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The dynamics of hump removal in Rhinoplasty

A more precise, simplified and safer approach to hump removal emphasising visio-spatial analysis Pieter F Swanepoel MD


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Introduction History Pre-operative analysis Digital photography & morphing The surgical game plan Operative stage (prepping & anaesthesia) Closed vs. Open approach Examples & clinical cases Conclusion

The Nose Clinic and this presentation is not sponsored by any vested interest

The history of Rhinoplasty  Reconstructive surgery appeared 2000 years ago  Functional surgery arrived late 19th century  Cosmetic surgery, mid 20th century  Exponential improvements, last decade

Cosmetic Surgery NOSE SURGERY Technically, intellectually & emotionally, the most difficult and demanding surgery FACIAL REJUVENATION Face & eyebrow lifts, skin rejuvenation, Botox, fillers ‌

BODY RE-SHAPING Lipo-suction, abdominal lipectomies, breast augmentation and reduction

ANALYSING STRUCTURE Divide the face into 1/3rds & 1/5ths

The Nose conforms to three triangles


Frontal triangle

Base triangle

Lateral triangle

Rhinoplasty: Psycho-somatic surgery

 The eyes and chin form a triangle  At the centre, the nose, the most visible point  We focus 60% on the triangle  A minor change within the triangle influences shape profoundly  Thus, the patient’s self esteem

You cannot hide a surgical defect in this triangle

RHINOPLASTY IS AN ART & A SCIENCE The surgical pinnacle

“Rhinoplasty is an easy operation, but it is hard to get good results� (Gustav Aufricht MD) A good result depends on harmonising aesthetics, anatomy and function - a balance involving proportion and 3-D aesthetic considerations linked to anatomical function This is why good results often evade the generalist, or a casual approach

THE BELL CURVE Illustrates the consequences of stopping short, or over-shooting the peak - remove LESS rather than MORE

The dynamics of nasal anatomy

Successful surgery depends on understanding & using the anatomical dynamics that shape the tip projection of the nose

“It is difficult to simplify things, but once you simplify them, you reduce the potential for mistakes�

Hump removal: a common side-effect

ďƒź The larger the hump, the more likely that removal may cause a mid-vault constriction ďƒź A mid-vault constriction contributes to mouth breathing, lower blood oxygen levels, decreased physical energy & lower mental concentration levels.

“Each nose is as individual and unique as a finger print”  Rhinoplasty - intellectually and technically - is intricate & demanding; more so than any other surgery  No other surgery changes looks & lives as much as Rhinoplasty A SURGEON CONTENDS WITH A VARIETY OF –  240 plus anatomical variants  Critical, functional impairments  Psychological anomalies

Operative planning

• A detailed, visio-spatial pre-operative analysis will yield better results • Plan progressive, incremental and sequential steps


 Observe the patient from moment of entry into your room  Analyse both patient and the patient’s nose  Note nasal movement during breathing, talking and smiling  Observe movement of both sets of nasal valves

Observe patient breathing

 Internal & external nasal valve anomalies obstruct air flow more than a deviated septum or enlarged turbinates  Even a 60/40 ratio = 100%  Septoplasty warranted only if ratio = 30/70

The physical assessment

ďƒź Physical assessment begins with an external & internal examination of the nose to identify the offending anatomy. ďƒź Avoid operating on patients with thick, oily sebaceous skin

Affect of aging on technique

Consider the Skin Soft Tissue Envelope (S-STE)

The thicker the skin, the more the upward rotation of the tip.

Physiological analysis

The naso-labial angle determines the direction of the inspiratory airflow currents.

Gender differences in nasal hump removal

ďƒź Minor aesthetic considerations influence gender appearance significantly ďƒź The bridge, a major determinant

Mentoplasty: the size & position of the chin

The chin, in relation to the position, size and shape of the nose creates an optical illusion; the stronger the chin, the more conservative the hump removal

The importance of chin projection

Chin and tip projection influence the profile so profoundly, a hump removal may not be necessary

The importance of chin projection

Notice how an increase in tip projection eliminates the hump

Cephalic rotation of the two tripod complexes, or the M-Arch module

Use the long & strong lateral crurae to increase tip-projection

A lateral crural overlay rotation will increase or restore tip projection

Pseudo hump explanation

“I have no regrets for those patients, I have not operated on”- (Jack Anderson MD)

SCREEN OUT PSYCHOLOGICALLY UNSTABLE PEOPLE Unstable patients are demanding, difficult, and impossible to please.

MOST COMMON DISORDERS - (BDD) Body dysmorphic disorders - (ADD) Attention deficit disorders - (SIMON) - Single, Immature, Male Obsessive Narcissist - Anorexics, Bulemic and obese patients

PRE-OPERATIVE PREVIEW STAGE Digital photography & morphing

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After physical exam, create a digital preview Previews ensure the surgeon and patient share common goals Morphing illustrates the influence of grafts Illustrates ‘open’ vs ‘closed’ approach, before surgery

Clients expect previews. Morphing and preview prints are standard pre-operative requirements

Avoid an aesthetic ‘disconnection’

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Detect danger signs during consultation During ‘morph’ preview A quest for perfection Repeated surgery Victimhood Criticism of original surgeon Email correspondence

The nose is a 3-D visio-spatial organ





Lateral (both sides)

 With tall patients, look at base view of the nose during interaction  Retain a high dorsal height & sufficient nasal length  We do not operate on boys under 18/19 or girls under 17/18

THE GAME PLAN The anatomical analysis HUMP: RATIO OF BONE VS CARTILAGE Nasal hump has five components  Two nasal bones  The two dorsal borders of the upper lateral cartilages  The dorsal border of the cartilaginous septum With large humps, introduce spreader-grafts to avoid mid-vault constrictions

The prepping stage

ďƒź Use a comfortable, adjustable dental chair ďƒź Raise the patient to eye level to mark the hump

The prepping stage

 We use intra-venous target-controlled conscious sedation  And sensory nerve block anaesthesia; not general anaesthesia.  Do not inject the membranous septum (distorts tip projection)  Similarly, do not inject the area above the marking

The prepping stage

ďƒź We insert, intra-nasally, 1ml of 10% cocaine and adrenalin on a 8cm neuro-pattie per nostril

OPERATIVE STAGE A simple hump removal technique

 Rotate the tip of the nose  Excise a pie-slice of the anterior inferior septal angle  Minimum effort  Maximum effect

OPERATIVE STAGE Support the projection of the nose

OPERATIVE STAGE “ There is a supreme excellence in simplicity ” Henry Wordsworth Longfellow

 Draw an operative game plan  Project onto a screen  Operate with economy of movement  Respect tissue and conserve anatomy

Use hauzy gauze

 Skeletonise the Skin Soft Tissue Envelope (S-STE)  Perform a stretch dissection with sharp pointed Joseph scissors  Use hauzy gauze. Suction irritates the blood vessels & causes more bleeding  We do not use electro-cautery

Minimal blood loss

ďƒź As a rule, the blood loss is between 5 and 10ml ďƒź A hump removal is less traumatic and painful than undergoing a tattoo

Cartilaginous hump removal

 Create a mucosal tunnel at the apex of nasal passage before you section upper border of upper lateral cartilages from upper border of cartilaginous septum  Lower dorsal border of cartilaginous septum with #15 blade  Leave dorsal borders of upper lateral cartilages intact

Position naturally occurring spreader grafts

Roll, inwards, upper borders of upper laterals to create an adjacent, naturally positioned spreader graft: acts to prevent midvault narrowing


ďƒź Remove the bony portion of the hump with a modified, narrow Rubens osteotome


ďƒź Working at a slanting angle on either side of septum, remove a V-section of the bony hump ďƒź Close the open roof by executing a curved, low lateral osteomy to create an infracture of the frontal processes of the maxillae.

The importance of the differential skin thickness

Do not leave a straight dorsal profile. The differential skin thickness will introduce a concave profile to the refinement


We have treated more than 320 cases of hump removal since adopting the natural spreader graft technique in April 2006

The result is not only more accurate, but more satisfying & rewarding

Clinical cases and operative worksheet

Clinical cases and operative worksheet

The result

Clinical cases and operative worksheet

The result

The result

Clinical cases and operative worksheet

The result

The result

Clinical cases and operative worksheet

Clinical cases and operative worksheet

The result plus augmentation mentoplasty

Clinical cases and operative worksheet

The result

The result

CONCLUSION “Let each man exercise the art he knows” Aristophanes (450 BC - 388 BC)

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Cultivate functional and cosmetic skills Specialisation creates the freedom to dictate practice protocols A high demand for nasal correction and refinement 12-million cosmetic procedures in the USA (+457% for 2010)

Invitation to young surgeons

Learn the art of Rhinoplasty Contact Robert Fysh at

Thank you ‌

The dynamics of hump removal in Rhinoplasty  

Lecture by Dr. Pieter Swanepoel

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