Breaking Down A Blunt Osteotomy Rhinoplasty

The term osteotomy, derived from Greek, is defined in the medical dictionary as a surgical operation in which a bone is divided or a piece of bone is excised (as to correct a deformity). This article concerns the surgical technique of cutting bone in the performance of rhinoplasty (nasal surgery).

Most, although not all, rhinoplasties require the use of a form of osteotomy, because most standard rhinoplasties require the movement or alteration of the osseocartilaginous vault that composes much of the nose.

In general, indications for osteotomies in rhinoplasty are anatomic findings of a high nasal dorsum that requires “hump” removal, an “open roof” after the hump has been removed, and a wide nasal base. Correcting these conditions requires osteotomies. Understanding these factors requires a familiarity both with the basic anatomy of the nose and surrounding facial and cranial structures and with the goals of aesthetic (cosmetic) and functional rhinoplasty.

Simplistically, the nose is a structure consisting of a bone and cartilage framework over which is draped a skin envelope. The size, shape, quality and/or thickness, texture, and position of the various parts help determine the appearance and function of the nose. The bony portion is referred to as “the bony vault.”

This portion of the nasal structure consists of the paired nasal bones and the frontal ascending processes of the maxilla. The vault is generally pyramidal in shape… The most narrow part of the bony pyramid is at the intercanthal line… Laterally the nasal bones articulate with the ascending or frontal process of the maxilla…” Surgeons who perform rhinoplasties need to have a thorough understanding of nasal anatomy.

High Septal Osteotomy

When attempting to straighten a patient’s healed, deviated bony nasal dorsum, deviation of the central structure (high dorsal septum and medial nasal bones) must be addressed following the completion of medial and lateral osteotomies. When hump resection is not performed, blunt fracture (digitally or with forceps) of the deviated central structure is not a reliable method of mobilization, often leading to postoperative nasal drift. An intranasal osteotomy technique to mobilize the central structure of the nose is described, called “high septal osteotomy.”

Dr. Philip Miller demonstrates how a spreader graft is not always needed during a rhinoplasty. Instead of using a 2mm osteotome tool to create a transition, an instrument with a blunt end will make for a better tool due to the clean fracture it can yield.

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