ljritish Journal of Plastic Surgery ~I97i), 24, 375-381 A SIMPLE PROCEDURE FOR CORRECTION OF THE HUMP NOSE By Professor O. NEUNER, M.D. Department of Maxillo-Facial Plastic Surgery, University of Berne, Switzerland THE nasal hump consists of varying amounts of the osseous and cartilaginous dorsum of the nose and its removal is generally carried out by chisel, saw, rasp, osteotome or bone cutting forceps. It is almost always necessary to infracture the nasal bones for Fro. I, A One of the set of four forceps which have been developed for nasal hump removal. msthetic reasons as well as closing the open bony roof of the nose. When the mobilised bone segments are shifted medially, however, the dorsum of the nose is raised somewhat. While this is welcome in the treatment of saddle nose, it must be compensated for in obtaining the desired profile line in nasal hump corrections. 375
376 BRITISH JOURNAL OF PLASTIC SURGERY In the IO years during which we used saws for hump reductions, we always had some difficulty in obtaining the desired concavity and in making this compensation; nor did the use of a chisel and straight bone-cutting forceps (Kazanjian and Converse, 1947; Rowland, 1955) eliminate the problem. We have therefore developed a set of bone-cutting forceps with blades of varying curvature (Neuner, 197 o) so that the precise concavity desired can be given to the nasal profile (Fig. i). The appropriately curved forceps is selected pre-operafively from the FIG I~ B FIG I~ C Fig. B to D.--B~ C and D, The curvature of the blades is varied and the appropriate forceps chosen pre-operatively from a profile radiograph. FIG I, D study of a profile radiograph, taking into account any elevation of the bridgeline which might occur on infracture. As a rule men prefer a straight or occasionally even a slightly hooked nose ; women prefer a more concave profile. Operative Technique.--The new nasal profile is first marked on the skin, which is then undermined ill the usual way through two intercartilaginous incisions. The lateral triangular cartilages are separated from the anterior border of the septum. The selected forceps is now guided through the intercartilaginous incision and appropriately placed beneath the external skin marking (Figs. 2 and 3). By closing the forceps the cartilaginous and bony hump can be separated as one piece (Fig. 4). If required, one can use the cartilage from the excised hump as a free transplant in the lower lip for the
SIMPLE PROCEDURE FOR CORRECTION OF HUMP NOSE 377 FIG. 2~ A FIG. 2, B FIG. 2, C FIG. 3 FIG. 2 A, As a guide the outline of the new profile is marked on the skin in ink. B, Cutting through the hump. C, Removing the detached portion. FIG. 3 Diagram of the forceps in use through an intercartilaginous incision.
378 BRITISH JOURNAL OF PLASTIC SURGERY FIG. 4 A typical excised hump. 7 ~ i A B FIG. 5 A, The small rotating saw designed by the author for the transverse osteotomy at the root of the nose. B, The saw in use.
SIMPLE PROCEDURE FOR CORRECTION OF HUMP NOSE adjustment of a deep labiomental groove. The whole hump can also be implanted in the columella and the tip of the nose elevated somewhat, particularly in cleft lip and post-traumatic deformities ; the bony portion is set on the anterior spine and the cartilaginous part is pushed forward between the two Mar cartilages so that the nasal tip remains elastic and the bony base unites with the spine. B79 I FIG 6, B FIG. 6 A, The bur designed by the author for the lateral osteotomy. B, Drill in use. FIG. 6, A Following hump removal any irregularities can be adjusted by filing. An oblique osteotomy is now made across the nasal root using the circular saw developed by the author (Neuner, I966) (Fig. 5). The lateral osteotomy is carried out through an incision in the canine fossa. Usually the straight, hollow-ground saw is used for this. If a curved effect is desired or additional nasal root correction is needed, we use our own specially developed drill (Neuner, I966) (Fig. 6). In addition to the osteotomy
380 BRITISH JOURNAL OF PLASTIC SURGERY and medialisation the appropriate correction in the septum and alar cartilages is undertaken. A forehead nose plaster splint is applied for I week. Results. We have been using this method for about 5 years and have operated on about 13o cases during this time. All operations proceeded without complication. A FIG. 7 A~ Pre-operative. B and C~ Post-operative. B C The results were, without exception, good and in no cases did the profile need later modification (Figs. 7 and 8). Four patients required further correction of minor irregularities on the dorsum. Summary.--A procedure for the correction of the excessively aquiline nose is presented in which the hump reduction adheres strictly to a pre-operatively decided profile. A set of specially developed forceps is described with which the osseocartilaginous hump can be removed in one piece and, if necessary, be set as a free implant into the upper lip or columella. The remaining osteotomies are completed with
SIMPLE PROCEDURE FOR CORRECTION OF HUMP NOSE A 381 FIG. 8 A, Pre-operative. B and C, Post-operative. At the same time chin augmentation was carried out by advancing the lower border of the mandible by a step osteotomy. B C a straight saw or a special rotating drill inserted through the oral cavity. During its 5 years of use, this method has proved to be excellent. The hump removal forceps are made by Ulrich & Co., Bahnhofstr. II, 9000 St Gallen, Switzerland. The rotating instruments shown in Figs. 5 and 6 are made by Dentalwerk W. & H., 51 II Bfirmoos bei Salzburg, Austria, while the burs are supplied by Maillefer SA, I338 Ballaigues, Switzerland. REFERENCES KaZANJIAN, V. H. and HOLMV.S, E. N. (r947). Special rongeur forceps for removal of nasal hump. Archives of Otolaryngology, 457 361-364. NEUNER, O. (I966). Plastische Versorgung von Zertrfimmerungen, Defektbildungen und Wachstumsst6rungen im Bereich der Gesichtsknochen, in " Handbuch der Plastischen Chirurgie ", yon Gohrbandt, E., Gabka, J. und Berndorfer, A., Band 2. W. de Gruyter & Co., Berlin. NEUN~R, O. (r97o). Operationen bei Spalttr/igern im Erwachsenen.alter, in " Handbuch der Plastischen Chirurgie ", von Gohrbandt, E., Gabka, J. und Berndorfer, A., Band 2. W. de Gruyter & Co., Berlin. ROWLAND, A. L. (I955). The treatment of the hump in rhinoplasty. Archives of Otolaryngology, 62, 28-36.