We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Surgical Technique |

The Use of "Inside-Out" Lateral Osteotomies to Improve Outcome in Rhinoplasty

Patrick J. Byrne, MD; William E. Walsh, CMI; Peter A. Hilger, MD
Arch Facial Plast Surg. 2003;5(3):251-255. doi:10.1001/archfaci.5.3.251.
Text Size: A A A
Published online

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. On one 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.

Figures in this Article

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?


Place holder to copy figure label and caption
Figure 1.

Planned osteotomies. Continuous high-low-high osteotomy performed on the right side with 4-mm guarded osteotome; transnasal "inside-out" lateral osteotomy performed on the left side.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

After dissection of soft tissue from the side undergoing continuous lateral osteotomy, the disruption of the periosteal attachments laterally is demonstrated. Note the mobility of the involved segment.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

A Boies elevator inserted on the side undergoing "inside-out" lateral osteotomy. The periosteum is preserved laterally, and the segment is stable to gentle manipulation.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Nasal valve. On the right, after the high-low-high continuous osteotomy and without further manipulation, the subtle narrowing of the nasal valve angle is seen. On the left, the "inside-out" lateral osteotomy has resulted in a widening of the nasal valve angle, again without manipulation.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

A, Preoperative view of the patient's nasal deformity. B, Underlying anatomic abnormality. C, Inferior-oblique view of the underlying anatomic abnormality.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

A, "Inside-out" lateral osteotomy technique using a 2-mm straight osteotome, which results in a laterally displaced bony nasal wall. This improves the dimension of the nasal airway and preserves mucosa and periosteum. B, Lateral osteotomy technique using a curved osteotome may result in an inwardly displaced bony nasal wall. This may result in collapse of the nasal airway and disrupt the periosteum and mucosa.

Graphic Jump Location




Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

0 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles