Partial Extracorporeal Septoplasty in Crooked Noses

BACKGROUND

In crooked noses, the standard septoplasty is a challenge because of the complex deviation of the septum, where straightening of the cartilage in situ is impossible. Hence, it is required to remove the partial/total septum and later is replaced back after being straightened; the procedure is called partial/total extracorporeal septoplasty. In the present study, we shared our experience of partial extracorporeal septoplasty in patients with crooked noses.

MATERIALS AND METHODS

It is a retrospective analysis of 30 crooked noses who underwent extracorporeal septoplasty due to gross septal deviation from March 2020 to August 2022. The functional and aesthetic outcomes were evaluated at the end of 12 months.

RESULTS

Of 30 cases, partial and total extracorporeal septoplasty was performed in 28 cases and two cases respectively. Neoseptum was reconstructed with septal cartilage in 27 (90%) cases, costal cartilage in one case and conchal cartilage was used in two instances. All the patients had good functional and aesthetic outcomes till 12 months of follow-up, and there were no major intraoperative or postoperative complications.

CONCLUSION

Extracorporeal septoplasty can be an excellent surgical procedure in the highly deviated nasal septum, in Indian noses with a crooked nasal deformity. It provides adequate exposure to the whole septum, ensuring good functional and aesthetic outcomes with minimal complication rate.

LEVEL OF EVIDENCE IV

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Key stone plasty and asymmetric hump resection in crooked nose deformity

OBJECTIVE

The aim of this study is to propose a new approach in crooked nose deformity with key-stone plasty and asymmetric hump resection.

METHOD

Twelve patients with crooked nose deformities were operated using the open rhinoplasty technique. Our method, unlike other methods, has two different steps. Following asymmetric hump resection, cartilaginous and osseous septum were cut separated at the key stone area or more caudally and fix the septum with sutures again by allowing them to slide over each other in a way that directs the septum to the midline. If there is an inability to reveal the septum, we apply a longer spreader graft to the cartilage septum side.

RESULTS

The mean ages were 27.4 years. The mean follow-up time of the patients was 19.1 months. No complications were observed due to this technique. This technique was effective in the treatment of all our patients with crooked nose deformities.

CONCLUSION

A novel surgical approach with key-stone plasty and asymmetric hump resection method was proposed in crooked nose deformity with a video animation.

A Comparative Study of Isolated Osteotomies Versus Osteotomies with Spreader Graft Placement to Correct Primary Deviated Nose

BACKGROUND

It is a complete objective and subjective comparative study between two techniques of septorhinoplasty in patients undergoing primary rhinoplasty for crooked nose deformity.

METHODS

Forty patients having crooked nose deformity were randomly divided into 2 groups exhibiting two different techniques of correction. Patients were randomly divided into 2 group: Group 1: 20 patients underwent correction of crooked nose by performing bilateral triple osteotomies + Septoplasty Group 2: 20 patients underwent correction of crooked nose by performing bilateral triple osteotomies as well as placement of spreader grafts + Septoplasty Objective and subjective assessment of patients in preoperative and postoperative period was done by various scales and scores.

RESULTS

Both the groups showed improvement in facial angles, ROE score, nasal airflow, and NOSE score. But, group 2 patients were more satisfied than group 1 patients in terms of both aesthetic appearance of nose and breathing function.

CONCLUSION

It is very well known to the authors that aesthetic result of rhinoplasty is not just dependant on one technique. Keeping this in mind, we conclude that as group 2 patients were more satisfied with their overall results, the additional step of spreader graft placement helped these patients with the complaints associated with crooked nose deformity. However, we also emphasize that additional studies on larger numbers of patients should be performed to compare and know other intricacies of each technique that may play minor or major roles in deciding the success of each technique.

LEVEL OF EVIDENCE III

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A Useful Approach to I-Shaped Crooked Nose Correction: Cross-Spreader Graft Technique

OBJECTIVES

Correction of crooked nose with long-term functional and aesthetic success remains a great challenge for rhinoplasty surgeons. The aim of this study was to present the aesthetic and functional results of the cross-spreader graft technique applied for the correction of I-shaped crooked nose.

METHODS

A retrospective examination was made of 25 patients applied with open technique rhinoplasty using cross-spreader graft for the correction of I-shaped crooked nose between March 2016 and June 2019. The functional results of the patients were evaluated using the Nasal Obstruction Symptoms Evaluation scale. The Rhinoplasty Outcomes Evaluation was used to evaluate the subjective aesthetic results, and the external nose deviation angle was measured from the frontal aspect to evaluate the objective aesthetic results.

RESULTS

Evaluation was made of 25 patients comprising 11 males and 14 females with a mean age of 26.64±7.08 years. The post-operative mean NOSE and ROE scores were significantly improved compared to the preoperative values (p<0.001). A statistically significant improvement was determined in the deviation angle values from preoperative to postoperative (p< 0.001).

CONCLUSION

According to the current study functional and aesthetic results of the cross-spreader graft technique applied for the correction of I-shaped crooked nose, this new technique appears to be an effective method for the treatment of I-shaped crooked nose deformity.

LEVEL OF EVIDENCE IV

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A new approach for crooked nose: Separated spreader graft "puzzle graft"

INTRODUCTION

The nasal septum takes an important role in nasal shape and function. The term "crooked nose" is commonly used for all of the clinical conditions involving deviation of the nasal axis from the midline. This situation leads to both aesthetic concerns and breathing problems. In this study, we describe a new method in order to nasal dorsum on the midline and improving airway function in crooked nose patients, that will be contribute to the literature.

MATERIALS AND METHODS

This study enrolled 50 (fifty) patients who had undergone open septorhinoplasty operation were included in our study. The puzzle graft, which was prepared as a spreader graft consisting of three separate parts, was used to correct crooked nose in all patients. Anterior rhinoscopic examination, photographs and Nasal Obstruction and Septoplasty Effectiveness (NOSE) scores for the pre-operative and post-operative 1 year were compared and evaluated in this study.

RESULTS

The new approach was used successfully in all of the patients. Anterior rhinoscopic and 1 year photographic evaluations revealed a significantly correction of external appearance post-operatively. None of the patients had any additional complaints and complications during the post-operative period. We observed that NOSE scores, with which the post-operative nasal obstruction was evaluated, were significantly better in all 50 patients.

CONCLUSION

Crooked nose deformity is one of the most difficult problems in rhinoplasty. There is no absolute true technique for solving this situation. Each method works properly in appropriate cases. Sometimes we should use more than one technique in the same operation to correct the pathology. Our purpose is to present a new option to help surgeons in "crooked nose"; to provide a new method that can work safe and effective in convenient conditions.

Treatment of the Crooked Nose

The crooked nose is a challenging esthetic and functional problem. The surgeon must carefully evaluate baseline facial asymmetry as well as whether deviation stems from the upper third, middle third, or lower third of the nose. Surgical intervention should be tailored accordingly, with techniques geared toward addressing each deviated section. Modified dorsal preservation techniques represent a newer means to address deviations. Operative results must be measured, ideally through patient-reported outcomes measures, to quantify overall success.

Awareness of Facial Asymmetry and Its Impact on Postoperative Satisfaction of Rhinoplasty Patient

INTRODUCTION

Rhinoplasty surgeons often find that despite their best efforts to straighten the nose, patients often continue to perceive their nose as deviated, and this perception is particularly prevalent in patients with concurrent facial asymmetry. The aims of this study were to determine whether facial asymmetry influences the satisfaction of rhinoplasty patients and whether there is a difference in postoperative happiness between patients with and without facial asymmetry.

MATERIALS AND METHODS

In this retrospective study, we reviewed the charts and photographs of patients who underwent rhinoplasty between 2016 and 2018. Patient photographs were analysed; 30 patients with facial asymmetry and 30 patients with symmetric faces were randomly selected for the study. The preoperative and postoperative rhinoplasty outcome evaluation (ROE) and standardized cosmesis and health nasal outcomes survey (SCHNOS) scores were compared between the two groups.

RESULTS

The mean preoperative symmetry scores of the group with facial asymmetry were significantly higher than those of the group with symmetric faces. The magnitude of increase in the average ROE score from pre- to postoperatively was significantly larger in the group with symmetric faces than in the group with facial asymmetry. The magnitude of decrease in the mean SCHNOS score from pre- to postoperatively was significantly larger in the group with symmetric faces than in the group with facial asymmetry (p: 0.006).

CONCLUSION

It is important to clearly evaluate patients with facial asymmetries before surgery to increase their postoperative satisfaction and outcomes and make their expectations more realistic.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Preservation Rhinoplasty and the Crooked Nose

Crooked or deviated noses pose a specific challenge as many of the elements in a deviated nose are not symmetric and therefore not ideal for preservation techniques. Deviated noses are often where a hybridization between preservation and structural rhinoplasty is required. Careful preoperative evaluation of the soft tissue and bony anatomy of the patient is very important and congenital or post-traumatic asymmetry may involve more than the nasal pyramid. Full exposure of the nasal pyramid allows for visualization and appropriate osteotomy or rhinosculpture.

The Combined Use of Spreader Flap and Asymmetric Spreader Graft in Crooked Nose

OBJECTIVE

The crooked nose is still a challenging deformity for rhinoplasty surgeons although a significant number of correction methods have previously been described. The aim of this study is to present a new technique that the authors have used to correct the crooked nose in selected patients.

MATERIALS AND METHODS

This retrospective study was carried out on 53 patients who underwent open technique rhinoplasty due to crooked nose. Pictures were taken from five different angles using digital cameras and recorded pre- and postoperatively. Patients who have a minimum follow-up period of 12 months are included in the study.

RESULTS

Fifty-three patients who have I-shaped and C-shaped crooked nose were enrolled in this study. The mean ages were 27.4 years. The mean follow-up period of the patients was 19.1 months. Patients who have I-shaped and C-shaped crooked nose deviation angle values were calculated preoperatively as 7.1 ± 2.1 and 163.4 ± 3.6, respectively. Postoperatively, deviation angle values were 0.75 ± 0.83 and 177.9 ± 3.1. Postoperative deviation angles were significantly lower than preoperative angles on patients who have I-shaped crooked noses (p < 0.001). On patients who have C-shaped crooked nose, postoperative deviation angles were significantly higher than preoperative angles (p < 0.001).

CONCLUSIONS

This unique study shows that the combined use of one-sided spreader flap and asymmetric spreader grafts is a very good choice for satisfactory long-term outcome and durable correction of crooked nose deformity.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Counter Autografting of Dorsal Septum in Crooked Nose

INTRODUCTION

The nasal septum plays an important role in nasal form and function. In this study, we describe a novel, alternative septoplasty approach that results in an aesthetically acceptable dorsal profile and improves airway function in patients with a crooked nose.

PATIENTS AND METHODS

This study enrolled 26 patients who presented with crooked noses between 2012 and 2017. All patients underwent open rhinoplasty under general anesthesia. During correction of the cartilaginous part, a dorsal strip from the deviated septum was prepared and inverted in a 180° fashion to exert a counter-force to correct the remaining septum and fixed by suturation. This maneuver allowed application of the maximum possible force in the opposite direction to reset the deviation by its own force.

RESULTS

The approach was used successfully in 26 patients with severe nasal septal deviations in the caudal septum and dorsal angulation of the nasal shape. There was no case of hematoma, synechia, septal perforation, dorsal irregularity, or saddle deformity. Temporary nasal obstruction occurred in 4 patients but improved in all of them by the third postoperative month. One patient had a recurrence of the septal deviation, dorsal angulation, and persistent nasal obstruction, which were treated by revision nasal valve surgery 14 months postoperatively. There was no subsequent recurrence during the long-term follow-up. The improvement between the preoperative and postoperative 12-month deviation angle measurements, Nasal Obstruction and Septoplasty Effectiveness (NOSE) scores were significant (P < 0.05), Improvement in the NOSE score correlated strongly and significantly with deviation angle changes and patient satisfaction.

CONCLUSION

Our counter-autografting technique in septoplasty is safe and effective in the correction of severe dorsal and/or caudal deviations, as long as the severely angulated cartilage septum remains in one piece after careful dissection.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparison of Double Lateral Osteotomy and Asymmetric Dorsal Hump Reduction in Correction of Crooked Nose

BACKGROUND

Several methods have been introduced to correct crooked nose during rhinoplasty. This study aimed to compare the final shape of nasal pyramid as well as patients' satisfaction of the outcomes in two different rhinoplasty techniques.

METHODS

Participants in this study underwent rhinoplasty with two different techniques of double lateral osteotomy in comparison with asymmetric dorsal hump reduction using rasp. Ninety patients were allocated in two groups by a quadruple block randomization. Patients were compared for the correction of nasal deviation 6 and 12 months after surgery. Their self-rated satisfaction with rhinoplasty outcome was also assessed using a researcher-made questionnaire.

RESULTS

Crooked nose correction was performed in 45 patients in each surgery group. Primarily, the mean of nasal deviation in two study groups were relatively similar (159.83±22.37 degree in C-shaped group vs. 11.79±4.98 degree in I-shaped group). The changes in degree of deviation after rhinoplasty were statistically significant in both intervention groups. However, based on the shape of nasal curvature, double lateral osteotomy was superior in long term follow up in I-shaped curvatures. Patients' post-operative satisfaction with their nasal appearance was higher in the group of double lateral osteotomy and they were less interested in re-surgery.

CONCLUSION

The two rhinoplasty techniques were not statistically different in terms of changes in nasal deviations correction after the surgery. However, long term changes in I-shaped curvatures were more desirable in group of double lateral osteotomy. Use of double lateral osteotomy was associated with better satisfactory aesthetic outcomes among study participants.

Open Structure Approach to the European or Caucasian Nose

This article discusses common abnormalities found in the European or Caucasian nose. The treatments of the disorders via open structure rhinoplasty techniques are presented in a case-based manner. Multiple references are provided for further study of these techniques.

Correction of Severe Deviated Nose by Intermediate Short Osteotomy

BACKGROUND

The deviated nose is a common deformity encountered in rhinoplasty, and yet it is the most challenging pathology to treat, because multiple internal and external structures have deformity, so there is a need to be corrected.

METHODES

The intermediate short osteotomy has been applied as a technique to correct severe nasal bony deviations. Eleven patients with severe deviated nose who had been operated by the senior author from 2013 through 2016 were included in the study (follow-up period of 6-24 month). Intermediate short osteotomy was performed after medial and before lateral osteotomy. Surgical outcomes were assessed by another otolaryngologist based on review of pre- and post-operative (6 to 24 months after surgery) photographs. The post-operative outcome in terms of deviation correction was classified as excellent, good, fair, or no change.

RESULTS

Of all 11 cases, 6 (54.5%) were accepted as excellent, 4 (36.4%) as good, and 1 (9%) as no change.

CONCLUSION

Intermediate short osteotomy can be considered as a modification of intermediate osteotomy that eliminates nasal dorsal deviation more completely. This osteotomy is very simple and need only 1 to 2 minutes and use of this method is recommended for correction of severe deviated bony noses.

Osteoplasty in Crooked Nose Deformity: A Novel Approach

BACKGROUND

Crooked nose deformity is one of the most difficult issues to correct by rhinoplasty, as it can result in undesired late sequelae. Revision rates are often high, and numerous operational techniques have been tested. This study describes a crooked nose rhinoplasty technique that reduces the need for a double osteotomy in the long nasal bone.

METHODS

This study included 26 patients with an I-shaped crooked nose deformity. In the surgical correction of the crooked nose deformity, previously defined techniques were applied to the cartilage identically. However, the traditional double osteotomy of the long nasal bone was not performed. Instead, the bone protruding laterally from the long nasal bone was narrowed by rasping with a file or burr, and this section was delivered to the maxilla accordingly. Angle values were measured preoperatively and postoperatively. Two lines were used to measure the angle: The first was drawn from the midpoint of the glabella to the midpoint of the upper lip, while the second, representing the nasal dorsal axis, consisted of both the osseous and cartilaginous parts from the nasion to the anterior nasal spine. The angle between these two lines was taken as the angle of deviation from the median line.

RESULTS

Postoperatively, patients' angle values were significantly smaller than preoperatively. After 1 year, no persistence was observed.

CONCLUSION

In crooked nose deformity surgery, the osteoplasty technique applied to the lateral protrusion of the long nasal bone described here was as successful as a double osteotomy. Thus, certain complications of a double osteotomy can be avoided. In addition, as no greenstick fractures were induced, the long-term persistence risk was also reduced.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Osteotomies Demystified

Osteotomies are critical techniques in rhinoplasty. There are a variety of approaches, trajectories, and tools used with no widely standardized classification or nomenclature. Percutaneous osteotomies are gaining in popularity, and picture framing the nasomaxillary bone is crucial for predictable fracture and reproducible results. This is best accomplished with medial, lateral, and transverse osteotomies. Intermediate osteotomies are used less frequently, but provide more mobility. With a detailed understanding of anatomy and a thorough approach to nasal osteotomies, the contour and function of the bony vault can be reshaped with a successful outcome for both the surgeon and patient.

The Crooked Nose

Correction of a crooked nose is one of the most common requests from patients presenting for rhinoplasty. Both esthetic and functional issues are typically present in patients with this deformity. Rhinoplasty for the crooked nose is particularly challenging because multiple nasal structures, both external and internal, are commonly involved. A major septal deformity is almost always a component of severely deviated noses. The crooked nose results from extrinsic and intrinsic forces that produce distortion of the nasal structures and nasal deviation. The open approach is particularly useful and is the focus of this article.

Forty-five degree cutting septoplasty

BACKGROUND

The crooked nose represents a challenge for rhinoplasty surgeons, and many methods have been proposed for management; however, there is no ideal method for treatment. Accordingly, the 45° cutting septoplasty technique, which involves a 45° cut at the junction of the L-shaped strut and repositioning it to achieve a straight septum is proposed.

METHODS

From October 2010 to September 2014, 43 patients underwent the 45° cutting septoplasty technique. There were 28 men and 15 women, with ages ranging from 20 to 58 years (mean, 33 years). Standardized photographs were obtained at every visit. Established photogrammetric parameters were used to describe the degree of correction: Correction rate = (preoperative total deviation - postoperative residual deviation)/preoperative total deviation × 100% was proposed.

RESULTS

The mean follow-up period for all patients was 12.3 months. The mean preoperative deviation was 64.3° and the mean postoperative deviation was 2.7°; the overall correction rate was 95.8%. One patient experienced composite implant deviation two weeks postoperatively and underwent revision rhinoplasty. There were no infections, hematomas or postoperative bleeding.

CONCLUSION

Based on the clinical observation of all patients during the follow-up period, the 45° cutting septoplasty technique was shown to be effective for the treatment of crooked nose.

An often neglected area in crooked nose: middle turbinate pneumatization

Introduction

Crooked or deviated nose is a deviation of the nose from the straight vertical position of the face. Extensive pneumatization of the middle turbinate, also called concha bullosa or bullous middle turbinate (BMT) is known to be one of the possible etiologic factors in nasal obstruction, recurrent sinusitis, and headache. There is no study concerning a link between BMT and crooked nose.

Objective

To investigate the association between crooked nose and the presence of a BMT.

Methods

A total of 199 patients who underwent open septorhinoplasty were retrospectively analyzed. Preoperative paranasal Computerized Tomography (CT) findings, preoperative photodocumentation, and anterior rhinoscopic examination findings were documented. Of the 199 patients, 169 were found to meet the criteria and were included in the study. CT scans were examined to note the presence of BMT, inferior turbinate hypertrophy, and septum deviation (SD). SDs and crooked noses were classified.

Results

Ninety-four of 169 patients (56%) presented a crooked nose deformity and seventy-five of 169 patients (44%) presented a straight nose. While 49 (52%) crooked nose patients had a bulbous and extensive BMT, 20 patients with straight nose (26.6%) had a BMT. A statistically significant relationship was found between the presence of crooked nose and BMT, regardless of the side of the disease (p = 0.011).

Conclusion

This study revealed a link between crooked nose and BMT.

A Combined Approach To Crooked Nose Deformity

BACKGROUND

Crooked nose deformity is a complex anatomical deformity; therefore, repair remains a challenge. Here, we introduce a new technique for crooked nose deformity repair.

MATERIALS AND METHODS

Twenty-two patients underwent intraoperative evaluations and measurements, followed by surgery using the open rhinoplasty technique. Our method involves three major steps. First is the creation of an asymmetric medial oblique osteotomy using piezoelectric ultrasonic surgery and double lateral osteotomies, wherein the asymmetric bony ascending part of the maxillary bone at the base of the nasal vault is fractured, pushed in, and delivered to the face. Second is septoplasty with L-strut preservation. The L-strut is removed as a 1-cm block caudally from the septal stump of the keystone area. A (or double) fabricated batten cartilage graft is placed on the concave side of the deviation and sutured to cover the septal stump. The L-strut is then replaced and sutured on the batten graft, redirecting the septum toward the midline. Third is an overlapping cruroplasty on the side of the long asymmetrical lower lateral cartilage to equalize both wings and correct tip deviation.

RESULTS

Our new technique was effective for the treatment of crooked nose deformity.

CONCLUSIONS

Our technique of K-stone batten plasty with delivery to the face and overlapping cruroplasty may be an effective surgical method for crooked nose deformity.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Surgical Treatment of the Twisted Nose

The twisted nose is a challenging procedure in rhinoplasty. The goal of surgery is to realign the nasal skeleton to create symmetry in the face and restore nasal patency. Key in the surgical procedure is that all structures of the nasal skeleton be dissected free, mobilized, repositioned, and stabilized. Important surgical steps are intermediate osteotomies on the contralateral side of the deviation for the upper nasal third; for the mid nasal third, a unilateral spreader graft or splint on the nondeviated side, and for the lower nasal third, fixation of the caudal septum to the anterior nasal spine.

The crooked nose

The crooked nose is unquestionably the most severe deformity of the nasal septum due to the simultaneous involvement of very important functional and aesthetic elements. As everyday interpersonal relations are primarily conducted face-to-face, deviation of the nasal pyramid from the median line is immediately obvious even to the least observant. The surgical procedures used to address this pathology must take into account the risk of relapse due to the elastic "memory" of the cartilage and avoid any undue weakening of the structure resulting in collapse of the nasal dorsum. The complexity of the problem requires techniques capable of addressing the situation radically and providing results that are stable over time. Extracorporeal septoplasty, spreader grafts and the crossbar graft are all particularly effective, not only in correcting deformity of the nasal pyramid but also in solving functional respiratory problems. The author describes the techniques in detail and discusses their strengths with respect to specific problems of the crooked nose.

Radial bone graft usage for nasal septal reconstruction

Background:

Although various techniques have been described for correction of crooked and saddle nose deformities, these problems are challenging with high recurrence and revision rates. Conventional septal surgery may not be adequate for nose reconstruction in crooked and saddle nose deformities.

Materials and Methods:

Between December 2005 and October 2009, six patients with crooked nose and five patients with saddle nose deformities underwent corrective surgery in our clinic. All patients were male, and the mean age was 21 years (range, 19-23 years). We used rigid radial bone graft to prevent redeviation and recurrence following corrective nasal septal surgery.

Results:

The mean follow-up period was 28 months, ranging from 18 to 46 months. Mean operation time was 4 hours (3-4.5). All patients healed uneventfully. None of the patients required secondary surgery.

Conclusions:

We believe that radial bone grafts offer a long lasting support in treatment of challenging cases with crooked and saddle nose deformities.