Middle and upper vault and dorsum paramedian plateau resection is an essential tool in structure, ethnic, custom, revision and reconstructive rhinoplasties, whenever the nasal dorsum upper lateral cartilages feature a thick synchondrosis or fusion with the soft cartilaginous septum and the nasal bones synostosis with the osseous septum is a also a thick fusion one, therefore leads to the so called the reverse spreader graft effect, this is a too broad and flat dorsum, with or without hump, with either too broad middle vault, too broad upper vault or both, with a rectangular (homogeneous plateau), hourglass (upper and lower plateau with narrow middle dorsum) or rhomboid (middle dorsum plateau with narrow radix and supratip) shape.
It is carried out with scalpel parallel to septum resection of the soft cartilaginous middle vault synchondrosis and precision chisel resection of the bony upper synostosis, customized to the specific rectangular, hourglass or rhomboid shape of the plateau, so that an open roof gap between the nasal walls and the septum is achieved, therefore it is mandatory to perform nasal bones infracture osteotomies to close it and prevent deformities requiring revision in the future.
It is considered a highly demanding technique of high difficulty, long consuming in the operating room and pretty much artistic in terms of its versatility, allowing full deployment of creativity reshaping noses.
This gesture can be done by either closed or open approach rhinoplasties, notwithstanding the open approach is a must of safety, reliability and precision for its execution.
Patients warning: only highly experienced surgeons who have underwent optimal training and have performed already a large number of closed and open approach structure and non structure rhinoplasties should execute high end rhinoplasty cases, should they feel capable and comfortable with the challenge.