VIDEO+

Spare Roof Technique: A New Technique for

Hump Removal—The Step-by-Step Guide
Miguel Gonçalves Ferreira,
M.D.
Mariline Santos, M.D.
Francisco Rosa, M.D.
Cecília A. Sousa, M.D.
Jorge Santos, Ph.D.
Nuno Dourado, M.D.,
Ph.D.
José Amarante, M.D.,
Downloaded from http://journals.lww.com/plasreconsurg by BhDMf5ePHKbH4TTImqenVAaoM33QR5KTFkk7E55VmCAFdGYA9VIUWzQ6miQ/EJUQ on 03/02/2020
Summary: Humpectomy is one of the most common steps in reduction rhino-
plasty among Caucasian patients. The most widespread procedures to address
hump removal are both the “en bloc humpectomy” (with reconstruction of
the middle third with spreader grafts) and the “split hump technique” (with
confection of spreader flaps). The spare roof technique, for rhinoplasty reduc-
tion, has been developed over the past 4 years. In this technique, the upper
lateral cartilages are completely preserved—even the hidden part under the
caudal aspect of the nasal bones. It consists of five main steps: step 1, the upper
lateral cartilages are released from the dorsal aspect of the nasal septum; step

Ph.D.
Porto and Guimarães, Portugal
2, a 1-mm strip of the dorsal septum is taken in each movement as required;
step 3, ostectomy of the caudal aspect of nasal bones, keeping the upper lateral
cartilages intact and releasing the “lateral” (left and right) pyriform aperture
ligament; step 4, classic medial and lateral osteotomies (closing the open bony
roof); and step 5, suturing the upper lateral cartilages to the dorsal septum and
thus avoiding the natural spring effect. The outcomes of the first 100 patients
have been validated by a prospective, interventional, and longitudinal study
performed on patients undergoing primary rhinoplasty by means of the spare
roof technique. This study confirms that the spare roof technique significantly
improved patient quality of life regarding nose function and appearance. It is a
reliable technique that can help deliver consistently good results in Caucasian
and Mediterranean patients with a dorsal hump seeking rhinoplasty.  (Plast.
Reconstr. Surg. 145: 403, 2020)

T
he majority of Caucasian aesthetic rhino-
plasty patients complain about a noticeable
hump on profile view.1–5 Since the beginning
of rhinoplastic procedures, the middle third has
been probably the most difficult segment to deal
with regarding stability, functionality, and the
brow-tip line.6–11
The spare roof technique is a new middle
third technique, described in 2016 by Ferreira et
al., that allows the surgeon to isolate the entire
cartilaginous roof of the middle third, separat-
ing the quadrangular septum from the upper lat-
eral cartilages, without splitting the upper lateral
From the Centro Hospitalar Universitário do Porto, I­ nstituto
de Ciências Biomédias Abel Salazar, Faculdade de ­Medicina
da Universidade do Porto, Hospital da Luz, ­ Arrábida;
Hospital Militar do Porto; and the Departamento de
­
­Engenharia Mecânica, Universidade do Minho.
Received for publication February 12, 2019; accepted July
11, 2019.
Presented at the 24th Congress of the International Society of
Aesthetic Plastic Surgery, in Miami Beach, Florida, October
31 through November 4, 2018.
Copyright © 2020 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000006512
cartilages among them.12 As a conservative tech-
nique, it can always be converted into classic en
bloc humpectomy or split hump technique if the
surgeon does not feel comfortable with it.
METHODS
Live operations performed by the surgeon
that first described the spare roof technique and
cadaver dissections were recorded. Some three-
dimensional animations were added to enrich
this didactic video. All procedures performed
in studies involving human participants were in
accordance with the ethical standards of the insti-
tutional and national research committee and
with the 1964 Declaration of Helsinki and its later
amendments or comparable ethical standards.
Disclosure: The authors declare that they have no
conflict of interest.
Related digital media are available in the full-text
version of the article on www.PRSJournal.com.

www.PRSJournal.com 403
 Plastic and Reconstructive Surgery • February 2020
Informed consent was obtained from all individ-
ual participants included in the study.
Patient Selection
In our opinion, patients with a straight dorsum
(i.e., noncrooked) Caucasian nose with a hump
less than or equal to 5 mm (the vast majority) are
the best candidates to be submitted to the spare
roof technique. It can also be used in patients that
have a deviated nasal bone but straight middle
nasal vault. Humps larger than 5 mm and severe
crooked noses, in which the asymmetry of the
upper lateral cartilages plays a main role, might
be contraindications for this technique.
Procedure
Cottle septoplasty and radiofrequency turbin-
oplasty were performed in all patients. The spare
roof technique for reduction of the overprojected
nasal dorsum can be performed using either a
closed or an open approach. It depends on the
surgeon’s skills.
Before starting the spare roof technique, the
surgeon should perform an “L-shaped” septo-
plasty (through transfixing incision in the closed
approach) and expose the quadrangular septum
and upper lateral cartilages by submucosal dis-
section. The septoplasty is mandatory because of
functional and cartilage harvesting issues. Then,
by a closed or open approach, the dorsum is
accessed by subperichondrium and subperiosteal
dissection to achieve complete skeletonization of
the upper lateral cartilages. The spare roof tech-
nique consists of five main steps, as follows.
Step 1
Step 1 consists of longitudinal cut of the dorsal
septum, from the anterior nasal angle till the per-
pendicular plate of the ethmoid, 1 mm below the
upper lateral cartilages, separating completely the
dorsal aspect of the septum and the upper lateral
cartilages, and preserving the union among the
upper lateral cartilages (which remain preserved).
[See Video 1 (online), which demonstrates step
1 of the spare roof technique: separation of the
upper lateral cartilages from the dorsal septum.]
Step 2
Step 2 consists of removing the remaining
excess of dorsal septum (from 1 to 5  mm, as
needed) to enable the hump’s decrease as desired.
[See Video 2 (online), which demonstrates step 2
of the spare roof technique: removing the excess
dorsal septum as needed, preserving the upper
lateral cartilages.]
404
Step 3
Step 3 consists of ostectomy of the caudal
edge of nasal bones to “dehump” the bony part.
The release of the “lateral” (left and right) pyri-
form aperture ligament must be performed as
needed (releasing the lateral aspect of the upper
lateral cartilages and the lateral bony walls).
This step is easier by the open approach. In the
closed approach, the Aufricht retractor should be
raised as high as possible to achieve the best sur-
gical exposure of the nasal dorsum. [See Video
3 (online), which demonstrates steps 3 and 4 of
the spare roof technique: ostectomy of the caudal
edge of nasal bones, preserving the upper lateral
cartilages, and medial and lateral osteotomies to
close the open bony roof.]
Step 4
Step 4 involves the classic medial and lateral
osteotomies to close the open bony roof. We rec-
ommend endonasal osteotomies with previous
subperiosteal dissection to create a tunnel access.
This procedure is similar for both open and closed
approaches.
Step 5
Step 5 consists of suturing the “roof” (upper
lateral cartilages) to the dorsal aspect of the
remaining or reshaped septum, with absorbable
polydioxanone 4-0, to stabilize the roof and fix
any spring effect that may arise. [See Video 4
(online), which demonstrates step 5 of the spare
roof technique: suturing the upper lateral carti-
lages to the remaining quadrangular septum.]
Similar to step 3, it is easier to perform by the
open approach. Septoplasty is performed in the
beginning of the operation and the L-strut shape
is always preserved—attached to the perpendicu-
lar plate of the ethmoid and nasal spine. Any part
of the horizontal part of the L-strut can be used
to “anchor” the sutures to the upper lateral car-
tilages. If severe caudal septum deviation exists,
a subtotal extracorporeal septoplasty can be per-
formed, and it can be used as a septal extension
graft. In these cases, the sutures septum/upper
lateral cartilages are placed behind, more cephali-
cally. When deviation is in the caudal septum, the
authors stabilize the caudal septum to the ante-
rior nasal spine fibers with 5-0 polydioxanone.
Based on our experience, both in vivo and
cadaveric, the “splay effect” can be useful in some
middle thirds thinner than the aesthetic brow-
tip lines. When the hump is larger than 5  mm,
this “splay effect” tends to occur, and this can be
mitigated by a complete release of the pyriform
aperture ligament. During the ostectomy, the “K
Volume 145, Number 2 • Spare Roof Technique for Humpectomy
area” is cranially moved; thus, there is always some
degree of “step” in the new K area that should not
be noticed in the superficial anatomy. [See Video
5 (online), which demonstrates final results of
the spare roof technique: preoperative and post-
operative images at 1-year follow-up are shown.]
However, it can always be covered by a cream of
cartilage powder and platelet rich plasma.13 Spon-
gostan nasal packing and Silastic (Dow Corning,
Midland, Mich.) with side tubes are placed and
removed after 7 days.
Postoperative Care
Postoperative care is the same as in all other
rhinoplasty techniques: analgesia (paracetamol
1000 mg every 8 hours) and amoxicillin and cla-
vulanic acid (875 mg plus 125 mg every 12 hours).
Doyle and thermic nasal splints are typically taken
out 7 to 8 days after surgery.
DISCUSSION
Based on the integrity of the upper lateral car-
tilages, there are two different ways to “dehump”
a nose: the destructive/reconstructive techniques
and the conservative techniques.14–17 The former
consists of splitting the upper lateral cartilages
and the dorsal septum, with complete separation
of this M-shaped segment into three parts.14 In the
classic en bloc humpectomy, there is always some
degree of excision of the upper lateral cartilages;
most of the time, reconstruction is performed
with spreader grafts.15 In the split hump tech-
nique, there is a simple separation between both
upper lateral cartilages and the dorsal aspect of
the septum, most of the time with confection of
autospreader flaps.16,17
The latter allows complete preservation of
upper lateral cartilages. Among them, some rel-
evant differences exist. In a “push-down” tech-
nique, either classic or modified, all pyramid
(bony and cartilaginous) is mobilized and the K
area is preserved because surgery is conceived for
the base of the nasal pyramid.18 This is why it is
considered a “foundation technique,” contrast-
ing with the spare roof technique that can be
considered a “superficial conservative technique”
because it preserves the upper lateral cartilages
but deals with the bony part of the hump with
traditional lateral osteotomies (similar to the split
hump technique). Thus, the push-down tech-
nique and the spare roof technique are different
techniques. The first addresses the foundations of
the nasal pyramid as one piece, and the second
addresses only the nasal dorsum, in a superficial
way, moving the K area while preserving the upper
lateral cartilages.
In our opinion, the spare roof technique has
some advantages over other traditional proce-
dures: technically, the spare roof technique seems
to be faster than the traditional “destructive/recon-
structive” procedures, because it is not necessary to
reconstruct with either spreader grafts or flaps. Aes-
thetically, the dorsum is smoother, and the absence
of grafts or flaps is much more likely to avoid small
bumps and other dorsal defects with regard to the
medium- and long-term results. Functionally, dur-
ing our cadaveric dissections, in which we have
performed the classic split hump technique on one
side and the spare roof technique on the other side
in the same specimen, there are no doubts that
the spare roof technique provides a higher cross-
sectional area on the internal nasal valve. However,
further studies are needed to prove this.
Regarding complications and their preven-
tion, during the procedure, it is very important to
feel and see (endoscopically if necessary) the new
K area. To reduce a potential step at the new nasal
dorsum, one must consider two statements: (1)
the more delicate the ostectomy (piezo, rasp, or
diamond drill), the smaller the step; and (2) the
more the K area is moved upward, the thicker the
skin, and thus the impact on surface anatomy is
lower. Even taking this into account, we always use
cartilage powder in the dorsum at the end of the
procedure to mitigate some possible irregularities.
The aesthetic and functional outcomes of
the first 100 patients operated on by the sur-
geon that first described this new technique have
recently been published.19 Based on the Utrecht
Questionnaire for Outcome Assessment in Aes-
thetic Rhinoplasty scores, a statistically significant
improvement in both aesthetic and functional
outcomes was found 3 months after surgery;
even 1 year after surgery, a slight improvement is
expected on both outcomes. No score remained
constant or worsened after performance of the
spare roof technique. This study confirms that the
spare roof technique is a reliable technique for
a better nasal appearance, and these patients will
likely have additional functional improvement.
CONCLUSIONS
The spare roof technique is a new technique
that allows the surgeon to isolate the entire carti-
laginous roof of the middle third, separating the
quadrangular septum from the upper lateral carti-
lages, without splitting the upper lateral cartilages
among them. It is a reliable technique that can help
405
 Plastic and Reconstructive Surgery • February 2020
deliver consistently good aesthetic and functional
results in Caucasian and Mediterranean patients
with a dorsal hump seeking rhinoplasty. Since there
is no violation of upper lateral cartilages and subse-
quently in the inner mucosa, this is clearly a pres-
ervation technique under Cottle principles. Lateral
osteotomies are not to "close the open bony roof,"
but to control the base bony width.
Miguel Gonçalves Ferreira, M.D.
R Dr. Miguel Martins, 282
4450-806 Matosinhos, Portugal
mgferreira.md@gmail.com
Facebook: @rinoplastiaporto
Instagram: @clinicadonarizeface
Twitter: @Clinicadonariz
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