Commentary on: An Anatomic Analysis of the Bony Vault: From the Perspective of Osteotomy in Rhinoplasty Free

See the Original Article here.

In “An Anatomic Analysis of the Bony Vault: From the Perspective of Osteotomy in Rhinoplasty,” Kim et al utilize imaging technology to describe bone thickness along the planned osteotomy path of a cohort of rhinoplasty patients.¹ To quantify the bony vault (BV) thickness, they utilize 3-dimensional (3D) facial bone computed tomography (CT) scans. The authors’ goal in performing the study is to better describe the anatomy of the bony vault for optimization of surgical planning and osteotomies among rhinoplasty surgeons. We commend the authors on a well-done study in which a novel methodology is utilized to reinforce anatomical findings of previous studies and highlight the importance of a comprehensive anatomical understanding of the nose and skull when performing rhinoplasty surgery.

The authors present a few notable results. First, although the majority of patients presenting for primary rhinoplasty had symmetric BVs (64.8%), a substantial portion were found to have asymmetric BVs (35.2%). With over a third of primary rhinoplasty patients presenting with asymmetry of their BV, we agree that rhinoplasty surgeons need to pay detailed attention to examining the bony vault during preoperative visits. As the authors correctly conclude, ignoring potential asymmetries and bony vault thickness variations in rhinoplasty patients may result in poor outcomes following rhinoplasty and osteotomy. Second, the authors found that BV is thickest at the middle level of the lateral osteotomy path. Third, the authors corroborate other studies that have found that male patients often have significantly thicker BVs than their female counterparts. Fourth, a major takeaway of this study is that the BV is thicker on the deviated side in patients with asymmetric BVs at almost all levels (except for the lower level of the lateral osteotomy path and the high level of the intermediate path); the authors found that asymmetric BVs are overall thicker than the mean thickness of the bones in a symmetric BV. Interestingly, they also found that in asymmetric BVs the bone contralateral to the deviated bone was thinner than that of the symmetric BV bone.

Overall, the authors concluded that, based on their results in patients with asymmetric BVs, surgeons should perform osteotomy on the contralateral side of the deviation first, where the bone is thinner. They reasoned that the contralateral bone was thinner, and therefore osteotomy on this side could be performed with a more controlled fracture. The result would be a more precise osteotomy and correction of BV deviation.

This study has numerous strengths, particularly the informative tables and illustrative imaging figures. The authors should be credited for a sound research methodology that employed 3D CT imaging and measurement points along the path of the most common osteotomy patterns. Nevertheless, the study is limited by several factors that are fairly recognized by the authors. Namely, the patient cohort was selected entirely from a single research hospital in Korea, with a majority of male patients. Several studies have described anatomical ethnic variations in rhinoplasty; as such, the homogenous study cohort limits the generalizability of these findings.^2-5 Moreover, because patients were presenting primarily for functional rhinoplasty, these results may not be as widely applicable to the cosmetic rhinoplasty population.^6-8

This study highlights a few important topics that are consistent with our extensive rhinoplasty experience. First, we agree with the authors that designing optimal osteotomies is a difficult aspect of rhinoplasty surgery, in both revisional and primary cases.⁹ The adept surgeon must be able not only to analyze the bony dorsum for any deviations or irregularities, but also to determine the direction and cause of the deviation. Furthermore, the skilled surgeon must be able to design a surgical plan that corrects the deformity of the BV with the least amount of trauma. Failing to recognize deviations of the BV may result in poor functional or cosmetic outcomes. In our experience, inappropriately treated BV deformities are present in many patients presenting for revisional rhinoplasty. We commend the authors for providing greater detail on the underlying anatomy of the BV, especially in the asymmetric vault. Although this study does not present groundbreaking data, it does meaningfully contribute to the existing literature and increase our understanding of the BV.

Moreover, we agree with the authors’ contention that, as a general principle, rhinoplasty surgeons should consider performing first the osteotomy on the contralateral side of the deviation, as manipulation is easier on this side. With that said, rhinoplasty is one of the most difficult plastic surgery operations, and surgeons must be prepared to alter their “usual” plan in certain scenarios. This study also lays a foundation for future work. For instance, it would be interesting to study bone thickness in revisional rhinoplasty patients as well.

In summary, we applaud the authors for their excellent contribution to the rhinoplasty literature. Rhinoplasty surgeons may find this study helpful in broadening their understanding of BV anatomy. A firm foundation of knowledge surrounding nasal anatomy is vital to the rhinoplasty surgeon for diagnosis, treatment plan design, and optimizing surgical outcomes.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES

Author notes