1. Broad Nasal Bone Reduction: An Algorithm for Osteotomies Ronald Gruber, M.D. Te Ning Chang, M.D. David Kahn, M.D. Patrick Sullivan, M.D. PRSJ 2007 March ;119(3):1044-53

2. Background □Aim of this study: To create an algorithm as to which osteotomy to use in nasal bone reduction. □The study was designed to examine the medial oblique osteotomy more carefully.

3. Background □The medial oblique osteotomy has largely resolved problems relating to reducing the width of the dorsal nasal bone and avoiding spicule formation.

4. □Harshbrger, R. J., and Sullivan, P. K. The optimal medial osteotomy: A study of nasal bone thickness and fracture patterns. Plast. Reconstr. Surg. 108: 2114, 2001.

5. Medial oblique osteotomy Classic medial osteotomy

6. Background □Problems of nasal osteotomies: □Inability to: (1) consistently reduce the width of the nasal dorsum (as opposed to the nasal base) either independently or in conjunction with reduction of the nasal base. (2) precisely control the slope of the nasal bone. (3) consistently avoid having to move the osteotomized nasal bone into its ideal position without having to apply excessive digital force.

7. Laboratory Experiment □9 adult Caucasian cadaver noses were skeletonized. □6 had a dorsal hump, 3 had no significant bony hump. □On one side of the nose of every cadaver, a medial oblique osteotomy (approximately 15 to 30 degrees off the midline) was performed on the medial side of the apex. On the contralateral side, it was performed on the lateral side of the apex.

9. Laboratory Experiment □In 5 of the cadavers a lateral osteotomy (low-to-low) was combined with the medial oblique osteotomy. □2 to 5 mm distance between the cephalic ends of the osteotomy sites. □The lateral nasal bone was then grasped with a forceps and manipulated.

10. Laboratory Experiment □ Results: □The reduction of the dorsal width after a medial oblique osteotomy alone was due to the slippage of the lateral nasal bone under the hood of the nasal bone. □A slightly sharp ridge could be seen and palpated, representing the lateral aspect of the hood.

12. Laboratory Experiment □ Amount of dorsal width reduction following a medial oblique osteotomy: ( p < 0.008) Cadaver Laterally Located Osteotome Medially Located Osteotome 1 20 2 20 3 32 4 31 5 43 6 22 7 30 8 32 9 22 Mean2.71.3

13. Laboratory Experiment □ Cont. Results: □In those who received both medial & lateral osteotimies; the entire nasal bone acted as a unit that was hinged at the cephalic end. That made it possible to grasp the nasal bone with forceps and manipulate its slope.

14. Clinical Study □The following algorithm was formulated: TypeNasal BaseNasal DorsumManagement I Broad---Lateral Osteotomy Only II Broad Lateral + Medial Osteotomy III ---BroadMedial Osteotomy Only

15. Classification Type I Type II Type III

16. Technique □ Medial Oblique Osteotomy: □Nasal skin is marked. □Directed halfway between the medial canthal ligament and the nasion. □A slightly curved osteotome of 3 mm or less is placed on the lateral aspect of the open-roof deformity, directed 15 – 30 degrees off the midline.

17. Technique □ Medial Oblique Osteotomy: □In an open approach it is possible to see the lateral aspect of the open roof. □In the closed approach, the osteotome is placed up against the bony septum & then sliding it laterally to what is percieved to be the lateral aspect of the open roof, then it is driven in & pried posteriorly.

18. Technique □ Medial Oblique Osteotomy: □If the dorsal edge of the nasal bone does not migrate medially, mild pressure is applied & it may be necessary to drive the osteotome further in. □If the dorsal edge (hood) is palpable, it is rasped.

19. Technique □ Lateral Osteotomy: □Nasal skin is marked. □Straight osteotome is used. □Optional method (what is comfortable for the surgeon). □After driving the osteotomy cephalically until a change in sound is heard, the osteotome is pried anteriorly.

20. Technique □ Both osteotomies: □Nasal skin is marked. □The medial oblique is done before the lateral. □The result should be nasal bone that is attached cephalically by a 2-5 mm piece of bone. □A forceps is used to grasp this piece of bone & manipulate it into the desired postion.

21. Results □ n = 53 cases. □Type I = 27 cases, Type II = 20 cases, Type III = 6 cases. □Follow up of 15 - 32 months. □Nasal bone width reduction was satisfactory in all cases except 3 cases (one from Type I, and two from Type II), one required a secondary osteotomy.

22. Type I nasal bones, required a lateral osteotomy (buccal sulcus, low-to-low). Improvement at 17 months.

23. Type II nasal bones, required both lateral osteotomy (buccal sulcus, low-to-low) & medial oblique osteotomy. Improvement at 22 months.

24. Type III nasal bones, required a medial oblique osteotomy. Improvement at 19 months.

25. Discussion □Before the advent of this algorithm, the medial oblique osteotomy was used infrequently. Instead, the low-to-high osteotomy was commonly used and it did reduce the width of both the dorsum and the base ( below the level of the cephalic end of the open roof).

26. Discussion □Medial oblique osteotomy results in less bleeding & spicule formation. Also, it creates a dorsal hood under which the nasal bone can migrate and locks in place. □The low-to-low lateral osteotomy was preferred because it minimizes any step-off deformity and allows to move the largest piece of nasal bone medially( there is a risk of a slight airway compromise).

27. Discussion □Alternative methods such as augmentation of the dorsum were not part of this study. □Since using the new combined medial oblique osteotomy and lateral osteotomy, it has been possible to replace the low-to-high lateral osteotomy completely. It has also been possible to obtain independent reduction of the nasal dorsum.

28. Conclusion □Despite the increased control with the method that has been described, there remains some chance that fracture lines do not go exactly where desired. □This study should stimulate further advances in nasal bone manipulation.

29. Thank You