The use of "inside-out" lateral osteotomies to improve outcome in rhinoplasty

Objective: To evaluate the anatomic effects of the transnasal nasal "inside-out" lateral osteotomy in comparison to a continuous lateral osteotomy to widen the excessively narrow bony nasal pyramid. Design: A series of 4 fresh cadavers were used. Lateral osteotomies were performed on each cadaver.Onone side, a continuous lateral osteotomy was performed with a curved, guarded 4-mm osteotome. On the contralateral side, a straight 2-mm osteotome was used to perform the transnasal perforating inside-out lateral osteotomy. The soft tissue was then dissected off the nasal dorsum and the effects were noted. Specifically, the following factors were assessed: (1) the continuity of the internal and external periosteum; (2) any change, without manipulation, of the position of the lateral nasal walls; (3) the mobility of the fragments; and (4) the effect of any of the preceding factors on the nasal airway. Results: All 4 cadavers showed identical results. The external and internal periostea were significantly disrupted on each of the sides with continuous osteotomies. The periosteum was completely preserved on the sides, which underwent inside-out lateral osteotomies, with the exception of the 3 or 4 holes created by the 2-mm osteotome. In each of the sides with continuous osteotomies, the lateral nasal wall was demonstrably unstable, as the segment was, to varying degrees, displaced inwardly. The inside-out lateral osteotomized segments were uniformly lateralized and stable to gentle palpation. Finally, these changes corresponded to a visible effect on the diameter of the nose in the region of the nasal valve. The inward displacement of the segments undergoing continuous osteotomies narrowed the airway. However, the contralateral inside-out osteotomized segments were lateralized, which widened the diameter of the valve. Conclusions: The inside-out lateral osteotomy is an effective technique for lateral repositioning of the bony lateral sidewall of the nose. It is reproducible and accurate and appears to provide greater preservation of the periosteal support of the bony segments than a continuous osteotomy. This technique provides a more predictable long-term result, with preservation and/or improvement of the nasal airway. The procedure is ideal for managing the bony nasal segment that needs lateralization, particularly in revision rhinoplasties or after trauma.