Osteotomies

Eric J. Dobratz, MDa,b,*, Peter A. Hilger, MDa

KEYWORDS
 Osteotomies  Lateral osteotomy
 Medial osteotomy  Intermediate osteotomy
 Nasal deformity  Nasal bones  Crooked nose

Rhinoplasty remains to be one of the most should be placed in the thicker ascending process
challenging facial plastic surgical procedures of the maxilla instead of the thin lateral nasal bone.
performed. The surgeon seeks to achieve the The nasal bones are supported by their articula-
combination of aesthetic harmony with the tion superiorly with the frontal bone at the
surrounding facial features and preservation or nasofrontal suture line (nasion), laterally at
development of nasal function and support. One the ascending process of the maxilla and in the
of the most challenging and instrumental steps in posterior-midline where the bones are fused with
achieving harmonious form and function during the perpendicular plate of the ethmoid. It is impor-
rhinoplasty is the successful completion of osteot- tant to consider the midline attachment to the
omies. Osteotomies are performed to correct perpendicular plate while treating the twisted
deformities of the bony nasal vault. Successful nose deformity. In patients with this deformity,
treatment of deformities of the bony vault is the nasal bones and ethmoid plate are deviated
achieved through organized thinking, comprehen- and the nasal bones may have variable symmetry,
sive knowledge of nasal anatomy, and thorough with one side being longer than the other.
careful preoperative and intraoperative planning. The surgeon must address the nasal bones and
In this review the authors discuss the pertinent the deviated bony septum. If the deviation at the
anatomy, technical considerations, including perpendicular plate is not treated, the patient will
selection of various osteotomy techniques, and often have persisting deviation of the bony vault.
complications that rhinoplasty surgeons should Inferiorly the nasal bones overlap the cephalic
be aware of to optimize correction of deformities margins of the upper lateral cartilages, providing
of the nasal bony vault. support to the cartilaginous middle vault. Thus,
narrowing of the nose by infracture of the bony
sidewall will also result in the narrowing of the
ANATOMY middle third caused by this connection between
the nasal bones and upper lateral cartilage. The
The bony framework of the external nose consists surgeon should be aware of this especially after
of the paired nasal bones and the ascending hump reduction, where the width of the broad
processes of the maxilla. The nasal bones are native dorsal septum is significantly narrowed
thick cephalically where they articulate with the (Fig. 1). The resultant upper and middle vault
frontal bone, and are thin as they extend inferolat- narrowing may lead to profound obstruction in
erally where they articulate with the maxilla and the patients who already have a narrow bony base or
upper lateral cartilage.1 This variability in thickness when the base is significantly narrowed through
is important for consideration of placement of the lateral osteotomies with medial displacement of
osteotomies. For example, the lateral osteotomy the bony base.
plasticsurgery.theclinics.com

a
Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology Head and Neck Surgery,
University of Minnesota, 420 Delaware Street, MMC 396, Minneapolis, MN 55455, USA
b
Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology Head and Neck Surgery,
Eastern Virginia Medical School, River Pavilion, Suite 1100, 600 Gresham Drive, Norfolk, VA 23507, USA
* Corresponding author. Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology
Head and Neck Surgery, Eastern Virginia Medical School, River Pavilion, Suite 1100, 600 Gresham Drive,
Norfolk, VA 23507.
E-mail address: dobratej@evms.edu

Clin Plastic Surg 37 (2010) 301–311

doi:10.1016/j.cps.2009.11.002
0094-1298/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.
302 Dobratz & Hilger

relationship between the soft tissues and the

underlying bony framework determines the overall
contour of the nose, thus a comprehensive knowl-
edge of these structures is required to achieve
optimal results when altering the bony framework
of the nose. The soft-tissue envelope varies in
thickness over the dorsum of the nose (Fig. 2).
The skin and subcutaneous tissues are thicker
superiorly in the area of the nasion and inferiorly
at the supratip. The soft tissue thins over the
rhinion, the osseocartilaginous junction of the
nasal bones, and the upper lateral cartilages.
Thus, when altering the bony profile, a slight
hump should remain at this junction to give an
overall straight appearance of the profile. If the
bony profile is straight there will be a small
‘‘saddle-nose’’ appearance when the soft tissues
are redraped (see Fig. 2).
The periosteum represents the layer between
the soft-tissue envelope and the underlying bony
framework. It is important to use caution while
raising the adherent periosteum from the nasal
bones, because preserving the periosteum as an
intact layer will provide a thicker flap, which
provides better camouflage over the newly recon-
structed bony framework. Raising the periosteum
with the flap also decreases the risk for postoper-
ative trophic changes. Minimal lateral elevation of
the periosteum should be performed to preserve
the periosteal attachments to the ascending
process of the maxilla. This action will help
stabilize the bony fragments after performing
lateral osteotomies.
It is important to have a thorough understanding
Fig. 1. The surgeon must beware of profound
narrowing of the airway that may occur after hump of the relationship between the bony/cartilaginous,
reduction. The width of the dorsal septum is and soft-tissue architecture of the nose. It is also
narrowed with excision of the hump. The overall important to understand the changes that occur
narrowing of the nasal cavity can be profound when in the bony framework with age. While performing
the bony base is narrow as well (bottom panel). osteotomies on young patients the nasal bones
are soft and may result in greenstick fractures.
These fractures are incomplete, making mobiliza-
One must also take care to preserve the articu- tion of the fragment difficult, therefore in younger
lation of the nasal bones and upper lateral carti- patients continuous osteotomies are generally
lage during dissection or rasping near the inferior preferred to help avoid greenstick fractures and
edge of the nasal bones. Disruption of this junction ensure proper mobilization. Older patients tend
will result in collapse of the upper lateral cartilage to have brittle bones or may have a history of
and a resulting depression of the middle vault previous fractures or surgeries that can lead to
that is difficult to correct. Rasping at the inferior comminution while osteotomies are performed.
medial edge of the nasal bone makes the superior In older patients one may preferably create green-
medial edge of the upper lateral cartilage promi- stick fractures or incomplete osteotomies, with
nent; this is due to the flexible character of the digital completion of the osteotomy in order to
cartilage, which may disarticulate and bend avoid comminution of the bony fragment.
outward. This anomaly should be corrected as it It is also important to consider a patient’s age
may cause a persistent fullness after surgery. when determining the degree of anatomic change
The soft tissues overlying the bony framework that is to be created. Older patients have grown
include the skin, subcutaneous tissues, superficial accustomed to their appearance and will be
musculoaponeurotic system, and periosteum. The more affected by significant alterations in their
 Osteotomies 303

Fig. 2. The thickness of the skin over the nasal dorsum varies (left). A slight bony/cartilaginous hump should
remain to allow for a straight profile. Completely removing the hump, creating a straight bony profile will result
in a small ‘‘saddle-nose’’ appearance (right). (Left diagram From Hilger P. Nasal analysis. In: Papel I, Holt GR, Frodel
JL, editors. Facial plastic and reconstructive surgery. Thieme; 2009; with permission.)

appearance. It is best to perform more conserva- one-thirds. Ideally the dorsum of the nose would
tive alterations to the bony framework in older be straight and symmetric on either side of this
patients. Younger patients tend to be more ac- midline. Asymmetries may be caused by deviations
cepting of significant changes to their nasal of the bony vault toward one side of the nose or
appearance. may be due to the width irregularities between the
upper and middle one-thirds of the nose.
The width of the bony vault should be analyzed
EVALUATION OF BONY VAULT
to include the width at the nasal facial sulcus or
With all aspects of rhinoplasty, proper preopera- bony base and also at the dorsal ridge. The ideal
tive analysis is critical to obtaining optimal results. width is influenced by features such as nasal
It is imperative to correctly determine the patient’s length, projection, skin thickness, and other facial
deformities so that the most effective techniques proportions, and will vary depending on the
for correction of these deformities may be per- individual. The width of the nasal dorsum should
formed. One should be able to visualize and be approximately two-thirds of the width of the
palpate the external anatomy, and at the same alar base, which should approximate the intercan-
time predict the underlying structure that deter- thal distance (Fig. 3).
mines the external appearance. Complete nasal The nasal bones and ascending process of the
and facial analysis is essential as the appearance maxilla are palpated for irregularities. Previous
of the bony vault must be in balance with the other fractures because of trauma or previous surgery
aspects of the nose and the rest of the face. During with their associated inward or outward displace-
nasal analysis, the nose is divided into vertical ment may be palpated. The bones should be
thirds with the upper one-third representing the assessed for a concave or convex shape as this
bony nasal vault. may require an intermediate osteotomy to correct
On anterior evaluation the overall alignment, the associated deformity. Significant differences in
length, and width of the bony vault should be deter- the height of the nasal bones should also be
mined. Alignment of the bony dorsum may be evaluated, as this will often occur in crooked
evaluated by determining a relative midline of the nose deformities.
nose. A line defined by the mentum, upper incisors, The profile evaluation of the bony dorsum deter-
philtrum, and glabella may be used to determine mines the level of the radix, the nasofrontal angle,
the midline. Deviation toward the right or the left and dorsal alignment. The radix or root of the nose
should be determined in relation to this line and corresponds to the junction of the nasal and frontal
any continued deviation into the middle or lower bones, and this should be located at the level of
304 Dobratz & Hilger

Fig. 3. The width of the bony dorsum should be approximately two-thirds the width of the alar base (left). The
width of the alar base should approximate the intercanthal distance (right). (From Hilger P. Nasal analysis, In:
Papel I, Holt GR, Frodel JL, editors. Facial plastic and reconstructive surgery. Thieme; 2009; with permission.)

the supratarsal crease. The nasofrontal angle, aperture may present with nasal valve obstruction
defined by glabella-to-nasion line intersecting as well. The degree of airway impingement with
with nasion-to-tip line, should be between 115 this type of osteotomy will be accentuated in
and 130 . A high radix or shallow nasofrontal angle patients with preexisting narrow pyriform
may require rasping in order to improve the apertures, hypertrophied inferior turbinates, or
contour in this area. The desired change may long nasal bones.2
be achieved through rasping; however, this
change often becomes muted through healing, TYPES OF OSTEOTOMIES
and long-term deepening of the radix is difficult Hump Reduction
to accomplish. Occasionally a transverse osteoto-
my at the nasal root may be performed to push The bony hump reduction is performed through an
down this area and deepen the radix. On the other osteotomy. The techniques involved with hump
hand, a low radix may accentuate the appearance reduction are described in detail in another article,
of a dorsal hump, and this should be identified so so they are not repeated in this discussion.
that the surgeon may augment the radix with However, medial and lateral osteotomies are often
a graft, thus reducing the amount of hump to be performed to close an open roof that is created
removed. It is also important to determine the during a hump reduction. Here the authors
appropriate tip projection and rotation in evalu- discuss types of osteotomies by describing the
ating the bony profile alignment. The tip and radix medial, lateral, and intermediate osteotomies in
position will influence the dorsal height required to further detail.
achieve an aesthetically pleasing profile.
Medial Osteotomies
It is important to include an intranasal evaluation
for complete assessment of the bony vault. Medial osteotomies are generally performed along
Collapsed nasal bones will be evident as they with lateral osteotomies to mobilize the nasal side-
cause impingement of the airway and are often wall to close an open roof after hump reduction or
associated with the collapse of the attached upper to narrow the nasal base. Medial osteotomies may
lateral cartilage. This may contribute to decreased also be performed to straighten a deviated bony
patency at the internal valve as the upper lateral septum. Occasionally medial osteotomies will be
cartilage collapses toward the septum. Patients performed without lateral osteotomies to place
who have had previous placed ‘‘low to low’’ spreader grafts that extend beyond the medial
osteotomies with medialization at pyriform bony/cartilaginous junction. This procedure may
 Osteotomies 305

allow for greater lateral displacement of the nasal heal well, with 94% of patients having impercep-
bone and upper lateral cartilage, allowing greater tible scars. The incision should be created as
opening of the nasal airway. a stab incision with a number 11 blade. Occasion-
Medial osteotomies may be performed as ally a perforating transverse osteotomy will be
straight, fading, or perforating osteotomies used to complete the fading medial osteotomy
(Fig. 4) and are generally not carried high into the that does not communicate completely with the
root of the nose, as this may predispose the lateral osteotomy. The transverse fracture
surgeon to create a rocker deformity (described connecting the medial and the lateral osteotomies
later) during completion of the lateral osteotomy. may also be created through digital pressure.
However, when the septum is significantly Medial osteotomies are performed through
deviated, the surgeon may carry the medial endonasal or external techniques. While perform-
osteotomy high into the root to provide a fulcrum ing endonasal rhinoplasty, an intercartilaginous
point for moving the septum to a more midline incision is created and a pocket is raised in the
position. A lower fading osteotomy may then be supraperichondrial plane to an area just past the
performed to meet the lateral osteotomy. Other junction of the nasal bones and upper lateral
surgeons may perform the medial osteotomy and cartilage. A Joseph elevator is then used to create
then mobilize and straighten the perpendicular a subperiosteal pocket over the nasal bones. A
plate of the ethmoid intranasally. straight or curved guarded osteotome is passed
In the authors’ practice, fading osteotomies are through the incision, over the upper lateral
most often used because the root of the nose is cartilage, and is then articulated into the caudal
solid bone and infrequently needs narrowing. edge of the nasal bone just lateral to the midline
These osteotomies also facilitate the precise on the same side. The osteotomy is then
completion of the lateral osteotomy without performed and repeated on the opposite side in
performing a percutaneous incision. The lateral a similar fashion as indicated. During the external
osteotomy must communicate with the medial approach the caudal edge of the nasal bone is
osteotomy to mobilize the nasal bone. If a fading visualized after elevation of the soft-tissue
medial osteotomy is not performed, a transverse envelope. The osteotome is articulated at the
osteotomy may be used to connect a straight caudal edge of the nasal bone and the osteotomy
medial osteotomy to the lateral osteotomy. This is performed. If the upper lateral cartilage has
procedure may be performed percutaneously or been separated from the dorsal septum the osteo-
under the skin envelope. Gryskiewicz3 showed tome is passed through this space to articulate
that percutaneous osteotomy incisions tend to with the caudal edge of the nasal bone, displacing
the upper lateral cartilage laterally, and the osteot-
omy is then performed. In either approach, care
must be taken to ensure that the attachment of
the upper lateral cartilage to the nasal bone is
not disrupted.
Occasionally in patients who undergo hump
reduction with short nasal bones and a predomi-
nantly cartilaginous hump, the reduction will not
create a significant open roof and osteotomies
will not be performed. The surgeon should ensure
that the patient has an adequate width at the nasal
base and that there is a straight nasal bony vault
before making a decision not to perform an
osteotomy.

Lateral Osteotomies
Lateral osteotomies are traditionally described for
closing an open roof after hump reduction,
narrowing a wide nasal base, or straightening the
deviated nose. The lateral osteotomy may also
Fig. 4. Medial osteotomies may be performed as be used to increase the width of the nasal bones
a fading osteotomy (patient’s right side) or straight in patients who have had their nasal vault aggres-
(patient’s left side). A perforating transverse osteoto- sively narrowed with previous surgery or trauma.
my is shown on the left side as well. These patients require lateral displacement of the
306 Dobratz & Hilger

nasal bone and attached upper lateral cartilage to maxilla. The guard is placed beneath the mucosa,
provide an adequate airway. which is preserved, and the osteotomy is
The early techniques for lateral osteotomies, performed. This reduces swelling and provides
popularized by Joseph and those whom he increased stability of the fragment due to the
trained, involved the use of a saw osteotomy tech- reduced injury to the periosteum and mucosa.6
nique.4 A subperiosteal tunnel was created and When the guard is placed externally the osteotomy
the saw osteotomy began at the inferiormost may be performed with or without a subperiosteal
aspect of the pyriform aperture, extending along tunnel overlying the external surface of the
the ascending processes of the maxilla ending at ascending process. The guard is placed on the
or beyond the nasofrontal suture (low to low). external surface just superior to the inferior
During saw osteotomies the curl of the saw causes turbinate and the osteotomy is performed.
a loss of height of the nasal bones. Surgeons Advocates for this approach believe that they
began transitioning to the use of osteotomes have superior control, as they are able to palpate
instead of the saw to perform the lateral osteoto- the guard as it travels along the path of the osteot-
my. In time it became apparent that patients omy. As the unguarded edge passes on the
were experiencing postoperative nasal airway mucosal surface, it can lead to extensive injury to
obstruction caused by the excessive narrowing the internal nasal mucosa. Becker and colleagues7
of the lateral nasal walls with the ‘‘low to low’’ described differences in intranasal mucosal injury
technique. Webster and colleagues5 described with osteotomes of differing sizes. The 4-mm
the importance of leaving a triangular piece of guarded osteotome caused mucosal tears 95%
bone at the pyriform aperture intact just superior of the time and a 2.5-mm osteotome caused
to the level of the inferior turbinate. They described mucosal tears only 4% of the time. These investi-
performing a curved osteotomy that started high, gators then evaluated computed tomography
preserving the triangular bone at the pyriform, scans and noted that the average thickness of
extending low onto the ascending process, and the lateral osteotomy site was 2.47 mm in men
then curving back high to avoid extension into and 2.29 mm in women. Becker and colleagues
the frontal process (high to low to high). This concluded that the 2.5-mm osteotome was reli-
pathway allowed for preservation of the airway able and the least traumatic. The 2.5-mm osteo-
by avoiding medial displacement of the inferior tome also has a lower profile and causes less
portions of the lateral nasal wall. By transitioning damage to the lateral soft tissues; however, palpa-
to a high position at the completion of the osteot- tion of the guard is more difficult and thus requires
omy, the frontal process is preserved. When the more skill to anticipate the path of the osteotomy.
osteotomy is carried superiorly into the frontal The 2- and 3-mm unguarded osteotomes are mini-
process (low position) and the nasal bones are mally traumatic to intranasal mucosa and lateral
infractured, the radix acts as a fulcrum and the soft tissues during a continuous osteotomy;
osteotomized segment beyond the radix lateral- however, these tend to be reliable only in the
izes, creating a rocker deformity. By ending the hands of the most experienced surgeons.
osteotomy high the path can communicate with At the completion of the lateral osteotomy,
a transverse or fading medial osteotomy below the osteotome is turned inward to complete the
the frontal bone, thus avoiding extension of the fracture and displace the fragment internally. The
osteotomy into the frontal process and avoiding back-fracture that communicates the lateral and
a rocker deformity. medial osteotomies may be performed as a trans-
Lateral osteotomies may be performed in verse osteotomy, fading medial osteotomy, or
a continuous or perforating fashion. For contin- facture by digital pressure. The medial and trans-
uous lateral osteotomies a straight or curved verse osteotomy or medial fading osteotomy is
guarded osteotome is generally used. The authors performed prior to the lateral osteotomy and
prefer to re-inject local anesthesia just before the inward fracture of the nasal bone fragment. The
osteotomy to hydrodissect the soft tissues fracture by digital pressure is performed after the
overlying the bone and also to assist with hemo- lateral osteotomy and the nasal bone fragment is
stasis. Next, a subperiosteal tunnel is created then displaced internally.
before the osteotomy is performed. This protects Perforating lateral osteotomies are the alterna-
the periosteum from injury, allowing for decreased tive to continuous osteotomies. Tardy and
bleeding and subsequent swelling and ecchy- Denneny8 described the use of the micro-
mosis. The guard of the osteotome may be placed osteotome to perform precise endonasal perfo-
internally or externally. When the guard is placed rating osteotomies with minimal damage to the
internally, a submucosal tunnel is created along periosteum and intranasal mucosa. Murakami
the nasal surface of the ascending process of the and Larrabee4 compared a percutaneous
 Osteotomies 307

perforating lateral osteotomy with continuous os- because of the stability provided by preservation
teotomies. The perforating osteotomy resulted in of the lateral periosteum with this technique.
a complete, irregular osteotomy with small
comminutions along the path. There appeared to
Intermediate Osteotomies
be equivalent narrowing with both techniques;
however, the perforating osteotomy was noted Intermediate osteotomies are generally performed
to provide increased stability to the fragment. to straighten nasal bones with significant convexity
The investigators believed that this was a result or concavity. These osteotomies may also be
of the preservation of the mucosa and periosteum. performed to correct a deviated nose with one
Occasionally patients will present with an nasal bone that is significantly longer than the other
excessively collapsed bony vault caused by the side. The osteotomy is performed in the midportion
aggressive narrowing of the nasal bones during of the nasal bone, parallel to the lateral osteotomy.
a previous rhinoplasty (Fig. 5). Other patients The exact location at which the osteotomy is
present with a unilaterally narrowed bony vault as performed within the midportion of the nasal bone
a result of trauma on the lateral surface of the depends on the anatomy of the nasal bone and
nose with subsequent collapse of the fractured the surgical goals. The osteotomy is often
nasal bone. In these instances the patient will performed for convexity or concavity of the nasal
require lateral displacement of the osseous frame- bone, and in these cases the osteotomy is generally
work to widen the vault and open the airway. A performed at the apex of the curvature of the bone.
transnasal percutaneous lateral osteotomy or Intermediate osteotomies may be performed as
‘‘inside-out’’ lateral osteotomy allows for reliable continuous or perforating osteotomies. The
mobilization of the previously traumatized nasal continuous intermediate osteotomy technique is
bone while preserving the periosteum to help similar to that of the medial osteotomy as
support the new lateral position of the bone described in earlier sections. The osteotome is
(Fig. 6). Byrne and Hilger9 showed that mobiliza- placed at the caudal border of the nasal bone
tion of the nasal bone followed the medial to lateral and the osteotomy is performed in a straight,
vector of the osteotomy, allowing for lateralization continuous fashion. The periosteum is often not
of the segment several times without manipula- elevated this far laterally, allowing the soft-tissue
tion. At the conclusion of the case, a small piece attachments overlying the nasal bone to be left
of Merocel (Medtronic Inc, Minneapolis, MN, intact, which provides additional support to the
USA), is placed high in the nose and secured fragments. The perforating osteotomy is
with externalized suture to stabilize the mobilized performed as a postage stamp or interrupted
segments. However, this is often not required osteotomy and is done percutaneously or

Fig. 5. A patient presents with collapse of the nasal bones due to excessive narrowing during previous rhino-
plasty (left). She underwent ‘‘inside-out’’ lateral osteotomies with significant improvement of the nasal airway
and appearance of the bony vault (right).
308 Dobratz & Hilger

Fig. 6. A continuous osteotomy showing complete disruption of the periosteum (A). An ‘‘inside-out’’ perforating
osteotomy showing preservation of the periosteum between the osteotomies (B). Photo (C) shows the difference
in the stability of the osteotomized fragments. On the cadaver’s right side the continuous osteotomy resulted in
collapse of the nasal bone and a narrowed airway. On the cadaver’s left side an ‘‘inside-out’’ perforating osteot-
omy was performed, resulting in increased stability of the fragment and a larger airway. (From Byrne PJ, Walsh
WE, Hilger PA. The use of ‘‘inside-out’’ lateral osteotomies to improve outcome in rhinoplasty. Arch Facial Plast
Surg 2003;5(3):251–25. Copyright 2003, American Medical Association. All rights reserved; with permission.)

intranasally, depending on the deformity. The perform the osteotomy. The intermediate osteoto-
percutaneous osteotomy is performed for a convex my cannot be easily performed after the lateral
deformity, and the bone is pushed in as the osteot- osteotomy because of the mobility of the nasal
omy is performed. The intranasal perforating inter- bone.
mediate osteotomy is performed when there is
a concave deformity, and the concave portion is SEQUENCE OF OSTEOTOMIES
pushed out as the osteotomy is performed.
The intermediate osteotomy is performed before The sequence of the osteotomies will vary
the lateral osteotomy, which allows the stability to depending on the deformity that the surgeon
 Osteotomies 309

wishes to correct. In general the medial osteotomy nasal root, which is used as a fulcrum to
will be performed first as a straight or fading reposition the septum in a midline position.
continuous osteotomy, depending on the  The intermediate (if necessary) and lateral
surgeon’s preferences and treatment goals. If an osteotomy is then performed on the oppo-
intermediate osteotomy is required, this is site side and the nasal bone is placed into
performed after the medial osteotomy but before an appropriate position.
the lateral osteotomy, to allow for stability of the
nasal bone during the osteotomy. The lateral When the septum is not severely deviated and
osteotomy is then performed and the mobilized the osteotomies are being performed to narrow or
segments are placed into the desired position. widen the bony vault without reorientation in rela-
The timing of the osteotomies within the time tion to the midline, the surgeon may wish to post-
frame of the entire rhinoplasty procedure may pone the osteotomies until nearing the completion
vary depending on the surgeon’s preference as of the case. This postponement gives the surgeon
well as the deformity being treated. In the case of the ability to hold pressure after the osteotomies,
a severely deviated nose, the surgeon may wish followed by immediate splinting of the nose to
to perform the osteotomies first to allow for the decrease the ultimate edema and bleeding associ-
midline positioning of the bony septum and nasal ated with osteotomies. If the osteotomies are per-
bones, thus allowing for the ultimate alignment of formed earlier in the case, the surgeon may still
the middle and lower thirds from the now midline hold pressure to reduce the swelling and bleeding;
bony vault. In these cases sequence of osteoto- however, the resultant edema is inevitable. The
mies is performed in the following order (Fig. 7): soft-tissue swelling may interfere with the
surgeon’s ability to evaluate the necessary struc-
 The medialized nasal bone should be mobi- tural changes that should be made to achieve the
lized first with a medial, intermediate (if desired aesthetic result. Therefore it is often best
necessary), then lateral osteotomy. to delay the osteotomies until the completion of
 The medialized nasal bone is then the procedure whenever possible.
displaced laterally to allow space for the
midline repositioning of the deviated COMPLICATIONS
septum.
 A straight medial osteotomy is then The correct execution of osteotomies requires
performed on the opposite side into the a certain level of knowledge and skill. The

Fig. 7. Sequence of osteotomies for the deviated nose. First the medial, intermediate, and lateral osteotomy is
created on the medialized nasal bone. This bone is then displaced laterally (top right). Next the medial osteotomy
is created on the opposite side and the septum is repositioned to the midline (bottom left). Finally the interme-
diate and lateral osteotomy is created on the opposite side and the nasal bone is repositioned to straighten the
bony vault (bottom right).
310 Dobratz & Hilger

procedure is often performed under an envelope As stated in earlier sections, if the osteotomy is
of soft tissue, and requires exceptional coordina- carried into the frontal process (low position) and
tion based on tactile feedback. The surgeon the nasal bones are infractured, the osteotomized
should have knowledge of the bony vault anatomy segment beyond the radix will lateralize, creating
and the consequences of inappropriately placed a rocker deformity. If this occurs, the surgeon
osteotomies. The authors have found cadaver should perform a percutaneous transverse osteot-
dissection to be an invaluable experience, and omy in a lower position to move the nasal bone
have recommended this practice to all novice independently of the nasal root. If the soft tissue
rhinoplasty surgeons. The surgeon may and periosteum is excessively elevated beyond
perform the various osteotomy techniques, then the osteotomy site, the fractured segment will
deglove the nose to compare the anticipated lose support and may become a flail segment
course of the osteotomies to the actual fracture that is difficult to maintain in position. This situation
pattern that occurs. may also occur if the segment becomes commi-
In practice it is important to carefully plan and nuted, which may happen if the patient has had
execute the osteotomy to avoid complications. multiple injuries in the past with previous fractures

Fig. 8. In the case of a comminuted or flail segment, a Merocel sponge may be positioned high in the nasal vault
to provide support. The sponge is secured with percutaneous sutures to hold the it in place, and is removed at 1
week postoperative. The superior suture is placed through the osteotomy site and then through the skin.
 Osteotomies 311

that have healed by a fibrous union. As the osteot- the authors will often place a small 2-mm osteo-
omy is created comminution may occur, making it tome percutaneously over the spicule of bone
difficult to position the fragments. In these cases it and will push the fragment back into place with
may be necessary to place a piece of Merocel the osteotome. If this is not done, the fragment
under the nasal bones and secure this with percu- may move or degrade, leaving a palpable or
taneous sutures to help hold the flail segment or visible dent.
segments in place (Fig. 8). Extensive damage to
the intranasal mucosa may result in synechiae SUMMARY
between the lateral nasal wall and the septum.
These adhesions may contribute to nasal airway Nasal osteotomies may be used to treat various
obstruction and can be difficult to treat as they deformities of the bony nasal vault, including
tend to reform after lysis of the adhesions. A piece closing an open roof after hump reduction,
of silastic sheeting may be placed for 2 to 3 weeks straightening asymmetric or deviated nasal bones,
after surgery to try and discourage reformation of narrowing a widened nasal base, or widening
the adhesions. Epistaxis may also occur with excessively narrowed nasal bones from prior
significant mucosal injury. Bleeding is often trauma or rhinoplasty. To achieve optimal
temporary, and will resolve with expectant aesthetic and functional results one must have
management and use of vasoconstrictant nasal a comprehensive knowledge of the bony and carti-
spray such as oxymetazoline hydrochloride (Afrin). laginous framework of the nose and its relationship
If packing is required, caution must be taken so as with the overlying soft tissues. A thorough under-
not to disrupt the position of the osteotomized standing of the various osteotomy techniques will
bone because the packing may displace the allow the surgeon to improve the overall contour
bone laterally. and appearance of the nose, while ensuring pres-
Improper placement of the osteotomy along the ervation of or improvement on the functional
lateral nasal wall may lead to complications. An internal anatomy of the nasal airway.
inappropriately low osteotomy may lead to nasal
obstruction when the fragment is displaced medi- REFERENCES
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