Narrowing the bridge

What repeats

Four findings that hold across the literature.

Width is a measurement, and the measurement is the dorsal aesthetic lines

The bridge is read on the frontal view as two lines running from the inner brow to the tip. Across 100 consecutive primary cases measured on standardised photographs, the symmetry of those lines rose from 68% before surgery to 94% after, and the number of patients whose lines were judged harmonious rose from about a third to nearly all. Width itself moved both ways: 43 of the group were narrower afterward and 21 were wider.

Rests on: Mojallal et al., dorsal aesthetic lines · Rohrich et al., component dorsal hump reduction.

Narrowing the bony roof still needs a cut, even when the profile is left alone

Lowering the bridge and narrowing it are separate problems. Where a nose has both a hump and a wide roof, one series added a paramedial cut to the push-down and let-down techniques in 68 patients, with the median outcome score rising from 48.5 before surgery to 91.5 at a year. The same problem is framed in preservation surgery as avoiding widening in the first place, by redefining where the dorsal lines run and controlling the surface of the side wall.

Rests on: Ozturk, narrowing the nasal roof · Neves et al., precision segmental preservation · and preservation rhinoplasty.

The bones can be thinned rather than moved

Narrowing does not have to mean fracturing. With the bone exposed and an ultrasonic tip, the vault can be sculpted in place. In the series that introduced the method, that was done without any osteotomy in 95 of 185 cases. Where cuts are made, the amount and position of each is chosen from the shape of the individual vault, and the bone is thicker on the deviated side of an asymmetric nose.

Rests on: Gerbault et al., piezoelectric instrumentation · Ghanaatpisheh et al., precise nasal osteotomy · Kim et al., anatomic analysis of the bony vault · and ultrasonic rhinoplasty.

Supporting the middle third works against narrowing it

The grafts that hold the breathing valve open push the middle vault outward. Pooled across ten studies and 567 cases, spreader grafts and spreader flaps restored the dorsal lines and the valve angle equally, and the graft scored better on satisfaction. Measured on photographs at a year, prophylactic autospreader flaps left width at the keystone reduced, with an increase of 1 mm lower down that did not reach significance. Width at the middle of the nose increased after both preservation and hump resection.

Rests on: Keyhan et al., spreader graft versus spreader flap · Jabbour et al., dorsal width with autospreader flaps · Xu et al., dorsal aesthetic lines after preservation and resection · and spreader grafts.

By where the width sits

The upper third and the middle third are narrowed by different means.

The bony roof is too wide

The upper third is bone. It is narrowed by moving the side walls inward after a lateral and a transverse cut, or by reducing the bone surface in place. Which applies depends on the thickness and symmetry of the vault, which a scan shows and palpation does not.

Rests on: Kim et al. · Ghanaatpisheh et al. · and nasal osteotomies.

The middle third is too wide

The middle third is cartilage. Narrowing it means reducing the horizontal width of the cartilaginous dorsum rather than adding to it, which is the opposite of a spreader graft and is limited by what the breathing valve will tolerate.

Rests on: Keyhan et al. · Wright et al., nasal obstruction and rhinoplasty · and the internal valve after hump reduction.

The two sides are not the same width

An asymmetric pyramid needs different cuts on each side, since the deviated wall is longer and its bone thicker. The plan is drawn per side, not per nose.

Rests on: Kim et al. · Ghanaatpisheh et al..

The bones move back apart

Narrowing only lasts if the bone stays where it is put. Suturing the freed lateral walls to the dorsum through small bone holes was done in 28 patients, with stable symmetry and no hump return reported at a year or more.

Rests on: Rusetsky et al., dorsal aesthetic lines bony sutures · Nassif and Kulbersh, bony vault complications.

There is a hump as well as a width problem

When bone is removed from the top, the roof opens and closing it narrows the nose whether that was wanted or not. In a nose that is already narrow, bone dust from the hump can fill the gap instead, which was done in 240 patients. Folding the upper lateral cartilages inward closes it without any cut, used in 34 patients.

Rests on: Tas, bone dust for the open roof · Arslan, no osteotomy rhinoplasty · and the open roof deformity.

What to ask about narrowing the bridge

Questions the evidence supports asking.

How much narrower will it actually be

Ask for the number in millimetres and for photographs at a year. The published measurements move in single millimetres, and swelling in the first months makes the early photographs misleading.

Rests on: Jabbour et al. · Xu et al..

Will it be harder to breathe

Narrowed nasal bones are listed as an anatomic cause of nasal obstruction, and narrowing the vault is listed as a pitfall of rhinoplasty. Against that, a randomised comparison of a low cut with a high cut that spares Webster's triangle found no difference in symptom scores, acoustic rhinometry, peak flow or rhinomanometry in 46 patients. Ask what the surgeon does to protect the airway while narrowing, not whether narrowing is safe in general.

Rests on: Wright et al. · Kamburoglu et al., Webster's triangle · and nasal airway obstruction.

What happens to the airway measurements after surgery

Objective and subjective results do not always move together. In 31 patients measured before and after septorhinoplasty, breathing scores improved by 38% overall, volume rose and resistance fell, but the minimal cross-sectional area did not change. Patients with severe obstruction to begin with gained the most, improving that area by 55%.

Rests on: Zoumalan and Constantinides, breathing after rhinoplasty · and the septum and the airway.

What holds the result

Ask what keeps the bones in their new position: the splint alone, a greenstick fracture that keeps the segment attached, or a suture through the bone. Loose or over-mobilised bone is a named cause of asymmetry and irregularity.

Rests on: Rusetsky et al. · Nassif and Kulbersh.

What if it ends up too narrow

Over-narrowing of the middle vault is a recognised outcome of dorsal work, and it shows as an inverted V and as a pinched look on the frontal view. Ask what the surgeon does about it, and whether spreader grafts are planned as part of the first operation rather than the second.

Rests on: Rohrich et al. · and the pinched tip · and revision rhinoplasty.

The terms, defined

The words used about the width of the nose.

• Dorsal aesthetic lines: the two lines on the frontal view that run from the inner brow to the tip and define the width of the bridge. [21701345]
• Bony vault: the upper third of the nose, made of the paired nasal bones and the maxilla. [36594157]
• Middle vault: the middle third, made of the upper lateral cartilages and the septum between them. [15457053]
• Keystone: the junction where the nasal bones meet the upper lateral cartilages and the septum. [42415377]
• Rhinosculpture: reducing the surface of the nasal bones with an ultrasonic tip instead of fracturing and repositioning them. [26545389]
• Paramedial osteotomy: a cut beside the midline used to narrow the roof while the bridge is preserved. [39191923]
• Spreader flap: the upper lateral cartilage folded inward on itself to support the valve, instead of a separate graft. [34864854]
• Minimal cross-sectional area: the narrowest point of the airway, measured by acoustic rhinometry. [22965002]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what should be assessed and documented before the shape of the nose is changed.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries two chapters covering the bridge and how its width is managed. They are written for surgeons and go further into technique than a patient page should.

• The Dorsal Hump
• Ultrasonic Rhinoplasty. Osteotomies and Dorsum Refinement

The reference summary

Rhinoplasty in StatPearls, on the National Library of Medicine's Bookshelf, gives the anatomy, the indications and the complication list in full text at no charge.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

The trials in progress

What narrowing the vault does to the breathing valve is under test in a registered study.

• Effects of Preservation Rhinoplasty Nasal Valve Angle and Area, completed, 100 participants.

What is not settled

• No trial takes bridge width as its primary endpoint. The width measurements come from photographic and software analyses inside studies designed to answer other questions. [21701345] [41369038]
• How much a nose can be narrowed before the airway suffers has no published threshold. The randomised airway comparison enrolled patients with no breathing complaint. [33598741] [32328743]
• Subjective and objective airway results diverge after rhinoplasty, so a patient who breathes better and a rhinometer that reads unchanged are both reporting correctly. [22965002]
• Bone sutures, greenstick fractures and splints are all offered as the answer to bones drifting apart, and none has been compared against another. [41263986] [22723231]
• Whether preservation techniques widen the middle of the nose more than hump resection is unresolved. One matched comparison found widening in both groups and no difference between them. [41369038]