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One of the very common reasons that a patient wants to change their nose is for the reduction of hump or bump. Known as dorsal reduction, it is one of the most common maneuvers in all of rhinoplasty. Contrary to the perception of many patients, a hump reduction is not just about taking down and smoothing bone. Rather a hump, even the smallest one, is a combination of bone and cartilage. That is because the hump area is really where the cartilage of the middle third of the nose (middle vault) meets the bone of the upper third of the nose. (nasal bones)

While a hump reduction seems like it would be a simple rhinoplasty maneuver, it is not. The skin is very thin over this area (the thinnest on the nose) and it is not uncommon to have unhappy patients who can feel and even see irregularities and unevenness after surgery across this area. Worse complications can also occur including collapse or separation of the cranial end of the upper lateral cartilages resulting in middle vault collapse (evidenced by a pinched appearance of the middle third of the nose) with internal nasal valve obstruction and breathing difficulties.

Maintaining straight and symmetric dorsal lines as well as good internal airway function is as important as the amount of nasal hump reduction in rhinoplasty. Many techniques have been described as to how to take down a nasal hump but the one I have found most successful is the component dorsal hump reduction technique. It is a series of five graduated steps including initial separation of the upper lateral cartilages from the septum, dorsal septal reduction, dorsal bony reduction with a rasp, external skin palpation and finally osteotomies or spreader grafts if needed. Why this approach works well is that the bone and cartilages of the hump are treated separately and sequentially, unlike the radical hump reductions of the past.

The determination of the success of any hump reduction technique in rhinoplasty is the preservation or restoration of the dorsal aesthetic lines. In the July issue of Plastic and Reconstructive Surgery, a study was reported that looked at this aspect of rhinoplasty. One hundred primary rhinoplasty patients from a single plastic surgeon was assessed by digital image analysis one year after their surgery. Dorsal line symmetry and nose width were assessed and compared before and after surgery. The study showed significant improvements in both dorsal line symmetry and nasal width lines. Almost all of the patients had harmonious dorsal lines after surgery.

Dorsal reduction using the components technique demonstrates a very reliable method for preserving or obtaining the aesthetic dorsal lines and significantly reducing the risk of middle vault collapse. This has proven to me to be the safest hump reduction method in rhinoplasty with fewer postoperative problems such as dorsal irregularities. Rasping of the nasal bones is a slower method of bony hump reduction than an osteotome in surgery but allows for a smoother result in my hands. This excellent study proves it with a careful digital computer analysis.

Dr. Barry Eppley

Indianapolis, Indiana

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