The Keystone: Consistency in Restoring the Aesthetic Dorsum in Rhinoplasty

Afrooz PN, Rohrich RJ.

What this paper says

A short technique article on the keystone, the junction of six anatomical structures between the bony and cartilaginous parts of the nose, arguing that equalizing width across it prevents the inverted V deformity.

Overview

The keystone is where the nasal bones meet the cartilage of the middle nose. When a hump is removed, the fusion points there are released and the individual parts of the nose settle in different ways. This article addresses how to restore that junction so the bridge line stays smooth.

Sections of note

The keystone is defined as the union of six distinct anatomical structures between the bony vault and the cartilaginous midvault.
When the dorsum is reshaped, the individual components respond variably as the keystone fusion points are released.
Restoration requires meticulous effort to equalize the width between the bony vault and the cartilaginous midvault.
The authors state that width equalization techniques yield gratifying long-term results.
The named pitfall to be avoided is the inverted V deformity.
The abstract reports no patient numbers, techniques by name, outcome rates, or follow-up.

What it means for a patient

A visible V-shaped shadow partway down the nose comes from a width mismatch where the bone ends and the cartilage begins.
That mismatch is created when a hump is removed and must be corrected in the same operation.
The stated principle is matching the widths of the two sections rather than reducing one further.
This is a brief technique article with no data, so it reports no rates of the deformity or of its prevention.

Why this paper matters

The inverted V is one of the recognizable signs of an older rhinoplasty and a common revision complaint. Framing prevention as a width matching problem at one anatomical junction makes it a checkable step. No outcome data accompanies the recommendation.

Terms

Keystone: The junction where the nasal bones meet the cartilage of the middle nose.
Bony vault: The upper part of the nose supported by bone.
Cartilaginous midvault: The middle third of the nose supported by cartilage.
Inverted V deformity: A visible V-shaped shadow where the bone ends and the middle vault has narrowed.
Nasal dorsum: The bridge of the nose.

Summary written by rhinoplasty.cc from the abstract, 2026-09-09; not medical advice. The authors' own abstract follows.

From the abstract

“The keystone represents the union of six distinct anatomical structures between the bony vault and the cartilaginous midvault. In reshaping the nasal dorsum, the individual components of the nose respond variably as the fusion points of the keystone are released. In restoring the nasal dorsum, meticulous effort is…”

Excerpt; the full abstract is on PubMed.