straight, remove all residual bone dust and debris by gently rasping under the surface of the skin with a fine rasp. If dust and debris remain, this might cause an early infection or an unexplained hump or irregularity later.
7. Large hump and crooked nose:
   T-shape twelve mm osteotome is used. The osteotome is not positioned parallel to the face but in a slightly oblique position away from the deviated side in order to achieve and leave equal nasal bony lateral walls and to avoid overlapping of the bones after approximation. Imagine the nose as a triangle with unequal sides; in order to leave two equal borders, you have to cut obliquely. (Fig. 9 – 12)
8. For smaller hump: In the author’s opinion, it is best to leave it alone and try to achieve balance by achieving more tip projection, elevation and definition. Rasping alone without the use of hump osteotome may lead later to irregularity and persistent hump due to fibrosis and scarring. At the same time, osteotome may overtake the smaller hump leading to further augmentation with the problems related to grafting such as graft absorption, mobility, displacement and line of demarcation later on.

Fig. 6 - 5. The bony hump is removed on the conjunction w ith the cartilagenous component w ith an osteotome.

Fig. 6 - 6. Large hump is best removed in a single unit:
I . Trimming of the cartilagenous hump by dorsum scissors. Trimming of humpy upper lateral cartilage and dorsum septum.
2. Removal of bony hump by osteotomies.

Fig. 6 - 7. The dorsum alter hump removal. Now, osteotomies are needed to close the open roof by approximating the nasal bones and upper lateral cartilages.

Fig. 6 - 8. (A,B,C) The hump has been reduced w ith tip plasty also been considered in order to achieve a straight nose and tip projection.

Fig. 6 - 9. (A,B,CJ Hump has been narrowed and tip plasty considered in order to achieve a straight dorsum and tip projection, elevation and rotation.

Fig. 6- I 0. (A,B,CJ Following hump reduction and our routine intercatilagenous and transfixion incision w ith cephalic trimming of lateral crus, the tip wi ll loose its support, tensile strength and droop down. Therefore, supportive means should be considered to support and elevate the tip in order to avoid the later unpleasant results of pollybeak, underprojected tip and or wider nares.

Fig 6 - 11 . (A,B,C) Hump has been reduced and tip plasty performed. In order to reach the hump, we have to perform intercartilagenous and hemitransfixion incisions. This w ill divide the anatomical attachment of the tip to the rest of the nose resulting in dropped, underprojected tip w ith w ider nares. Therefore, tip plasty is essential to obtain tip projection, definition, rotation, and stretching of the nares

Fig. 6 - 12. (A) Patient with hump and underprojected tip and short columella. (B,C) The patient w ith mild hump with drooping tip.

Fig. 6 - I 3. (A,B,CJ Hump reduction achieved and tip plasty performed in order to achieve tip projection and a straight nose.

Fig. 6 - 14. (A,B) The hump has been lowered and the tip projection has been achieved by the manoeuvres of Bizrahs modification of vertical dome division, columellar strut and tip grafts.

Fig. 6 - I 5. (A,B) Hump reduction achieved by a twelve mm osteotome. Tip projection and refinement obtained by the manoeuvres of new dome creation, columellar strut and tip grafts.

References

Hump Removal

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