How a nasal hump is corrected

What is a nasal hump?

A nasal hump, sometimes called a hooked nose, is the common term for a bridge that bulges outward in the middle when the nose is seen from the side. The medical term is a dorsal hump, and in many cases both the nasal bones at the top and the cartilage below them protrude together.

The middle part of the bridge is called the middle vault, and it is formed by the upper lateral cartilages, which attach above to the nasal bones and on the inside to the septal cartilage ^[1]. Surgery to reduce a hump involves this area, so breathing needs to be considered along with appearance.

A hump can also become more prominent with age. A systematic review of rhinoplasty in patients aged 55 and older summarized the features of the aging nose as thinning of the soft tissue (atrophy), weakening and resorption of bone, a drooping tip, collapse of the nasal valve, and a more pronounced dorsal hump ^[5].

How surgery reduces the hump

In surgery, the protruding bone and cartilage are shaved down or cut away to lower the height of the bridge. After the hump is removed, an osteotomy, which cuts the nasal bones, is often performed as well to realign the contour of the nasal bones.

Osteotomy is an important technique in rhinoplasty, and it is described as involving a wide variety of approaches, directions, and instruments, with no widely standardized classification or naming ^[2]. One review summarized that, for a predictable fracture and reproducible results, it is important to cut around the nasal bones like a picture frame using medial, lateral, and transverse osteotomies ^[2].

The same review explained that osteotomy performed through the skin (percutaneous osteotomy) is increasingly used, and that intermediate osteotomies are used less often but allow greater movement ^[2]. Which combination is used depends on the shape of the nasal bones and the change needed.

Why does the middle part of the bridge need rebuilding?

After the hump is removed, how the middle part of the bridge is handled matters. One review listed the situations that call for middle vault reconstruction in a first rhinoplasty as a narrow middle vault, removal of a dorsal hump, a crooked middle vault, and an asymmetric middle vault ^[1].

Failing to manage the middle vault properly is described as potentially harming both function and appearance ^[1]. As a way to rebuild it, the spreader graft, introduced in the 1980s, is described as still being regarded as the standard repair ^[1].

A nonsurgical approach using filler

There is also nonsurgical rhinoplasty, which uses filler above and below the hump to make the bridge look even. Hyaluronic acid filler is injected above and below the bulging part of the bridge to even out its height. Rather than removing the hump itself, it works by filling in the surrounding area so the hump is camouflaged ^{[3, 4]}.

According to data from the United States, filler injections are the second most common nonsurgical cosmetic procedure, accounting for about 26% of all nonsurgical procedures ^[3]. The same review explained that nonsurgical rhinoplasty has grown greatly in popularity, but that in the United States, injecting filler into the nose is an off-label use, outside the approved indications ^[3].

Filler is a procedure that carries risks. Knowledge of the surgical anatomy of the nose and of how to manage complications is emphasized as essential for a safe result ^[3]. It has also been noted that an understanding of the blood vessels of the nose, the choice of filler, and precise injection placement is needed ^[4].

Complications and factors that affect the result

With surgery, inadequate management of the middle vault can cause problems with both function and appearance ^[1]. Osteotomy is described as able to change the contour and function of the bony part of the nose successfully only when there is a detailed understanding of the anatomy and a systematic approach ^[2]. Other problems, such as swelling and bruising, asymmetry between the two sides, and irregularities in the contour of the bridge, can also occur, and the speed of recovery varies from person to person.

Age is another factor to consider. Soft tissue atrophy and weakening of the bone have been reported in the aging nose, and the review concluded that considerations specific to this age group should be reflected in the treatment plan ^[5]. In the same study, the main reasons the author's 27 older patients had surgery were deformity after an injury (17 patients, 63%) and nasal blockage (10 patients, 37%) ^[5].

What to check during your consultation

The size and makeup of the hump, skin thickness, and the balance of the nose as a whole differ from person to person. Even with a similar-looking hump, the right method can differ, so it is best to decide after an examination has confirmed the structure of your nose.

• Whether the hump is made of bone, cartilage, or both
• Whether an osteotomy is needed, and how it would be done
• Whether the middle part of the bridge needs rebuilding
• Whether you have functional problems, such as a stuffy nose
• The risks and limitations if you choose filler