Rhinoplasty Dr Bashar Bizrah Article on: PostRhinoplasty Probleins and Revision Surgery Part 5: Persistent Hump

8. Persistent hump:

Causes:

1. Hump under-resection:
   Undertrimmed dorsum septum, upper lateral cartilage and insufficient removal of bony hump. (Figs. 13 – 13B,20)
2. Excessive hump rasping:
   A sharp chisel is preferable because it is less traumatizing. Excessive rasping leaves fragments of bone, periosteum and traumatized tissue causing fibrosis and calcification with thickness of the nasal bones later on.

Treatment:

Careful resection of the persistent hump by sharp chisel, fine rasping, osteotomy and application of pressure taping.

Dorsum irregularities:

Causes:

1. Irregular trimming of upper lateral cartilage.
2. Irregular trimming of dorsum septum.
3. Step or gap between cartilagenous and bony dorsum due to excessive dorsum trimming or not resecting the “cartilagenous bony” hump in one block.
4. Excessive rasping causes soft tissue irregularities and remnants of bone and periosteum fragments with frequent fibrosis and calcification.
5. Conchal dorsum graft:
   Irregular surface of the graft may show through the skin.

Prevention:

1. Equal trimming of upper lateral cartilage and septum.
2. Resection of the bony and cartilagenous hump in one block.
3. Reducing the use of a rasp to a minimum and removing all bone fragments and irregular soft tissue.
4. Covering gaps and depressions by dorsum grafts.
5. Scoring and trimming of the conchal grafts to make it as smooth as possible and ideally a septal graft is used to cover the conchal graft in order to disguise the irregularity.

Treatment:

Treat according to the cause. Trim protruded upper lateral and septal cartilages, smooth the dorsum by fine rasp and if indicated cover by septal graft.

Crooked noses:

Causes:

1. Unilateral incomplete mobilization of nasal bone in initially straight noses. eg: Incomplete osteotomies in a patient with a hump and a straight nose.
2. Unequal hump reduction:
   Unequal rasping of both sides or incorrectly applying the chisel obliquely, leaving one nasal bone higher than the other.
3. ‘:lplete mobilization of initially crooked deviated noses. (Figs. 13 – 14A,18)
4. Failure to correct initial re-existing nasal bone depression.
5. Poorly performed septoplasty:
   In particular, failure to correct C-shaped dorsum septum deviation by spreader grafts and failure to correct caudal dislocation which will push the tip and columella away from the midline.
6. Unilateral depressions look like a crooked or deviated nose but bilateral depressions lead to saddling.
   Causes of depressions:
   • Failure to correct initial bone and upper lateral cartilage depressions resulting from trauma.
   • Poor technique:
     • Poor osteotomies:
       This may cause collapse of the nasal bone.
     • Excessive trimming of the upper lateral cartilage.
     • Failure to consider intermediate and transverse osteotomies.
7. Early postoperative crooked like nose could be due to excess oedema of one side of the nose giving the impression that the nose is deviated towards the more oedematous side. Assess carefully and wait at least three months before re-osteotomies.

Prevention:

1. Perform adequate cartilagenous and bony septal correction and correct caudal dislocation.
2. Complete mobilization of nasal bone by medial and lateral osteotomies.
3. It is preferable to perform lateral osteotomies under full control with two mm osteotome. The osteotome penetrates the periosteum and the bone, but should not penetrate the endostrium to avoid nasal bone collapse. (Figs. 7 – 1,2)
4. Consider intermediate osteotomies to break the banana shaped nasal bone. Medial and lateral osteotomies alone are not enough to break the concavity and convexity of the nasal bones, it will move the banana shaped nasal bones to a more central position without correction. Therefore, intermediate osteotomies are essential to break the banana shape. (Fig. 7 – 3)
5. Consider transverse osteotomies to correct deviation starting from the root of the nose (nasion). (Fig. 17 -18)
6. Do not squeeze the nasal bone too much following osteotomies. Squeezing the nasal bone may cause dorsum septum and perpendicular plate dislocations leading to depressions and collapse of the bony dorsum and septum.
7. Consider spreader grafts to correct C-shaped dorsum septum deviation.
8. Consider augmentation and grafting of initial pre-existing depressions.
9. Avoid hump over removal and treat nasal bone equally.

Treatment:

Carefully assess the cause of crooked like appearance and treat accordingly.

1. Re-osteotomies for full mobilization of the nasal bone.
2. Revise septoplasty if indicated. Consider spreader grafts for dorsum septum C-shaped devi.ation and correct persistent caudal dislocation.
3. Consider transverse osteotomies to straighten deviation starting from the root of the nose.
4. Consider intermediate osteotomies to break the banana shaped, concave and convex nasal bone.
5. Consider grafts for upper lateral cartilage depressions and depressed nasal bone.
6. Consider intranasal packing for treatment of coltapsed nasal bone or in severe cases a plate wiring.
7. Reassure the patient and advise bidigital pressure massage in patient with oedema of the sides of the nose.