The correction of the crooked nose is one of the most challenging deformities in rhinoplasty surgery. It is difficult because it requires improvement of two nasal problems; a functional breathing problem and an aesthetically asymmetric appearance. The goals of this type of rhinoplasty is the creation of a rigid and straight nose that has an increased patency in internal nasal airflow.
The crooked nose is caused by a variety of derangements in the internal structures of the nose, dominated by the shape of the internal septum on the external appearance of the nose. They can be classified into five main types of nasal deviations. The most common is the caudal septal deviation also known as a septal tilt. This is obvious externally by looking at the shift in the nostrils. The anteroposterior C-shaped deviation is also common and is observed to have an external nasal deviation which is on the opposite side of the internal deviation. The others include an anteroposterior s-shaped and cephalocaudal c- and s-shaped nasoseptal devations. The diagnosis of these various septal deformities can be made primarily by visual speculum assessment and finger palpation. (which I find particularly useful)
Successful correction of deviated noses almost always requires an open rhinoplasty approach. This is the only way to truly see and release all deviated structures. All mucoperichondrial attachments must be released , meaning the upper lateral cartilages and the septum must be completely separated. Often such release can bring a near straightening of the septum. Then any deviated structures are removed which can includeportions of the septum, the maxillary crest, vomer bone and the perpendicular plate.
The septum is then straightened and supported with spreader and batten grafts as well as using ethmoid bone grafts if necessary. The creation of a rigid and straight L-strut construct is critical. In very severe deviations, it may be necessary to completely remove the septum (extracorporeal resection) and fashion a straight L-strut ouside before re-inserting it. Once septal support is re-established, osteotomies of the nasal bone is performed followed by reduction of the size of the inferior turbinates.
While every step is critical in correction of the deviated nose, the fabrication of a straight and stable septal L-strut in the midline is paramount. Because of the natural memory of cartilage, if the septum is not stented by grafts there will be relapse and recurrent deviation. The reconstructed and stabilized septum is finally secured to the anerior nasal spine. Between the upper lateral cartilages and the anterior nasal spine, these are the only two fixation points.
After closure, it is critical to use some form of internal nasal support or packing. I am not a usual fan of nasal packing after most less complicated rhinoplasties and almost always usequilting sutures. But the extent of the mucosal dissection and cartilage grafting requires good compression of the mucosa against the septum to prevent internal adhesions and obstructive scarring. Some plastic surgeons prefer actual packing but I like to use Doyle plastic splints sutured in and removed a week later.
Correction of the deviated is one of the most difficult problems in rhinoplasty and has an historic high rate of either relapse or some residual nasal deviation. With this more aggressive cartilage resection and grafting approach, straighter noses after surgery are more likely to result with better long-term corrections.
Dr. Barry Eppley
Indianapolis, Indiana