An osteotomy between the medial and lateral osteotomies is occasionally indicated. Specific indications include the abnormally contoured nasal bone that is either excessively con – vex or concave. Intermediate osteotomies are most effective for decreasing the curvature of an excessively convex nasal bone. The intermediate osteotomy allows recontouring of the nasal bone for correction of the severely deviated bony vault. This osteotomy is performed before the lateral osteotomy. A 2-mm transcutaneous osteotomy performed midway up the nasal bone is typically used to complete the intermediate osteotomy.


Medial osteotomies are performed to control the backfracture of the nasal bones after lateral osteotomies. If a large dorsal-hump removal was performed, leaving an open roof, it may not be necessary to perform medial osteotomies.

High-to-low-to-high lateral osteotomies are performed to leave a small triangle of bone at the base of the pyriform aperture and prevent medialization of the inferior turbinate.

The dorsal nasal septum at the level of the bony vault must be midline to allow symmetric medialization of the nasal bones. If there is difficulty medializing the nasal bones, a blade handle can be used to shift the bony septum to the midline with the nasal bones.

If a greenstick fracture is noted, a transcutaneous 2-nun osteotome can be used to complete the backfracture and infracture the nasal bone.

Greenstick fractures are acceptable in older patients.


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