Nasal dorsum alterations — Diagnosis and surgical planning
Hump, kyphosis and pseudo-kyphosis, saddle nose, supratip, deviation, inverted V and axe-cut sign: what causes them, how to tell them apart and which manoeuvre corrects each.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- Dorsal alterations are fewer and simpler to treat than tip alterations, but they are the most conspicuous: they are seen from a distance.
- Before touching the dorsum, look for three variants that condition recovery: short nasal bones, low radix and narrow internal valve.
- Pseudo-kyphosis is not excess dorsum: it is a sunken radix. Lowering the dorsum here is the error that leaves a short, scooped nose.
- The osteocartilaginous profile should have its highest point at the bone-cartilage junction. When it does not, the axe-cut sign and inverted V appear.
- In secondary rhinoplasty, the premise is to limit correction to the defect wherever possible. Reoperating everything multiplies risk without improving the result.
First branch: too much or too little dorsum?
On the lateral view, is the dorsal contour convex or concave?
Hump, kyphosis and pseudo-kyphosis
The patient calls it “excess septum”, but precision helps. When the convex dorsum appears as a localised elevation we speak of a hump. When it is a continuous line from radix to tip, of kyphosis. In both there is real excess osteocartilaginous structure, and assessment is made on the lateral view.
Pseudo-kyphosis: the commonest dorsal trap
There is a form that optically mimics kyphosis and in which the dorsum is not excessive: pseudo-kyphosis. The cause is not excess dorsum but a sunken nasal root. The practical consequence is direct and costly: treated as kyphosis and lowered, the result is a short, scooped, unsupported nose that later needs grafts to rebuild what should not have been removed. What needs raising is the radix.
Radix alterations
The radix is the skin point where the nose begins, corresponding to the frontal–nasal bone junction, the nasion. It varies in height and projection, influencing both apparent nasal length and the sense of the eyes being close or deep-set. The reference for judging it is the upper eyelid crease: above it, a prominent radix with a high nasion; below, a sunken radix with a low nasion.
Radix: finding and manoeuvre
- High nasion (prominent radix)Osteocartilaginous resection, paying particular attention to lowering the insertion of the nasal bones on the frontal
- Low nasion (sunken radix)Cartilage graft. Check first whether the “hump” was in fact pseudo-kyphosis
Short nasal bones
Recognising them before surgery matters because fracturing them can collapse the upper valve. In such cases dorsal spreader grafts may be needed to prevent collapse of the upper lateral cartilages, or the fracture avoided altogether. It is one of the three anatomical variants to look for deliberately before planning any dorsal manoeuvre.
Saddle nose
This is the opposite defect: the dorsum is sunken, and it may involve the bony portion, the cartilaginous, or both. Congenital origin is rare; the usual causes are traumatic, infectious or surgical — indeed it is one of the commonest sequelae of rhinoplasty. It is usually accompanied by dorsal collapse and breathing difficulty, and this occurs despite the valve angle increasing from superior tip rotation once dorsal support is lost.
How a surgical saddle nose happens
- Excessive hump resection. The commonest cause.
- Collapse of the structure into the nasal cavity, more likely if the periosteum was over-elevated before fracturing.
- Comminuted fracture of the nasal bones.
- Excessive resection of the anterior septal border.
- Septal abscess or necrosis, leaving the dorsum without central support.
Saddle nose: what to use by severity
| Grade | Material | Approach |
|---|---|---|
| Mild | Thin sheet of crushed cartilage, fat micrografting by needle, or hyaluronic acid as a temporary solution | Transcutaneous |
| Moderate | Septal or conchal cartilage graft. Spreaders can be made wider to project beyond the septal border and compensate the descent | Unilateral intercartilaginous |
| Severe | Costal cartilage, as a single piece along the dorsum or stacked pyramidally and fixed with non-absorbable suture | Transcolumellar (open), to place and fix securely |
Materials better avoided
Bone grafts — costal, iliac, tibial, olecranon or calvarial — have a very high resorption rate. Silicone implants may be used in very thick dermis, but in thin skin they extrude readily and should be avoided. Preserved homologous cartilage combines high resorption, contamination risk and legal implications. And for filling mild dorsal defects, do not use injectable non-resorbable material: the changes it produces in the skin envelope are permanent. When autologous material is short, reasonable alternatives remain: chondro-platelet grafts, a temporal fascia pocket filled with cartilage fragments, or lyophilised dermal allograft.
Prominent supratip: the polly beak
The name has settled to designate increased volume at the tip–dorsum junction, ranging from simple loss of tip definition to the deformity called polly beak. It occurs in unoperated noses, but is far commoner as a sequela of previous rhinoplasty, and especially likely in thick skin from exaggerated cutaneous retraction, persistent oedema or excess fibrosis.
Prominent supratip: cause and treatment
| Cause | What to do |
|---|---|
| Persistent oedema or fibrosis | Localised compressive dressing for longer than usual. Steroid injection is second line and used cautiously: resorption can be irregular and leave asymmetries, and superficial application causes skin atrophy |
| Insufficient resection of the anterior septal border or the upper laterals | Revision by vestibular route: lowering the anteroinferior septum and resecting excess upper lateral cartilage |
| Inadequate treatment of subcutaneous or muscular tissue | Measured lipectomy or myectomy, preserving lobular skin vascularity as far as possible |
| Loss of tip projection (excessive resection of hump, dome or mucosa; columellar shortening; division of the lateral crura) | Open rhinoplasty to regain projection or definition: columellar strut between the medial crura or a Sheen graft |
The approach matters in the supratip
Wherever possible use a vestibular incision — transcartilaginous, intercartilaginous or marginal — to preserve lobular skin vascularity, already compromised by resection of fibrosis and residual subcutaneous tissue. That route usually suffices to lower the anteroinferior septum, resect excess upper lateral cartilage or graft the dorsum. Open rhinoplasty is reserved for when the tip must also be modified.
Depressed supratip
The opposite alteration: depression at the tip–dorsum junction. The usual cause is exaggerated resection of the anterocaudal septum combined with tall, strong medial crura. It also appears when excessive resection of the caudal septal border or of the cephalic alar portion is added to a pre-existing supratip. It is corrected by treating the supratip — using the excess tissue itself to fill the defect — or, failing that, with cartilage or fat grafts.
Nasal deviation: telling real from optical
Nasal deviation reflects septal position, and the first step is to separate real deviation from the optical effect produced by depressions or prominences of the lateral walls. When real, the origin is usually a persistent septal deviation or asymmetric mobilisation of the bony fragments. Treatment is, as the case requires, correct septoplasty or refracture and repositioning of the walls; in mild cases rasping or camouflage with cartilage grafts suffices.
Dorsal widening and bony dehiscence
Width is assessed at the base of the pyramid and at the ridge, and they influence each other: a wide base looks wider with a thin ridge, and vice versa. After resecting the osteocartilaginous dorsum the bony edge widens, requiring fracture and approximation of the walls. But after fracturing, a dehiscence may occur: separation of one or both bony walls. It is recognised by one very specific sign — loss of continuity of the line running from the brow to the dome — and produces flattening of the anterior dorsal border.
Wide dorsum: cause and correction
- Deficient or incomplete osteotomyComplete or repeat the osteotomy
- Persistent anterior septal deviationAdequate septoplasty: without correcting the septum, the wall separates again
- Rocker deformityResect the medial bony excess before fracturing
- Too high an osteotomy: visible lateral stepDelicate rasping, camouflage with cartilage or fat graft on the lateral walls, or double refracture of the ascending maxillary process
Ridged dorsum
We speak of a ridged dorsum when dorsal support rests on the anterior septal border. It is a secondary alteration caused by one or more of three deficiencies: excessive resection of the anterior border of the upper laterals, excessive resection or rasping of the bony portion, and insufficient resection of the anterior septal ridge. Treatment depends on the goal: to separate the lateral walls, spreader grafts; to lower the middle portion, reduce the anterior septal excess; and if the base is wide, fracture is essential to balance the dimensions.
Inverted V and axe-cut sign
They almost always appear together and share a mechanism. The inverted-V deformity is loss of osteocartilaginous continuity of the dorsum with narrowing of the upper valve, caused by excessive resection of the upper laterals or their luxation from careless rasping of the caudal portion of the nasal bones: that rasping tears the delicate ligamentous union between the anterior surface of the cephalic end of the upper laterals and the posterior surface of the nasal bones. The axe-cut sign is an angulated depression in that same transition zone, from excessive descent of the caudal nasal bones or insufficient resection of the anterocaudal septal border.
The rule that prevents both
The osteocartilaginous profile should have its highest point at the bone–cartilage junction. When that relationship is lost — because the bone is lowered too much or the anterocaudal septum too little — the axe-cut sign and inverted V appear. And one scenario makes it especially likely: short nasal bones with tall cartilages. On fracturing, the caudal ends of the upper laterals lose support, approach the septum and can collapse the valve. In those patients fracturing is inadvisable, or spreader grafts must be placed to prevent it. Once established, if there is no functional impairment a camouflage graft usually suffices; if the patient breathes poorly, spreader grafts are needed.
Dorsal irregularities
Common in traumatic noses and after rhinoplasty. There are five causes and it is worth identifying which before touching: bony, septal or upper lateral remnants; bone or cartilage spicules; abnormal bony healing as osteoma or callus; fibromas and adhesions of subcutaneous tissue; and malpositioned grafts or grafts that have become visible over time. A sixth is less frequent but important to exclude: a foreign body, siliconoma or vaselinoma. Treatment is excision, resection or rasping, as appropriate.
In secondary rhinoplasty, degloving is different
The premise is that correction should be limited to the defect wherever possible. Depending on what is needed, one approaches the anterior surface of the upper laterals, the nasal bones or the ascending maxillary processes, from a lateral incision or under direct vision if opening. And one technical detail saves trouble: degloving is difficult because of scar tissue and is best done with a blade, not blunt scissors. Beyond fibrosis, always account for the circulatory changes left by the previous operation.
References
- 1.Arquero P. Alteraciones nasales: alteraciones del dorso. rinoplastia.eu.
- 2.Daniel RK, Palhazi P. Rhinoplasty: An Anatomical and Clinical Atlas. Cham: Springer; 2018.
- 3.Piedra Buena IT, Kahn D. Rhinoplasty. In: StatPearls. Treasure Island: StatPearls Publishing; 2024.
- 4.Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P. Dorsal Preservation: The Push Down Technique Reassessed. Aesthet Surg J. 2018;38(2):117-131.
Related specialty: Rhinoplasty