The Crooked Nose and Major Septal Deviations in Dorsal Preservation

The crooked nose deformity (CND) has a multifactorial origin. Trauma, previous surgery, septal deviation, and maxillary and nasal bone hypertrophy contribute to asymmetry. The crooked nose has been deemed one of the most difficult to repair of all nasal deformities. Dorsal preservation (DP) rhinoplasty techniques have evolved to correct the boney vault, high septal deviations, and boney hypertrophy while limiting cartilage usage. A paucity of literature exists detailing functional and aesthetic outcome measures for DP. Herein the author’s approach to improve the CND utilizing different DP techniques including the modified subdorsal strip method, Z flap, and the modified Cottle technique is presented.

Key points

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Dorsal preservation (DP) rhinoplasty can be utilized to improve the nasal dorsal axis for the crooked nose deformity.
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DP rhinoplasty techniques are cartilage sparing and require less grafting in patients presenting with asymmetry of the dorsum.
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Utilization of ultrasonic rhinoplasty can improve both nasal dorsal height and width in the crooked nose.
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Major septal deviations can be addressed using combined preservation and structural grafting techniques.
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Patient-related outcome measures show improvement of both functional and cosmetic results in patients presenting for DP.

Introduction

First published by Dr Goodale, preservation of the dorsum combines septal strip and boney osteotomies for patients with a dorsal hump while preserving the osseous cartilaginous junction. Foundation techniques have been described to address the overall height and width of the nasal dorsum by addressing hypertrophy of the ascending process of maxilla and nasal boney junction. Incorporating lateral and transverse osteotomies to address dorsal deviations are key elements for dorsal preservation (DP) correction of the crooked nose. ^, It has been said, “as the septum goes, so does the nose.” Whether of developmental or traumatic origin, the septum and particularly the perpendicular plate of the ethmoid bone are sources of axis deviation leading to the crooked nose deformity (CND). Correcting nasal physiology by addressing septal and boney deformities were a paramount work of Cottle in patients with and without septal deviations. The contemporary application of Joseph’s composite resection of the hump combined with the Sheen spreader grafts is a traditional approach popularized in structural rhinoplasty. Cartilage grafting techniques are subject to dorsal irregularity, scarcity of material, and widening of the dorsum. The use of spreader flaps helped to address some of these limitations but was not an ideal choice for the crooked middle vault which required much larger grafts to correct asymmetry and depression of the upper lateral cartilage. The spare roof approach as described by Ishida and Ferreira has obviated the need for open roof approaches once deemed necessary. Further, a cartilage sparing approach is considered necessary in patients with crooked noses. The high subdorsal strip approach was first described by Lothrop and contemporized by Saban. Modern DP modifications of the modified subdorsal strip method (MSSM) and Z flap strip methods have furthered the ability to correct the axis deviation in crooked noses by addressing high septal deviations, and controlling deviations stemming from the perpendicular plate of ethmoid bone, and the dorsal hump. While septal strip techniques address the intrinsic factors associated with the crooked nose, extrinsic pathology in the foundation of the nose often coincide. These extrinsic factors include the width of the nasal bones, the junctional thickness of the ascending process of maxilla with the nasal pyramid, and the axis of nasal boney dorsum from glabella through columella and dental midline. Both push down osteotomies and let down boney strip maneuvers have been developed in DP to address the boney axis. ^, ^,

Discussion

Review of the Literature

CND can be differentiated by the external deviation of the nose and/or the internal septal impact on the lower cartilaginous framework. A classification can then be derived from the resulting deviation describing a C-shaped, reverse C-shaped, linear I-shaped, or S-shaped nose. On the frontal view, the dorsum can be delineated as C-shaped nose or reverse C-shaped where by the middle vault is noted to be concave and the other side convex. In a linear deviation, the dorsum and tip may be an I-shaped, thus shifted to one side of the vertical midline of the face. Severely crooked patients can also present with an S-shaped deformity. ^, Although I-shaped patients may be improved with a swinging door septoplasty and unilateral spreader grafting, C-shaped deformities often require boney osteotomies to improve this deformity. Further, S-shaped deformities require a combination of cartilage grafting for the nasal tip and osteotomies. Many patients with I-shaped deviations also present with facial asymmetry secondary to maxillary hypoplasia and deviations off the dental midline. Premaxillary augmentation may be a consideration in these patients.

Limited data exist utilizing outcome measures in patients with CND. Patient-related outcome measures (PROMs) have emerged as additional validation tools for assessing functional and cosmetic changes in patients undergoing rhinoplasty. Incorporating outcome measures including the Nose Obstruction Symptom Evaluation (NOSE), Sinonasal Outcome Test (SNOT-22), Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS), Epworth Sleepiness Scale (ESS), and standardized before and after photographs for patients undergoing DP rhinoplasty have shown significant improvements. The median and total, functional, and cosmetic scores utilizing all 45 PROMs at 1-year follow-up showed no difference in MSSM and Z flap septal strip methods with let down osteotomies.

In contrast, it has been recognized that reductive rhinoplasty does affect the functional and cosmetic results of patients. Morphologic evaluation of the internal valve angle is considered a key anatomic result determining nasal obstruction after rhinoplasty. The internal valve angle is often compromised in reductive rhinoplasty but has been showed to be preserved in preservation rhinoplasty.

Asymmetric dorsal preservation (ADP) utilizes a push down technique for the deviated side and a let down technique for the contralateral nondeviated side. It is an alternative to traditional methods to correct the CND. ADP can be utilized to improve the functional and esthetic outcomes for the CND. Asymmetric boney resections incorporated into the lateral osteotomy in combination with transverse osteotomies have formed the basis for let down preservation techniques for crooked boney foundations. Often considered in axis deviation, a larger asymmetric wedge resection of bone contralateral to the axis deviation can assist in correcting the axis when combined with a transverse osteotomy. The use of ADP techniques have been described in 23 patients with 12-month postoperative results comparing rhinomanometry and SCHNOS surveys. Improvement in total nasal airflow, SCHNOS scores, and deviation angle was noted. In comparing conventional osteotomies with mid-vault spreaders with ADP, mean angles of deviation correction showed no difference at 6 months in a cohort of patients.

Severe septal deviations necessitate a tension-free release of the cartilage and ligamentous supports. Often deemed as the most important pillar of the nasal framework, the septum is paramount in the DP. The Pisa tower concept combines the “swinging door” septoplasty with asymmetric boney wedge resections and let down osteotomy. Using nasal axis deviation as an end point and satisfaction scores, the PISA tower approach demonstrated an alternative to structural techniques alone.

DP rhinoplasty techniques are cartilage sparing and require less grafting in patients presenting with asymmetry of the dorsum. The spare roof technique describes surface approaches which have been validated in CND. The Portuguese version of the Utrecht Questionnaire for Aesthetic Outcome measures showed improvement in subjective nasal function and esthetic in a 12-month prospective, longitudinal study. ^,

Utilization of ultrasonic rhinoplasty can improve both nasal dorsal height and width in the crooked nose. Major septal deviations can be addressed using combined preservation and structural grafting techniques. While preserving the middle vault has its advantages, piezoelectric release of the boney cap and lateral wall can mobilize the boney cap allowing correction of slight asymmetries.

Surgical technique

The senior author presents his technique to improve the CND utilizing let down DP rhinoplasty with asymmetric osteotomies where applicable in patients. Dorsal humps of all sizes were able to be addressed as well as mid-vault deviations. A case representation of 3 septal strip techniques is described including: (a) modified subdorsal septal strip (MSSM), (b) Z flap septal advancement technique, and (c) modified low strip Cottle maneuver.

In general, a standard inverted V trans columellar incision combined with marginal incisions are made and the nose opened. The periosteum over the nasal bones is incised and elevated. Stab incisions at the superior head of each inferior turbinate are made, and the periosteum is elevated off the frontal process of the maxilla on each side to prepare for endonasal osteotomies. For asymmetric osteotomies, an open approach is performed. The periosteum is elevated off both the external and internal aspect of the frontal process of the maxilla. The piezoelectric saw is used to make all let down wedge resections staring with lateral low-low-high osteotomies on each side, followed by wedge excisions of nasal-maxillary bone which includes Webster’s triangle. Asymmetric wedges are made with larger osteotomies on the concave side of a C-shaped or S-shaped deformity or contralateral side of an I-shaped deformity. These boney osteotomies are made with either a straight piezo blade for endonasal osteotomies or a 90° angle piezo blade for an open approach to the osteotomy. Next, a transverse osteotomy at the nasion is made using the piezoelectric chisel attachment while protecting the undersurface of the soft tissue envelope with an Aufricht retractor followed by an endonasal release of the perpendicular plate of the ethmoid bone. The transverse nasion osteotomy connects with the let down osteotomies on each side.

Dorsal septal cartilage is manipulated in one of 3 ways. Either a high septal strut excision ( Fig. 1 ), modified Z flap incision ( Fig. 2 ), or a modified low strip septal excision is performed ( Fig. 3 ). The techniques are modifications of the Most, Kovacavic, and Cottle ^, maneuvers. In the MSSM technique, a horizontal strip of septal cartilage approximately 5–10 mm from the dorsal edge is excised and reserved for future spreader grafting. The septal excision leaves at least a 1.5 cm caudal strut intact to maintain tip support. The width of the excised cartilage depends on the amount of hump let down desired. A vertical releasing incision through the dorsal septum is made inferior to the point of maximum dorsal convexity. This incision is not through and through but rather stops short of the junction between the upper lateral cartilage and septum. This creates a flexion point for dorsum let down. The let down dorsal hump is secured in place with a 4-0 PDS suture passing inferior to the high septal strut excision starting on the left, up through the upper lateral cartilage on the right side of the septum, and back through the upper lateral cartilage on the left side of the septum. A wedge of septal cartilage or complete transection of the septal cartilage through the dorsum at the anterior aspect of the high dorsal strut excision may need to be performed to alleviate buckling of the cartilage. A narrated video of this technique can be accessed via a previous publication. Fig. 1 depicts the steps made in the MSSM procedure. Fig. 1 demonstrates osteotomies and septal incisions shown for the high septal strut excision technique with resultant let down dorsal hump.