Nasal Hump Rhinoplasty

Updated: Feb 20, 2020
Author: Elizabeth Whitaker, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA 



As the central feature of the face, the nose has a profound effect on facial aesthetic values. Perhaps more than any other aspect of nasal aesthetics, the nasal dorsum determines the character of the nose. As stated by Lupo, "The profile, above all, is of special fascination, since it is the aspect of ourselves we never actually see." In addition to the height and configuration of the nasal dorsum, the projection of the nasal tip affects the nasal profile, and the contribution of both of these factors must be considered.

History of the Procedure

Modern concepts of nasal aesthetic values have their roots in ancient Egypt and Greece. Indeed, the first known descriptions of nasal deformities and therapies date to the Egyptian papyrus. Early descriptions of nasal and facial characteristics date to the 1600s, and the dorsal profile of the nose figures prominently in these classification schemes.

In 1845, Dieffenbach performed the first operation to alter nasal shape through external skin incisions. A lack of adequate anesthesia was a major limitation of early rhinoplasty. However, the discovery of cocaine in 1884 revolutionized the development of aesthetic rhinoplasty. The first aesthetic rhinoplasty is attributed to Roe in 1887. However, Joseph pioneered much of the early development of aesthetic rhinoplasty, including techniques and instrumentation.

Dorsal hump excision has been an integral part of aesthetic rhinoplasty surgery from its inception. The techniques and instrumentation of the early practitioners of rhinoplasty have been refined and advanced over time. However, the principles involved in dorsal hump reduction remain very similar to those of early nasal surgeons.


A dorsal hump can detract from overall nasal and facial aesthetics, particularly because of the central prominence of the nose in relation to other facial features. In men, the dorsum should ideally be straight or slightly convex to preserve a strong and masculine dorsal profile. In women, the nasal dorsum should be relatively straight with a supratip break and a nasal tip that projects 1-2 mm above the nasal dorsum.

When a dorsal nasal prominence is considered, the contribution of the depth of the nasofrontal angle and the projection of the nasal tip must also be taken into account. When a prominent osseocartilaginous vault is assessed, the forehead and the nasofrontal angle, in particular, should also be considered. The root of the nose should begin at approximately the level of the supratarsal crease with a nasofrontal angle of 115-130° (ideal angle, 120°).

The nasofrontal angle is measured by drawing a line tangent to the glabella through the nasion, which intersects a line tangent to the nasal dorsum. Any dorsal hump should be transected by the nasal dorsal line to prevent distortion of the angle. An angle that is too deep accentuates whatever dorsal prominence is present and makes the hump appear larger. Lowering the hump to the level of the nasofrontal angle may result in excessive dorsal resection. Frequently, a combination of nasofrontal angle augmentation and conservative dorsal hump resection results in a smooth dorsal profile. The dorsal line (nasion-tip) should form a 30-40° nasofacial angle with the facial plane (glabella-pogonion). Tip projection can also be assessed by various methods.

The variable skin thickness overlying the nasal dorsum should also be considered. The skin–soft tissue envelope tends to be thinnest overlying the rhinion, and straight-line resection of the dorsal prominence can result in a scooped-out appearance or a polly beak appearance in the supratip area. Overreduction of a man's nasal dorsum can feminize the patient's appearance and should be avoided.


Genetics is the predominant factor affecting growth of the nasal dorsum and nasal hump development. However, either birth trauma or trauma later in life has also been implicated in the development of a prominent dorsal convexity. Childhood injuries may go undetected until adolescence; therefore, a definitive antecedent traumatic episode may not always be elicited.

In the initial few months of life, the nose grows rapidly. This growth subsequently slows until puberty when a second peak in nasal growth occurs, during which early nasal trauma may become manifest. Because the upper lateral cartilages and nasal septum are a contiguous unit, injury to one area can affect the entire cartilaginous vault and, ultimately, the development of the nasal dorsum. Additionally, if trauma causes collapse of the middle nasal vault or decreased tip projection, the illusion of a dorsal hump may result. In patients presenting for secondary rhinoplasty, a nasal hump may represent inadequate previous resection or polly beak formation.


Both the bony and cartilaginous vaults of the nose contribute to a dorsal nasal hump. The paired nasal bones vary in size, shape, and thickness and generally provide the smaller contribution to the dorsal hump. Most of the nasal hump usually lies in the cartilaginous vault of the nose, consisting of the paired upper lateral cartilages and nasal septum. The depth of the nasofrontal angle and the projection of the nasal tip should also be considered in a prominent nasal hump.


Any surgical evaluation includes taking a careful history. Specific inquiries into past nasal trauma and symptoms of nasal airway obstruction should be made. If prior nasal trauma has occurred, any differences in nasal appearance or function should be elicited. Preaccident photographs may be useful in this assessment.

If a family member accompanies the patient, that person's nasal appearance may provide insight as to whether the nasal hump is inherited. Inquiry can be made regarding whether other family members have a similar dorsal prominence. Occasionally, family traits can carry additional hidden emotional weight. If the family is not supportive of or is resistant to the patient having rhinoplastic surgery, the physician may wish to proceed cautiously. Similar consideration should be given to patients of various ethnicities; their nasal appearance may play a role in their sense of identity and heritage. Nasal hump excision in these patients should generally be conservative, maintaining a strong nasal profile and the ethnic appearance of the nose. However, this should be discussed in detail with the patient to assess their concerns and desires.

In addition to a good medical history, any past surgical procedures or history of bleeding or anesthesia problems in the patient or the patient's family members should be noted. Any medications or herbs the patient is taking should be recorded. This information allows the surgeon to assess if any additional preoperative evaluation or testing may be necessary. Past cosmetic or rhinoplasty procedures are of specific interest. In revision rhinoplasty patients, previous operative notes are occasionally beneficial.

However, the patient's specific concerns and reasons for seeking surgical revision are more important than past operative notes. The surgeon must assess whether the patient's specific concerns are appropriate and correctable and discuss this in detail with them. In primary or revision rhinoplasty, the patient's expectations must be tempered by what can be realistically achieved. Although preoperative photographs are essential in preoperative planning and for documentation and follow-up, they can also be used to educate the patient as to what is possible and, perhaps more importantly, what is not possible.

The nasal bones should be evaluated for symmetry and width. In patients with previous nasal trauma, intermediate osteotomies may be indicated if significant convexity or concavity to a nasal bone is present. The nasal dorsum should be palpated to assess for any irregularities or asymmetries. The quality of the overlying skin should be assessed, particularly because of differences in skin thickness of the nasal dorsum. The relative contribution of the bony and cartilaginous components of the nasal hump can be assessed by palpation. An intranasal examination should be performed to evaluate for any septal deviation, turbinate hypertrophy, or nasal valve narrowing. The nasal tip should be carefully assessed.


Dorsal hump excision is an integral part of the rhinoplasty procedure in patients with prominent nasal dorsa. The dorsal hump should always be assessed in relation to the nasofrontal angle and nasal tip projection.

Relevant Anatomy

The bony pyramid

The bony pyramid consists of the ascending (frontal) processes of the maxilla and the paired nasal bones. The nasal bones are one half to one third of nasal length. Their thickness varies, with a tendency to be thicker more cephalomedially and thinner inferolaterally. Cephalically, the nasal bones articulate with the nasal process of the frontal bone at the nasofrontal suture. The nasal bones are also fused to the perpendicular plate of the ethmoid. The periosteum overlying the bony pyramid is a strong layer, adherent midline between the nasal bones at the internasal suture line.

The anatomy of the bony pyramid is significant in performing osteotomies. Generally, lateral osteotomies are performed low on the maxillary face to prevent a step-off deformity. Therefore, most of the osteotomy is made along the ascending process of the maxilla, curving to involve the nasal bones at the superior extent of the osteotomy. Because the nasal bones are thick and narrow in the region of articulation with the frontal bone, further surgical narrowing of this area is not generally indicated.

If carefully preserved, the periosteum can serve as a supportive sling for the nasal bones. The periosteum is elevated sharply in the midline out of the intranasal suture to allow dorsal hump resection without its violation. Laterally, it is elevated only as far as access to the midline bony hump requires. Ideally, the remaining attachments to the nasal bones are left intact to stabilize and support the bony fragments after osteotomies. The lacrimal sac and drainage apparatus are found laterally in the ascending process of the maxilla. Although, theoretically, a misdirected osteotomy could result in lacrimal injury, the thick heavy bone of the lacrimal crest protects the lacrimal structures, and injury rarely occurs.

Refinement of the nasofrontal area is occasionally necessary and can be difficult because the skin–soft tissue envelope is thick and may tend to bridge the concavity and blunt the underlying skeletal changes. Guyuron has estimated that approximately 25% of skeletal modifications are visible externally in soft tissue changes.[1] Because of this tendency, overcorrection is necessary in this area. Nasofrontal augmentation is accomplished more easily using autogenous cartilage or alloplastic materials. The presence of a deep nasofrontal angle is best addressed by nasofrontal augmentation combined with conservative hump resection.

The bony and cartilaginous vaults of the nose are intimately related. The cephalic margin of the upper lateral cartilages is adherent to the undersurface of the nasal bones for a distance of 7-10 mm. To avoid destabilizing the middle nasal vault, preservation of this attachment is imperative. Middle nasal vault destabilization results in a cosmetic deformity that is difficult to correct and, frequently, airway compromise. The periosteum should be carefully incised directly overlying the nasal bones to prevent inadvertent division of the attachment of the upper lateral cartilages. Also, rasping must be carefully preformed to avoid avulsing this attachment. Orienting the rasping motion in an oblique direction can minimize the risk of detachment.

The cartilaginous pyramid

The middle vault of the nose is composed of the upper lateral cartilages and the dorsal septum. The cephalic edge of the upper lateral cartilages firmly adheres to the undersurface of the bony pyramid. Caudally, the upper lateral cartilages are relatively mobile and have varying attachments with the lower lateral cartilages. Although tightly adherent or fused to the dorsal septum cephalically, more caudally the edge of the cartilage may lie more laterally and be only loosely adherent via fibromembranous connections to the septum. Laterally, the upper lateral cartilages have fibrous attachments to the pyriform aperture, and small accessory sesamoid cartilages may be present.

The upper lateral cartilages usually form a 10-15° angle with the anterior septal angle. This area comprises the critical internal nasal valve, which accounts for 50% of nasal airway resistance.

Commonly, most of the dorsal nasal hump is cartilaginous in nature with a smaller contribution from the bony component. Cartilaginous profile alignment consists of excision of the portion of the dorsal septum and upper lateral cartilages that constitute the dorsal prominence. This portion can be removed in continuity with the contribution from the bony component. The mucoperichondrium, which underlies the upper lateral cartilages and maintains their attachment to the dorsal septum, should be carefully preserved. Separation of the upper lateral cartilages from the septum is indicated for correction of a deviated middle vault or a very large dorsal hump where excision risks violation of the intranasal mucosa.

Skin–soft tissue envelope

In addressing a bony-cartilaginous hump, the overlying skin–soft tissue envelope should be considered. Unlike the skin of the nasal tip, the skin overlying the upper two thirds of the nose is relatively thin and mobile, containing little subcutaneous fat and sebaceous glands. Nasal skin varies in thickness along the length of the nose. It is thinnest over the rhinion then becomes progressively thicker in the regions of the nasion and supratip. Because of the varying thickness of the nasal skin, a slight skeletal hump should exist at the rhinion to maintain a straight dorsal profile. In addressing a dorsal hump, a straight-line reduction of the nasal skeleton should be avoided because this results in an unacceptable profile. See images below.

Because of the varying skin thickness over the nas Because of the varying skin thickness over the nasal dorsum, straight-line hump resection can result in a concave nasal dorsum profile. Rather, the nasal dorsum should be left with a slight convexity at the rhinion where the skin is thinnest, resulting in a straight nasal profile.
Because of the varying skin thickness over the nas Because of the varying skin thickness over the nasal dorsum, straight-line hump resection can result in a concave nasal dorsum profile. Rather, the nasal dorsum should be left with a slight convexity at the rhinion where the skin is thinnest, resulting in a straight nasal profile.

Overresection must be carefully avoided in the area of the rhinion where the nasal bones are more delicate. The thicker bone more superiorly in the region of the nasofrontal angle must be adequately addressed to produce a smooth dorsal profile. The dorsal hump, if present, can be removed by rasping or with a Rubin osteotome or powered instrumentation in the case of a larger dorsal hump. The dorsal hump must be carefully resected submucosally to avoid communication with the nasal cavity.

Anatomic considerations

Narrowing of the nasal dorsum is achieved with osteotomies. If minimal reduction of the nasal dorsum is required and the width of the dorsum is proportional to the nasal base, then no narrowing may be required. Decreasing the dorsal height results in an apparent widening of the nose, because the width of the nose is viewed in relation to its height. Reducing the width of the nose may restore the apparent nasal proportion. Similarly, dorsal augmentation results in an apparent narrowing of the nose.

However, whenever significant dorsal reduction has been performed, osteotomies are required to prevent open roof deformities. Lateral osteotomies medialize the lateral nasal walls. Back fracture ideally takes place between the thin and thick areas of the nasal bones. If the fracture takes place through the thicker superior bone, a rocker deformity may result, requiring an additional osteotomy in the appropriate back fracture location. If minimal hump resection has been performed, medial osteotomies may be performed to control the back fracture and alter the position of the nasal bones. Medial osteotomies are directed superolaterally and performed prior to lateral osteotomies.


Because rhinoplasty is an elective procedure, significant medical problems that could potentially increase the surgical risk are a relative contraindication. Any history of significant bleeding problems or a family history of bleeding problems warrants a more extensive preoperative evaluation. Any patient taking anticoagulants must be able to stop these medications during the preoperative and postoperative periods.



Laboratory Studies

A history of excess bleeding or bruising with mild trauma or a significant family history of bleeding problems warrants a preoperative hematologic evaluation.



Surgical Therapy

Dorsal hump excision can be accomplished through a closed or open rhinoplasty technique. The surgical approach chosen depends on the etiology of the nasal hump and other rhinoplasty maneuvers incorporated into the procedure.[2]

Preoperative Details

Once the patient and surgeon come to a mutual understanding that corrective surgery is desirable and that realistic expectations can be met, the surgical procedures, potential complications, and limitations of the surgery are discussed. Specific details are emphasized, including methods of anesthesia, financial aspects, timing, and frequency of postoperative visits, and specific postoperative instructions. At an appropriate time prior to surgery, the patient is instructed to cease any medication or herbs with anticoagulant effects.

Intraoperative Details

The procedure can be performed under general or local anesthesia. In either case, local anesthesia is injected via an intercartilaginous approach to infiltrate the lateral nasal walls. If septal and tip work are also to be performed, the septum is infiltrated, and a small amount of anesthetic is placed between the domes and subcutaneously in the columella. In delivery or open rhinoplasty approaches, injections are made in the marginal incisions. Injections are not made in the nasal dorsum to prevent any distortion. Generally, less than 8 mL of local anesthetic is required.

Surgical access can be obtained using multiple rhinoplasty approaches, including nondelivery, delivery, and open techniques, depending on the other rhinoplasty maneuvers to be performed. Access is obtained through intercartilaginous and marginal incisions in delivery approaches and through an intracartilaginous or intercartilaginous incision in nondelivery approaches. In the external rhinoplasty approach, exposure of the dorsum is achieved via marginal incisions combined with a midcolumellar incision.

In all surgical approaches, the flap is elevated in a relatively avascular plane immediately adjacent to the underlying cartilages. Over the dorsum, the periosteum overlying the nasal bones is incised and elevated in continuity with the skin–soft tissue envelope centrally. To preserve periosteal attachments and nasal bone stability, the periosteum is left intact on the nasal bones laterally.

The dorsum is then carefully evaluated. Most dorsal humps consist primarily of cartilage with a bony component. Hump excision can be performed using various techniques. Rasping alone can be used to address small bony humps. Larger dorsal humps are usually excised using a Rubin osteotome or a combination of sharp excision of the cartilaginous hump (with a knife blade or scissors) and an osteotome to remove the bony and cartilaginous hump in continuity. Powered instrumentation has also been described for bony hump removal.

To prevent blunting of the angle, dorsal hump reduction is carried to the nasofrontal angle. When excising a large dorsal hump, mucoperichondrium must not be excised with the cartilaginous hump. The elevation of the mucoperichondrium off the undersurface of the medial upper lateral crura and dorsal septum or the separation of the upper lateral crura from the septum can facilitate this. If necessary, the upper lateral cartilages are trimmed to lie flush with the nasal dorsum. After excision of the cartilaginous hump, the nasal tip is depressed to ensure that the anterior septal angle is not visible. This maneuver reduces the risk of polly beak formation if postoperative loss of tip projection is present.

The presence of a deep nasofrontal angle is best addressed by nasofrontal augmentation combined with conservative hump resection. Nasofrontal augmentation can be accomplished with autogenous cartilage grafts or alloplastic material. Deepening of the nasofrontal angle is more technically difficult. The skin–soft tissue envelope is thick in the region of the nasion and may tend to bridge over the concavity in this area and blunt the underlying skeletal changes. Guyuron has estimated that approximately 25% of skeletal modifications are visible externally in soft tissue changes.[1] Because of this tendency, overcorrection is necessary in this area. Deepening of the nasofrontal angle can be accomplished with rasps, osteotomes, or powered instrumentation.[3]

After hump excision, the patient is generally left with an open roof deformity. Rasps are then used to smooth the bony margins. All bone fragments should be carefully removed. The dorsum is carefully evaluated, both internally and externally, to assess if any additional hump removal or smoothing with the rasp is indicated. The dorsal profile should be evaluated externally both visually and by palpation. The gloved finger is moistened to allow improved tactile sensation to assess for any irregularities or asymmetries. The skin over the dorsum is pressed down to reduce edema and allow better assessment of the dorsal profile obtained. This careful evaluation allows further fine-tuning to be performed, if necessary.

Osteotomies are required to close the open roof and reestablish the bony nasal pyramid as depicted in the image below. However, in the excision of a very small hump, osteotomies may not be required if narrowing of the upper third of the nose is not desired. Medial osteotomies can be performed to create a line for a controlled back fracture. Medial osteotomies may not be necessary if a large dorsal hump resection has been performed that leaves an open roof deformity. Medial osteotomies are performed by placing the osteotome at the junction of the nasal bone and septum and fading the osteotomy line obliquely in a lateral direction while avoiding the thick bone of the nasofrontal region.

After resection of the dorsal hump, osteotomies ar After resection of the dorsal hump, osteotomies are required to close the open roof and reestablish the nasal pyramid.

Intermediate osteotomies are performed when excessive convexity or concavity of the nasal bone is observed in a severely deviated bony nasal vault. This procedure allows recontouring, as well as repositioning of the nasal bone, and is most effective in persons with overly convex nasal bones. The intermediate osteotomy is performed before the lateral osteotomies while the nasal bone still has some stability. A transcutaneous osteotomy with a 2-mm osteotome may be necessary to complete the osteotomy.

Lateral osteotomies can be performed various ways; namely, low-low, low-high, or high-low-high (curved) techniques. The high-low-high osteotomy leaves a triangle of bone intact at the pyriform aperture, which allows mobility of the lateral nasal wall without disrupting the lateral suspensory ligaments and prevents medialization of the inferior turbinate to minimize any nasal airway compromise.

An incision is made onto the pyriform aperture above the inferior turbinate. A subperiosteal tunnel can be elevated along the osteotomy tract to preserve the perichondrium. The osteotome is then seated on the bone 3-4 mm above the pyriform aperture, advanced down onto the face of the maxilla, and then angled toward a point medial to the inner canthus. The nondominant hand is constantly assessing the position of the osteotome. The osteotome is then rotated medially to complete the back fracture and to medialize the nasal bone. If the back fracture is incomplete, pressure can be applied to the nasal bone. To avoid a greenstick fracture, a 2-mm transcutaneous osteotomy can be performed to complete the fracture.

If true medialization of the nasal base is required in a nose with a wide upper and middle vault, then low-low osteotomies may be indicated. Low-high osteotomies may be used in patients with wide nasal bases with adequate nasal airways that can tolerate some narrowing. Perforating osteotomies can be performed via either a percutaneous or a transnasal approach, theoretically increasing stability by preserving a bridge of periosteum between osteotomy sites.

In performing osteotomies, the thicker bone of the nasofrontal region should be avoided. Back fracture in this region can result in a rocker deformity, in which the superior aspect of the bony segment moves laterally because of the fulcrum effect when the lateral nasal wall is moved medially. This deformity can be corrected by performing a percutaneous transverse osteotomy to complete the back fracture in the appropriate position.

After the rhinoplasty is complete, a nasal dressing, which consists of adhesive, careful taping, and a nasal splint, is applied.

Postoperative Details

The nasal splint is removed one week after surgery, and the nose is retaped using adhesive. One week later, the tape is removed, and the patient begins daily taping of the nose for the next several weeks. This taping is performed for at least 2 more weeks after the surgery or for longer if the edema is significant. Taping of the nose is an important postoperative measure because it helps eliminate the dead space between the nasal skeleton and the skin–soft tissue envelope and allows for optimal redraping.


Long-term monitoring is needed to evaluate results. Generally, patients should be monitored for one year before considering revision surgery. This monitoring period allows time for healing, scar maturation, and skin–soft tissue envelope redraping. However, subtle changes of healing and scar maturation, which can affect nasal contour and shape for years, continue to occur.


Early and late complications

Early postoperative complications include hemorrhage, edema, and ecchymosis. Hemorrhage is best treated by avoiding predisposing factors. All medications or herbs with anticoagulant effects should be avoided prior to surgery. Salicylates, in particular, should be stopped a full 10-14 days prior to surgery. A history of excess bleeding or bruising with mild trauma or a significant family history of bleeding problems warrants a preoperative hematologic evaluation.

Edema and ecchymosis occur commonly with rhinoplasty to varying degrees, depending on the patient and procedures performed. Ecchymosis generally resolves in 2-4 weeks but can be persistent for months in some patients, particularly those of Mediterranean heritage. Edema resolves more slowly over a period of months.

Fortunately, infection is a rare complication. Periostitis can occur along fracture or osteotomy lines and generally resolves with antibiotic therapy. Bone dust or fragments should be carefully removed to minimize this problem. Occasionally, callus formation at the site of bony hump removal or osteotomy sites can occur.

Osteotomy complications

Open roof deformity is primarily an issue in the following types of patients:

  • Those who require removal of large wide humps and have thick nasal bones

  • Those who have high thin humps where flattening and widening of the dorsum tends to occur postoperatively rather than the normal roundness

  • Those who have strong dorsal humps with a deviated septum, which must be corrected to allow infracture

Stair-step deformity results when the lateral osteotomy is placed too high. Greenstick fractures due to an incomplete superior fracture at the nasal root can result in lateralization of the nasal bones with time. A rocker deformity can result when the back fracture takes place through the thicker bone of the nasofrontal region. A fulcrum effect results in lateralization of the superior aspect of the bony segment when the lateral nasal wall is moved medially. Correction requires an additional osteotomy in the appropriate back fracture location.

In patients with short nasal bones, lateral osteotomy and infracture to close an open roof deformity can result in the collapse of the middle nasal vault. If this collapse is a concern, spreader grafts can be placed between the septum and the upper lateral cartilages to support the internal nasal valve and to prevent the medial collapse of the upper lateral cartilages.[4, 5]

Overresection or underresection

Saddle-nose deformity can result from overresection of the nasal dorsum. This can be corrected with dorsal augmentation with autogenous cartilage or bone grafting, depending on the severity of the deformity. Alloplastic materials can also be used.

Polly beak deformity can result from insufficient lowering of the dorsal septum as part of the dorsal hump resection. Insufficient trimming of the upper lateral cartilages to lie flush with the dorsal septum can also result in this deformity.

In dorsal hump resection, the surgeon should be conservative, as overresection is a more difficult problem to correct than underresection. If a slight dorsal prominence remains because of failure of adequate skin–soft tissue envelope redrapage or underresection, correction can be achieved readily via conservative reexcision (cartilage) or refinement with rasping (bone) at the time of revision surgery.

However, a high dorsum and slight prominence conveys a natural, unoperated look and can be a desirable outcome, particularly in the noses of men and individuals of certain ethnicities. This outcome is in contrast to the scooped-out appearance of an overresected dorsum, which can be a telltale sign of surgery.

Outcome and Prognosis

Dorsal hump resection can be a very satisfying operation for both patient and surgeon. Conservative resection of bone and cartilage can translate into a significant effect on nasal contour and character. In patients with very large humps, results may be limited by the ability of the skin–soft tissue envelope to redrape over a significant skeletal reduction. Overall, most patients are satisfied with the outcome of rhinoplasty surgery, and revision rates are low.[6, 7]

For excellent patient education resources, see eMedicineHealth's patient education article Broken Nose.

Future and Controversies

Although the general principles and techniques of dorsal hump reduction remain essentially the same, instrumentation has continually evolved. In recent years, powered instrumentation for the nasal dorsum has become available. Proponents of this technology note the advantages of increased precision and less soft tissue trauma. Traditional instruments such as rasps and osteotomes, particularly in experienced hands, accomplish the same end and remain the standard of care. However, powered instrumentation may have an advantage in challenging areas such as the nasofrontal angle.