Correction of a crooked nose is one of the most common requests from patients presenting for rhinoplasty. Both esthetic and functional issues are typically present in patients with this deformity. Rhinoplasty for the crooked nose is particularly challenging because multiple nasal structures, both external and internal, are commonly involved. A major septal deformity is almost always a component of severely deviated noses. The crooked nose results from extrinsic and intrinsic forces that produce distortion of the nasal structures and nasal deviation. The open approach is particularly useful and is the focus of this article.
Key points
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Both esthetic and functional issues are typically present in patients with this deformity.
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A major septal deformity is almost always a component of severely deviated noses.
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The crooked nose results from extrinsic and intrinsic forces that produce distortion of the nasal structures and nasal deviation.
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The exposure afforded by the open approach allows maximal accuracy in diagnosis and control in achieving optimal repair of the crooked nose.
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The osteocartilaginous framework can be modified and reconstituted under direct visualization through the open approach, resulting in more predictable correction of the crooked nose.
Introduction
Correction of a crooked nose is one of the most common requests from patients presenting for rhinoplasty. The crooked nose is also referred to as the deviated or the twisted nose. The nose can appear crooked for several reasons ( Fig. 1 ):
- 1.
The nose or parts thereof deviate from the vertical midline of the face
- 2.
The nose has asymmetries and irregularities that create an unbalanced and crooked appearance.
The crooked nose may be congenital or acquired secondary to trauma or previous surgery. Both esthetic and functional issues are typically present in patients with this deformity. Severely crooked noses are particularly challenging because multiple nasal structures, both external and internal, are commonly involved. A major septal deformity is almost always a component of severely deviated noses.
The crooked nose results from extrinsic and intrinsic forces that produce distortion of the nasal structures and nasal deviation. Extrinsic forces include congenitally asymmetrical attachments of the osteocartilaginous skeleton, including attachments between the bony pyramid, the upper lateral cartilages, the lower lateral cartilages, and the septum, and can also be secondary to scar contracture following trauma or surgery. Intrinsic forces are those inherent to the septal cartilage as well as the upper and lower lateral cartilages.
Given the underlying structural deformities that are commonly observed in the crooked nose, the open approach is particularly useful and is the focus of this article. Outlined are principles for treating the crooked nose to improve predictability and reliability of rhinoplasty for this challenging problem.
Introduction
Correction of a crooked nose is one of the most common requests from patients presenting for rhinoplasty. The crooked nose is also referred to as the deviated or the twisted nose. The nose can appear crooked for several reasons ( Fig. 1 ):
- 1.
The nose or parts thereof deviate from the vertical midline of the face
- 2.
The nose has asymmetries and irregularities that create an unbalanced and crooked appearance.
The crooked nose may be congenital or acquired secondary to trauma or previous surgery. Both esthetic and functional issues are typically present in patients with this deformity. Severely crooked noses are particularly challenging because multiple nasal structures, both external and internal, are commonly involved. A major septal deformity is almost always a component of severely deviated noses.
The crooked nose results from extrinsic and intrinsic forces that produce distortion of the nasal structures and nasal deviation. Extrinsic forces include congenitally asymmetrical attachments of the osteocartilaginous skeleton, including attachments between the bony pyramid, the upper lateral cartilages, the lower lateral cartilages, and the septum, and can also be secondary to scar contracture following trauma or surgery. Intrinsic forces are those inherent to the septal cartilage as well as the upper and lower lateral cartilages.
Given the underlying structural deformities that are commonly observed in the crooked nose, the open approach is particularly useful and is the focus of this article. Outlined are principles for treating the crooked nose to improve predictability and reliability of rhinoplasty for this challenging problem.
Treatment goals and planned outcomes
Attaining consistently good esthetic and functional results when correcting the crooked nose requires a thorough understanding of nasal anatomy and physiology, accurate preoperative clinical analysis and intraoperative diagnosis, and the knowledge and skill to precisely execute a variety of surgical techniques required to predictably create an attractive and straight nose with a patent and functional nasal airway. When performing rhinoplasty for the crooked nose, the goal should be to achieve both esthetic and functional goals in one surgery because the external deformity is often intimately related to the functional problems with nasal airflow.
Preoperative planning and preparation
The preoperative consultation serves as an opportunity to understand the patient’s concerns and expectations for surgery and to identify the nasal deformities and disproportions and formulate the goals of surgery. Critical components of the history include age, history of trauma, nasal airway complaints, previous nasal surgery, smoking history, and any other medical comorbidities.
Clinical analysis is a key factor to successful outcomes in rhinoplasty. Evaluating nasofacial proportions and using a systematic nasal analysis will allow for thorough and accurate identification of all structural abnormalities and deformities contributing to the crooked nose. The external examination should include a systematic nasal analysis from frontal, lateral, and basal views. Particular emphasis is placed on identifying the abnormalities that contribute to the crooked nose. Asymmetries and irregularities of the bony vault, dorsal esthetic lines, nasal tip, and nostrils, as well as deviation of these structures from the facial midline, should be noted.
Standardized photography with frontal, oblique, lateral, and basal views should be obtained for all patients. Careful evaluation of these photographs will often reveal subtle deformities that were not appreciated during physical examination. Reviewing these photographs with the patient can facilitate communication and help the patient to fully understand the deformities that are present and the goals of surgery. In addition, photographs are a key component of the medical record and can be used as a reference postoperatively.
The frontal view allows evaluation of the nasal asymmetries and its relationship to facial asymmetries. In some instances, nasal asymmetries are secondary to asymmetries of the facial skeleton, and rhinoplasty will have a limited effect on full correction of these. The basal view is especially important for assessing caudal septal deviation, tip deviation, and asymmetries of the nostrils related to the columella and alar rims.
There are 3 basic types of nasal deviation, 2 of which have subtypes :
- 1.
Caudal septal deviation
Straight septal tilt
S-shaped septal tilt
- 2.
Concave deformity
C-shaped dorsal deformity
Reverse C-shaped deformity
- 3.
Concave/convex dorsal deformity.
The internal examination is performed to evaluate for anterior septal deviations and the status of inferior turbinates.
After evaluating the patient, the goals of surgery should be reviewed with the patient. The patient should understand the esthetic goals of surgery and if there will be any improvement in nasal airflow. There should be a frank discussion about what can be realistically achieved when performing rhinoplasty for the crooked nose: it is impossible to create a perfectly straight and symmetric nose. Setting the patient’s expectations preoperatively is critical to avoid dissatisfaction postoperatively.
Principles for treating the crooked nose
Correction of the crooked nose is based on the 8 key operative principles ( Box 1 ).
- 1.
Wide exposure of deviated structures
- 2.
Wide release of mucoperichondrial attachments
- 3.
Straightening the deviated septum and septal reconstruction
- 4.
Correcting caudal septal deviation
- 5.
Correction of dorsal septal deviation
- 6.
Restoration of septal support
- 7.
Inferior turbinate surgery
- 8.
Nasal osteotomies
Wide Exposure of Deviated Structures
The open approach is preferred for the management of the crooked nose. The exposure afforded by the open approach allows maximal accuracy in diagnosis and control in achieving optimal repair of the crooked nose. The crooked nose results from extrinsic and intrinsic forces that produce distortion of the nasal structures and nasal deviation. The open approach is particularly advantageous for releasing attachments between the soft tissue and osteocartilaginous framework that are creating extrinsic deforming forces. Following release of these extrinsic forces, intrinsic forces contributing to distortion of each anatomic part can be fully appreciated without distortion from the overlying soft tissue envelope. The osteocartilaginous framework can be modified and reconstituted under direct visualization through the open approach, resulting in more predictable correction of the crooked nose ( Fig. 2 ).
Wide Release of Mucoperichondrial Attachments
The mucoperichondrial attachments are preserved when possible to maintain the blood supply to the cartilage to minimize resorption. However, septal deviation frequently occurs as part of the crooked nose, and the mucoperichondrial attachments to the deviated portion of the septum must be widely released before the septum can be returned to the midline. Beginning at the anterior septal angle, bilateral submucoperichondrial flaps are elevated and a submucoperichondrial dissection is performed using a Cottle elevator to free the septum from the overlying mucosa. In the case of caudal septal deviation, the mucoperichondrium must be released all the way to the anterior nasal spine. Bilateral mucoperichondrial tunnels are dissected deep to the upper lateral cartilages, and a scalpel is used to separate the upper lateral cartilages from the dorsal septum ( Fig. 3 ). If the deformity exists because asymmetrical upper lateral cartilages are causing twisting of the septum, this will result in straightening of the septum. Once this has been done, the septum can be visualized to accurately assess for any intrinsic forces causing septal deviation.
If extrinsic forces are causing distortion of the lower lateral cartilages and upper lateral cartilages at the scroll, these can be released through a direct incision through the scroll area, or if the lateral crura require modification using techniques such as cephalic trim and lower lateral crural turnover flaps.
Straightening the Deviated Septum and Septal Reconstruction
Once the deviated septum has been widely exposed and separated from the upper lateral cartilages, it must be straightened by addressing and correcting the intrinsic deforming forces. The goal is to straighten the septum and return the septum to the midline while ensuring that the remaining anterior septum has adequate strength for dorsal nasal support.
Before septal reconstruction, the component dorsal hump reduction should be performed ( Fig. 4 ). After setting the dorsal profile, the deviated portion should be resected, taking care to preserve at least 10 mm of an L-strut. However, this will depend on the strength of the septal cartilage, and in many instances, a width of 15 mm or more may be required to ensure long-term support ( Fig. 5 ). The resection may include septal cartilage, maxillary crest, vomer, and perpendicular plate of the ethmoid. The L-strut should remain attached to the perpendicular plate at the keystone area and the anterior nasal spine and maxillary crest area. In addition, curving the transition points between the perpendicular plate of the ethmoid and the dorsal L-strut and, also, between the dorsal and caudal L-strut can help to strengthen the construct.
Septal reconstruction involves returning the deviated septum to the midline. The principle of cartilage preservation is paramount. Cartilaginous septum that is deviated or required for grafting should be removed. When addressing the bony septum, the septum can be microfractured and returned to the midline. In cases of C- or S-shaped craniocaudal deviation, there is vertical excess of the septum, and removing the inferior aspect of the septum allows for microfracture of the remaining septum and return to the midline. Microfracture should be performed in a careful and controlled manner to avoid uncontrolled fractures into the superior nasal septum and cribriform plate. This is particularly important in posttraumatic cases where there may have been a prior septal fracture. Bony spurs of the septum can be removed using Takahashi forceps. Septal cartilage or bone should be removed with ease; if there is any resistance, residual soft tissue attachments should be completely released.
Correcting Caudal Septal Deviation
Following reconstruction of the posterior septum, if there is persistent deviation of the anterior septum, this is commonly due to vertical excess of the anterior septum ( Fig. 6 ). Vertical excess of the septum is associated with caudal septal deviation, and the caudal septum can be found seated on one side or the other of the anterior nasal spine and maxillary crest as opposed to directly articulated with these structures. Correction of vertical excess of the septum and caudal septal deviation is performed by disarticulating the caudal portion of the L-strut from the osteocartilaginous junction with the anterior nasal spine and maxillary crest. The degree of vertical excess is assessed, and this is excised to allow the previously deviated septum to be returned to midline. A 5-0 polydioxanone (PDS; Ethicon US, LLC, Somerville, NJ, USA) suture is used to suture the caudal septum down to the periosteum of the anterior nasal spine ( Fig. 7 ). When the anterior nasal spine is located away from the midline, it may be necessary to perform an osteotomy to the anterior nasal spine to return it to the midline or excise the anterior nasal spine and suture the septum down to the periosteum of the maxilla. Excessive resection of the anterior nasal spine can damage the anterior maxillary nerve and subsequently cause some upper lip numbness. When extensive work has been done to the caudal septum, it is usually necessary to place several through-and-through horizontal mattress 5-0 chromic gut sutures in the caudal septum to reapproximate the caudal mucoperichondrial flaps to the midline, allowing the flaps to scar down in the midline position and providing extra long-term support.
