Nasal osteotomies

What repeats

Five findings that hold across the literature.

There are three cuts, and they do different jobs

The lateral cut runs up the side wall from the pyriform aperture, the medial cut beside the midline, and the transverse cut joins them near the root. Together they free a segment of bone that can be repositioned. A fourth, the intermediate cut, is added when one side wall is convex or too long. In one consecutive series a lateralised medial oblique cut was used in 95% of cases, a bilateral intermediate cut in 72%, and no base cut at all in 33% of patients whose lateral wall width was already acceptable.

Rests on: Ghanaatpisheh et al., precise nasal osteotomy · Ferreira and Santos, barn doors greenstick · and the anatomy of the nose.

The bone is not the same thickness everywhere, and the plan follows the scan

Computed tomography of 250 primary rhinoplasty patients found the bony vault thickest at the middle of the lateral osteotomy path, thicker in men at every point, and asymmetric in 88 of the 250. In the asymmetric noses the deviated side was thicker than the other side along every path. Cadaver work on 44 specimens found the caudal nasal bone angulated in 88% and straight in 12%, which is why the same cut produces a different fracture in different noses.

Rests on: Kim et al., anatomic analysis of the bony vault · Lazovic et al., the nasal bones.

Bruising comes mostly from the soft tissue, not the bone

Periorbital ecchymosis follows a set pattern. In 183 consecutive closed rhinoplasties it filled the inner quarters of the eyelids on the first and second days and moved to the outer lower quarters by the seventh. Where the periosteum was swept off the bone on one side and left alone on the other, the swept side had more eyelid swelling and more bruising on day 1.

Rests on: Mizrachi et al., ecchymosis natural history · El-Sisi et al., periosteal sweeping · and recovery.

Direct vision and instrument choice change how controlled the fracture is

Making both the medial and lateral cuts under direct vision is described as more predictable than working blind, and as conserving the nasal muscle, the angular vessels and the periosteum. A powered oscillating micro saw was used for the transverse cut in 1374 of 1550 operations to avoid the unwanted fracture a blind manual cut can produce near the root. Scanning of 16 patients put that line at 2.5 mm at its thickest, falling to 1.2 mm near the inner corner of the eye. An instrumented hammer predicted the moment of fracture in 83% of impacts.

Rests on: Hontanilla et al., open external osteotomy · Avsar, the oscillating micro saw · Giunta et al., instrumented hammer.

Ultrasonic cutting reduces the early morbidity, not the operating time

Pooling ten studies and 554 patients, piezoelectric osteotomy came out ahead of the conventional osteotome on swelling, bruising and pain, and the odds of a mucosal tear were lower. Neither the duration of the osteotomy nor the duration of the whole operation differed.

Rests on: Khajuria et al., piezoelectric versus conventional osteotomy · and ultrasonic rhinoplasty.

By the reason the cut is made

The same fracture line answers several different problems.

The bridge is too wide

Narrowing is the classic indication. The lateral and transverse cuts free the side walls so they can be moved toward the midline. How far each side moves is decided from the frontal view and by palpation, which is unreliable in a nose that is only slightly deviated. One algorithm reads the septal position at the nasal floor, the alar length and the pyramidal length instead, and was used to choose the level and number of lateral cuts in 521 patients.

Rests on: Cabbarzade, the SELF algorithm · and narrowing the bridge.

Hump removal has left the roof open

Taking down the bony hump leaves a flat top with the cut edges of the nasal bones exposed. Closing that gap by moving the walls inward is the second classic indication. It is not the only way to close it. Bone dust harvested from the hump itself was laid over the gap in 240 patients whose bony vault was narrow to begin with, a group in whom moving the walls further inward would be a problem.

Rests on: Tas, bone dust for the open roof · and the open roof deformity.

The nose is crooked

An asymmetric pyramid needs different cuts on the two sides, since the deviated wall is longer and its bone thicker. In revision surgery an old fracture line often reopens under thumb pressure alone, which avoids opening dead space and keeps the skin attached to the skeleton.

Rests on: Kim et al. · Lisiecki et al., digital osteotomies · and revision rhinoplasty.

No cut is needed

Osteotomy is not compulsory. Where the only reason to cut would be to close an open roof, folding the upper lateral cartilages inward as autospreader flaps closes it instead. That was done in 34 patients, with the lateral wall support failing in one.

Rests on: Arslan, no osteotomy rhinoplasty · and component dorsal hump reduction.

What to ask about an osteotomy

Questions the evidence supports asking.

Which cuts are planned, and why

Ask for the list: lateral, medial, transverse, intermediate, and which side gets which. Ask whether the plan comes from a scan or from the frontal view.

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

Will the cut be made from inside the nose or through the skin

The internal cut is made through an incision inside the nostril. The external cut is made through a small stab in the skin at the side of the nose. Percutaneous cuts are described as causing less trauma at the cost of a visible mark. A meta-analysis pooling 13 randomised trials and 1008 patients found the two approaches level on eyelid swelling and on bruising at every day measured. The mean step-off score was higher after the external cut, while the proportion of patients with a step did not differ. Ask which the surgeon uses and what the skin looks like at a year.

Rests on: Albazee et al., meta-analysis of randomised trials · Rettinger, risks and complications · El-Sisi et al..

How much bruising should I plan for, and when does it clear

Ask for the surgeon's own photographs at days 1, 3 and 7. Bruising sits at the inner corner of the eye first and moves outward and downward over the first week.

Rests on: Mizrachi et al. · and recovery.

What happens if the fracture goes where it was not meant to

Named complications include a palpable step at the cut line, a rocker deformity when the cut runs too high into the frontal bone, asymmetry, and a bone segment that stays mobile. At one year after the greenstick technique, a step was felt by 10% of 50 patients and was visible in 4%.

Rests on: Nassif and Kulbersh, bony vault complications · Ferreira and Santos · and the inverted-V deformity.

Will narrowing the bones make it harder to breathe

Ask this directly. Guyuron measured 96 nasal sides in 48 consecutive patients during surgery and found the osteotomy narrows the airway in most noses. Short nasal bones narrowed less than normal ones, an anteriorly placed inferior turbinate narrowed more than a posterior one, a large inward shift of the bone narrowed more than a small one, and the high-to-low cut narrowed least. A randomised comparison of a low cut against a high cut sparing the triangle of bone Webster described in 1977 found no difference in symptom scores, acoustic rhinometry, peak flow or rhinomanometry in 46 patients. The loss of internal volume tracks how much reduction is done.

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

The terms, defined

The words used about this part of the operation.

• Osteotomy: a planned cut through bone, made so a segment can be moved. [22723231]
• Lateral osteotomy: the cut up the side wall, from the pyriform aperture toward the root. [35112156]
• Medial osteotomy: the cut beside the midline, made before the lateral one. [25568232]
• Transverse osteotomy: the cut across the top, joining the medial and lateral lines. [22738757]
• Intermediate osteotomy: an extra cut between those two, used when one wall is convex or long. [25568232]
• Greenstick fracture: bone bent and cracked on one side while the other side stays intact. [36972604]
• Webster's triangle: the wedge of bone at the base of the pyriform aperture, left intact in a high cut to protect the airway. [33598741]
• Open roof: the flat gap across the top left after the bony hump is removed. [29879004]
• Ecchymosis: bruising, here around the eyelids, graded on photographs. [37448765]

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 a surgeon should assess and document before operating, whatever is done to the bones.

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

The surgeons' own textbook chapter

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries a chapter on cutting and reshaping the bony vault with ultrasonic instruments. It is written for surgeons and goes further into technique than a patient page should.

• Ultrasonic Rhinoplasty. Osteotomies and Dorsum Refinement

The reference summaries

• 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.
• Nasal Fracture Reduction in StatPearls covers the same bones broken by injury rather than by a surgeon.

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

Ways of reducing the bruising an osteotomy causes are under test in registered trials.

• Intra-operative Nasal Compression After Lateral Osteotomy to Minimize Post-operative Peri-orbital Ecchymosis and Edema, completed, 16 participants.

What is not settled

• The internal and external approaches are compared on eyelid swelling, bruising and the palpable step, not on where the fracture line runs. Pooled across 13 randomised trials, swelling and bruising did not separate them. [41130590] [30789649] [22073084]
• The bone thickness data come from single-population scan series. Thickness differs by sex and by side within one nose, and between populations. [36594157] [25805278]
• Whether sparing Webster's triangle protects the airway is unresolved. One randomised study found no difference, and it enrolled patients who had no breathing complaint to begin with, while the prospective study of narrowing during surgery recorded observed grades. [33598741] [9727456]
• Piezoelectric cutting reduces early swelling and bruising. Whether it changes the shape of the nose at a year, or the revision rate, is not established. [36448013]
• The number of cuts a nose needs is decided by algorithms and by surgeon judgment, and the published algorithms are single-surgeon series without a control group. [35112156] [25568232]