Straightening a crooked nose is one of the more difficult endeavors in rhinoplasty. Crooked noses could be a result of trauma or previous surgery. Oftentimes, however, I see many patients without this history. Addressing the issue of straightening an extremely crooked nose takes an understanding of the different components of the nose. The nose can be thought of composing of three essential areas: the upper portion consisting of the nasal bones, the mid-portion of the nose referred to as the middle vault, and the tip of the nose. Either one or all of these components may be attributing to the crooked appearance of the nose.
Good photographs from different angles are essential in analyzing the nose. These photographs should be performed with a high resolution lens under good lighting. The subtleties of the photos reveal to me as a surgeon a lot of the underlying framework of the nose contributing to the crooked appearance of the nose. They may also reveal asymmetries of the face itself which may also contribute to the crooked appearance of the nose. The first assessments I make of the nose itself are the nasal bones. These could be deviated in any number of different positions.
The straightening of the bones is performed through osteotomies or the controlled fracturing (breaking) of the bones to realign them. The most intricate aspect of the straightening of the nose is the middle third of the nose or the middle vault. Multiple cartilages contribute to the shape of the middle third of the nose: the septum as well as cartilages on either side of the septum known as the upper lateral cartilages. These can all be deviated in any number of different positions. Herein is where most noses remain deviated even after attempts are made to straighten the nose. Correcting a crooked dorsum requires meticulous attention to detail and, at times, aggressive techniques to try and provide for a long-term correction.
A simple septoplasty will often not correct the deviation. Instead I will often use cartilage grafts from the septum in order to give the nose a straighter appearance. These grafts need to be positioned in such a manner that they not only correct the deviated portion of the nose but also provide long term structure and stability to the nose. Correcting the septum and placing it in the midline is essential as this provides the main framework to the nose. After the upper and mid-portion of the nose is corrected I then turn my attention to the nasal tip. Again the placement of the septum in the midline is key to the correction of the nasal tip. Once the septum is set in the midline then the cartilages which support and makeup the tip can be positioned around it. In the severely deviated nose these cartilages which make up the tip (lower lateral cartilages) are often asymmetric as well. If so, maneuvers need to be performed to try and create symmetry between the two sides. As one can see attempting to adequately correct a crooked nose is a multifaceted approach which involves not only a meticulous attention to detail and understanding of the different anatomical components of the nose but the execution of techniques which will provide for adequate structural support.