Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 301e306

Classification of convex nasal dorsum deformities

in Asian patients and treatment outcomes
Yong Ju Jang*, Ji Heui Kim
Department of Otolaryngology, Asan Medical Centre, University of Ulsan College of Medicine, 388-1 Pungnap-2
dong Songpa-gu, 138-736 Seoul, South Korea
Received 2 April 2010; accepted 28 May 2010

KEYWORDS
Rhinoplasty;
Convex nasal dorsum
deformity;
Classification;
Asian

Summary Background: A new classification system for dorsal humps in Korean patients with
nasal dorsum deformities was designed. Patients were treated based on these classifications,
and their treatment outcomes were assessed.
Methods: A total of 164 patients, who underwent rhinoplasty for correction of convex nasal
dorsum deformities, were analysed. Convex dorsum deformities were classified based on
anthropometric measurement, nasal length, hump length and tip projection. The three classifications were generalised hump, isolated hump and relative hump because of a low tip. Postoperative photographs were analysed to assess hump reduction outcomes.
Results: Generalised hump was the most common deformity, occurring in 88 (53.7%) patients;
an isolated hump was observed in 67 (40.9%) patients and a relative hump, with a low tip, was
observed in nine (5.5%) patients. Successful surgical outcomes were achieved in 65.9% of
generalised hump cases and 80.6% of isolated hump cases (p Z 0.014). Of the fair or poor
outcomes, 89.6% were attributable to hump undercorrection.
Conclusion: Our classification system could help surgeons tailor management of convex nasal
dorsum deformities. The present study showed that the milder the deformity, the better
was the outcome. It was also found that excessive conservation in hump reduction was the
main factor predictive of unsatisfactory outcome.
2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

Reduction rhinoplasty for dorsal humps is one of the most

commonly performed procedures on Caucasian noses.1
Compared with the noses of Caucasians, Asian (i.e.,
Korean, Chinese and Japanese) noses are generally smaller

and less prominent. Accordingly, the prevalence of hump

nose is relatively low among Asians.
Rhinoplasty for Asian noses has traditionally been oversimplified, with over-use of augmentation rhinoplasty

* Corresponding author. Tel.: 82 2 3010 3712; fax: 82 2 489 2773.

E-mail address: jangyj@amc.seoul.kr (Y.J. Jang).
1748-6815/$ - see front matter 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2010.05.032

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Y.J. Jang, J.H. Kim

Figure 1 Preoperative profile views. Convex nasal dorsum deformities were classified as (A) generalised humps, (B) isolated
humps, or (C) relative hump with low tip.

employing an alloplastic material such as prefabricated

silicone.2,3 However, this simple approach is not a universal
remedy for the various aesthetic features presenting in
Asian noses, particularly a dorsal hump.
Humpectomy, followed by osteotomy and tip surgery, is
typically required for dorsal-hump reduction in Caucasian
noses.1,4 However, the under-developed and under-projected Asian nose may require a different strategy such as
reduction, in combination with dorsal augmentation.
There are many types of dorsal-hump deformity in Asian
noses. Whereas some convex nasal deformities would be
considered typical hump noses, others could be considered
variants thereof. Different types of humps require distinct
therapeutic plans, but reports addressing this issue are
sparse.
The present study describes our approach to treating
convex nasal deformities in Korean patients. A new classification system was designed based on hump characteristics. Our surgical experience and patient outcomes,
according to our classification system, is presented.

Methods
Study design
This study was approved by the Institutional Review Board
of Asan Medical Center before we undertook this study. This
study involved 164 patients, who underwent rhinoplasty for
correction of convex nasal dorsum deformities from 1
January 2003 to 31 July 2008. The patients comprised 109
men and 55 women ranging in age from 15 to 68 years
(mean 27.7  9.0 years). The minimum follow-up was 20
months. Two independent rhinoplastic surgeons (J.Y.M and
M.S.Y) classified humps, and analysed the pre- and postoperative photographs. Postoperative outcomes in terms of
successful hump reduction were classified as excellent, fair
or poor, 10 months after the surgery.

Figure 2 Receiver operation characteristic curve used to

discriminate between generalised and isolated humps for
convex nasal deformities. y Both sensitivity and specificity
were high when a hump length greater than 45% of the total
nasal length was defined as a generalised hump (p<0.001).

Classification of convex nasal-dorsum deformities

Table 1 Distribution of convex nasal deformities according to our classification
Types

Number of cases
(N Z 164)

Generalised
Isolated
Relative hump due to low tip

88 (53.7%)
67 (40.9%)
9 (5.4%)

Classifications of the convex nasal dorsum

deformity
Convex nasal dorsum deformities were designed based on
anthropometric measurements, emphasising the profile
view. Using such preoperative profiles, the nasal length,
hump length and nasal-tip projection were measured using
sliding callipers. Nasal length was measured from the nasion
along the dorsum to the point where a line from the nasolabial angle intersected the line of measurement. Hump
length was assessed by measuring the basal portion of the
hump parallel to the nasal length. Nasal-tip projection was
estimated from the nasolabial angle to a point where a line
from the nasion along the dorsum intersected the line of
measurement.5 The proportions of nasal length, hump
length and nasal-tip projection were next calculated.
Deformities were then subjectively categorised into one of
the three groups: generalised hump, isolated hump and
relative hump attributable to low tip. The generalised hump
represents the typical hump seen in Caucasian populations in
which hump curvature begins from the bony vault and
continues down to the cartilaginous dorsum in a gentle curve
(Figure 1A). An isolated hump is an instance of abrupt
protrusion of a small hump in a triangular or rounded shape
on the dorsal line (Figure 1B). The total length of an isolated
hump is short, and, when exposed at surgery, most of the
hump is located around the rhinion. The relative hump with
low tip is seen when the height of the nasal dorsum is not so
prominent, but, instead, the nasal tip is very low, giving
a false impression of a dorsal hump (Figure 1C). These
observer classifications were next converted into numerical
objective classifications using a cut-off point derived from
receiver operating characteristic (ROC) curve analysis. When
a hump length, over 50% of the nasal length, was defined as
a generalised hump, the sensitivity was 88.6% and the
specificity was 100%. When a hump length, over 40% of the

Table 2
dorsum

Additional surgical procedures on the nasal

Dorsal
augmentation
Radix
augmentation

Generalised
hump
(n Z 88)

Isolated
hump
(n Z 67)

Relative hump
with low
tip (n Z 9)

69 (78.4%)

61 (91.0%)

6 (66.7%)

14 (15.9%)

6 (9.0%)

1 (11.1%)

303
nasal length, was defined as a generalised hump, sensitivity
was 100% and specificity was 70.1%. When a hump length,
over 45% of the nasal length, was defined as a generalised
hump, sensitivity was 98.9% and specificity was 98.5%.
Therefore, the cut-off point for discriminating between
a generalised and isolated hump was set at 45% (i.e., the
hump length was 45% of the nasal length) (Figure 2). In
patients with a relative hump and a low tip, the mean
proportional height of the nasal tip with respect to nasal
length was 27.3  3.5%. Therefore, a proportional hump
length over 45% of nasal length was defined as a generalised
hump, a hump length below 45% of the nasal length was
considered to be an isolated hump and, when the tip
projection with respect to nasal length was below 30%, the
deformity was classified as a relative hump with low tip.
Differences between groups in terms of postoperative
outcomes were analysed using chi-square tests. Data analyses were performed using Statistical Package for the Social
Science Programme (SPSS) for Windows, version 15.0 (SPSS
Inc., Chicago, IL, USA).

Surgical techniques
Generalised hump
An open approach was preferred for treating generalised
humps. Hump removal was conducted using component
dorsal hump reduction, in which the first step was division
of the upper lateral cartilage from the septal cartilage
proper. Excessive septal cartilage in the dorsal aspect was
next resected using a blade, and the bony hump was
reduced using a hump osteotome. Judicious removal of the
dorsal aspect of the upper lateral cartilages was then
undertaken. Open-roof deformities in the bony dorsum
were usually closed using medial and lateral osteotomies.
Placement of spreader grafts was the preferred method of
reconstructing the cartilaginous dorsum. In most patients,
tip surgery techniques were required to project the nasal
tip and to improve tip support. When a patient presented
with a low radix, radix augmentation was performed using
crushed cartilage, resected hump or fascia. Some patients
with generalised humps requested dorsal augmentation.
In such instances, augmentation of the cartilaginous
dorsum e the level of which was adjusted based on the
newly created tip height e was conducted to create an
ideal dorsal profile line.
Isolated hump
Isolated humps were treated using either open or closed
approaches based on the degree of deformity. Hump
reduction was usually conducted as an en bloc removal and/
or incremental rasping. Osteotomy was performed based on
the width of the open-roof deformity or dorsal deviation.
Osteotomy was not performed if the removed hump was
small and the remaining dorsal ridge was not very prominent. Placement of spreader grafts was also performed in
selected patients. Tip surgery and dorsal augmentation
were performed as described above for generalised humps.
Relative hump with low tip
The mainstay treatment, for patients presenting with
relative humps and low tips, was surgery to improve tip
projection and support. Various surgical techniques were

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Y.J. Jang, J.H. Kim

Figure 3 Examples of excellent surgical outcomes according to 20-month postoperative photographs. (A) generalised hump, (B)
isolated hump, and (C) relative hump with low tip.

used including caudal septal-extension grafts, columellar

struts, shield grafts and suture techniques. Caudal septalextension grafts were preferred when significant tip
projection was required. These patients did not usually
require significant dorsal augmentation. The dorsum,
particularly the cartilaginous dorsum, was raised to correspond to the newly elevated nasal tip. During the dorsal
augmentation procedure, we avoided the use of large hard
implants to re-elevate the deprojected dorsum, and

Table 3

Surgical outcome according to deformity

Generalised
hump (n = 88)
Isolated
hump (n Z 67)
Relative hump with
low tip (n Z 9)
a

Excellent

Fair

Poor

58 (66.7%)

27 (31.0%)

2 (2.3%)

54 (80.6%)a

12 (17.9%)

1 (1.5%)

3 (33.3%)

5 (55.6%)

1 (11.1%)

A higher success rate was achieved in the milder cases (Chisquare test, p Z 0.014).

instead employed relatively soft materials such as autologous cartilage, fascia and Gore-Tex.

Results
A total of 164 patients were examined, and nasal deformities were classified as being either generalised humps,
isolated humps or relative humps attributable to low tips.
Generalised humps were the most common deformity,
occurring in 88 (53.7%) patients. The second most common
deformity was the isolated hump, observed in 67 (40.9%)
patients. Relative humps with low tips were recorded in
nine (5.4%) patients (Table 1).
Dorsal augmentation was performed on 69 (78.4%) generalised hump patients, 61 (91%) isolated-hump patients and six
(66.7%) relative hump with low-tip patients. Radix augmentation was required in 14 (15.9%) generalised hump patients
and in six (9%) isolated-hump patients (Table 2). The types of
augmentation used were fascia allograft plus crushed cartilage in 37 (27.2%) patients, fascia allograft in 35 (25.7%)
patients, crushed cartilage in 33 (24.3%) patients, resected
hump, together with fascia allograft and/or crushed cartilage, in 10 (7.4%) patients, pericardium allograft with crushed

Classification of convex nasal-dorsum deformities

Figure 4

305

Example of poor surgical outcomes. (A) undercorrection, and (B) overcorrection.

cartilage in seven (5.1%) patients, pericardium allograft in six

(4.4%) patients, silastic sheet in three (2.2%) patients, GoreTex in three (2.2%) patients, costal cartilage in one (0.7%)
patient and alloderm in one (0.7%) patient.
Two independent surgeons (J.Y.M and M.S.Y) viewed
postoperative photographs to assess the outcomes. Fair-toexcellent surgical outcomes were achieved in 80.6% of isolated-hump patients, 66.7% of generalised hump patients
and 33.3% of relative hump with low-tip patients (Figure 3).
Further analysis indicated that a higher success rate was
achieved in patients with milder hump problems (p Z 0.014)
(Table 3).
Outcomes were judged to be fair or poor in 48 (29%)
patients, based on either over- or undercorrection, with the
major problem being undercorrection (Figure 4). In such
instances, undercorrection was observed in 86.2%
of generalised hump patients, 92.3% of isolated-hump
patients and 100% of relative hump with low-tip patients.
Further, overcorrection was observed in 13.8% of generalised
hump patients and 7.7% of isolated-hump patients (Table 4).

Discussion
Management of hump-nose deformities can be challenging in Asian patients as Asians have less cartilaginous
support and a smaller tip projection compared with
Caucasians.6 Thus, a simplistic reductive surgical

Table 4 Cause of fair or poor surgical outcome in

different convex nasal dorsum deformity classes
Overcorrection

Undercorrection

Generalised hump
Isolated hump
Relative hump
with low tip

4 (13.8%)
1 (7.7%)
0 (0%)

25 (86.2%)
12 (92.3%)
6 (100%)

Total

5 (10.4%)

43 (89.6%)

approach may jeopardise aesthetic success, when applied

to Asian noses. A comprehensive nasal deformity classification system would greatly enhance surgical planning
and management. However, no such system appears to
exist, with current descriptions often limited to hump
size assessment such as small, medium (i.e., 3 mm or less)
or large.7
The present study is the first to attempt to classify convex
nasal deformities in Asian noses. The classifications of
generalised and isolated deformity correlated well with
objective hump assessment using anthropometric measurements. Both sensitivity and specificity were at their highest
values, when the cut-off point dividing deformities into
generalised and isolated humps was set to 45% (the proportion of the nasal length affected by the hump).
Hump reduction can be performed using open or closed
approaches. An open rhinoplasty approach was preferred
and particularly useful in generalised hump cases where
several surgical manoeuvres, other than simple-hump
reduction, were required.
The present patient series was treated using a relatively
high number of dorsal augmentation procedures. There are
several reasons why augmentation should be included in
hump management. First, some patients require correction
of minor contour irregularities. Second, many Asian
patients desire augmentation, together with reduction,
because they have relatively small, flat and low-projection
noses. In addition, most patients with convex nasal deformities require tip elevation first, after which the dorsum
should be correspondingly elevated to create a harmonious
dorsal line. This is particularly applicable in patients with
a low-nose tip. Therefore, we suggest that corrective
surgery for convex nose deformities in Asian patients should
be considered more as a redistribution surgery, rather than
merely reduction.
In this study, the hump reduction success rate was higher
for isolated humps than for either generalised humps or
relative humps with low tips. This suggests that the milder
the deformity, the greater is the likelihood of surgical
success. Five cases (3%) of overcorrection, out of a 164strong study population, were experienced. However,

306
a relatively high incidence of undercorrection was
observed. It appears this was mostly attributable to our
conservative approach to resection of the cartilaginous
hump. Thus, surgeons might need to have a little aggressive
attitude in the management of convex dorsum to avoid
undercorrection.
It is the authors belief that convex nasal dorsum
deformity correction in Asian patients should be
considered a redistribution rather than a classical
reduction. To this end, dorsal augmentation with soft
material such as Tutoplast-processed fascia lata is quite
useful.8,9In addition, the establishment of proper tip
projection and support is critically important for
a successful outcome.
We designed a classification system for convex nasal
dorsum deformities in Asian patients. Such an approach
is likely to assist in tailored management planning. In
addition, the hump needs to be reduced more aggressively
to have a better surgical outcome.

Conflict of interest
There are no financial and personal relationships with other
people or organisations that could inappropriately influence this manuscript.

Y.J. Jang, J.H. Kim

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