Correction of the deviated tip and columella in crooked nose.

A deviated nose, also known as a crooked nose, is defined as a condition in which the nose does not follow the mid-vertical line of the face. A deviated nose poses both functional and aesthetic problems, the former of which is exemplified by nasal obstruction. Correction of nasal deviation is among the most challenging aspects of rhinoplasty and surgeons should explore functional and aesthetic solutions.

Introduction to deviated nose correction.

The primary procedural components of deviated nose correction are as follows: osteotomy to correct bony deviation, septal deviation correction, manipulation of the dorsal septum to correct upper lateral cartilage deviation, and correction of functional problems (manipulation for correction of internal valve collapse and hypertrophy of the inferior turbinate). The correction of tip and nostril asymmetry cannot be overemphasized, because if tip and nostril asymmetry is not corrected, patients are unlikely to provide favorable evaluations from an aesthetic standpoint. Tip asymmetry, deviated columella, and resulting nostril asymmetry are primarily caused by lower lateral cartilage problems, which include deviation of the medial crura, discrepancy in the height of the medial crura, and asymmetry or deformity of the lateral crura. However, caudal and dorsal septal deviation, which is a more important etiology, should also be corrected. A columellar strut graft, correction of any discrepancy in the height of the medial crura, or lateral crural correction is needed to correct lower lateral cartilage deformation depending on the type. In order to correct caudal septal deviation, caudal septal shortening, repositioning, or the cut-and-suture technique are used. Surgery to correct dorsal septal deviation is performed by combining a scoring and splinting graft, a spreader graft, and/or the clocking suture technique. Moreover, when correcting a deviated nose, correction of asymmetry of the alar rim and alar base should not be overlooked to achieve tip and nostril symmetry

A deviated nose, also known as a crooked nose, is defined as a condition in which the nose does not follow the mid-vertical line of the face. A deviated nose poses both functional and aesthetic problems, the former of which is exemplified by nasal obstruction. Correction of nasal deviation is among the most challenging aspects of rhinoplasty and surgeons should explore functional and aesthetic solutions.

Therefore, the primary procedural components of deviated nose correction are as follows: osteotomy to correct bony deviation, septal deviation correction, manipulation of the dorsal septum to correct upper lateral cartilage deviation, and correction of functional problems (manipulation for correction of internal valve collapse and hypertrophy of the inferior turbinate). Many studies on deviated nose correction have covered operative techniques involving the aforementioned procedures. Simultaneously, because almost all deviated noses involve a deviated tip, oblique columella, or asymmetry of the nostrils it is difficult to achieve an optimal result in deviated nose correction without correcting those problems. A symmetric tip and nostril is a criterion for a beautiful nose. When there is tip, columella, or nostril asymmetry because these areas have been incompletely corrected, the patient is likely to be dissatisfied and the surgeon’s reputation will suffer. Therefore, surgeons should focus on deviation of the tip and columella, as well as the correction of bony and mid-vault framework deviation.

Causes of deviated tip/columella and deviated nostrills

Tip asymmetry, deviated columella, and the resultant nostril
asymmetry are primarily caused by lower lateral cartilage problems. Examples of lower lateral cartilage problems include deviation of the medial crura, a discrepancy in the height of the medial crura, and asymmetry or deformity of the lateral crura.

The mechanism through which caudal septal deviation causes
columella deviation is that the deviated caudal septum moves
the medial crura laterally. A deviated dorsal septum
contributes to tip and columella deviation by laterally moving
the dome in the lower lateral cartilage and lateral crura.

Operative techniques of deviated nose correction

Correction of lower lateral cartilage problems

When deviation or twisting of the medial crura is the cause of a
deviated columella or asymmetric tip, the definitive correction
is to straighten the medial crura using a columellar strut graft.

The septum is preferred as the donor of the columellar strut
graft because it is possible to obtain the donor cartilage when
septal correction is performed as part of deviated nose correction. If a surgeon considers that it is inappropriate to use septal
cartilage, conchal cartilage can be used. The cymba conchae is a
more preferable donor site because it is longer than the cavum
conchae.
When performing a columellar strut graft, the nostril apex is
the most important reference point to make a symmetric nostril. The surgeon should fix the medial crura to the columellar
strut graft with the apex of the nostril located on both sides of a
single horizontal line. In this way, the same nostril height of left
and right can be obtained, and any lingering asymmetry of the
alar dome or lateral crura can easily be corrected by suturing or
segmental resection. On the contrary, if the position of
the dome, instead of the nostril height, is used as a reference
point and is adjusted first, the remaining asymmetry of nostril
height is not easily corrected.
Differences in the height of the medial crura on both sides
cause nostril asymmetry because the heights of the nostril apex
on the left and right become different. In order to correct this,
shortening of the longer medial crus or elongation of the shorter
medial crus needs to be performed.

Shortening of the longer medial crus

After cutting a columellar segment of the longer medial crus, an overlapping suture is performed.

Lengthening of shorter medial crus

A gap is made by excising a columellar segment in the shorter
medial crus, and a columella strut graft is performed. Deformed lateral crura or asymmetric lateral crura also contribute to tip asymmetry and columella deviation.

Buckling of the lateral crura

A concavity control suture can be used to correct mild buckling of the lateral crura. Severe cases may necessitate a lateral crural onlay graft.

Asymmetry in the length of the lateral crura

Caudal displacement of the lateral crus, which detaches from the hinge complex on the shorter side, or shortening of the lateral crus on the longer side is performed. Shortening of the lateral crus is carried out at the lateral most part of the lateral crus using the cut-and-overlapping suture technique.

Correction of deviation of the caudal and dorsal septum

Correcting deviation of the caudal and dorsal septum is a vitally
important part of surgery to correct a deviated tip and columella.

Correction of deviation of the caudal septum

Anteroposterior deviation of the caudal septum is corrected as
follows. In one type, the anterior nasal spine (ANS) is placed on the middle line and the caudal septum is located on the ANS, and the caudal septal cartilage is deviated in a C or S pattern because of its excess length.
Correction of this type of deviation requires caudal septal shortening, and can be performed through segmental resection of the caudal septum or the cut-and-suture technique.

Correction of deviation of the dorsal septum

After SMR is performed and deviation of the caudal septum is corrected, deviation of the dorsal septum improves spontaneously. The choice of an operative technique is made after examining the shape and extent of the remaining dorsal septal deviation. The surgical methods to correct dorsal septal deviation are double mattress sutures, scoring and splinting grafts, the cut-and-suture technique, spreader grafts, and dorsal septal
rotation sutures (clocking sutures). Most dorsal septal correction procedures are performed by combining multiple of the aforementioned methods.
The operative technique that the author prefers is a combination of a scoring and splinting graft (which additionally provides the functionality of a spreader graft) and clocking sutures.

Scoring and splinting grafts

The dorsal septal cartilage is moved to the midline by performing one-third-thick multiple scoring on the convex side of the dorsal septum. Since the predictability is low and the dorsal septum is only weakened by scoring, a splinting graft is performed on the opposite side of the scored site. The splinting graft additionally provides the functionality of a spreader graft. The spreader graft is a very important technique that is almost always included in dorsal septal correction, and it is usually located on the concave side. The spreader graft straightens the deviated dorsal septum and spreads the sunken supper lateral cartilage laterally. Moreover, it strengthens the
dorsal septum weakened by scoring or the wedge resection, enables the prevention or correction of an inverted V-deformity, and increases the width of the internal nasal valve. The septal cartilage is the optimal donor site, but it is also possible to use the auricular cartilage or costal cartilage.
The sunken area is spread out by a spread graft on the concave side of the dorsal septum, whereas the transverse wing is resected if the convex side of the dorsal septum shows excessive concavity.

Clocking suture (septal rotation suture)

A clocking suture is a horizontal mattress suture that is anchored
at the more cephalic portion of the upper lateral cartilage that passes through the more caudal part of the deviated dorsal septum and the spreader graft. Thus, this suture can pull the deviated dorsal septum toward the midline. The opposite upper lateral cartilage is then sutured to the straightened dorsal septum.

Correction of an asymmetric alar rim and alar base

An asymmetric alar rim (retracted alar rim) or alar base asymmetry can cause nostril asymmetry in a deviated nose. Correction of these factors should not be overlooked in order toachieve tip and nostril symmetry when correcting a deviated nose.
The correction methods of a retracted alar rim are caudal rotation of the lower lateral cartilage, alar rim grafts, lateral crural strut grafts, and composite grafts.
Normally, a width asymmetry of the alar base can be easily corrected by reduction of the wider side.

The full article was published on Archives of Plastic Surgery and is available here