Nasal Hump before and after, Lateral RightBEFORE AND AFTER
Some patients with a nasal bump may be a result of excessive bone or cartilage. Most nasal humps are made up of a combination of either bone or cartilage. Most nasal humps have a cartilaginous component with amount of bone but all humps vary. The cartilage of the nasal hump consists of the septum connected to the upper lateral cartilages which is often called the cartilaginous pyramid of the nose. Every nose is different and some patients will have longer upper lateral cartilages or smaller ones based on their anatomy. The angle at lower edge of this pyramid is important near the top of this pyramid is important and is called the internal nasal valve. This angle is normally around 10-15 degrees and is where in many people the narrowest part of the airway. We need support along this area or breathing can be compromised. This area can be assessed with direct visual inspection and supporting the nose. In substantial nasal humps, the nose may even require rebuilding of certain components to help maintain symmetry of the nose on the frontal view with the use of spreader grafts.
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TECHNIQUES FOR NASAL HUMP REMOVAL
Removing the nasal hump can be done in a variety of techniques. In some cases, the nasal hump can be reshaped with rasping or filing of the nasal hump. Dr. Shah recommends the use of a specific set of rasps which allow contouring of the nasal bones in a precise manner. In rare cases, he will use powered instrumentation to remove nasal humps. Other cases require removal of the hump with a sharp cut along the bridge of the nose and bringing in the nasal bones later with osteotomies. In some cases, the nasal hump can be mostly cartilaginous and require reshaping of the cartilage portion.
In rhinoplasty, there are many different ways of performing surgery with sometimes more than one approach being acceptable and creating a beautiful result. This is the challenge for the surgeon to use the best approach and attempt to create it along the nose. Seven of the most common techniques in hump removal of the cartilaginous component are listed below:
TECHNIQUE ONE
Remove Both Upper Lateral Cartilage and Cartilaginous Hump
Fig 1. Full ULC
Fig 2. Cut ULC Septum
Fig 3. Cut ULC Suture
Solely removing both the upper lateral cartilage and the cartilaginous dorsum is a common technique. This is one of the more common methods of hump removal since it is simple. The technique can be used in patients with small humps and wide internal nasal angles but has a risk of overly narrowing the middle portion of the nasal airway which is sometimes called an Inverted-V Deformity (see below for explanation). Some patients like a narrower nose and can account for this type of hump removal particularly patients with wider noses.
INVERTED V DEFORMITY
The inverted V deformity is where the nasal bones are wider than the upper lateral cartilage. Many patients have a natural wider nasal bones than the upper lateral cartilages, so determination of a true inverted V deformity is subjective. Patients with collapse of the internal nasal valve, where the valve overly moves with inspiration can also have an inverted V deformity. A narrow internal nasal valve is diagnostic (can be measured) but there is some subjectivity to a collapsed internal nasal valve as normal noses will have some movement with deep inspiration.
TECHNIQUE TWO
Remove Just the Cartilaginous Hump and Preserve the Upper Lateral Cartilage
Fig 1. Full ULC
Fig 2. Hump Cut
Fig 3. Preserve
For this technique, the surgeon is going to remove just the nasal hump and preserve the upper lateral cartilage along the edges. This technique is best used for small nasal humps since the amount of removal is limited. This is a highly technical approach which preserves nasal valve function and the length of the upper lateral cartilage and nasal valve.
TECHNIQUE THREE
Suture Back Upper Lateral Cartilages
Fig 1. Nasal Hump with Upper Lateral Cartilage
Fig 2. Upper Lateral Cartilage is Spread and Hump is Removed
Fig 3. Upper Lateral Cartilage is Sutured
Here, the surgeon is going to first separate the upper lateral cartilages from the bridge of the nose. The elevated cartilage can now readily be seen and taken down without risk to the upper lateral cartilage. Once the surgeon is satisfied with the bridge appearance. The upper lateral cartilages are simply sutured back in position.
TECHNIQUE FOUR
Separate the Upper Lateral Cartilages and Remove Cartilaginous Hump Then Fold The Upper Lateral Cartilage
Fig 1. Upper Lateral Cartilage is Spread and Hump is Removed
Fig 2. Upper Lateral Cartilage is Folded
Fig 3. Upper Lateral Cartilage is Sutured
After separating the upper lateral cartilages from the bridge of nose, the surgeon will now fold the upper lateral cartilage along the nose, which is called a “spreader flap”. This will put a spring in the middle part of the nose and open up the airway and create width here.
TECHNIQUE FIVE
Separate the Upper Lateral Cartilages and Remove Cartilaginous Hump Then Insert Spreader Graft
Fig 1. Upper Lateral Cartilage is Spread and Hump is Removed
Fig 2. Spreader Graft Is Inserted
Fig 3. Upper Lateral Cartilage is Sutured
Instead of folding the upper lateral cartilages, here the surgeon will use a spreader graft to open up the airway. To find out more about what a spreader graft is, click here.
TECHNIQUE SIX
Separate the Upper Lateral Cartilages and Remove Cartilaginous Hump Then Fold the Upper Lateral Cartilage and Insert Spreader Grafts
Fig 1. ULC is Spread, Hump is Removed and Spreader Graft is Inserted
Fig 2. ULC is Folded
Fig 3. ULC is Sutured
For this technique, a combination of folding the upper lateral cartilages with spreader grafts to create a wider nasal dorsum is used.
The bony removal of the nasal hump which has different techniques for this and methods to account for removal of the bone. Surgeons who perform rhinoplasty for hump removal should have understanding of the anatomy and internal nasal valve. Mention to patients if a surgeon performs surgery without looking in your nose prior that is a red flag even for a solely cosmetic rhinoplasty. Surgeons with both cosmetic and functional training of the nose have an advantage of surgeons with only one of those aspects.
TECHNIQUE SEVEN
Remove the Upper Lateral Cartilage and Cartilage Hump and Replace with Spreader Grafts
Fig 1. ULC and Hump are Cut
Fig 2. Spreader Graft is Inserted
Fig 3. ULC is Sutured
Instead of just leaving the patient with missing upper lateral cartilage, here the surgeon will use cartilage to replace the missing tissue. These grafts are placed along the dorsum and can extend all the way into the nasal tip and spread the angle out and are called spreader grafts. These grafts can help with breathing and maintaining stiffness of the upper lateral cartilage and improving opening of the valve.
Real Patient Testimonial:
Some quick background: Prior to my revision rhino/septoplasty with Dr. Anil Shah approximately 1 year ago, I had been modeling on a very infrequent level and got booked for only about a photoshoot a month, largely due to the huge amount of time I had to dedicate to contouring my nose before photoshoots and because I couldn't ever take shoots where I'd have to come in with a fresh face (no makeup). Today, I’ve been chosen to represent major brands (including from Microsoft and Mercedes-Benz) and average about 3-4 shoots/week, if not more. People have even compared my nose to that of the Miss Venezuela Miss Universe 2017 contestant and you can see in the photos the resemblance is definitely there! Needless to say, I'm absolutely thrilled with the results and if I had the choice to go back in time, I'd do it again in a heartbeat with the same amazing team, only sooner! When I started modeling about 3 years ago, I was unsure of if I could ever really turn it into a career because my features just didn't fit me without makeup, but I enjoyed modeling so much that I decided to at least look for a doctor with a proven track record for producing results in revision rhino/septoplasty with the highest care taken for both functionality and aesthetics. Not only would s/he have to open up my airways, but for the surgery to be worth it, I'd also need to have my nose slimmed and my very bulbous tip refined. At first, after contacting about 15 or so doctors, I thought it was impossible to find a physician that was skilled enough to craft a beautiful nose while still correcting the breathing difficulties that persisted after my first surgery ~12 years ago to fix a deviated septum. Finally, after researching RealSelf reviews and photos for about a year and a half (!!) I stumbled upon Dr. Shah's amazing results at equally amazing price points. I was excited to take the surgery decision seriously, but the only thing was--he is located 4.5 hours away from me (a totally different state) so I was worried I'd have to keep looking because the entire trip would take about 9 hours just driving time. Luckily, Dr. Shah holds all his patients' satisfaction and comfort at highest regard, and his team promptly set up a remote Skype appointment with me, where he could tell me his initial thoughts on what could be done. After that first virtual appointment, I was ready to make the 4.5 hour drive into the office for an in-person consultation and was ecstatic to find out my seemingly impossible goal was an actually possibility at an unbelievable value (definitely the most affordable of all the doctors I had talked to). Maybe the best thing about Dr. Shah is he is never in it for the money. In fact, he gave me several options, one of which was to do nothing. After seeing the virtual predicted results, I was absolutely certain I wanted to get the surgery, but was so appreciative that he didn’t try to pressure me into anything. The whole staff was so supportive of me and always kept a completely clear and open line of communication with me be it face-to-face, email, or via phone. Leading up to the surgery, they gave me all the information I needed to have the perfect pre-surgery prep and an amazing recovery, and the surgery and recovery went so smoothly I almost couldn’t believe it. For follow-up appointments, he and his team worked with me to do virtual appointments and if I had to come in, they were very accommodating of my time and drive. What’s amazing too is that even when I have to make multiple facial expressions, my nose looks perfect in every shot and never loses the integrity of its shape or it’s feminine profile. Now looking back at everything, I am 100% certain I found the dream team! Needless to say, I decided to move on with the surgery and it remains one of the best decisions I've ever made for my career and relationships (my makeup routine has been slashed from a few hours to mere minutes and most days I don’t wear makeup at all). I couldn't be more grateful for the time and confidence Dr. Shah and his team have given me back. His expertise in acheving the perfect aesthetic and experience in challenging cases coupled with his incredibly reasonable rates (trust me, I shopped around for 2 years so I know!!) have made him now my go-to physician for all things from skin care to filler, even with the 4+ hour drive both ways. Even when other models have talked about getting procedures done, there’s only one team I recommend—Dr. Shah and his team!
Frequently Asked Questions
Is there a best method of hump removal? Which do I prefer?
They all have their merits and hump removal is based on patient’s anatomy. Surgeons should vary their technique to accommodate their patient’s goals. Consultation is important.
Can you create a perfectly smooth dorsum?
Palpation of the bridge almost always has some little irregularities. Visual appearance is most important of the nose as is function.
Will making my nose wider improve my breathing?
A wider nose does not necessarily breathe better than a narrower one as the nose is extraordinarily complex. There are many parts of the nose which contribute to breathing and the sensation of breathing is highly subjective. How breathing feels to a patient is perhaps the most important.
Can these techniques be used to straighten a crooked bridge?
Yes a combination of these techniques can be used along with others to straighten the nasal bridge.
What are some controversies of nasal hump removal?
A common issue many patients have after a revision or even some primary rhinoplasty is excessive width along the middle portion of the nose. The vast majority of rhinoplasty surgeons will utilize large bulky grafts which may not help all patients functionally or even aesthetically. Dr. Shah has developed a technique to maintain a natural line without creating excessive bulk along the middle portion of the nose.