--- title: "Osteotomies in Rhinoplasty - Types, Approaches, Steps & Complications" description: "ENT notes on Osteotomies in Rhinoplasty." source: "The ENT Resident" author: "Dr. Mausumi Das" canonical_url: "https://www.theentresident.com/ent-notes-lectures/rhinoplasty-osteotomies-types-complications" categories: ["Rhinology", "Surgery"] video: "https://www.youtube.com/watch?v=vwDVYijyV-0" image: "https://media.theentresident.com/og-images/rhinoplasty-osteotomies-types-complications.png" --- # Osteotomies in Rhinoplasty - Types, Approaches, Steps & Complications ENT notes on Osteotomies in Rhinoplasty. Watch the full video lecture on YouTube: https://www.youtube.com/watch?v=vwDVYijyV-0 ## 👃 Osteotomies in Rhinoplasty ### 📝 Definition of Osteotomy Osteotomy is the **controlled surgical fracture or cutting of the nasal bones to reposition them**. ⭐ The word osteotomy literally means **bone cutting**. > What is the surgical anatomy of the nose in relation to rhinoplasty? --- ### 🎯 Purpose of Osteotomies in Rhinoplasty 1️⃣ **Closure of the open roof deformity** > What is open roof deformity? 2️⃣ **Narrowing of a wide bony vault** 3️⃣ **Straightening a deviated bony pyramid** 4️⃣ **Correction of asymmetry of the nasal bones** --- ### 📋 Types of Osteotomies | Type | Site of Cut | Purpose | | --- | --- | --- | | **Lateral osteotomy** | Along the side wall of the nasal bone, from the piriform aperture upwards | Frees the nasal bone so it can be pushed inwards to narrow the bony nasal vault | | **Medial osteotomy** | Along the midline of the nasal dorsum | Separates the two nasal bones so they can be moved independently | | **Transverse osteotomy** | Horizontal cut across the top of the nasal bone | Acts as the upper limit of bone movement and completes mobilization | ⭐ All types of lateral osteotomy narrow the airway to some extent. > What are the different types of Lateral Osteotomy? Describe each type. > What is Webster's Triangle? What is it's clinical significance? --- ### 🔍 Lateral Osteotomy - Steps #### 📍 Position of the Lateral Osteotomy ⭐ In the region of the **root of the nose**, a **high osteotomy is preferred** over a low osteotomy. The space left behind after shifting the lateral wall inwards is later obliterated by the process of **osteogenesis**. > What dye is usually used for surface marking before lateral osteotomy? --- #### A. Internal Approach 1️⃣ **Local Anaesthetic Infiltration** 2️⃣ **Incision** * A **stab incision about 0.5 cm** in length, with a **No. 15 blade** * Placed in the **pyriform crest region**, just in front of the attachment of the inferior turbinate 3️⃣ **Elevation of the Periosteum** * Periosteum separated alongside the **frontal process of the maxilla**, creating a tunnel 4️⃣ **Introduction of the Joseph's Saw** * Introduced carefully along the frontal process of the maxilla, along the nasofacial groove * **Teeth of the saw face against the bone** for easy introduction and to avoid soft tissue injury * Saw positioned at a **right angle to the surface of the bone** * Patient's head is turned to the side and immobilized by the assistant 5️⃣ **Sawing the Frontal Process** * The frontal process is sawed through its **entire length** in the nasofacial groove, **without cutting the mucosa** * Movements of the saw are controlled and guided with the fingers of the left hand > What other alternative instruments are used in Lateral osteotomy other than Joseph's Saw? > What are the contraindications of Lateral Osteotomy? --- #### B. External Approach - A tiny **stab incision** is placed externally at the nasofacial groove ⚠️ The external scar may be visible later. - The osteotomy cut is begun **above the inferior turbinate on the pyriform crest**, to save a triangular piece of bone - Injecting anaesthetic **inside and outside the bone** before the cut minimizes bleeding and pain - The osteotome or chisel is driven along the **nasofacial groove**, and from the **infraorbital border** an oblique cut is made towards the midline > What is Curved Lateral Osteotomy? What is the advantage of Curved Lateral Osteotomy? --- ### 🔍 Medial Osteotomy The cut is given **along the midline of the nasal dorsum**, and may be **oblique or vertical**. ⭐ Used only in cases of **significant deviation**. #### ✅ Indications * Bones do not fracture easily at the **frontonasal suture** after lateral osteotomy * Need for satisfactory **infracture or outfracture** at the frontonasal suture * When a **straight lateral osteotomy** has been used #### ❌ Contraindications * **Large hump removal**, where the bone becomes mobile and weakened at the frontonasal area * **Curved lateral osteotomy**, as the greenstick fracture extends along the frontonasal suture on its own > What are the steps of Medial Osteotomy in Rhinoplasty? --- ### 🔍 Transverse Osteotomy Creates a **transverse fracture at the frontonasal suture**. #### Internal Approach * After completing the medial osteotomy cut, the same osteotome is **rotated laterally** * The bones are **outfractured** from their attachment at the frontonasal suture * The **nasal septum** is used as a **fulcrum** for the osteotome 👉 An audible and perceptible **click** indicates that the transverse fracture has been made. #### External Approach * Performed separately with a **small chisel** * A **stab incision** is given on the upper part of the bony vault ⚠️ May result in an external scar. --- ### 🔨 Movement of the Bones After Osteotomy 1️⃣ The **lateral bony wall is moved inwards**, with the nasal bones and frontal processes of the maxilla pushed medially using the thumb and fingers 2️⃣ The nasal wall is steadied using a **gauze piece**, and the new position confirmed 3️⃣ The whole bridge of the nose is evaluated by **inspection and palpation** 4️⃣ Any bony irregularity is **resected** or smoothed with a **bone rasp** > What are the Causes of Difficulty in Moving the Bones Inwards After Osteotomy? How would you correct each of them? --- ### ⚠️ Complications of Osteotomies - Rocker Formation - Periorbital Ecchymosis & Edema - Injury to the Medial Canthal Ligament or Lacrimal Sac - Irregular Fracture at an Undesirable Site - Step Deformity - Dislocation of the Cephalic Border of the Upper Lateral Cartilage - Nasal Obstruction - Skin Puncture or External Scar > What are the causes behind each of the above complication of Osteotomy? How would you manage them? --- ### ⭐ Exam Pearls - Osteotomy is the **controlled surgical fracture** of the nasal bones to reposition them - Lateral osteotomy narrows the **bony nasal vault** - Medial osteotomy **separates the two nasal bones** - Transverse osteotomy is the **upper limit of bone movement** - Curved lateral osteotomy produces a **greenstick fracture** and obviates the need for a medial osteotomy - **High osteotomy** is preferred at the root of the nose - Elevation of periosteum must be **superficial to the medial canthus** - Medial osteotomy placed too medially → **Rocker formation** - Transverse fracture is confirmed by an audible **click** --- ## About This Note This free ENT note on Osteotomies in Rhinoplasty - Types, Approaches, Steps & Complications was written by Dr. Mausumi Das and is paired with a corresponding video lecture. 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