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Dean M Toriumi, Commentary on: Reassessing Surgical Management of the Bony Vault in Rhinoplasty, Aesthetic Surgery Journal, Volume 38, Issue 6, June 2018, Pages 603–604, https://doi.org/10.1093/asj/sjy039
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In this paper, the authors have redefined the pertinent surgical anatomy of the bony nasal vault.1 Their observations are not only impactful from a technical point of view but also help to justify the introduction of a new method of managing the bony nasal vault. Their description of the “bony cap” over the osseous nasal vault improves the surgeons understanding of the relationship between the cartilaginous vault and bony vault. The authors note that the nasal hump results from the anterior movement of the cartilaginous vault, pushing the bony cap forward. The authors state, “Thus, there is no bony hump, only a bony cap that covers a cartilaginous hump.” Their anatomic observations more accurately represent the bony nasal vault that we see clinically.
The authors provide an elegant description of the 3-dimensional contours of the bony vault. They describe the asymmetries of the nasal bones structures which they note as universal. With the wider exposure of the bony vault, these asymmetries are seen, and the authors are then compelled to treat these asymmetries. With conventional osteotomies using limited dissection and limited visualization of the actual nasal bone contour, most experienced rhinoplasty surgeons are still able to achieve good alignment of the nasal bones with adequate narrowing. With conventional techniques, the surgeon is almost exclusively manipulating external contour and not reacting to defects seen when the bones are completely exposed. By keeping the skin and periosteum attached to the underlying bone, changes in bony vault contour are relatively predictable. Of course this leads us to the question, how do treating these asymmetries impact the final outcome of management of the bony vault? Are the outcomes improved? Will this wide field dissection create a paradigm shift similar to the move from endonasal rhinoplasty to open rhinoplasty?
