The middorsal notch: an intraoperative guide to overresection in secondary rhinoplasty.

A notch commonly appears at the midpoint of the nasal dorsum when the bridge has been resected beyond the ability of the soft tissues to contract. This notch, commonly seen in secondary rhinoplasty patients, occurs at the cephalic end of the supratip convexity and appears whether or not the tip has been overresected. The notch corresponds to the center of the "inverted V" deformity that signals middle vault collapse and may occur even when the middle vault has been reconstructed by spreader grafts. The middorsal notch also appears intraoperatively and therefore can guide the surgeon in determining the limits of dorsal skeletal resection. Ablation of the mid-dorsal notch by dorsal grafting is effective in both primary and secondary rhinoplasty patients.