Long term evaluation of "push down" procedures.

The "push-down" technique for hump removal, or hump elimination, is just one maneuver of a number of surgical steps to obtain a more functionable and esthetic appearing nose. The maxilla-premaxilla Cottle approach to extensive nasal septum surgery is used, using techniques of his to modify the nasal dorsum. The "push-down" procedure usually eliminates the bony hump. The cartilaginous hump, (the upper lateral cartilage area) remains intact, and produces little trauma to the subcutaneous tissue, the mucous membranes, the periosteum, the perichondrium, and preserves the nerves and blood supply of the area. The amount of "push-down" that can be done depends on the nasal septum, which is the key to the surgical procedure. One must know how to handle part or all of the septum; its reconstruction with the patient's own bone and cartilage, so that saddling and deformity of the external pyramid and lobule may not occur later. In the repair of the roof, all anatomic relationships should be restored. The upper lateral area should be spared, however, if modified, very conservatively done and with little or no shortening. If there is partial removal of the hump, there should also be reparation of the nasal dorsum with crushed septal cartilage. Further "push-down" depends upon the width of the nose, the location and number of lateral osteotomies and intra-septal osteotomies, incomplete or complete separation of the upper lateral cartilage, done chiefly through the intra-septum space; thus, the nose becomes narrower, smaller, and the roof remains an unimpaired insulating organ playing its important physiological role. Secondary nasal revisions were minor in nature and were usually performed as outpatient procedures. The hump removal concept of total excision should be changed to "push-down" elimination of the nasal bones with total preservation of the dorsum.