Correcting an aquiline nose: Filing or osteotomy? Understanding the surgical approaches

There are three main surgical approaches to correct an aquiline nose: filing down the dorsal hump with a rasp, combining osteotomy (bone cutting), and the conservative technique of lowering the entire dorsum while preserving its shape. Which is most suitable depends largely on the size of the dorsal hump, the ratio of bone to cartilage (tissue softer than bone), and what you want to do about the nasal bridge width[1]. Additionally, if skin thickness varies between the left and right sides, the amount of filing needed can be harder to predict accurately. The surgical plan for how much to file will greatly affect the final result[2].

When is "filing alone" sufficient for correcting an aquiline nose?

For an aquiline nose with a small dorsal hump and a bony protuberance as the main component, filing with a rasp may be sufficient. The rasp technique gradually removes the bony hump at the step while leaving the cartilaginous roof underneath intact[3]. For longer nasal bones, the hump can sometimes be smoothed by filing alone without adding osteotomy. In such cases, it is reported that you can maintain nasal bridge width while reducing the risk of narrowing the nasal airway[4]. In summary, aquiline noses with smaller dorsal humps centered on bony protuberances are better candidates for correction by filing alone.

What is the purpose of combining osteotomy?

The main purposes of adding osteotomy are to close an open roof, narrow the bony portion of the nasal width, and straighten a deviated nasal bridge. Filing away a large dorsal hump can leave an "open roof" condition in the bone (open roof deformity).[1]The procedure of combining bilateral osteotomies to straighten the nasal bridge along with filing is described in surgical textbooks as a standard approach.[4].

There are also differences in the instruments used. Piezo—an ultrasonic device for cutting bone—reportedly minimizes damage to surrounding soft tissues like skin and mucosa compared to conventional chisels (osteotomes) and rasps, and allows for more precise control of bone cutting.[5]Which instrument is used is less important than how the design closes the open roof, but it's worth knowing as one option.

What's different about the "Preservation method" that maintains the nasal bridge shape?

The Preservation method (Preservation technique) doesn't directly access the surface of the nasal bridge. Instead, it slightly reduces bone and cartilage supporting the nasal bridge from below, lowering the step while preserving the overall nasal bridge line.[6]Its key feature is not creating an open roof in the first place, which is a problem with conventional methods. However, a systematic review synthesizing many studies points out that the indication (the range this method is suited for) may have broadened too much, even to people whose nasal bridge line is already irregular. In such cases, conventional surgical techniques may be more appropriate.[6].

How is the amount to be reduced determined? The pitfall of skin thickness

Even if the same amount is reduced, the change visible on the surface differs between thick-skin areas and thin-skin areas. It's been pointed out that when skin thickness varies side-to-side, determining the reduction amount based solely on appearance during surgery tends to create discrepancies.[2]In response to this, a method has been proposed that carefully pre-plans the reduction amount based on actual measured values.[2]If you ask during counseling "How do you decide how much to reduce?", you can see the surgeon's attention to design detail.

How do you determine which surgical technique suits you?

To summarize: if the step is small and bone prominence is the main issue, a filing-only method is a candidate. When the reduction amount is large, you want to narrow the width, or correct curvature, combining osteotomy becomes a candidate. When the nasal bridge line is well-proportioned and you don't want to disturb it, the Preservation method becomes a candidate.[6][1][4]However, you cannot judge the bone-to-cartilage ratio or skin thickness from the outside yourself. Having your nose evaluated during examination to understand its composition, receiving explanation on which approach suits you, and even how the roof will be closed—this is the starting point.