Dorsal Hump Removal

One of the more common requests in rhinoplasty is for surgeons to improve the dorsal hump, or bump on the nose. However, while this may seem like a relatively straightforward procedure, it does have a variety of challenges associated with it depending on the individual anatomy. The goal for this is to improve the profile in a manner in which the nose looks natural and fits the patient’s facial features. One of the most common complaints of patients seeking rhinoplasty is removal of the nasal hump. A nasal hump is an elevation along the bridge of the nose also called the nasal dorsum. Dorsum means the upper side of an anatomic part (for example on a shark it is called the dorsal fin). Hence, the term “nasal hump.”

Nasal Hump before and after, Lateral Right

BEFORE 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 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.

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.

Dorsal Hump Removal in Chicago