Key points

Videos of the steps in the correction of the twisted nose accompany this article at http://www.plasticsurgery.theclinics.com/

Introduction

The nasal septum plays an essential role in the twisted nose. Cottle’s dictum, “as the nasal septum goes, so goes the nose,” is true and implies that a successful correction of a crooked nose starts with accurate septoplasty. Isolated cartilaginous deviations, including the nasal septum and upper lateral cartilages (ULCs), are rare, and in most cases, the nasal bones are involved in the deformity with a need for additional osteotomies. Usually, the deformity is caused by nasal trauma; sometimes, however, the cause is unknown.

Typically on the ipsilateral side of the deviation, the twisted nose has a shorter and steeper bony and cartilaginous nasal sidewall. On the contralateral side of the deviation, the nasal bone usually is longer and has a more gradual angle with the cheek area; this has important implications for the osteotomies, which should be performed in an asymmetric manner. Because the ULC and nasal septum form a T-bar, if the middle nasal vault appears to be deviated, then by definition the dorsal septum is also deviated. In contrast, the basal part of the nasal septum is usually deviated to the contralateral side with or without a deviation of the premaxilla and anterior nasal spine. Therefore, both sides of the nasal airway can be blocked partially or completely in patients with a twisted nose. These patients have a functional and esthetic problem of the nose.

The nasal septum, ULCs, and nasal bones should be brought into midline in order to straighten a twisted nose. Therefore, all structures of the nasal skeleton need to be dissected free, mobilized, repositioned, and stabilized. Because the upper and middle third of the twisted nose are asymmetric, the right and left side of the nose require a different surgical technique. In most cases, the open, or external approach, provides the best exposure to the anatomic regions in the nose for optimal reconstruction.

Introduction

The nasal septum plays an essential role in the twisted nose. Cottle’s dictum, “as the nasal septum goes, so goes the nose,” is true and implies that a successful correction of a crooked nose starts with accurate septoplasty. Isolated cartilaginous deviations, including the nasal septum and upper lateral cartilages (ULCs), are rare, and in most cases, the nasal bones are involved in the deformity with a need for additional osteotomies. Usually, the deformity is caused by nasal trauma; sometimes, however, the cause is unknown.

Typically on the ipsilateral side of the deviation, the twisted nose has a shorter and steeper bony and cartilaginous nasal sidewall. On the contralateral side of the deviation, the nasal bone usually is longer and has a more gradual angle with the cheek area; this has important implications for the osteotomies, which should be performed in an asymmetric manner. Because the ULC and nasal septum form a T-bar, if the middle nasal vault appears to be deviated, then by definition the dorsal septum is also deviated. In contrast, the basal part of the nasal septum is usually deviated to the contralateral side with or without a deviation of the premaxilla and anterior nasal spine. Therefore, both sides of the nasal airway can be blocked partially or completely in patients with a twisted nose. These patients have a functional and esthetic problem of the nose.

The nasal septum, ULCs, and nasal bones should be brought into midline in order to straighten a twisted nose. Therefore, all structures of the nasal skeleton need to be dissected free, mobilized, repositioned, and stabilized. Because the upper and middle third of the twisted nose are asymmetric, the right and left side of the nose require a different surgical technique. In most cases, the open, or external approach, provides the best exposure to the anatomic regions in the nose for optimal reconstruction.

Treatment goals and planned outcomes

The goal of surgery is to realign the bony and cartilaginous nasal skeleton in order to create symmetry in the face and to restore nasal patency. Despite the highest personal effort of the surgeon, the patient should understand that a perfectly straight nose is not always possible due to nonsurgical factors. These factors include other asymmetries of the face, wound healing, scar tissue or stresses, trauma in the postoperative phase, and so on.

Preoperative planning and preparation

A standardized rhinoplasty protocol is essential for a successful outcome. This protocol includes standardized preoperative documentation using an assessment and surgical rhinoplasty sheet. The medical history should be reported including the use of medication. Medication that can influence blood coagulation should be stopped before surgery. Inhalation allergies should be tested and treated as needed with antihistamines and nasal corticosteroids. Inspection of the nasal airway using an endoscope might be required in selected cases. Standardized preoperative rhinoplasty photographs (frontal, oblique, lateral, basal, and bird’s eye view) should always be performed and documented. Sometimes 3dimensional imaging or computer-simulated imaging is helpful in the communication with the patient. In all cases, a written informed consent with all possible side effects of the surgery and postoperative period should be given and signed by the patient.