One of the more common requests by Rhinoplasty patients has to do with the desire to “not look too different” following cosmetic Nose reshaping surgery. This is particular true when it comes to patients who have what is often times called a hump deformity. This type of nose has a convex shape of the bridge – also commonly called a bump by many rhinoplasty patients. It is precisely this distracting feature of the nose that pushes them to seek out possible rhinoplasty surgery. However, in many of these cases, the patient wants to still look the same from the front view.

Domino Effect

What so many patients don’t understand, though, is the fact that changing the height of the entire bridge makes it incredibly challenging to preserve the view of the nose from the front. The reasons behind this are somewhat difficult to understand if you are not a rhinoplasty expert. But, here is an attempt. Once the bridge height is reduced to any significant degree (to take down the hump of the nose), a domino effect occurs – an entire series of steps involved in making sure the nose remains looking somewhat normal. This domino effect is automatically triggered whenever any surgeon reduces the nasal bridge even a moderate amount.

For example, once the excess bone is removed to make the bridge height lower, something has to be done to the bone that remains. If the nasal bone is just left alone, the nasal bridge would look way too wide from the front view. Keep in mind that the lower the bridge height, the wider the nose looks from the front. The remaining bone is not only wide – there is a gap in between them now. This is analogous to tearing off the top portion of the roof of a home – and being able to see into it from above. In fact, in the world of rhinoplasty this exact issue is called an open roof deformity. So what has to be done with the open roof deformity? The remaining nasal bones need to be strategically cut (or broken as they say) on the sides so they can be moved closer together – thus ‘closing’ the open roof deformity by bring the bones together at the level of the nasal bridge.

The bone is not the only problem, though. Taking down a nasal hump also involves removal of cartilage. It happens to be a critical junction zone where the paired upper lateral cartilages meet the dorsal segment of the septum. Usually, the dorsal segment of the septum is removed in the process of taking down a hump – hopefully leaving the upper lateral cartilages intact. But if nothing is done to reattach the upper lateral cartilages, they will fall down into the nasal cavity as the nose heals from the rhinoplasty surgery. When this occurs, patients end up with what is referred to as an inverted V deformity – where unwanted shadowing appears in an upside down V pattern across the middle of the nasal bridge. So how do you prevent this complication? You have to carefully reattach the upper lateral cartilages after the hump has been removed. And in some cases, cartilage grafting has to be done in this process in order to restore sufficient structural integrity to the nasal bridge.

Once the new bridge height has been finally established and the bone and cartilage have been dealt with accordingly, the rhinoplasty surgeon then has to make the tip appear in harmony with the new bridge. This includes making sure the nasal tip projection and rotation are appropriately established. This may include things like bringing the nasal tip closer to the face and/or turning the nasal tip upward slightly.

All of these considerations arise directly as a result of taking the bridge height down – or removing a dorsal hump deformity. What patients have to keep in mind is just how complicated and challenging it is to address each step noted above – all the while making that new nose look natural and fitting for the face. This is really the essence of doing beautiful rhinoplasty work and achieving outstanding results as a rhinoplasty surgeon.

Dirty Little Secret

One of the dirty little secrets in the world of rhinoplasty is just how complicated hump reduction really is when it comes to keeping the nose looking nice and natural on the front view. Taking the bridge height down and creating a nice profile is actually one of the less challenging aspects of the surgery. That is because you can do this on one side and achieve a very nice result – while the other side and the front view simply don’t match and don’t look as nice.

This is precisely why so many plastic surgeons will show you a side view of a nose that had hump reduction performed by them. But in so many cases, they won’t show you the front view and/or the other side. Why is this? That is because there is something wrong with the front view that they don’t want you to see.

As indicated in the domino effect noted earlier, taking a hump deformity down is just not that easy. As the domino effect unfolds, there are more and more variables brought into the mix that then make up what the front of the nose will look like. If you don’t get each of these variables right surgically and/or the patient doesn’t heal as expected from the rhinoplasty, the front view of the nose will be compromised in one way or another. This can include, but is not limited to:

• A deviation in the alignment of the nose
• A crooked nose
• One nasal bone being wider than the other
• Inverted V deformity
• Unwanted shadowing through the middle vault of the nose
• Asymmetrical cartilage contour
• Abnormal transition into the nasal tip

So you can see there are a number of problems that can arise directly as a result of doing nasal hump reduction, which can make the front view less than ideal. And that is precisely why so many plastic surgeons will avoid showing the front view after they take a hump down during rhinoplasty. I even dare patients to contact offices that only show side views of their noses in before and after galleries – and request to see the front view of those noses that they are showing. In so many of these cases, the office will likely decline your request. This is not because they don’t have the photos available – it is because the front view of that nose just doesn’t look right. Getting the nose to look right on the side view is just so much easier than making it look right on the front view. Keep that in mind when you are assessing any rhinoplasty surgeon’s gallery of before and after photos.

Rhinoplasty Case Example

Here is a rhinoplasty case example that highlights all the points that were discussed previously regarding the domino effect. This young lady came to see Dr. Hilinski because she disliked the hump on her nose. When looking at her head on, you don’t see a whole lot wrong with her nose. She is fairly straight in terms of her alignment. And her nose looks fitting for her overall facial features.

When she starts to turn to the side, you then begin to see her issues with the nose. On her oblique and side views, you can appreciate how the bridge of her nose is convex in shape – or has a hump deformity as discussed above. This was her main concern, although she also desired to have her nasal tip brought up just a bit so as to not look so droopy – especially on her smile view.

Dr. Hilinski consulted with her regarding possible changes that could be made with an open rhinoplasty approach to help reduce the nasal bump and lift the nasal tip. The goal, as discussed with the patient preoperatively, was to try and maintain as much of her current frontal view as we could. So many patients feel like this lessen the chances they will look much different after rhinoplasty surgery.

With those goals in mind, Dr. Hilinski performed the surgery that included reduction of her nasal hump deformity. The excess cartilage was trimmed down and the bony part of the hump was sanded. Because of the domino effect discussed previously, Dr. Hilinski then had to break her nasal bones (very carefully) to help close the open roof deformity and provide improved symmetry in terms of her frontal alignment. The middle vault of the nose (the middle one-third) needed to be rebuilt using spreader graft technique. Then the nasal tip was reshaped to match the new bridge height. All this was done as predicted by the domino effect. Her actual intraoperative result is shown her as seen from the side view.

Before and After Rhinoplasty

The proof is here in the pudding. You can see in her series of before and after rhinoplasty photos that her hump is now gone. In addition, the tip of her nose has been lifted so it no longer droops down. This is particularly evident in her lateral smiling view where her nasal tip remains in a nice position. But above all – take another, closer look at her frontal photos. Even after all of this work – including the domino effect of surgical steps and techniques discussed above – she still looks very much like herself! And for the most part, her front view looks quite good – with minimal abnormal shadowing, great symmetry and alignment and smoother brow-tip aesthetic lines. She is not perfect – but nobody is even after detailed cosmetic surgery. But she certainly looks great in our opinion.