It is a matter of highly experienced aesthetic judgment determining what is the right level of a dorsum; such a decision has to take into consideration the tip level, the frontal bone level, the overall facial profile balance and the final nasal size wished or planned.
The same perfect and straight profile can be set at different levels or heights, as long as the radix, the bony dorsum, the cartilaginous middle vault, the supratip and the tip are in the right alignment; deciding what is the adequate alignment line is important in many cases but in those like the one shown here it is extremely difficult to assess and much more to execute technically.
After a thorough reflection it was deemed, evident by the final outcome, necessary applying the principle of the two elevators, one ascending and the other descending in order to meet at the right level.
On one side there is an excessive hump at the upper dorsum, made up by oversized nasal bones which was aggravated by the multiple fractures happened leading to bone thickening; on the other side there is a sunken profile or saddle nose deformity at the lower half of the dorsum or middle vault, caused by multiple crushes of the supportive caudal septum which has collapsed; finally, the tip, in this specific case, was deemed optimal in projection, considering the heavily masculine facial balance of this patient.
With that said, the right neo level for the dorsal profile is somewhere between the bony hump and the sunken middle vault; setting the right level at the bony hump would lead to a straight profile by means of massively raising the sunken part and significantly lengthening the tip, however this would entail an oversized nose; setting the right dorsum at the sunken middle vault would force to perform an aggressive reduction scooping of the nasal bones and deproject the tip, ending in a disproportionately small and flat nose, like some ethnicities; this patient's nose needed both, lowering the upper part of the dorsum and raising the lower part, with no changes of tip length.
A complex revision rhinoplasty procedure was applied to shave down the osseous hump and apply a double layered onlay supratip cartilage grafting to raise the sunken middle vault, adding a columella strut graft to prevent the collapse tendency of the tip; minor tip downsizing was performed.
Not seeking the patient other specific refinements but correcting his posttraumatic step shaped dorsum, the procedure did not include other interesting high end techniques of structure rhinoplasty in order to achieve a more ambitious result; being the dorsal skin of the nose thick prevented the use of temporalis fascia grafting to camouflage the double dorsal work, shaving plus grafting; the final outcome is simply as seen in the images, a perfectly balanced dorsum level, straight, not too high and neither too low, with good tip support and complying with the patient's goals.
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