Crooked Nose
External deviation of the nose after rhinoplasty may be due to deviations of the dorsal border of the septal cartilage, forming a C- or S-shaped curve. The severely twisted nose presents with pathology in two principal areas, the external vault and the se
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Crooked Nose
External deviation of the nose after rhinoplasty may be due to deviations of the dorsal border of the septal cartilage, forming a C- or S-shaped curve. The severely twisted nose presents with pathology in two principal areas, the external vault and the septum. I classify deflected noses as: (1) deformities restricted to the external nasal skeleton, (2) deformities of the inner skeleton, and (3) deformities affecting both. Usually, the deformities involving these structures are interrelated and have to be managed as one complex. This is why the crooked nose should not be treated in a twostage procedure. All three categories can be encountered as postseptorhinoplastic deformities. In the first and third categories it is necessary to bring the displaced nasal bones into the normal positions by means of the usual osteotomies and by a paramedian wedge resection on the side where the bony lateral wall is too wide. The deflected nose can be combined with a residual hump. This hump has to be removed but asymmetrically, with a broader strip of bone resected on the flatter side of the bony pyramid, as I have previously shown. Along with the work on the external bone it is also important to perform adequate mobilization of the septum both in the cartilaginous portions and in the bony part. This should be done with an extramucosal access, which I have used to treat all primary septum deviations and
crooked dorsa (Figs. 22.1-22.5). If the crooked nose is combined with a hump there is a certain tension in the deviated septum, which can be released by removing the strip of cartilage along the vomer, which I usually do. If the vomer presents a high-grade deformity, as sometimes seen in unilateral hare lip noses, I have to reduce or remove it unless proper repositioning is possible. I do not agree with rhino surgeons who suggest that correcting a deviated nose in its bony portion by the simple removal of a strip of bone at the lateral osteotomy site, performing only a lateral osteotomy at the opposite side and rotating the whole pyramid into the gap left by bony resection without effecting any paramedian osteotomy, will provide correction. For me, this pushto-side represents an incomplete work comparable to the push-up and push-down procedures described by Cottle (1960a, b). Bony strip resections are better applied in the dorsum and not at the site of the lateral osteotomy (see Chap. 11: "Bony Deviations"). Paramount importance attaches to ilie stability of the septum, which can be achieved even if one resects a strip of cartilage along the vomer after repositioning the latter. Continuity of the septal plate at the base is not absolutely necessary. By means of transseptal mattress sutures I provide fixation of ilie scored and repositioned parts of the perpendicular bony plate and quadrangular cartilagi-
Fig. 22.1A - C Acaudal anterior deviation corrected with an extramucosal technique. A, BPreoperative view. ( Postoperative view
R. Meyer et al., Secondary Rhinoplasty © Springer-Verlag Berlin Heidelberg 2002
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