Reassessing Surgical Management of the Bony Vault in Rhinoplasty

Abstract

Management of the nasal bony vault is an integral part of rhinoplasty surgery, whether reducing the dorsal profile line or narrowing the base bony width. Since 2013, dramatic changes have occurred because of new insights into our understanding of nasal anatomy, how we analyze bony vault deformities, and the introduction of new surgical techniques and technologies including piezosurgery. Therefore, a reassessment and overview of bony vault surgery appears justified. With wide exposure and visualization of the bony vault, we have concluded that all bony vaults are asymmetrical and that the lateral bony wall may be analyzed in 3 axes: longitudinal, sagittal, and transverse. The longitudinal and sagittal axes may be judged as convex, straight, or concave. The transverse axis can be precisely rotated or translated depending on the design of ultrasonic osteotomies. We review this nasal anatomy as well as treatment including sculpting of the nasal bones, as well as different osteotomy patterns. Piezosurgery is certainly a disruptive technology in rhinoplasty that allows bony reshaping with precise osteotomies and sculpting. This versatility allows treatment of any type of bone (thin, brittle, short), mobile bones, and fractured bones. This enables the surgeon to achieve better symmetry with greater accuracy and precision.