Modification of the Dorsum in Rhinoplasty
A hump or ‘bump’ on the bridge of the nose is the most common anatomic deformity associated with rhinoplasty. It is true that there is no request that is more common than the removal of a dorsal hump. But while the request is the same, the humps to be removed are not.
Most people assume that removal of a dorsal hump is easy. ‘Can’t you just shave it off?’ is a question that I am often asked. If only it were that easy… And truthfully, part of the removal may actually involve ‘shaving.’ But achieving a perfectly straight dorsum is not as straightforward as it seems. The surgeon must assess a number of factors, including thickness of the nasal skin and tip projection. And what appears straight during surgery may not be so after months of healing. This is the art of dorsal modification.
The bridge, or dorsum, of the nose is made up of both bone and cartilage. The cartilage is partially made up of the nasal septum, which continues down to the nasal tip. A dorsal convexity, or hump, can be mostly bone, mostly cartilage, or maybe a mixture of the two. But in the majority of humps, both bone and cartilage must be removed. It is up to the surgeon to properly diagnose the components of the hump.
After a precise diagnosis is made, the surgeon must decide what technique is best suited for the job. Some prefer sharply cutting off bone and cartilage, while others prefer to sand down (rasp) the bone. Some even use powered instrumentation to accomplish this task. But the common goal is the same: Produce a smooth, natural dorsum.
 There are many pitfalls that can befall a rhinoplasty surgeon during hump removal. The dreaded sin is to remove too much hump. This can ‘scoop out’ the nose, and in some cases, even destabilize the nasal structure. Another common mistake is to leave the dorsum too high. Truthfully, some surgeons err on this side of conservatism, as this is a much safer approach that can keep the surgeon out of trouble. A related error is to remove too much bone, while leaving too much cartilage behind. This can cause aesthetic issues, such as a ‘polly-beak’ appearance.
The astute rhinoplasty surgeon does not analyze a dorsum as an isolated entity. Instead, the dorsum should be viewed in relation to the nasal starting point (radix) down to the nasal tip. Projection of the dorsum should be considered in a way that is similar to that of the tip. With this more profound understanding of the nasal aesthetic, the surgeon can now make a much more educated diagnosis, while formulating a more effective and safer plan. For example, a patient with a dorsal hump but an under-projected tip may simply need more tip projection to produce a straight dorsal line. In many cases, a small amount of hump still needs to be removed, but in a much more conservative (and safer) fashion. In some patients with saddling (collapse) of the supra-tip region below the dorsum, augmentation with small grafts can help. The bottom line is that the nose should be understood as a whole, never as isolated pieces. This will not only lead to a more well thought-out plan, but also more predictable and optimized outcomes.
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