A Grading System for Nasal Dorsal Deformities - JAMA Network
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ORIGINAL ARTICLE
A Grading System
for Nasal Dorsal Deformities
Matthew A. Kienstra, MD; Holger G. Gassner, MD; David A. Sherris, MD; Eugene B. Kern, MD
T
here is no uniform grading system for nasal dorsal deformities currently in general use
among surgeons who perform rhinoplasty. Given the popularity of this procedure among
both the general public and surgeons, it is time that there was a uniform system de-
scribing dorsal deformities. Such a system has value in the education of students of
rhinology and cosmetic nasal surgery. We have developed one such system, and applied it to
100 cases. In all cases it accurately describes the major pathological conditions of the dorsum, if
present, as noted on physical examination. We have found application of this system to be
facile. Arch Facial Plast Surg. 2003;5:138-143
A GRADING SYSTEM FOR abnormality is corrected, while in the case
NASAL DORSAL DEFORMITIES of deficiency, the area of abnormality is
built up with graft material to yield a
There is no uniform grading system for na- straight dorsum. Note that a deficiency in
sal dorsal deformities that is generally ac- the dorsum can result in the saddle nose
cepted. As noted by one author,1 “most appearance as well as in the hump nose
descriptions of the dorsum are qualita- appearance. Twisted, S-shaped, and C-
tive and anecdotal.” Commonly used shaped are also inadequate descriptors,
descriptors such as “saddle,” “hump,” again because they do not describe the por-
“twisted,” “S-shaped,” and “C-shaped” do tion (bony and/or cartilaginous) of the dor-
not adequately describe anatomic irregu- sum involved. Therefore, they are not help-
larities. For instance, a saddle nose is gen- ful in planning a surgical procedure.
erally defined as one in which there is a For experts to accurately discuss
dorsal deficiency, but whether this defi- cases, it is necessary for all discussants to
ciency is bony, cartilaginous, or both is not agree on and understand the terms used.
specified. For surgical planning, it is im- This also is extremely valuable for the edu-
perative to know which portion(s) is in- cation of surgeons as a tool aiding under-
volved, as it affects what the surgeon will standing of the anatomic anomalies of the
do to correct the deformity. Similarly, the nasal dorsum and their surgical correc-
term hump does not adequately describe tion. For these reasons, we have de-
the dorsal abnormality present. The hump signed a grading system for dorsal defor-
could involve the bony or cartilaginous mity that is easy to use and accurately
dorsum, or both. Furthermore, a hump describes nasal dorsal pathology.
could be due to an overprominence of the The term “dorsum” is used in this ar-
bony and/or cartilaginous dorsum, or a de- ticle to describe the region from the naso-
ficiency in one or both of these areas. In jugal or nasofacial groove to its opposite
the case of overprominence, dorsal resec- counterpart horizontally, and from the
tion is the surgical method by which the depth of the nasofrontal angle (nasion)
From the Division of Rhinology and Facial Plastic Surgery, Mayo Clinic, superiorly to the base (caudal end) of the
Rochester, Minn. upper lateral cartilage inferiorly (Figure 1).
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Downloaded From: https://jamanetwork.com/ on 01/11/2023Figure 1. The nasal dorsum.
THE GRADING SYSTEM They can coincide (eg, both too wide, too narrow, or nor-
mal) or differ (eg, wide nasal bones, normal or narrow
Kienstra-Sherris-Kern (KSK) Classification upper lateral cartilage, or wide upper lateral cartilage but
of Nasal Dorsal Deformities normal or narrow bony dorsum).
The classification is as follows: Deviation (D). Deviation describes variance of the dor-
sum from the midline. The dorsum should be straight
W+ wide dorsum
to give the best aesthetic result. Deviation to one side or
W− narrow dorsum the other results in asymmetry and a cosmetic defor-
W0 normal width mity. The bony and cartilaginous portions of the dor-
D+ deviation to the right sum, again, are examined separately. They both can de-
D− deviation to the left viate to the same side, one may deviate while the other
D0 no deviation is midline, or both may deviate in opposite directions.
C+ convex on lateral view In general, when dorsal deviation is present, the oppo-
C− concave on lateral view
C0 no curvature (straight)
site side of the dorsum is longer than the side to which
P+ overprojected (prominent) the dorsum is deviated.
P− underprojected (pushed in)
P0 normal projection Curvature (C). In profile, the dorsum can be straight,
or it may be concave or convex. The variance from straight
Description of Terms can be primarily bony or primarily cartilaginous, or it can
involve both parts of the dorsum nearly equally.
Width (W). Dorsal width describes the horizontal di-
mension of the dorsum. The bony and cartilaginous por- Projection (P). Dorsal projection describes the dorsum
tions are examined separately. The bony dorsum in- from its origin on the face to its outermost point in pro-
cludes the frontal processes of the maxillae, nasal portions file. Projection can be excessive, with the dorsum ex-
of the frontal bones, and the nasal bones. The cartilagi- tending too far off of the face, or it can be insufficient,
nous portion is composed of the upper lateral cartilage. not extending far enough off the face. The cartilaginous
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D+ D–
Figure 2. The grading system. Photographs depict examples of abnormalities in each of the categories. See “The Grading System” section for classification and
description of grades.
and bony portions of the dorsum must be examined sepa- Either can be overprojected, underprojected, or nor-
rately, as the projection of each may coincide or differ. mally projected.
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P+ P–
Figure 2. (cont)
Case Examples be surmised from the descriptions, in each category the
General examples of abnormalities in each of the catego- bony and cartilaginous portions of the dorsum are ex-
ries can be seen in the photographs in Figure 2. As can amined separately. We use “B” to represent a bony ab-
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C D
Figure 3. Sample case (A and B, profile view; C and D, frontal view). For detailed explanation of this case, see the “Case Examples” section of the text.
normality, if present, and “C” for a cartilaginous tion, the descriptor would be “P+B.” A rating is given in
abnormality. We use “BC” if both are present. Thus, for each case in each of the aforementioned categories. If
an overprojected dorsum with only bony overprojec- no abnormality is present in a given category, a rating of
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Downloaded From: https://jamanetwork.com/ on 01/11/2023“0” is given in that category (to signify absence of presence of curvature. In both situations, accurate grad-
abnormality). To illustrate, examine the case presented ing requires the evaluator to attempt to visualize the dor-
in Figure 3. sum as if the deformity were absent. Note the profile view
In Figure 3, note the profile view. There is a dorsal with the convexity in the photograph series of the ex-
convexity present (C+). This involves both the bony and ample patient (Figure 3). The dorsum is overprojected
cartilaginous dorsum (C+BC). The dorsal projection ap- at the convexity. However, the remainder of the dorsum
pears to be normal (P0) in profile, except where the con- has acceptable projection. If the convexity were re-
vexity is present. In frontal views, there is deviation of the moved by resection, the remaining, now straight,
bony portion of the dorsum to the left, while the cartilagi- dorsum (in profile) would have acceptable projection
nous portion deviates back to the right (D−B+C). Dorsal (figure with convexity shaded out). Therefore, this pa-
width appears to be acceptable in the bony portion, but tient’s projection grade is P0.
the cartilaginous portion appears wide (W+C). Thus, this Each of the portions of the grading system has surgi-
patient’s KSK grade would be W+C, D−B+C, C+BC, P0. cal implications. The wide nose requires narrowing. The
In using this system, focus should be maintained on narrow nose requires widening (eg, with spreader grafts).
cosmetically significant deformities. Many patients have The deviated nose requires careful osteotomy placement,
subtle isolated abnormalities, but have an overall excel- resection, rasping, cartilage shaving, and/or onlay grafting
lent cosmetic appearance. for correction.2-5 The convex or concave dorsum requires
straightening by resection, rasping, and/or grafting.6,7 The
METHODS overprojected dorsum requires removal of tissue, while the
To examine the utility of the grading system, 2 of us (M.A.K., underprojected dorsum requires buildup.6 Attention to each
D.A.S.) independently graded 100 (50 male, 50 female) uni- of these areas is crucial in surgical planning to ensure the
form sets (6 views, including frontal, left and right profile, left best cosmetic result. This is not to say that other factors
close-up, base, and left smiling) of 5⫻7 in nasal photographs. do not play a role. Obviously, the nasal tip must be exam-
The grades given in each case were compared. ined and any deformity corrected. The nasofrontal angle,
in addition, must be noted and corrected if overwide or over-
RESULTS narrow, or maintained if aesthetically pleasing. This sys-
tem addresses nasal dorsal deformity by itself. It is not an
Results of photographic evaluation are presented below: attempt to describe all nasal abnormalities that must be ad-
Grade Agree/Disagree, %
dressed during rhinoplasty, and should not be viewed as
Width 71/29 such.
Deviation 78/22 The advantages of having a uniform grading system
Curvature 78/22 are myriad. It provides a common ground for intelligent
Projection 65/35 discussion between experts. It assists education of future
Average 73/27 surgeons by providing a uniform teaching system that cov-
There was an average agreement over all categories ers most, if not all, aspects of pathology and provides the
of 73%. There was 78% agreement in the deviation and basis for logical decision making. It aids surgical planning
curvature categories, 71% agreement in the width cat- and therefore decreases risk of poor results.
egory, and 65% agreement in the projection category. We believe the KSK system is accurate and facile and
There were no complete disagreements where opposite can yield these advantages if generally adopted.
abnormalities were thought to have existed (eg, one evalu-
ator grading a “+” while the other graded “−” in the same
category). Accepted for publication July 9, 2002.
Corresponding author: Matthew A. Kienstra, MD, Di-
vision of Facial Plastic Surgery and Rhinology, Department
COMMENT
of Otolaryngology, University of South Florida, MCC-HN
We believe that the disagreements reflect subtle differ- PROG, 12902 Magnolia Dr, Tampa, FL 33612-9497.
ences that are not highly significant. We expect improve-
ment in agreement between surgeons when results of the
REFERENCES
physical examination can be added to the evaluation (all
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