Nasal Dorsum Complications

Under Resection and Asymmetric Resection

When revising a nasal dorsum that has been underresected or asymmetrically resected, adherence to these principles – sharp osteotomes and an anatomic approach – allows for the best chance for improvement in my hands. Sharp osteotomes are essential to provide for a clean, precise bony hump excision. When the osteotome is dull, the chance of an asymmetric resection or overresection of the bony hump increases. Some surgeons have at least two sets of osteotomes and rotate them so that one set is always out, being sharpened. Other surgeons sharpen their osteotomes manually with a sharpening stone during each case. Both approaches are effective.

An anatomic approach is preferable. Detailed anatomic nasal analysis should guide surgery. For example, when undertaking a hump reduction, the surgeon should examine the excised tissue, assessing its symmetry, and whether it was the desired excision. (Of course, if the bony dorsum is rasped this will not be possible) (Fig. 18-8). Similar anatomic examination of the remaining cartilaginous and bony nasal dorsum also must be undertaken. It is expected that additional, calibrated refinement will be needed and should be undertaken with dogmatic adherence to the anatomic examination. Preoperative markings on the skin may be helpful to some surgeons for hump reduction, as well as for osteotomies.

En bloc resection

Figure 18-8 En bloc resection of the nasal hump allows careful anatomic examination as the surgeon assesses the need for additional calibrated refinements of the nasal dorsum.

In addition, persistent irregularities of the bony dorsum may be addressed by rasping. I find the powered rasp to be far preferable to manual rasping in this situation (Fig. 18-9).26-28

Powered Rasp

Pollybeak

A pollybeak refers to a specific problem of the nasal dorsum, specifically postoperative fullness of the supratip region, with an abnormal tip-supratip relationship. This may have several etiologies, including failure to maintain adequate tip support (postoperative loss of tip projection), inadequate cartilaginous hump (anterior septal angle) removal, or supratip dead space and scar formation.

Treatment of the pollybeak deformity depends on the anatomic cause.29 If the cartilaginous hump was underresected, then the surgeon should resect additional dorsal septum. Adequate tip support must be ensured; maneuvers such as placement of a columellar strut may be of benefit. If the bony hump was overresected, a graft to augment the bony dorsum may be beneficial. If a pollybeak is from excessive scar formation, Kenalog (triamcinolone) injection or skin taping in the early postoperative period should be undertaken before any consideration of surgical revision.

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