Hump Rasping Using Powered Instruments: A Retrospective Review

Abstract

Background:

Nasal hump reduction, a common procedure in rhinoplasty, aims to create a harmonious nasal appearance with smooth dorsal lines. An alternative to traditional osteotomes is the carbide-tip nasal rasp, effective in eliminating modest contour deformities. However, the broad movements and physical forces of manual rasping can significantly weaken the osseocartilaginous vault. Power-assisted instruments have been used to reduce soft tissue trauma. Although long-term clinical outcomes of power-assisted instrumentation are pending, initial reports have been positive.

Methods:

This retrospective chart review encompassed 220 consecutive rhinoplasty cases conducted by the senior author, all involving women aged 19–37 years. Excluding 80 cases that did not involve bone reduction, the analysis concentrated on 140 patients who underwent bone reduction procedures. The success of nasal hump reduction was evaluated based on the joint satisfaction of both the patient and the surgeon with the surgical improvement.

Results:

The open rhinoplasty approach was predominantly used for surgical exposure to minimize inadvertent rasping of the nasal cartilage. Among the 140 patients undergoing power-assisted bone removal, all but five achieved an initially satisfactory refinement of the bony nasal contour. Notably, no serious complications were observed throughout the study. Unfortunately, one patient did not comply with the monthly steroid injections, leading to the necessity of revision surgery for the removal of regenerated bone.

Conclusion:

The integration of power-assisted instrumentation in rhinoplasty procedures represents a promising advancement, addressing challenges associated with traditional methods.

Takeaways

Question: How to use powered instruments in nasal hump reduction.

Findings: A retrospective chart review of 220 cases of rhinoplasty was performed by a senior surgeon author. We found that using power-assisted instrumentation minimizes inadvertent rasping of the nasal cartilage. Therefore, a result of long-term aesthetic results compared with the traditional rasping techniques is achieved.

Meaning: The integration of power-assisted instrumentation in rhinoplasty represents a promising advancement, addressing challenges associated with traditional methods.

INTRODUCTION

Nasal hump reduction, often performed during rhinoplasty, aims for a harmonious nasal appearance with smooth dorsal lines and a seamless transition from the nasal bridge to the tip.^1,2 The keystone area, encompassing the dorsal hump, where the bony nasal vault attaches to the cartilaginous vault, plays a pivotal role in shaping the nasal profile.³ The rhinion, an osseocartilaginous junction, may present as a genuine dorsal hump or an illusion thereof, often due to overprojected upper lateral cartilage, tall nasal bones, or an overprojected dorsal septum, individually or combined.^4,5

Nasal hump reduction is a primary objective in cosmetic rhinoplasty.¹ Although novice surgeons may perceive profile realignment as straightforward, experienced surgeons view hump reduction as a complex procedure fraught with challenges for achieving a flawless long-term outcome.^6,7 Beyond the creation of a straight and natural nasal profile, successful hump reduction necessitates the establishment of smooth, continuous, and evenly spaced brow-tip aesthetic lines. The formation of an appealing brow-tip aesthetic line is intricately linked to the precision and control of nasal bone positioning postfracture of the nasal sidewall. However, achieving perfect brow-tip aesthetic lines is challenging, as overly aggressive destabilization of the bony vault can cause nasal bone misalignment and contour irregularities.^6,8 As a result, executing blunt-force osteotomies is challenging in nasal hump reduction, potentially leading to complications such as asymmetry, comminution, overresection, rocker deformities, sidewall collapse, and airway impingement. Even when performed correctly, osteotomies may trigger skeletal misalignment during the healing process, detracting from an otherwise satisfactory surgical result.^8,9

An alternative to traditional osteotomes is the carbide-tip nasal rasp, effective in eliminating modest contour deformities.⁸ However, manual rasping’s broad movements and physical forces can weaken the osseocartilaginous vault significantly. Although avulsion of the upper lateral cartilage is a noted complication, manual rasping may also intensify trauma to the soft tissue envelope or lead to traumatic bone regeneration. Moreover, manual rasps are criticized for their inability to selectively address focal bone defects without unintended reduction of surrounding bone.¹⁰

Contemporary rhinoplasty aims for controlled skeletal contour modification with minimal nasal vault disruption. As an attractive and natural-appearing nasal dorsum typically requires minimal bone reduction, precise bone removal is pivotal for successful hump reduction.¹¹ Although traditional blunt-force osteotomy techniques remain crucial, power-assisted instrumentation provides a valuable alternative for controlled bony hump resection. Beyond precise bone removal, power-assisted instrumentation enables three-dimensional sculpting without the soft tissue trauma associated with manual rasping.¹²

Although long-term clinical outcomes of power-assisted instrumentation are pending, initial reports have been positive. Becker and colleagues reported successful profile realignment in 30 patients using a shielded cutting bur for nasal bone removal, citing reduced soft tissue trauma, smoother bone contour, and more precise bone reduction as advantages over traditional nasal rasps. The resurgence of power-assisted technology in cosmetic rhinoplasty is marked by the variety of commercially available guarded cutting burrs and reciprocating power rasps.

ASSESSMENT

When evaluating the nose from a profile view, it is crucial to examine three distinct areas: the radix, the mid-dorsum, and the nasal tip. These areas, either independently or collectively, can contribute to the presence of an actual dorsal hump or create the illusion of one.

Despite the availability of multiple measurements, angles, and assessment tools for objectively analyzing the ideal nose size, experience and aesthetic judgment remain irreplaceable. A low radix, for instance, can contribute to the formation of a “pseudo-hump” and an under-projected or psychotic nasal tip. This becomes evident, particularly in patients considered for maxillary orthognathic surgery, where those with an anterior-posterior vector deficiency of the maxilla may exhibit the appearance of a large dorsal hump due to under-projection of the nasal tip. Correcting the nasal tip through advancements in the anterior nasal spine during maxillary osteotomy eliminates the “pseudo-hump.” In cases of a low radix or an under-projected nasal tip, dorsal augmentation or appropriate tip support may be more pertinent than dorsal hump reduction.

The mid-dorsum assumes primary focus during the nose’s profile examination. A thorough preoperative assessment of the hump’s size and its components, consisting of cartilage (dorsal septal cartilage, upper lateral cartilages) and bone (nasal bones), is crucial. Dorsal humps vary in size and shape, necessitating careful consideration during surgery. Additionally, the lateral bony extension along the dorsal sidewalls is a key factor that must be accounted for during the surgical intervention.

METHODS

This retrospective chart review encompassed 220 consecutive rhinoplasty cases conducted by the senior author, all involving female patients aged 19–37 years. Among these cases, 70 patients had a history of rhinoplasty, whereas the remaining 150 underwent primary procedures. Excluding 80 cases that required no bone reduction, the study focused on the analysis of 140 patients undergoing bone reduction. Among these, 100 individuals underwent dorsal hump reduction using a power-assisted rasp for bone removal, whereas the remaining 40 underwent power-assisted bone removal for leveling the nasal dorsum before dorsal implant or graft placement. The follow-up period ranged from 3 to 36 months.

The evaluation of success in nasal hump reduction procedures within our study was meticulously measured by assessing the satisfaction levels of both the patients and the surgeon involved. Patient satisfaction was systematically evaluated based on subjective feedback collected during follow-up visits. This feedback included direct comments from patients regarding their satisfaction with the aesthetic and functional outcomes of the surgery. Additionally, the need for or requests for surgical revision were also considered strong indicators of initial dissatisfaction or subsequent complications affecting patient contentment.

On the other hand, surgeon satisfaction was determined by a more objective criterion, focusing primarily on the aesthetic outcomes of the surgery. This involved a detailed assessment of the dorsal profile’s refinement and the alignment and smoothness of the brow-tip aesthetic lines. The surgeon evaluated whether the postoperative results aligned with the preoperative goals set for each patient, considering the overall harmony and proportions of the facial features, and whether any subtle imperfections necessitated further adjustments. This dual approach, incorporating both subjective patient feedback and objective surgical outcome assessments, provided a comprehensive measure of the overall success of the nasal hump reduction procedures performed. The open rhinoplasty approach was predominantly used for surgical exposure to minimize inadvertent rasping of the nasal cartilage. To ensure precision, the cartilaginous hump was initially removed through sharp dissection before bone reduction. Likewise, the overlying periosteum was carefully elevated to minimize periosteal inflammation during bone removal. The Micro-100 reciprocating rasp facilitated bone removal under direct visualization by using a setting of 75,000 RPM and a diamond burr tip, with irrigation to prevent heat damage and suction to clear the debris. A thorough irrigation of the subcutaneous pocket with saline followed to expel bone dust or tissue fragments. [See Video 1 (online), which displays use of the drill for hump rasping.] In cases where the width of the bony vault was considered excessive, lateral osteotomies were performed to achieve additional narrowing using the “incomplete” or “greenstick” lateral osteotomy technique, effectively accomplishing satisfactory sidewall narrowing in most instances. [See Video 2 (online), which displays close-up action of the drill on nasal bone.]

Video 1. displays use of the drill for hump rasping.

Download video file ^{(3.7MB, mp4)}

Video 2. displays close-up action of the drill on nasal bone.

Download video file ^{(11.7MB, mp4)}

RESULTS

All procedures reviewed were cosmetic in nature, aimed at improving the aesthetic appearance of the nasal structure. Among the 140 patients who underwent power-assisted nasal hump reduction, all but four patients achieved satisfactory outcomes initially. Notably, no serious complications were observed throughout the study. Additionally, a lower revision rate due to fewer incidents of accidental cartilage or bone removal has been observed, supporting the superiority of power-assisted methods in minimizing surgical trauma.

These four patients experienced delayed swelling over the nasal bones, necessitating monthly serial injections of triamcinolone acetonide (5–10 mg/mL) to control bone regrowth. Successful resolution of swelling was achieved in three of these patients through steroid treatment. The use of triamcinolone (5–10 mg/mL) postoperatively in cases of excessive swelling or osteogenic activity was found to effectively mitigate these conditions, based on our review of patient follow-up data, contradicting traditional views of its efficacy limited to soft tissue applications. Figures 1 and 2 show intraoperative pictures of prehump rasping and posthump rasping with a powered instrument, respectively.

Fig. 1.

Dorsal hump before using powered rasping instrumentation.

Fig. 2.

The resulting smooth contour of the nasal bone after rasping with powered instrument.

Unfortunately, one patient did not comply with the monthly steroid injections, leading to the necessity of revision surgery for the removal of regenerated bone. Surgical techniques were adjusted to accommodate the altered anatomical features due to prior surgery, such as increased use of subperiosteal dissection to minimize trauma to scarred tissues. It is noteworthy that the revision case ultimately achieved a satisfactory outcome.

DISCUSSION

Achieving the ideal nasal contour through hump reduction poses a considerable challenge, with the flawless execution of blunt-force osteotomies being a particularly demanding aspect. The need for creating a smooth and attractive nasal profile, along with slender and straight brow-tip aesthetic lines with perfect bilateral symmetry, adds to the intricacies of hump reduction. Essential elements for a successful hump reduction include optimal siting of intended bone cuts, controlled movement of the osteotome, and preservation of skeletal stability.⁸

Precise control of the osteotome is crucial for properly executed osteotomies. However, exacting movement is often disrupted by areas of dense bone, leading to osteotome deflection.¹³ Common examples include the Rubin osteotome being diverted deep to the dense outer cortex during dorsal hump resection, resulting in overresection.^8,14 Acquired imperfections in bone strength, such as those from prior nasal trauma or osteotomies, may further complicate bony hump resection.

Given the limitations of traditional osteotomies, power-assisted instrumentation emerges as an attractive alternative for delicate and precise bone reduction.¹⁵ Unlike the Rubin osteotome, which may leave an irregular bony surface after dorsal hump resection, the power-driven rasp is adept at incremental “planning” of the bone surface, resulting in precise, smooth, and uniform bone reduction. Power-driven bone removal also offers a smoother surface compared with manual rasping.⁸

An advantage of the power rasp lies in its capability to sculpt the nasal bones in three dimensions, rounding the bone edges for a slender, rounded contour of the dorsal crest.¹⁶ This reduces the need for aggressive sidewall in fracture in thick nasal bones with the exception of cases of wide bony vaults, which usually need lateral osteotomies. The reduced nasal bone mobilization diminishes the likelihood of severe osteotomy complications in high-risk patients.¹⁷

Potential drawbacks include the risk of pathologic thinning of the nasal bones. However, observed effects have been minimal and confined to a small dorsal bone margin segment near the caudal border.⁶ The power rasp’s absence of high-impact forces associated with blunt-force osteotomies or manual rasping allows for immediate bony hump reduction with minimal risk of bone disruption.¹⁶ This is particularly beneficial for patients with weak or brittle bones, such as older or osteoporotic individuals.

Moreover, the power rasp minimizes soft tissue trauma, facilitates rapid bone debulking, and allows for small focal bone reductions. It provides a precise and delicate alternative to the traditional osteotome or manual rasp for bony hump reduction, offering a focal and precise approach that enhances surgical outcomes.

As we consider the specific improvements our study brings to rhinoplasty techniques, particularly through the use of power-assisted instrumentation, it becomes imperative to place these advancements within the broader context of technological innovation in plastic surgery. Recent developments, as documented by Guarro et al,¹⁸ introduce a virtual measuring system which aligns with our goals of precision in surgical planning. Similarly, the LACE+ Index, as explored by Winter et al,¹⁹ underscores the predictive value of advanced tools in assessing patient outcomes: a principle that is fundamental to the evaluation of cosmetic surgical interventions. Moreover, the modified TIME-H scoring system, also highlighted by Guarro et al, offers a new approach to managing postoperative care, drawing parallels to our method of minimizing trauma through innovative surgical techniques.²⁰ These examples not only highlight the importance of integrating new technologies into plastic surgery but also echo our study’s aim of enhancing surgical accuracy and reducing patient recovery time.

CONCLUSIONS

In recent years, there has been a significant shift toward preservation rhinoplasty, with surgeons worldwide preferring preservation overresection. This approach emphasizes achieving a natural result.²¹

Power-assisted instrumentation excels in three-dimensional sculpting, creating a rounded dorsal crest contour, and reducing the need for aggressive sidewall fractures. This method reduces complications by lessening the impact on nasal bone mobilization, particularly in high-risk patients.

Despite potential drawbacks like the risk of nasal bone thinning, the power rasp’s ability to reduce high-impact forces makes it a notably advantageous tool. Its minimal bone disruption and reduced soft tissue trauma enhance its appeal, offering a precise, delicate alternative that improves surgical outcomes.

In conclusion, integrating power-assisted instrumentation into rhinoplasty procedures offers a promising advancement, overcoming the challenges of traditional methods. As technology continues to evolve, further research and long-term clinical outcomes will provide a more comprehensive understanding of the benefits and potential considerations associated with this innovative approach to nasal hump reduction.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.