Nuances in Rhinoplasty: Pearls and Pitfalls

The thin-skinned patient is more of a challenge, he said. “Again, it starts with counseling and education of the patient. They run the risk of having visible irregularities. Pay attention to the quality of cartilage. The challenge for me is people who want a lot of tip work. I ask if they can live with something more conservative.”

If you can’t avoid patients with thin skin, Dr. Byrne said to at least avoid cartilage-splitting techniques; soften the edges of the cartilage and do very meticulous carving of grafts.

Over the Hump

Rounding up the presentations, Dr. Park said he wanted to discuss the most common, most simplistic kind of rhinoplasty—hump reduction.

“It’s not the cleft lip nose, it’s not the revision, and it’s not the ultra thin-skin nose,” he said. “It’s the type of rhinoplasty where maybe you do a septoplasty or polypectomy and the patient says ‘While you’re there, can you just remove my hump?’”

“I think the perception of most people is that it’s pretty straightforward,” Dr. Park said. “And while it usually is, we also see complications in these patients.”

He noted that some patients will come back three months later and say that all they wanted was a septoplasty and the surgeon urged them to shave the hump. “I hear that surprisingly often,” he said.

For hump removal, he said there are a series of questions he goes through. “You can’t leave the initial consultation for a hump reduction without addressing these questions,” he said.

First, what is the hump made of? There are different anatomic etiologies to humps. The question is important because the answer will dictate the approach used. A large cartilaginous hump reduction will necessitate an external route in order to reconstruct the middle vault. Prophylactic spreader grafts are often needed in order to preserve width on the frontal view.

Second, recognize that the dorsal strut of the septum may be twisted and require elaborate splinting maneuvers.

Third, not all humps need reduction. Where does the nose begin and does the nasion need augmentation in order to restore balance to the profile?

Similarly, the fourth task is assessing chin projection with respect to the size of the nose. A small chin will create the illusion of a large nose, and the ideal aesthetic proportion may require chin augmentation in conjunction with a hump reduction.