Commentary on: The Osseocartilaginous Vault of the Nose: Anatomy and Surgical Observations.

The study by Palhazi, Daniel, and Kosins is a thorough anatomical and clinical analysis of the osseocartilaginous vault of the nose. The authors begin the article with some of the finest anatomical dissections of the nose currently in the literature. Their photography and measurements provide a high level of detail. On the basis of the data they collected in the cadaver laboratory, they were able to draw evidencebased conclusions with substantial clinical implications for humpectomy—a persistent problem for many surgeons. For example, they clearly show that whereas the shape of the hump is determined largely by the cartilaginous component prehumpectomy, the sides of the resultant nasal bones, posthumpectomy, determine the dorsal aesthetic lines. This anatomic finding reinforces the need to fashion the bones as much as or more than the cartilages to create the desired dorsal aesthetic lines. They also introduce the concept that the bony component of the dorsal hump should be thought of as a “cap” covering the cephalic part of the cartilaginous hump. They make the case that this cap can be removed easily enough with a rasp, although they indicate later in the paper that they occasionally use a power tool. This description is, perhaps, the single most important practical contribution from their anatomic studies. It provides encouragement for the beginning rhinoplasty surgeon to duplicate this seemingly atraumatic technique that leaves the cartilaginous hump in good condition to be able to construct spreader flaps. One of the most potentially frustrating problems of humpectomy is damage to the cephalic component of the upper lateral cartilages (ULC) (of the hump). Following bone removal, the cartilaginous component should have sufficient integrity so that it can support noncollapsing spreader flaps. Evidence for removing the bone cap with only a rasp and thereby exposing an intact cartilaginous hump is corroborated by a number of studies by the senior author, Daniel. Here, the authors recommend using an exceedingly sharp rasp for the function. Sheen has also commented that it is possible to remove the bony component of the hump without damaging the cartilages if a Foman rasp is used (using a closed technique). Presumably the shape of the cartilaginous hump was palpated to be unaltered after the cap was rasped off. Tebbetts has acknowledged, however, the potential for inadvertent trauma, avulsion, or abrasion to adjacent tissues (presumably the cartilages) when using a rasp. For that reason, he recommended a rasp or power burr, preferring the latter instrument under direct visualization for greatest accuracy, specifically an angled electric-powered low torque, low revolutions per minute (rpm) hand piece. Concerns for soft tissue and cartilage damage from rasps have prompted a number of surgeons to use power tools in this region of the nose when removing a large quantity of bone. Our personal experience with rasps has not been as successful as that of the authors, which should not be interpreted as a reason for the beginning rhinoplasty surgeon not to attempt the authors’ technique first. Quite the contrary, the authors’ success rate of 100% is not in dispute and is a good reason to attempt their method. Unfortunately, we damaged the cartilaginous hump in the process of removing the bony hump, perhaps because of using inappropriate