COSMETIC

The Probable Reasons for Dorsal Hump

Problems following Let-Down/Push-Down
Rhinoplasty and Solution Proposals
Umut Tuncel, M.D.
Oguzhan Aydogdu, M.D.
Samsun, Turkey
Background: Nasal hump relapse and its probable reasons or mechanisms have
been less discussed after dorsal preservation rhinoplasty. In this article, the
authors would like to share their experiences and offer solutions regarding
this subject.
Methods: Five hundred twenty patients who underwent primary rhinoplasty
between the years 2015 and 2017 were included in the study. The push-down
method was used for noses with a hump less than 4 mm and the let-down
procedure was performed for others. Hump height was measured from profile
photographs. The cases were evaluated in terms of nasal dorsal problems and
their probable mechanisms.
Results: Five hundred twenty patients, 448 with a straight nose and 72 with
a deviated nose, were enrolled in this study. Mean follow-up was 13 months
(range, 9 to 16 months). Visible dorsal hump recurrence was observed in 63
patients, and they appeared at 1 to 4 months postoperatively. Forty-one of these
had a dorsal hump more than 4 mm preoperatively. Hump recurrence was not
more than 2 mm in 34 patients, and they did not wish to have any revision
intervention because of cosmetic satisfaction. In 11 cases, the height of the
hump recurrence was 2 to 3 mm. These patients were treated with only mini-
mal rasping. The remaining 18 patients had a hump recurrence with a height
of 3 to 4 mm. They underwent secondary surgery using let-down rhinoplasty.
Conclusion: The authors recommend subperichondrial/subperiosteal dissec-
tion, subdorsal excision of cartilaginous and bony septum, scoring the resting
upper part of the septum just below the keystone area, and performing lateral
keystone dissection and preferring let-down procedure for kyphotic noses to
prevent hump relapse after dorsal preservation rhinoplasty.  (Plast. Reconstr.
Surg. 144: 378e, 2019.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

R
hinoplasty is the most popular aesthetic
procedure performed in the area of plas-
tic surgery. However, revision rhinoplasty
can be needed in certain cases.1 The incidence of
revision rhinoplasty varies from 8 to 15 percent.2
In most cases, the leading reasons for secondary
rhinoplasty are recurrence of the septal deformity
because of undertreatment, bony nasal dorsum
irregularity, and nasal adhesion.
Dorsal hump reduction can be considered
the central component in Western rhinoplasty.3
From the Departments of Plastic Reconstructive and Aes-
thetic Surgery of Liv Hospital and Medicana İnternational
Hospital.
Received for publication October 23, 2018; accepted Febru-
ary 28, 2019.
Copyright © 2019 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000005909
However, dorsal irregularity or hump recurrence
is not rare after dorsal hump resection. Numer-
ous techniques have been proposed to address
both functional and aesthetic problems follow-
ing hump resection,4 such as spreader grafts,
dorsal onlay grafts, the push-down/let-down tech-
nique, hump reinsertion, and spreader flaps.4–10
However, these solutions can also lead to new
problems, such as predisposition to infection,
resorption, and reactive chondrogenesis. The
newly popular method is the dorsal preserva-
tion rhinoplasty method, also called let-down/
push-down rhinoplasty. In this method, appro-
priate resection of the septal cartilage and the
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

378e www.PRSJournal.com
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 144, Number 3 • Nasal Hump Relapse
bony septum is performed, and nasomaxillary
and frontonasal osteotomies are performed for
reshaping of the nose. After osteotomies and sep-
tal resection, the distal portion of the nasal bone
and the medial portion of the maxillary bones are
relocated. The decision of which method is suit-
able—let-down or push-down—depends on the
height of the nasal hump. If the hump is less than
4 mm, the push-down technique is preferred;
however, if it is more than 4 mm, the let-down
procedure should be the treatment of choice.
The difference between let-down and push-down
techniques is that the let-down technique needs
maxillary wedge resection.11,12
The Pitanguy ligament is a thin, dynamic
musculoaponeurotic layer that has recently been
accepted to play a critical role in aesthetic rhino-
plasty.13–15 In dorsal preservation techniques, sub-
perichondrial dissection of the nasal framework
allows reshaping and redraping of the nasal tip
and controlled manipulation and repair of nasal
ligaments without disturbing the overlying soft tis-
sue, especially the musculoaponeurotic layer and
the Pitanguy ligament. However, dorsal hump
problems can also present in the postoperative
period after these procedures, leading to nega-
tive criticism from both surgeons and patients.
There is no report in the literature about poten-
tial causes of hump recurrence after dorsal preser-
vation rhinoplasty. Therefore, we aimed to share
our experience and solution recommendations in
the present study.
PATIENTS AND METHODS
Five hundred twenty patients who underwent
primary rhinoplasty between January of 2015 and
June of 2017 were included in the study. All cases
were performed under general anesthesia with
the same approach (let-down/push-down rhi-
noplasty) according to the technique formerly
introduced by the authors (U.T. and O.A.).14,15
The push-down method was used for noses with
a hump less than 4 mm, and the let-down proce-
dure was performed for noses with a hump greater
than 4 mm. The measurements were made from
profile photographs of the patients. In this article,
the cases are presented in terms of hump relapse,
its probable mechanisms, and possible solutions.
All patients were operated on under total
intravenous anesthesia with propofol (10 mg/ml)
and midazolam (5 mg/ml). In addition, ropiva-
caine (2 mg/ml) and adrenaline (0.005 mg/ml)
in a 5-ml syringe was injected with a 30-gauge nee-
dle in the columella, intercartilaginous region on
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
both sides, over the dorsum, and in the caudal sep-
tum for local regional block. A closed approach
was used for all cases. Bilateral transfixion incision
was made 3 to 4 mm cephalad to the caudal sep-
tum, and the septal cartilage was dissected in the
subperichondrial plane up to cranial edge of the
septal cartilage. Then, the dissection was contin-
ued in the subperiosteal plane at the level of the
bony septum. Next, nasal dorsal dissection was
performed up to the glabella, and the upper lat-
eral and lower lateral cartilages were also dissected
subperichondrially. Subperichondrial dissection
of lateral crura, medial crura, and dome was per-
formed using an elevator. After all dissections were
completed, nasal tip height and projection were
increased with cephalic dome and interdomal
sutures with lateral crus steal. A caudal septal strip
was resected for enhancing the cephalic rotation
of the nasal tip. Also, this strip cartilage graft was
used to fix the cephalic edges of the medial crura.
Next, a subdorsal septal resection was performed
using a scissors until the bony septum (Fig. 1). The
amount of septal resection was determined by the
existing height of the dorsal hump. Under direct
visualization, the upper cut was made to the con-
tour of the dorsal deformity. However, the lower
cut was determined according to the nasal dorsal
height. In our series, the height of this septal strip
resected differed from 2 to 8 mm in primary oper-
ations. Then, bony septum resection was carefully
performed using a rongeur or 2-mm osteotome
(Fig. 2). After septal resection was completed, the
Fig. 1. Subdorsal septal resection. Red area indicates excised
septal strip. The amount of septal resection was based on the
existing height of the dorsal hump. The upper cut was made to
the contour of the dorsal deformity. However, the lower cut was
made according to the nasal dorsal height.
379e
 Plastic and Reconstructive Surgery • September 2019

lateral osteotomies were performed through exist-

Fig. 2. Bony septum resection was performed carefully using a
rongeur or 2-mm osteotome. After septal resection was com-
pleted, the nasal bony pyramid was separated from the frontal
processes of the maxillary bones and the nasal spine of the fron-
tal bone by transverse and lateral osteotomies.
nasal bony pyramid was separated from the fron-
tal processes of the maxillary bones and the nasal
spine of the frontal bone by transverse and lateral
osteotomies (Fig. 3). Low-to-low lateral osteotomy
was performed using a guided osteotome. The
ing incisions in most of the patients and continued
until the anterior insertion of the medial canthal
tendon. Then, percutaneous radix and transverse
osteotomies were performed for separation of the
nasal bone from the frontal bone using a 2-mm
osteotome. The nasal bones were cut downward
to the cephalic termination of the lateral bone
osteotomy. Thus, the nasal pyramid was separated
en bloc and mobilized for transverse movement.
When the nasal hump was greater than 4 mm, the
let-down procedure was performed (Fig. 3). For
this, triangular bony wedges were resected from
both the left and right sides of the frontal pro-
cesses of the maxilla. Once the bony wedges were
resected, the bony pyramid was able to descend
freely. The push-down method was used for cases
with dorsal hump height less than 4 mm. With this
method, the nasal pyramid was impacted into the
nasal fossa without any maxillary resection. When
further lowering was needed, another strip from
the cartilaginous septum was resected. This resec-
tion depended on the desired nasal dorsal con-
tour, that is, if a more concave nasal dorsum was
desired, septal resection was made concave. How-
ever, excess septal resection in the supratip area
was avoided to avoid causing any saddle deformity.
In deviated noses, an asymmetric let-down proce-
dure was performed to avoid causing any bone
irregularity on one side or inequality between
two sides. After checking the position, shape, and

Fig. 3. In the let-down procedure, triangular bony wedges were resected from both the left and right sides
of the frontal processes of the maxilla. Once the bony wedges were resected, the bony pyramid was able
to descend freely. The push-down method was used for cases with a dorsal hump height less than 4 mm.
In this method, the nasal pyramid was impacted into the nasal fossa without any maxillary resection.

380e
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 144, Number 3 • Nasal Hump Relapse

Fig. 4. In revision cases, the remaining upper part of the septum under the keystone area
is scored.

symmetry of the dorsum, endonasal sutures were

performed using a 5-0 Vicryl Rapide suture (Ethi-
con, Inc., Somerville, N.J.), and the dressing was
performed in the standard manner with support
on the glabella to avoid any movement of the nasal
bony pyramid. The cast was removed after 7 days.
In revision cases, let-down/push-down pro-
cedures were repeated. The choice of procedure
was determined according to the technique used
in the previous operation. If the push-down proce-
dure was performed in primary rhinoplasty, it was
generally used again for secondary surgery. How-
ever, cases with an extremely high dorsal hump
were correctable by the let-down method.
In most of the secondary cases, minimal nasal
bone resection from the place where nasal bone
overlies upper lateral cartilage, an additional sep-
tal resection and transdorsal suture fixation with
Fig. 5. After minimal nasal bone resection from the place where
5-0 polydioxanone, and both dissecting the lateral nasal bone overlies the upper lateral cartilage, an additional sep-
keystone areas and scoring the remaining upper tal resection and transdorsal suture fixation with 5-0 polydioxa-
part of the septum under the keystone area were none was also performed in revisions. Black line, septum; red
performed (Figs. 4 and 5.) Bony resection from line, nasal bony cap; yellow dashed line, transdorsal suture.
the nasal bone was performed using a rongeur,
and lateral keystone areas on two sides were dis-
sected. The maneuver provided to overcome the RESULTS
straining force of the nasal dorsum and resulted Five hundred twenty patients, 448 with a straight
in a more flexible osseocartilaginous joint. Also it nose and 72 with a deviated nose, were involved in
was considered one of the factors causing hump this study. All patients were operated on through a
relapse. Minimal bony cap resection and lateral closed approach under general anesthesia by the
keystone area dissection have solved the prob- authors (U.T. and O.A.). Mean follow-up was 13
lem in most cases. Other maneuvers were added months (range, 9 to 16 months). Satisfactory results
in cases with kyphotic hump or when only bony were achieved in most cases, but visible dorsal hump
resection was considered not enough. was observed in 63 patients in the postoperative

381e
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • September 2019
Fig. 6. Preoperative view of a case with an extremely high
dorsum.
period (Figs. 6 and 7). Forty-one of these cases had
a dorsal hump greater than 4 mm preoperatively.
Thirty-four patients had hump recurrence less than
2 mm. Because of their cosmetic satisfaction, they
did not undergo any revision procedures (Figs. 8
and 9). In 11 cases, the height of the hump recur-
rence was between 2 and 3 mm. These patients were
treated with only minimal rasping. The remaining
18 patients had a hump recurrence with a height
of 3 to 4 mm. Surgeons preferred to repeat the let-
down/push-down procedure to secure the dorsal
aesthetic lines. In secondary operations, minimal
bony cap excision, lateral keystone dissection, addi-
tional septal reduction, scoring of the remaining
septum just below the keystone area, and suture
fixation were performed in the revision procedures
of the patients. Revision procedures were unevent-
ful postoperatively, and successful cosmetic results
were achieved.
DISCUSSION
The main difference of the let-down/push-
down rhinoplasty procedure from other tech-
niques is preservation of the nasal dorsum
continuity, and it is performed by impaction of
the bony and cartilaginous hump through the
keystone point.15 The osseocartilaginous keystone
area comprises the overlap of the bony cap and
the cartilaginous vault underneath. These two ana-
tomical structures are not rigidly fused, and the
area can be considered as an osseocartilaginous
joint. In the let-down/push-down rhinoplasty, it is
382e
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Fig. 7. Photograph showing hump relapse at 3 months after the
operation.
essential to reduce the underlying cartilaginous
septum to create a flexible and convex dorsum
for achieving an aesthetically pleasing dorsal pro-
file.15–21 It is important to keep the integrity of the
keystone area during dorsal hump reduction to
preserve nasal dorsal support. Disruption of the
insertion of the upper lateral cartilages can result
in midvault instability and subsequent develop-
ment of an inverted-V or hourglass deformity.22,23
Its major advantage is preservation of the dorsal
vault and its normal anatomy, to decrease nasal
dorsal complications, such as open roof, irregular-
ity, and saddle nose, which require use of spreader
graft or flap for reconstruction. A major limitation
of preservation rhinoplasty is the need for experi-
ence with the endonasal approach.
Postoperative hump recurrence and/or lat-
eralization of the nasal pyramid are possible
problems even after use of dorsal preservation
techniques.16 Ishida et al.21 reported a partial
hump recurrence with a rate of 15 percent in
120 patients who underwent conservative rhino-
plasty. According to our clinical experience, the
rate is 12 percent. The recurrence rate was higher
in patients whose humps were more than 4 mm
preoperatively. In primary cases, we have per-
formed subdorsal septal resection below the level
of the upper lateral cartilages/septal junction,
near the anterior septal angle, as suggested by
Saban et al.15 However, in revision cases, we also
 Volume 144, Number 3 • Nasal Hump Relapse
Fig. 8. Preoperative view of a moderately high dorsum.
performed minimal bony cap resection, especially
for kyphotic bony hump cases and also for dissec-
tion of the lateral keystone area and septal reex-
cision. When required, we performed scoring of
the upper part of the septum under the keystone
area; then, transdorsal septal fixation was per-
formed using 5-0 to 6-0 polydioxanone sutures.
We think that the straining force of the remaining
upper part of the septum after subdorsal resection
can play an important role in hump recurrence.
We observed that scoring and/or suture fixa-
tion in addition to subdorsal septal resection was
highly effective for overcoming the straining force
on the keystone area. After these experiences,
the authors have also routinely started perform-
ing these maneuvers in primary cases. They have
observed that the revision rate is decreased in the
ensuing period. However, more time is needed to
compare the results and will be the subject of the
next study.
According to anatomical studies,18–22 the nasal
superficial musculoaponeurotic system (SMAS) is
divided at the level of the nasal valve into deep
and superficial layers, consisting of the nasal mus-
cles. These muscles are the transverse nasalis, the
procerus, and the compressor naris major and
minor.21 It is known that there is a connection
between the nasal SMAS and the depressor septi
nasi and orbicularis oris muscles.22 The Pitan-
guy ligament, also called the dermocartilaginous
ligament of the nose, corresponds to the deep
medial expansion. Both the deep and the super-
ficial medial expansions correspond to the lower-
ing ligaments of the nasal tip. Thus, the cephalic
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Fig. 9. This hump was presented at our clinic at 1 month post-
operatively. It was considered a residual hump. The patient had
minimal hump relapse postoperatively but did not want any
intervention.
rotation of the nasal tip is allowed by their cut.21,22
Nevertheless, repair of the Pitanguy ligament is
a recommended maneuver when a cut or open
approach rhinoplasty was performed so that the
repair of the ligament pulls the soft-tissue enve-
lope downward, reduces supratip dead-space,
and stabilizes the nasal tip.22 We think that the
relationship between the nasal SMAS, the nasal
muscles, and the Pitanguy ligament can lead to a
pulling effect on the nasal dorsum. Also, the simi-
lar relationship between the Pitanguy ligament,
the depressor septi nasi, and the orbicularis oris
muscles is known to lead to the lowering effect
on the nasal tip. We think that these effects of the
Pitanguy ligament are created at the level of the
interdomal ligament. According to our hypoth-
eses, the pulling effect begins upward from the
interdomal ligament and the lowering effect
begins downward from the same level. It can be
said that because the distance between the nasal
tip and the base of the columella becomes lon-
ger after rhinoplasty, the lowering force of the
ligament will be greater compared to the force
preoperatively (Fig. 10). Similarly, the dorsal pull-
ing force will become less postoperatively because
the length of nasal dorsum will become less. It is
known that the nasal bone, septum, and upper
lateral cartilages are mobilized by surgical dissec-
tion in the let-down method; thus, they will move
either upward cephalically or downward inferiorly
because of the pulling and lowering effect of the
383e
 Plastic and Reconstructive Surgery • September 2019
Fig. 10. A, the distance between the columellar base and the
nasal tip preoperatively; A′, the distance between the columellar
base and the nasal tip postoperatively; B, the length of the nasal
dorsum preoperatively; B′, the length of nasal dorsum postop-
eratively; C, the nasal tip point preoperatively. C′, the nasal tip
point postoperatively. In the postoperative period, A′ is greater
than A, and B is greater than B′.
ligament during the healing period. Thus, if exci-
sion of septal cartilage is made insufficiently, the
possible effect will be upward and/or cephalad,
and it will result in hump relapse with time. It can
be considered to be evidence to support our claim
that hump relapse occurs at 1 to 4 months after
surgery in most recurrence cases.
Another reason for hump relapse can be the
height and length of the nasal bone. The nasal
bone is longer and higher in kyphotic hump cases.
In these cases, shortening the nasal bones can be a
reasonable treatment of choice. We strongly recom-
mend rasping to reduce nasal bone for both primary
and hump revision in kyphotic or high hump cases.
Thus, bony reduction is crucial to achieve a desirable
aesthetic result and shorten the nasal dorsal length.
This maneuver provides easier hump reduction and
a more flexible osseocartilaginous joint in this area.
Therefore, nasal dorsal problems can be asso-
ciated with many factors. We think these prob-
lems may be divided into two categories: residual
hump and recurrent hump. The residual hump
is actually present during surgery, but the edema
secondary to surgery can often conceal it from the
surgeon; thus, it can be difficult to notice a resid-
ual hump, but it is generally seen by the first or
second week after surgery. However, the recurrent
hump is not present during surgery. It occurs over
384e
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
time—in most cases, by 3 weeks after surgery. The
reason for residual hump can be a lack of experi-
ence with the surgical technique. Thus, it leads to
performing the method conservatively to reduce
the dorsal hump, and thus inadequate excision of
the cartilaginous septum may cause the residual
dorsal hump. Insufficient resection of the bony
septum can also lead to dorsal problems after sur-
gery. It is actually relatively easier to remove this
segment from the cartilage septum, but it is more
difficult to remove it from the bone septum, the
vomer perpendicular layer. Thus, this will prevent
impact to the nasal bone, and cause a residual
dorsal hump or relapse. Thus, we believe that the
Pitanguy ligament may cause remodeling of the
nasal tissues in the postoperative period, and by
its pull-up and push-down effect, it may be respon-
sible for the recurrent dorsal hump during the
healing period. There is no previous report in the
literature that the Pitanguy ligament can cause
a dorsal hump after protective rhinoplasty. How-
ever, more study is needed to confirm whether
the ligament and/or its connection with the nasal
SMAS and muscles can affect dorsal problems
after surgery.
With the results of our experiences and clini-
cal observations, we strongly recommend resect-
ing some of the caudal edge of the nasal bone
overlying the upper lateral cartilages, especially
for an extremely high dorsum or kyphotic noses.
Sufficient cartilaginous and septal bone resection
must be performed to decrease the dorsal height,
and cephalic resection from the upper lateral car-
tilages should be performed to reduce the nasal
length. In addition, nasal dorsum can be stabi-
lized with polydioxanone suture after subdorsal
septal resection. Scoring the remaining upper
part of the septal cartilage just below the keystone
area can also be added. All of these maneuvers
will reduce the straining force of the nasal dor-
sum. The let-down method therefore must be pre-
ferred rather than the push-down method in cases
with a significantly high dorsal hump. We think
that the above solutions are mandatory, especially
for extremely high and long noses, and we believe
that they will significantly reduce the revision rate
after preservation rhinoplasty.
Umut Tuncel, M.D.
Department of Plastic Reconstructive
and Aesthetic Surgery
Liv Hospital
F Sultan Mehmet Street
55100 Samsun, Turkey
drumuttuncel@gmail.com
Instagram: @drumuttuncel
 Volume 144, Number 3 • Nasal Hump Relapse
PATIENT CONSENT
Patients provided written consent for the use of their
images.
REFERENCES
1. Tuncel U. Rhinoplasty in the Black Sea region. J Craniofac
Surg. 2012;23:1355–1357.
2. Cobo R. Correction of dorsal abnormalities in revision rhi-
noplasty. Facial Plast Surg. 2008;24:327–338.
3. Barrett DM, Casanueva F, Wang T. Understanding approaches
to the dorsal hump. Facial Plast Surg. 2017;33:125–132.
4. Constantinidis J, Fyrmpas G. Reinserting the hump in pri-
mary rhinoplasty: The gain is three-fold. Plast Reconstr Surg
Glob Open 2016;4:e1021.
5. Cottle MH. Nasal roof repair and hump removal. AMA Arch
Otolaryngol. 1954;60:408–414.
6. Skoog T. A method of hump reduction in rhinoplasty: A
technique for preservation of the nasal roof. Arch Otolaryngol.
1966;83:283–287.
7. Constantian MB, Clardy RB. The relative importance of sep-
tal and nasal valvular surgery in correcting airway obstruc-
tion in primary and secondary rhinoplasty. Plast Reconstr
Surg. 1996;98:38–54; discussion 55–58.
8. Roostaeian J, Unger JG, Lee MR, Geissler P, Rohrich RJ.
Reconstitution of the nasal dorsum following component
dorsal reduction in primary rhinoplasty. Plast Reconstr Surg.
2014;133:509–518.
9. Park SS. The flaring suture to augment the repair of the dys-
functional nasal valve. Plast Reconstr Surg. 1998;101:1120–1122.
10. Kovacevic M, Wurm J. Spreader flaps for middle vault contour
and stabilization. Facial Plast Surg Clin North Am. 2015;23:1–9.
11. Jobe R. En bloc nasal shift rhinoplasty: An approach to the
small crooked nose. Ann Plast Surg. 1981;7:120–125.
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
12. Pinto RM. On the “let-down” procedure in septorhinoplasty.
Rhinology 1997;35:178–180.
13. Pitanguy I, Salgado F, Radwanski HN, Bushkin SC. The sur-
gical importance of the dermocartilaginous ligament of the
nose. Plast Reconstr Surg. 1995;95:790–794.
14. Cakir B, Oreroğlu AR, Doğan T, Akan M. A complete
subperichondrial dissection technique for rhinoplasty
with management of the nasal ligaments. Aesthet Surg J.
2012;32:564–574.
15. Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P. Dorsal
preservation: The push down technique reassessed. Aesthet
Surg J. 2018;38:117–131.
16. Palhazi P, Daniel RK, Kosins AM. The osseocartilaginous
vault of the nose: Anatomy and surgical observations. Aesthet
Surg J. 2015;35:242–251.
17. Rezaeian F, Gubisch W, Janku D, Haack S. New suturing tech-
niques to reconstruct the keystone area in extracorporeal
septoplasty. Plast Reconstr Surg. 2016;138:374–382.
18. Daniel RK, Glasz T, Molnar G, Palhazi P, Saban Y, Journel
B. The lower nasal base: An anatomical study. Aesthet Surg J.
2013;33:222–232.
19. Gerbault O, Daniel RK, Palhazi P, Kosins AM. Reassessing
surgical management of the bony vault in rhinoplasty. Aesthet
Surg J. 2018;38:590–602.
20. Gerbault O, Daniel RK, Kosins AM. The role of piezoelec-
tric instrumentation in rhinoplasty surgery. Aesthet Surg J.
2016;36:21–34.
21. Saban Y, Andretto Amodeo C, Hammou JC, Polselli R. An
anatomical study of the nasal superficial musculoaponeu-
rotic system: Surgical applications in rhinoplasty. Arch Facial
Plast Surg. 2008;10:109–115.
22. Daniel RK, Palhazi P. The nasal ligaments and tip sup-
port in rhinoplasty: An anatomical study. Aesthet Surg J.
2018;38:357–368.
23. KimL, Papel ID. Spreader grafts in functional rhinoplasty.
Facial Plast Surg. 2016;32:29–235.
385e