Ferreira-Ishida Technique: Spare Roof Technique B. Step-by-Step Guide to Preserving the Bony Cap While Dehumping

Summary: For V-shaped nasal bones, the authors consider that ostectomy of the dorsal keystone area can be avoided, and this has led to the development of a new preservation technique: the spare roof technique B (or Ferreira-Ishida technique), where the bony cap is preserved. It includes six main steps, as follows. Step 1, draw on the surface of the skin the desired dorsal brow-tip aesthetic lines, the pyriform aperture, the rhinion, and the amount of triangular bone that has to be taken out to allow pushing-down the bony cap, and the transversal line in the beginning of the nasal hump. Step 2, release the upper lateral cartilages from the dorsal septum (“high septal strip”). Step 3, take out the amount of dorsal septum necessary to dehump. Step 4, perform the paramedian high parallel osteotomies exactly below the marked brow-tip dorsal aesthetic lines. Then, perform the second group of lower osteotomies, until the E-point, to achieve a triangular shape of bone in each side of the bony cap. Perform the ostectomy of the mentioned triangular areas. Release the lateral keystone area. Perform partial ultrasonic ostectomy endonasally, below the nasal bones, to promote the weakening of the transverse fracture line, in the sagittal plane just above the E-point. Push-down gently the rectangular bony cap with a Luc nasal forceps (19 cm) in a greenstick fashion. Perform lateral traditional osteotomies from high to low to high to narrow the bony bridge as much as is needed. Step 5, perform a regular L-shape Cottle septoplasty (if necessary). Step 6, suture the cartilaginous middle vault (upper lateral cartilages) to the dorsal aspect of the remaining septum.