Modification of the Skoog dorsal reduction for preservation of the middle nasal vault.

Preservation of the middle nasal vault has increasingly become a topic of interest and concern in rhinoplasty. Modification of the nasal dorsum with traditional techniques may create unfavorable cosmetic results and adverse functional sequelae due to collapse of the middle nasal vault. Nasal dorsal reduction invariably involves separating the upper lateral cartilage (ULC) attachments from the dorsal septum. A number of procedures are used to reestablish the width of the middle nasal vault and competence of the internal nasal valve. Spreader grafts are the most frequently used technique. Although these grafts reliably preserve the middle vault, dorsal irregularities may result. Alternative techniques, such as suture suspension of the ULCs to dorsal onlay grafts or direct suturing of the ULCs to the septum, may pose similar problems. We have found that a modification of the Skoog technique for dorsal hump reduction preserves both a favorable aesthetic contour of the middle nasal vault and proper function of the internal valve. This procedure involves removal of the osseocartilaginous dorsum en bloc. The nasal dorsum is further reduced; the removed portion of nasal dorsum is sculpted and then replaced anatomically. Once a favorable position is found for the native dorsal graft, the upper lateral cartilages are resuspended to the graft with suture fixation. The dorsal segment thus acts as a dorsal onlay spreader graft, reestablishing a natural dorsal contour and preserving the middle nasal vault. We can avoid osteotomies in patients with an appropriate preoperative width of their bony base while correcting the open roof with the replaced dorsal segment.