The Probable Reasons for Dorsal Hump Problems following Let-Down/Push-Down Rhinoplasty and Solution Proposals

Abstract

Background: Nasal hump relapse and its probable reasons or mechanisms have been less discussed after dorsal preservation rhinoplasty. In this article, the authors would like to share their experiences and offer solutions regarding this subject. Methods: Five hundred twenty patients who underwent primary rhinoplasty between the years 2015 and 2017 were included in the study. The push-down method was used for noses with a hump less than 4 mm and the let-down procedure was performed for others. Hump height was measured from profile photographs. The cases were evaluated in terms of nasal dorsal problems and their probable mechanisms. Results: Five hundred twenty patients, 448 with a straight nose and 72 with a deviated nose, were enrolled in this study. Mean follow-up was 13 months (range, 9 to 16 months). Visible dorsal hump recurrence was observed in 63 patients, and they appeared at 1 to 4 months postoperatively. Forty-one of these had a dorsal hump more than 4 mm preoperatively. Hump recurrence was not more than 2 mm in 34 patients, and they did not wish to have any revision intervention because of cosmetic satisfaction. In 11 cases, the height of the hump recurrence was 2 to 3 mm. These patients were treated with only minimal rasping. The remaining 18 patients had a hump recurrence with a height of 3 to 4 mm. They underwent secondary surgery using let-down rhinoplasty. Conclusion: The authors recommend subperichondrial/subperiosteal dissection, subdorsal excision of cartilaginous and bony septum, scoring the resting upper part of the septum just below the keystone area, and performing lateral keystone dissection and preferring let-down procedure for kyphotic noses to prevent hump relapse after dorsal preservation rhinoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A Review and Modification of Dorsal Preservation Rhinoplasty Techniques

“…Therefore, the LD technique has been advocated for humps >4 mm. 24 In preliminary cadaveric studies at our center, we have found that the PD technique has a narrowing effect on the INV. 25 This is not seen with the LD operation.…”

“…Tuncel and Aydogdu reported on 520 patients undergoing successful closed PD or LD surgery with subdorsal cartilage resection. 24 Ishida et al, using a midseptal cartilage strip resection technique without preservation of the dorsal keystone, note satisfactory functional and aesthetic results in a series of 120 patients. 5 No patientreported measures or evaluation of nasal obstruction is discussed in either of these studies.…”

“…The intervening cartilage is removed and dictates the degree of dorsal reduc-tion. 18,24 A small amount of subdorsal ethmoid bone is resected using a rongeur, scissors, or osteotomes. Any remaining septum on the undersurface of the osseocartilaginous vault may be scored to release any tension that would prevent dorsal flattening.…”

“…20 However, if a patient has had a prior DP procedure, a secondary procedure using similar techniques is possible. 24 Patients with tension noses or a predominance of cartilage and shorter nasal bones are also considered good candidates for DP surgery. Those with a greater bony component, deep nasofrontal angle, or irregular bony pyramid are considered poor candidates for DP.…”

“…18 However, Tuncel and Aydogdu, in a series of 520 patients, report a 12% rate of hump recurrence with a subdorsal resection technique. 24 The authors recommend a subperichondrial/subperiosteal dissection, scoring any small amount of the septum remaining at the keystone area, performing lateral keystone dissection, and considering the LD procedure over the PD technique as means to prevent a hump relapse. As would be expected, larger humps have a greater risk for recurrence.…”