Internal Micro-Osteotomy For Control Of Nasal Bony Vault Concavity

Purpose  :  Bony nasal vault deformities mandates differential types of single or combination of osteotomies. In situ bone remodeling through inside out internal micro-osteotomies is presented as one of the efficient techniques for control of concave bony vault.

Material and Method : Through final stages of  open  rhinoplasty , at first  the area of bony vault concavity on nasal skin was demarcated. Then the “ mirror image “ of this area on  mucosal lining was marked  and infiltrated with hemostatic solution. With a 2mm non guarded osteotome , through multiple internal micro-osteotomy and micro fractures , the bone was weakened. Then with a gradual  inside- out force with a blunt convex surface of a large size Cottle periosteal elevator , the osteotomized bony vault was straightened . The Internal splint was applied.

Experience : 19 cases of Concave nasal bony vault with more than 12 months follow up were analyzed with preoperative and postoperative photography and CTS ( coronal and axial view). The degree of concavity of bony vault on photographs reflected as deviation was measured. The degree of measured nasal deviation on frontal view photographs was significantly corrected in follow up pictures.  CTS based analysis of bony concavity in anterior-posterior and cephalo-caudal direction in coronal and axial views revealed significant straightening of bony vault in follow up CTS.

Results  : 1. Straightening of concave bony vault with a lasting result, without use of any cartilage graft to camouflage.

2. No linear osteotomy, provide us with a more flexibility in reshaping the bone

3. The osteotomy approach from inside may keep us away from angular artery with a subcutaneous location. Hence, less bruising will be achieved.

Conclusion    . Despite a  variety of lateral osteotomy techniques for control of concave bony vault, the lasting result to straighten the bony vault can not be attained. However, Inside Out Micro-osteotomy may be considered as one of the most efficient techniques to correct inherent or acquired concavities of nasal bony vault with lasting result , less  bruising and without need to add camouflage cartilage grafts, especially in cartilage deprived setting .