The Use of Bone Dust to Correct the Open Roof Deformity in Rhinoplasty — Suleyman Tas PubMed

Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. www.PRSJournal.com 629 In primary rhinoplasty patients, hump removal is frequent, after which open roof deformity may be encountered. To close this gap, lat - eral osteotomies are often indicated. However, if the patient has a narrow bony vault, lateral osteotomy is problematic. Other methods, such as using a spreader graft, flap, or diced carti - lage, or shaping and replacing the hump, are well-known alternatives. However, these may result in complications such as step formation and dorsal irregularities.1–6 In this study, a new, practical, stronger, and more conservative and atraumatic approach is presented that results in a smooth dorsum. PATIENTS AND METHODS Between January of 2014 and May of 2016, 240 selected patients (187 women and 53 men) Disclosure: ‘TAS 1’ ‘TAS 2’ ‘TAS 3’ were designed by the author (S.T.) and patented in the Turkish Pat- ent Institute (No: 2016/05472). These instruments are not commercially available yet; however, they can be produced by Elektron Medical Company (a Turk- ish instrument company) with a special order via their website (http://www.elektronmedikal.com.tr/). The author does not receive any payment from the company and has no financial gain. Copyright © 2018 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000004706 Süleyman Taş, M.D. Istanbul, Turkey Background: Hump removal frequently results in an open roof during rhinoplas- ty, which is conventionally closed with lateral osteotomies. However, if the patient has a narrow bony vault, lateral osteotomies are problematic. In this article, the author presents a new and practical approach to fix the open roof deformity. Methods: A total of 240 patients (female, n = 187; male, n = 53) were enrolled and operated on with the presented technique. This approach has four steps, as follows: complete submembranous dissection, preparation of spreader flaps, harvesting of bone dust from the bony hump, and placement of the bone dust. The patient’s nasal dorsum was evaluated by ultrasonography. During the fol- low-up period, all patients were photographed postoperatively from standard views using a digital camera. Photographs were inspected by two independent plastic surgeons. A palpation test for the nasal dorsum was conducted by a senior surgeon to identify any irregularities. A rhinoplasty outcomes evalua - tion questionnaire was administered to all patients at a 1-year follow-up visit. Functional improvement was assessed with self-evaluation of nasal patency. The chi-square test was used for statistical analysis. Results: Of the 240 patients, 182 completed the 1-year follow-up period and rhinoplasty outcomes evaluation questionnaire. Thirty-seven patients were evaluated by ultrasonography at 1 year postoperatively. During the follow-up period, no resorption or displacement was detected. High patient satisfaction was achieved, and no complications were encountered. Conclusion: The presented four-step surgical concept was useful for rhino - plasty surgeons to successfully manage open roof deformity in selected pa - tients. (Plast. Reconstr. Surg. 142: 629, 2018.) From private practice. Received for publication June 4, 2017; accepted March 1, 2018. Presented in part at the Fifth Bergamo Open Rhinoplasty Course, in Bergamo, Italy, March 15 through 19, 2016, and selected for Best Presentation Award. The Use of Bone Dust to Correct the Open Roof Deformity in Rhinoplasty Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (www. PRSJournal.com). SUPPLEMENTAL DIGITAL CONTENT IS AVAIL- ABLE IN THE TEXT. COSMETIC

Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 630 Plastic and Reconstructive Surgery • September 2018 were enrolled and underwent the presented surgi- cal technique performed by the author (S.T.). All selected patients underwent primary and closed rhinoplasty. The study was conducted according to the Declaration of Helsinki for biomedical research on human subjects. Preoperatively, all patients received detailed information regarding the study and provided written informed consent to undergo the operation and for their photo - graphs to be published for educational purposes. During the follow-up period, all patients were photographed from standard views using a digi- tal camera at postoperative months 1, 3, 6, and 12. The photographs were inspected using image soft- ware (Adobe Photoshop; Adobe Systems, Inc., San Jose, Calif.) by two independent plastic surgeons. The dorsum was evaluated with a line drawn from the radix to the supratip area. Criteria for success included nasal dorsum in touch with the drawn line on lateral view, no irregularity or asymmetry on other views (i.e., frontal, oblique, base, and top), and palpation test for irregularities of the nasal dorsum by the author. Functional improvement was assessed with self-evaluation nasal patency ranging from 0 (complete obstruction) to 10 (optimal airflow). In addition, a rhinoplasty outcomes evalua- tion questionnaire (see Document, Supplemen- tal Digital Content 1, which shows the rhinoplasty outcomes questionnaire, http://links.lww.com/PRS/ C946), validated by Alsarraf et al.,7 w a s a d m i n i s- tered to all patients at their 1-year follow-up visit. This questionnaire includes six questions to assess patients’ functional, social, and aesthetic satisfac- tion. Each question has a maximum value of four points and a minimum value of zero. Patient satis- faction is defined as a total score of 20 or greater, and patient dissatisfaction is defined as a total score of less than 20, or if any question scores 2 points or less regardless of the total survey score. The chi-square test was used for statistical analysis. The nasal dorsum of each patient was evalu- ated by ultrasonography with a linear 9-MHz transducer (Siemens Acuson S2000 Ultrasound Machine; Siemens Medical Solutions, Tarrytown, N.Y.) at postoperative year 1 by an expert radiolo- gist. Longitudinal and axial sections of the nasal dorsum were visualized, and images were printed. Ultrasound gel was used to scan the nose in non- contact mode to prevent the distortion of the nasal anatomy caused by transducer pressure. 8 Bone dust areas were evaluated, and the volume of the bone dust was calculated for each patient. Surgical Anatomy The nose has a complex anatomy with intrin- sic and extrinsic structures and layer-on-layer construction, which is crucial for its function and aesthetics.9 The nasal dorsum is composed of two parts—a bony vault and a cartilaginous vault. The bony vault is composed of paired nasal bones, the frontal process of maxillary bones, and the nasal process of the frontal bone. The cartilaginous vault is a single unit comprising paired upper lateral cartilages and septum. The transition from bony to cartilaginous dorsum is named the keystone area.10 The thickness of the upper lateral cartilage is 1 mm, which can be up to 3 mm with folding.11 Nasal bones caudally continue over the upper lateral cartilage as a V-shape on the keystone area. The upper lateral cartilage cephalically continues to approximately 1 cm under the nasal bones.12 The perichondrium of the upper lateral cartilage shows continuity with the inner periosteum of nasal bones, which is called the transition zone.13 Because of this anatomy, the mucosal layer under the keystone area is called the mucop - erichondrium. This anatomical feature is very important for performing complete subperichon- drial and subperiosteal dissection.14 (See Figure, Supplemental Digital Content 2, which shows the anatomy of the dorsum area: yellow, light blue, orange, dark blue, purple, and red indicate the nasal bone, upper lateral cartilage, periosteum, peri - chondrium, mucosa, and transition zone, respec- tively, http://links.lww.com/PRS/C900.) Patient Selection Ideally, the intercanthal distance should be equal to the distance between the medial and lat- eral canthus of each eye, and the width of the nasal base should be approximately 80 percent of the intercanthal distance; if this width is greater than 80 percent, lateral osteotomies may be indicated, whereas if it is equal to or narrower than the inter- canthal distance, it can be accepted as a narrow nasal base and lateral osteotomies can be avoided.5 To determine the distances, vertical lines are drawn from each medial canthus in the frontal view. Patients with a nondeviated bony part, narrow nasal base, and hump are included for the aforementioned technique. Twisted or crooked noses, secondary cases, and large nasal bases were excluded from the study. Surgical Technique The key maneuvers of the surgical technique are demonstrated in the surgical video. ( See Video, Supplemental Digital Content 3 , which

Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Volume 142, Number 3 • Open Roof Deformity 631 demonstrates the key maneuvers of the surgical technique, available in the “Related Videos” sec- tion of the full-text article on PRSJournal.com or, for Ovid users, available at http://links.lww.com/ PRS/C901.) Patients were prepared under general anes- thesia. After a local injection of 1:100,000 adrena- line solution, the classic intercartilaginous and transfixion incisions were performed. The pre - sented technique has four steps, as follows. Submembranous Dissection Through the intercartilaginous incision, a special elevator (TAS 1) is used to go under the perichondrium.14 Staying on this plane is critical because it helps to hide possible irregularities and recognize real defects on the dorsum after hump removal. After identifying the subperi - chondrial plane, an elevator is used to reach the perichondrial–periosteal junction (Fig. 1, above). At this junction, another special elevator (TAS 2) is used to go under the periosteum. This elevator provides access to the subperiosteal plane with- out leaving remnant periosteum at the junction and prevents possible risks of damaging the sur- rounding tissue with blades. In this manner, an excellent bone-to-cartilage transition is obtained (Fig. 1, below).14 [See Figure, Supplemental Digital Content 4, which is a schematic demonstration of the situation after submembranous (subperichon- drial and subperiosteal) dissection, http://links. lww.com/PRS/C902.] If these instruments (TAS 1 and 2) are not available, blades or sharp-tipped scissors are used to find the subperichondrial and subperiosteal plane under loupe magnification. However, this may be time consuming and dam- age the surrounding tissues and cartilage. Preparation of Spreader Flaps After separating the upper lateral crura from the septum and inner mucosa using an elevator, the procedure continues with the preparation of submucoperichondrial tunnels under the bony hump. These tunnels allow the folding of upper cartilages over themselves (Fig. 2, above). Then, spreader flaps are sutured over themselves with 5-0 polydioxanone. Initially, the caudal part of the cartilage is sutured over itself. If successful folding is achieved, no more sutures are used on the cephalic part; if success is not achieved, the middle and cephalic parts of the upper lateral cartilage are also sutured using horizontal mat- tress sutures. (See Figure, Supplemental Digital Content 5, which is a schematic demonstration after creation of submucoperichondrial tun - nels, http://links.lww.com/PRS/C903. See Figure, Fig. 1. (Above) Subperichondrial dissection is demonstrated on the upper lateral cartilage. (Below) After submembranous (sub- perichondrial and subperiosteal) dissection is completed, naked upper lateral cartilage and nasal bones are demonstrated. Video. Supplemental Digital Content 3 demonstrates the key maneuvers of the surgical technique, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, available at http://links.lww.com/PRS/C901.

Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 632 Plastic and Reconstructive Surgery • September 2018 Supplemental Digital Content 6, which is a sche- matic demonstration after folding of the spreader flaps, http://links.lww.com/PRS/C904.) In this sec- tion, a curved needle holder is used to cephali- cally place the sutures. Harvesting the Bone Dust from the Bony Hump After the removal of the cartilaginous hump, the bony hump can be identified, which is the pri- mary source for bone dust (Fig. 2, below). However, bone dust can also be obtained from other parts of the nose such as lateral to the nasal bones, and the maxilla and maxillary crests. For harvesting the bone dust from the bony hump, the author uses a special rasp (TAS 3) that has a pocket in its center to collect the bone dust. A regular number 8 rasp can be used for this. However, collecting the bone dust from the teeth of the rasp is more difficult with this rasp, and a certain amount of bone dust may be lost (Fig. 3). During rasping, the nurse harvests the bone dust from the rasp using an elevator. This step can be referred to as the pul- verization of the bony hump (Figs. 4 and 5). (See Figure, Supplemental Digital Content 7, which is a schematic demonstration of the open roof defor- mity after pulverization of the bony hump, http:// links.lww.com/PRS/C905.) Placement of the Bone Dust After suturing the spreader flaps to the sep- tum, the open roof deformity is revealed (Fig. 6, above). Because the defect will be as large as the excised bony hump, the harvested dust will be enough to repair this aperture without additional morbidity on the part of the donor (Fig. 6, below). Using an elevator, the bone dust can be placed in the submucoperichondrial tunnels. (See Figure, Fig. 2. (Above) Submucoperichondrial tunnels under the bony hump allow folding of upper lateral cartilages over themselves. (Below) After the removal of the cartilaginous hump and prep- aration of spreader flaps, the bony hump, which is the main source for bone dust, can be identified. Fig. 3. The TAS 3 can be used to rasp the bony cap. The pocket in the center of the TAS 3 collects the harvested bone dust. The TAS 3A and 3B have a straight tip, and the TAS 3C and 3D have a 30-degree angled tip to adapt to curved surfaces. The width of the tips of the TAS 3A and 3C is 1 cm, and that of the TAS 3B and 3D is 0.5 cm. (Above) Frontal view. (Below) Side view.

Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Volume 142, Number 3 • Open Roof Deformity 633 Supplemental Digital Content 8, which is a sche- matic demonstration of the placement of bone dust into the defect of the open roof deformity; green marks indicate the bone dust, http://links.lww. com/PRS/C906.) The placement of the bone dust to this aperture is very safe, and no displacement occurs because the mucoperichondrium and periosteum cover the dust as they adapt and set- tle. (See Figure, Supplemental Digital Content 9, which is a schematic demonstration of the final closure, with which anatomical relationships of the structures are preserved, http://links.lww.com/ PRS/C907.) Consequently, a good, homogeneous, vascularized, safe graft is obtained on the dorsum. The technique is summarized in Figure 7. (See Figure, Supplemental Digital Content 10, which is the axial view of the reconstruction of the open roof deformity. Blue, yellow, green, and red indi- cate the periosteum/perichondrium, nasal bone, mucoperichondrium, and bone dust, respectively, http://links.lww.com/PRS/C908.) RESULTS Of the 240 patients, 182 (76 percent) (female, n = 140; male, n = 42) completed the 1-year follow- up period and rhinoplasty outcomes evaluation questionnaire. Thirty-seven patients were evaluated using ultrasonography at 1 year postoperatively. The early postoperative periods were unevent- ful. The postoperative photographs on lateral view, evaluated using image software, demon - strated that good, straight nasal dorsa were achieved. On other views, no asymmetry or irregu- larities were observed by the author and two inde- pendent plastic surgeons. During the follow-up period (postoperative months 1, 3, 6, and 12), no resorption or displacement was detected. At I year postoperatively, the palpation test conducted by the author on 182 of the 240 patients detected no irregularities. Fig. 4. After pulverization of the bony hump, the open roof deformity is revealed. Fig. 5. A large amount of bone dust can be collected. Fig. 6. (Above) The upper lateral cartilages are sutured to the septum with 5-0 polydioxanone to stabilize the folding. Then, the open roof deformity is ready to fill with bone dust. (Below) Schematic demonstration following the placement of bone dust into the defect of the open roof deformity.

Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 634 Plastic and Reconstructive Surgery • September 2018 The mean patency test score was 3.2 preop- eratively and 7.8 postoperatively, with statisti - cal significance (p < 0.001). No revision surgery was required during the follow-up period. The rhinoplasty outcomes evaluation questionnaire resulted in scores of 20 or higher for 90 percent of the patients, who were satisfied with the form and function of their rhinoplasty. Aesthetic and functional results were satisfactory for patients and surgeons (Figs. 8 and 9).15 After evaluating 37 patients at 1 year postop- eratively, in all patients, the bone dust survived, with a mean volume of 384 mm3 (range, 108 to 630 mm3). The mean dimension of the grafted area was 16 × 6 × 4 mm (range, 12 to 18 × 3 to 7 × 3 to 5 mm). Because of the hyperechogenicity of the bony framework and the hypoechogenicity of cartilage structures and the soft-tissue envelope, the graft with the bone dust was identified by the “stars-in-the-sky” view. In this view, a true bone continuity does not exist, but there is a bone den- sity area without true continuity (Fig. 10). DISCUSSION An aesthetically pleasing result of rhinoplasty can be obtained with knowledge of nasal anatomy. Controlling the relationships within the nasal structure is difficult, even in an open technique. In cadaver studies, it has been demonstrated that relationships between the septum, upper lateral cartilages, and nasal bones are unpredictable in the keystone area, where the bony vault dorsally and laterally overlaps the cartilaginous vault.16 In contrast, the soft tissue over the keystone area is the thinnest in the nose, given that it does not include any subcutaneous fat and the muscles merge into aponeurotic tissue. Because of this anatomy, hump reduction is critical in rhinoplasty to achieve a smooth dorsum and dorsal aesthetic lines.6,10 Dorsal hump reduction is a common proce- dure in rhinoplasty. However, if the dorsal hump reduction is not adequately performed, it can cause both functional and aesthetic problems, including dorsal irregularities, inverted-V deformity, and an excessive narrowing of the midvault because of underestimation or overresection.4–6 Following hump removal, open roof deformity is encoun- tered. This deformity can be classified as a widened dorsum and interruption in the bony part of the dorsum and can cause irregularities with palpation and unnatural dorsal aesthetic lines and discom- fort (hypersensitivity and irritation to palpation) to the patient. Lateral osteotomies are generally performed to close the open roof. However, oste- otomies are the least controlled and the most trau- matic procedure, making it difficult to achieve a standard and optimum result during rhinoplasty. If not adequately performed, osteotomies may result in asymmetry, step formation, mucosal lacerations, narrowing or collapse of the airway, open roof syn- drome, or visible scars in external osteotomies.1–3 In contrast, if the patient has a narrow bony vault, such as the patients discussed in this study, lateral osteotomies may not be an option. In these patients, spreader flaps, grafts, diced cartilages [wrapped in fascia or Surgicel (Ethicon, Inc., Somerville, N.J.)], or shaping and replacing the hump are well-known surgical alternatives.6,17–19 Rohrich et al.5 have demonstrated their approach to maintain dorsal aesthetic lines. They described their technique in five steps: separa - tion of the upper lateral cartilage from the sep- tum, reduction of the septum and bony dorsum, verification by palpation, and final modification (spreader graft, suturing techniques, and osteoto- mies). Arslan3 reported a no-osteotomy concept in 34 patients with a narrow bony vault. In this concept, spreader flaps are used to close the open roof, spreader grafts are used when needed, and onlay cartilage grafts are used in the lower part of the upper lateral cartilage to prevent depressions. Fig. 7. Schematic demonstration following reconstruction of the open roof deformity; orange and red indicate the open roof deformity and bone dust, respectively. Yellow, dark blue, and brown indicate the bone structure of the nose, cartilaginous structure of the nose, and septum, respectively.

Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Volume 142, Number 3 • Open Roof Deformity 635 Öreroğlu et al.20 have reported a combina- tion approach that includes diced cartilage, bone dust, and the patient’s blood to cover dorsal irregularities. They collected all cartilage and bone pieces during the operation and separated the slices using a number 11 scalpel and mixed Fig. 8. A 24-year-old female patient with a large hump with a narrow nasal base and dropping tip. Preoperative frontal (above, left) and profile (above, right) views. The preoperative patency score was 5 of 10. The right nasal airway was partially obstructed by the deviated nasal sep - tum, and there was a large left inferior concha. The surgical procedure included cartilaginous hump removal, rasping of the nasal hump, application of bilateral spreader flaps following sep- toplasty, reconstruction of the open roof deformity with the harvested bone dust, tip plasty [by means of delivery technique, lateral crural steal to reposition the dome, interdomal and cephalic intradomal sutures to achieve tip symmetry, and deep superficial musculoaponeurotic system layer suture (Taş S. A new way for supporting tip projection in closed rhinoplasty: Using the medial deep SMAS layer. Plast Reconstr Surg. 2014;133:76e–77e) to suspend and relocate the tip on the nasal dorsum], and concha surgery (lateralization and partial submucous resection of the left inferior turbinate). Results at 1 year postoperatively are demonstrated by the following postoperative views: frontal (below, left) and profile (below, right) smiling views.

Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 636 Plastic and Reconstructive Surgery • September 2018 3 to 5 ml of blood obtained from the peripheral vein for clotting. Gruber et al.11 have used the spreader flap technique to reconstruct the dorsum after hump removal in 25 primary rhinoplasty cases (open, n = 21; closed, n = 4). They concluded that this tech- nique is very useful in the open approach and can be routinely used and combined with spreader grafts, if needed. However, in the closed approach, it is difficult to prepare spreader flaps and to apply Fig. 9. A 23-year-old male patient with a large hump with a narrow nasal base and dropping tip. Preoperative frontal (above, left) and profile (above, right) views. The preoperative patency score was 3 of 10. The bilateral nasal airway was partially obstructed by the deviated nasal sep- tum. The surgical procedure included cartilaginous hump removal, rasping of the nasal hump, application of bilateral spreader flaps following septoplasty, reconstruction of the open roof deformity with the harvested bone dust, tip plasty [by means of delivery technique, lateral crural steal to reposition the dome, interdomal and cephalic intradomal sutures to achieve tip symmetry, strut grafting, and deep superficial musculoaponeurotic system layer suture (Taş S. A new way for supporting tip projection in closed rhinoplasty: Using the medial deep SMAS layer. Plast Reconstr Surg. 2014;133:76e–77e) to suspend and relocate the tip on the nasal dorsum]. Results at 1 year postoperatively are demonstrated by the following postoperative views: frontal (below, left) and profile (below, right) views.

Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Volume 142, Number 3 • Open Roof Deformity 637 sutures at the cephalic end of cartilage, and scor- ing of the cartilage is usually required. In the present study, a closed approach was used in 240 patients with the presented algorithm. The authors believe that subperichondrial dissec- tion provides an easier folding of cartilages and an excellent transition from cartilage to bone, making disarticulation and preparation easier. The insertion of the sutures at the cephalic part of the upper lateral cartilage is also easier using a curved needle holder, which improves with expe- rience. Following the disarticulation and fold - ing of the upper lateral cartilage, there is a gap in the keystone area, which can be imagined as a room. The base of this room is the mucoperi- chondrium and the roof is the periosteum of the nasal bone. The lateral side wall is the nasal bone and the medial side wall is the bony and cartilagi- nous septum. Bone dust is a useful tool with which to fill this gap. In our opinion, this limited aper- ture is very important to prevent graft (bone dust) displacement. Ultrasonography in septorhinoplasty is a very effective tool for appropriate evaluation of all ana- tomical structures of the nose, both preoperatively and postoperatively.9,21 On ultrasonographic find- ings, there is ossification with scar formation. After ultrasonographic evaluation of all patients, we concluded that bone dust survived in the grafted area with good adaptation and accordance and without loss. To our knowledge, this is the first study in the literature that demonstrates the long- term survival of the bone dust graft in rhinoplasty. As is known, small bones do not heal with ossifica- tion, and callus formation does not occur. Actu- ally, small bones heal with scar formation. In this study, bone defects were reconstructed with bone dust, and the ultrasonographic findings show us that bone dust survives and helps ossification. We speculate that bone dust may be an effective tool with which to reconstruct the small bone defects in other medical fields, such as orthopedics and hand surgery. Why is bone dust superior or more favor - able to fat or crushed cartilage, according to the author? Hump is composed of bony and cartilagi- nous structures. According to prevailing surgical philosophy, for an ideal and natural reconstruc- tion, the defect should be reconstructed with autogenic tissues each time. Also, to prevent any possible resorption, a supply mechanism of recon- struction should be considered. Therefore, a bony defect should be reconstructed with bone, and a cartilaginous defect should be reconstructed with cartilage. In the approach described in this arti- cle, the author repaired the cartilaginous defect with spreader flaps, achieved from the cartilagi- nous hump, and the bony defect with bone dust, Fig. 10. Ultrasound finding of a 32-year-old male patient following rhinoplasty with the presented technique at 1-year follow-up. The blue arrow indicates the glabella; the yellow arrow indicates the nasal dorsum; the red arrow indicates bone dust; and green indicates the pouch into which bone dust was inserted. The bone dust area gives a stars-in-the-sky view on ultrasound. In this view, a true bone con- tinuity does not exist, but there is a bone density area without true continuity.

Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 638 Plastic and Reconstructive Surgery • September 2018 harvested from the bony hump. In our opinion, this is the least traumatic approach for recon - structing the defect following hump removal in the narrow nasal base. CONCLUSIONS The author performed the presented tech - nique in 240 selected patients, and concluded that this technique is very effective for repairing the dorsum after hump removal and for fixing dorsal irregularities. Süleyman Taş, M.D. Hakkı Yeten Cad, No. 11 Terrace Fulya, Center 1, Apt. 97 Şişli, Istanbul 34349, Turkey drsuleymantas@live.com ACKNOWLEDGMENT The author thanks Isil Yurdaisik, M.D., for valu- able contributions in ultrasonographic evaluation. PATIENT CONSENT Patients provided written consent for the use of their images. REFERENCES 1. Kuran I, Ozcan H, Usta A, Bas L. Comparison of four dif - ferent types of osteotomes for lateral osteotomy: A cadaver study. Aesthetic Plast Surg. 1996;20:323–326. 2. Gryskiewicz JM, Gryskiewicz KM. Nasal osteotomies: A clini- cal comparison of the perforating methods versus the con- tinuous technique. Plast Reconstr Surg. 2004;113:1445–1456; discussion 1457–1458. 3. Arslan E. No osteotomy rhinoplasty: Indications and surgical details. Aesthetic Plast Surg. 2014;38:57–62. 4. Roostaeian J, Unger JG, Lee MR, Geissler P, Rohrich RJ. Reconstitution of the nasal dorsum following component dorsal reduction in primary rhinoplasty. Plast Reconstr Surg. 2014;133:509–518. 5. Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump reduction: The importance of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg. 2004;114:1298–1308; discussion 1309–1312. 6. Taş S. A new technique to correct saddle nose deformity in failure of diced cartilage grafts: Diced cartilage flap. Aesthetic Plast Surg. 2015;39:764–770. 7. Alsarraf R, Larrabee WF Jr, Anderson S, Murakami CS, Johnson CM Jr. Measuring cosmetic facial plastic surgery out- comes: A pilot study. Arch Facial Plast Surg. 2001;3:198–201. 8. Tasman AJ, Helbig M. Sonography of nasal tip anatomy and surgical tip refinement. Plast Reconstr Surg. 2000;105:2573– 2579; discussion 2580–2582. 9. Tas S, Colakoglu S, Lee BT. Nasal base retraction: A treat- ment algorithm. Aesthet Surg J. 2017;37:640–653. 10. Daniel RK, Letourneau A. Rhinoplasty: Nasal anatomy. Ann Plast Surg. 1988;20:5–13. 11. Gruber RP, Park E, Newman J, Berkowitz L, Oneal R. The spreader flap in primary rhinoplasty. Plast Reconstr Surg. 2007;119:1903–1910. 12. Palhazi P, Daniel RK, Kosins AM. The osseocartilaginous vault of the nose: Anatomy and surgical observations. Aesthet Surg J. 2015;35:242–251. 13. Karacalar A, Korkmaz A, Içten N. A perichondrial flap for functional purposes in rhinoplasty. Aesthetic Plast Surg. 2005;29:256–260. 14. Taş S, Celik N. New instruments for submembranous dissec- tion in rhinoplasty. Aesthet Surg J. 2017;37:NP73–NP78. 15. Taş S. A new way for supporting tip projection in closed rhi- noplasty: Using the medial deep SMAS layer. Plast Reconstr Surg. 2014;133:76e–77e. 16. Hinderer K. Fundamentals of Anatomy and Surgery of the Nose. Birmingham, Ala: Aesculapius; 1971. 17. Daniel RK. Diced cartilage grafts in rhinoplasty surgery: Current techniques and applications. Plast Reconstr Surg. 2008;122:1883–1891. 18. Erol OO. The Turkish delight: A pliable graft for rhino - plasty. Plast Reconstr Surg. 2000;105:2229–2241; discussion 2242–2243. 19. Byrd HS, Meade RA, Gonyon DL Jr. Using the auto - spreader flap in primary rhinoplasty. Plast Reconstr Surg. 2007;119:1897–1902. 20. Öreroğlu AR, Çakır B, Akan M. Bone dust and diced car- tilage combined with blood glue: A practical technique for dorsum enhancement. Aesthetic Plast Surg. 2014;38:90–94. 21. Stenner M, Rudack C. Ultrasound imaging of the nose in septorhinoplasty patients. Eur Arch Otorhinolaryngol. 2015;272:2831–2837.