The authors performed a prospective cadaveric study (N=20). They evaluated different fracture patterns in order to define the necessity for performing paramedian or transversal osteotomies. To do so, the cadavers were divided into two groups. Ten had a paramedian osteotomy combined with a high-low-high (HLH) osteotomy on one side and a HLH osteotomy alone on the other side. In the second group, a paramedian osteotomy was combined with a transverse osteotomy followed by a straight high-low-low (HLL) osteotomy on one side. On the other side the HLL osteotomy was only combined with the paramedian osteotomy. The authors found that single HLH osteotomies lead to more unstable and greenstick fractures than osteotomy patterns that included HLH and paramedian osteotomies (p<0.001). In the second group performance of transverse osteotomies resulted in more controllable HLL fracture lines (p<0.05). HLL osteotomies without transverse fractures, showed a tendency to deviate into a higher pattern as the osteotomy approached medial canthus, even if a straight osteotomy was used. In conclusion, the authors suggest in absence of a bony hump to combine lateral HLL osteotomies with paramedian osteotomies in order to mobilise the lateral bony sidewalls in a predictable manner. When performing a paramedian and HLL osteotomy the transverse osteotomy should be performed before the HLL to achieve predictable lines and adequate mobilisation of the nasal wall. In the absence of a bony hump removal, the central segment of the bony dorsum located between the paramedian osteotomies cannot be adequately mobilised reliably, unless transverse osteotomies of that segment are performed.