Managing the bony vault is one of the most challenging rhinoplasty procedures. Various techniques, such as medial, lateral, intermediate, and transverse osteotomies, are performed individually or in various combinations via the nasal and percutaneous routes [1]. However, despite the wide array of procedures, the revision rate is still high owing to recurrent or residual deviations [2,3].

In patients with severe deviation of the bony pyramid, medial and lateral osteotomies may not be sufficient to correct the bony deformity. In these cases, intermediate osteotomy is usually performed to obtain symmetry of the bony pyramid [4]. However, compared to Caucasians, most nasal bones of Koreans are shorter and thicker [5-7], and performing intermediate osteotomies can be difficult with an increased risk of comminuted fracture. Instead of performing additional osteotomy, the medial aspect of the nasal bone can be resected or trimmed to achieve symmetry in the nasal bony pyramid. Additionally, nasal bone trimming can be used to effectively narrow the wide nasal bone dorsum. This study aimed to evaluate the results of patients who underwent medial nasal bone trimming to manage the bony vault.

A retrospective study of patients who underwent rhinoplasty with medial nasal bone trimming between June 2010 and June 2013 was conducted. All procedures were performed by the senior author (TB Won). Medical records including diagnoses, computerized preoperative tomography scans, operative notes, intraoperative photographs, postoperative results, and complications were collected. Both preoperative and postoperative facial photographs were scored on a 4-point scale (0=worse or the same, 1=minor improvement, 2=improvement, and 3=major improvement). Patients who met the inclusion criteria had a minimum follow-up period of 6 months. Medial nasal bone trimming is usually performed unilaterally in patients with a deviated nose and bilaterally in patients with a wide nasal bone. Although the contralateral side of the deviation is usually trimmed, the final decision on laterality is made intraoperatively after mobilization of the nasal bones. IRB approval was obtained by the Institutional Review Board of Seoul National University Hospital (H-2305-042-1430).

Operative technique

Open rhinoplasty was performed in all patients through an inverted-V transcolumellar incision connected to bilateral marginal incisions. Dissection was performed in the supraperichondrial plane to expose the nasal tip and the upper lateral cartilage. Once the bony cartilaginous junction of the nasal bridge was identified, the dissection was extended in the subperiosteal plane over the nasal bones. The nasal septum is degloved in the submucosal plane. Both upper lateral cartilages were detached from the nasal septum, and overall structural abnormalities were evaluated. In patients with a deviated nasal pyramid, medial and lateral osteotomies were performed by mobilizing both components. The central bony pyramid, along with the bony and cartilaginous septa of the rhinion, was placed at the midline. When the mobilized lateral component was repositioned, varying degrees of bony overlap were usually found on the non-deviated side, which was the target of bony resection (Fig. 1, 2). Medial nasal bone trimming was performed incrementally using nasal scissors.

Figure 1. A schematic drawing of the medial nasal bone trimming on a patient with a deviated bony pyramid. The medial osteotomy (the red dash lines) and lateral osteotomy (the pink dash lines) are accomplished follow by correcting of the central bony pyramid and nasal septum. After the correction, the medial side of the non-deviated side of nasal bone (labeled in grey) is overlapping the central bony pyramid. This part of the nasal bone is trimmed away (the blue dash lines) in a wedge shape with a pair of nasal scissors, decreasing the risk of recurrent nasal deviation by extrinsic force of the overlapping nasal bones.

Figure 2. Intraoperative photographs of a patient with a deviated nose depicting the medial nasal bone trimming. Preoperative axial CT shows asymmetry of the nasal bones and nasal process of maxilla. Intraoperative picture of a wedge-shaped nasal bone trimming on the contralateral side of the deviation. The medial side of the nasal bone is trimmed with scissors.

For patients with a wide nasal bone, the medial bone trimming method was applied bilaterally after medial and lateral osteotomies and infarction of both nasal bones to narrow the bony pyramid (Fig. 3). A ring or nasal drill was used to smooth any bony dorsal irregularities, and dorsal augmentation was performed in selected patients according to their needs.

Figure 3. A schematic drawing of the medial nasal bone trimming on a patient with a wide nasal pyramid. Medialization of both nasal bones and nasal process of maxilla are achieved after medial (red dash lines) and lateral osteotomies (pink dash lines). The medial side of both nasal bone (labeled in grey) are moved toward the midline overlapping the central bony pyramid. The overlapping medial nasal bones are trimmed away (blue dash line) in a wedge shape with nasal scissors.

A total of 50 patients were included, of which 31 patients were diagnosed with a deviated nasal dorsum, 12 with a deviated nasal dorsum, and seven with a wide nasal dorsum without deviation. Wide nasal dorsum was diagnosed when the width of the bony dorsum was greater than 80% of the alar base width.

Nasal bone trimming was performed bilaterally and unilaterally in 29 and 21 patients, respectively. The nasal bone trimming patterns are presented in Table 1 and representative cases from our series are depicted in Fig. 4-6.

Figure 4. The representative case of a patient with a severe deviation of the bony vault. Instead of performing intermediate osteotomy on the right side, the right nasal bone was trimmed.

Figure 5. The representative case of a patient with a wide nasal base. Both bilateral medial and lateral osteotomies and bilateral symmetric trimming of the nasal bones were performed.

Figure 6. The representative case of a patient with a deviated and wide nasal base. Bilateral medial and lateral osteotomies and bilateral asymmetric trimming of the nasal bones were performed.

Table 1 . Patterns of medial nasal bone trimming.

Bone trimming	Deviated (n=31)	Deviated and Wide (n=12)	Wide (n=7)
Unilateral	26	3	0
Bilateral	5	9	7

Values are presented as number only..

Deviated, deviated nasal dorsum; Wide, wide nasal dorsum..

Dorsal augmentation was performed on 25 patients. Intermediate osteotomy was performed in two patients with residual convexity after nasal bone trimming. Postoperative aesthetic results were evaluated using a 4-point scale: 0, 1, 2, and 3. The average score were 2.31±0.61, 2.57±0.45, and 2.7±0.56 for the patients in the deviated, deviated and wide, and wide without deviated groups, respectively. No major complications such as saddling, infection, hematoma, major bleeding requiring transfusion, or bone absorption were observed. One patient who did not undergo further dorsal augmentation showed minor dorsal irregularities on postoperative palpation. One patient underwent revision surgery for reasons unrelated to the bony dorsum.

Among the various factors related to the successful management of a deviated nose, adequate mobilization of the bony vault is challenging [8]. Mobilization of the lateral nasal bony vault was achieved via medial and lateral osteotomies. In patients with severe deviations, an additional intermediate osteotomy may be required to obtain symmetry. However, these procedures typically yielded acceptable results. However, residual deviation or re-deviation in the early postoperative period is common [9] causing frustration for both patients and surgeons.

In most patients with a deviated nose, there is asymmetry in the length of the bony pyramids. The process of straightening the bony vault with osteotomies, together with the mobilization of the central compartment, involves telescoping of the longer nasal bones, either in the medial or lateral edges. Sometimes, telescoping can result in irregularities in the bony vault or act as a source of residual or re-deviation. The same principle can be applied to patients with a wide bony vault, where telescoping of both segments of the nasal bones is involved.

Performing a precise osteotomy is difficult, even in the most experienced hands, which can be even more challenging for the noses of Asians, because the nasal bones are smaller and thicker [7,8,10]. Performing intermediate osteotomies in short nasal bones can increase the risk of communition.

With this concept in mind, we performed medial nasal bone trimming, a simple procedure that involves wedge resection of the medial aspect of the nasal bones, avoiding telescoping and additional intermediate osteotomies. The nasal bones are usually thinner in the medial aspect and can be easily trimmed using nasal scissors under direct visualization. The extent of nasal bone resection is intuitive and can be accomplished incrementally. We believe that this procedure allows precise management of the bony vault. Further contouring of the bony vault can be achieved with fine rasping or preferably with 3-mm diamond nasal drills (Midas Rex; Medtronic, Jacksonville, FL, USA) under direct visualization.

As evidenced by our results, successful medial nasal bone trimming was achieved in all the patients. Intermediate osteotomy was performed before nasal bone trimming. There was no communication between the nasal bones and no unusual complications were observed. At the postoperative follow-up, correction of the deviated bony vault was achieved in all patients, and narrowing was achieved in patients with a wide bony vault after a relatively long-term follow-up period of at least 6 months. Residual deviation was found in two patients who were improved after surgery, and all patients who had linear deviation underwent considerable mobilization of the rhinion. One patient who did not undergo further dorsal augmentation experienced minor dorsal irregularities upon palpation that did not require revision.

The potential advantages of medial nasal bone trimming are as follows. It is a simple procedure performed under direct visualization that can avoid telescoping of the nasal bones, improve postoperative results, and avoid intermediate osteotomies, which in turn lowers the risk of comminuted fracture of the nasal bones during bony vault manipulation.

In conclusion, in patients with a deviated or wide bony pyramid, medial nasal bone trimming is a simple, safe, and effective procedure for achieving symmetry and narrowing of the bony vault.

The authors have nothing to disclose.