Introduction:
A dorsal hump is the presence of an irregular nose structure that involves both cartilage and bone. This hump can range in size and is known as a nose bump. It is noticed by looking at the profile of the patient's nose. This hump begins near the eye area at the nose's upper region and ends just before the tip of the nose. Dorsal hump is present from birth in many cases but can sometimes develop later in life due to injury trauma in the nose.
What Are the Causes of Dorsal Hump?
Various factors cause dorsal hump, such as genetics, due to injury or trauma, and medical conditions. Genetic predisposition is one of the common causes of the dorsal hump. Sometimes, in early childhood, it might not be visible and may be seen during puberty or when the nose grows further. Injury or trauma can also lead to a dorsal hump when there is a significant blow to the nose, and it is seen most commonly in developing children where the cartilage is relatively soft.
What Are Specific Considerations for Dorsal Hump?
-
To check whether the dorsal hump is present due to excess bone, cartilage, or both, as in some individuals, the hump is limited to the bony part of the bridge, and in others, the hump may be present due to excess cartilage. If the humps are limited to the bony part, rhinoplasty is the treatment of choice by removing the excess bone only, and if it is due to excess cartilage, trimming the cartilage is the best treatment option.
-
To check how much bone reduction is required depends upon aesthetic and personal preferences. To stimulate the hump reduction and give an idea of how the nose would look with varying levels of hump removal, surgeons should perform in-office digital morphing.
-
To verify whether the nasal skin redrapes well after the bump removal.
-
To check if a radix graft is required by the surgeon assessing the nose if there is pseudo-hump deformity present.
-
Surgeons will plan to adequately place the spreader grafts without inter-nasal valve narrowing or collapse to support the upper lateral cartilage after bump reduction.
What Are the Surgical Approaches for Dorsal Hump Reduction?
The surgical approach for dorsal hump reduction is the endonasal and external approaches.
Endonasal Approach: In this approach, all incisions are made inside the nose, where intercartilaginous incisions are connected with the hemitransfixion incision. Through this approach, maximum access to the nasal dorsum is obtained.
External Approach: This approach combines a mid-columellar incision with two infracartilaginous incisions.
What Is the Technique for Dorsal Hump Reduction?
In the endonasal approach, an intercartilaginous incision is made that is located just caudal to the nasal nerve that runs from lateral to medial around the anterior septal angle. Dissection should be done carefully in between the upper and lower lateral cartilage to prevent postoperative irregularities of the lateral nasal wall. The dorsal tunnel is made by lifting the soft tissue envelope where the cartilaginous part of the hump is exposed. Small circular movements are made with the knife to perform in supraperichondrial surgical planes. To avoid tearing small vessels, it is essential to stay underneath the nasal muscles by leaving the perichondrium on the nasal dorsum and upper lateral cartilage. Once the cartilaginous part of the hump is prepared, the bony part is exposed by transitioning to the subperiosteal plane. At the caudal side of the nasal bone, an incision is made in the periosteum that does not extend too far laterally. With the help of Joseph's elevator, the periosteum and soft tissue envelope are elevated towards the glabella region. As the view is clear, several procedures can be performed to correct the nasal dorsum. Before reducing the dorsum, the septum needs to be corrected if required. The posterior chondrotomy and the inferior strip are removed. Through the dorsal part of the septum and upper laterals, cartilaginous hump resection is done.
How Is the Height of Bone Reduced?
Several techniques can reduce the height of the bone. Powered instrumentation can be used when the hump is small to get the desired reduction. It will give a smooth contour of the bony pyramid. Broad flat osteotome reduces the large bony humps that will cut through both nasal bones simultaneously. The cutting plane of the cartilaginous hump that is already made, osteotome, is introduced into it. The cartilaginous hump is then removed. This will lead to an open roof, which will look unaesthetic and might cause pain due to mucosa contact with underlying skin. After performing nasal osteotomies, the open roof should be closed. It is closed by putting cartilage obtained during hump reduction if the open roof is small or sometimes with spreader grafts when the roof is large.
How Does Rhinoplasty Correct Dorsal Hump?
The bump on the bridge of the nose is due to excessive bone, cartilage, or sometimes the combination of both types of tissue. To correct the dorsal hump, it is indicated either to remove or reduce the excess tissue, bone repositioning, or to create a straighter shape by filling in areas on either side of the hump. A tissue graft might be required to preserve the septum, prevent collapsing, and ensure the function and structure of the nose are preserved. Reduction rhinoplasty is a procedure employed to achieve a smaller nose through the removal of tissue. After the procedure, there might be swelling and bruising.
What Is Component Dorsal Hump Reduction?
Component dorsal hump reduction is the correction of the nasal dorsum as it performs dorsal reduction, emphasizing the integrity of upper lateral cartilages. This approach will help minimize the need for spreader grafts in primary rhinoplasty patients. Five steps methods in this technique include:
-
Upper lateral cartilage is separated from the septum.
-
Reduction of septum proper in increments.
-
Dorsal bony reduction.
-
Palpation verification.
-
Final modification (spreader grafts, suturing techniques, osteotomies).
By preoperative clinical analysis, if the dorsal hump is isolated, there is a preference for a closed or endo-nasal approach. The open approach is indicated when more aggressive modifications to the nose are required.
Conclusion:
Dorsal hump reduction is one of the most common and essential procedures in rhinoplasty. The type of approach to be performed is selected based on primary or secondary rhinoplasty, the need for additional surgical steps such as spreader grafts, and the size of dorsal convexity.
