19 Deviation of the Nasal Dorsum
“Don′t you think my nose is crooked?” This question should prompt the surgeon to make a detailed search for the underlying cause. A crooked appearance of the nose may have various causes ranging from asymmetrical swelling, inadequate osteotomies, graft displacement, or residual septal deviation to less-than-optimum suture techniques. 1 – 4 Key factors to be considered are the time elapsed since the last operation, the choice of surgical approach, and the technique that will be used. Palpation is a reasonably accurate method of distinguishing between tissue swelling and displacement.
A deviated nasal dorsum always creates the impression of a crooked, asymmetric nose. Correction of the deviation should always be based on the anatomic problem. Deviations can be classified in simple terms as a bony or cartilaginous deviation, a C- or S-shaped deviation, or a pseudo-crooked nose due, for example, to asymmetric brow-tip aesthetic lines. It is helpful to draw an imaginary horizontal line between the pupils, then drop a straight vertical line from the center of the glabella through the nasal dorsum, tip, columella, philtrum, and menton. 5 , 6 This simple method can quickly distinguish between axial deviation and asymmetry of the dorsum while also assessing the degree of facial asymmetry.
Osteotomies are the most important tool for correcting deviations of the nasal pyramid. It is important to clarify the role of residual septal deviations. In the middle third of a deviated dorsum, much can be accomplished with contouring onlay grafts that are placed in tight pockets. In patients with significant cartilaginous deviation, it should be determined whether the upper lateral cartilages are symmetrical or whether side-to-side differences have caused abnormal tension or overlaps with the alar cartilages. This will aid the surgeon in deciding among various options: detachment of the upper lateral cartilages from the septum, shortening, the placement of spreader grafts, or the use of positioning sutures. Experience has shown that osteotomies are the treatment of choice if even the slightest residual tension exists at the bone-cartilage junction. Spreader grafts have become the “workhorse” for straightening of the middle third. 7 , 8 They can be placed through an endonasal or open approach or may be used in an extracorporeal septoplasty.
Case 14
Introduction
An 18-year-old male presented 2 years after a previous septoplasty with a desire to have his nose straightened and “shortened.”
Findings
Frontal view ( Fig. 19.2a ) shows a bony deviation of the nose to the left. Profile view ( Fig. 19.2b ) shows an overprojected nasal tip. Basal view ( Fig. 19.2c ) shows elliptical nostrils with narrowing of the valve area. Fig. 19.2d , Fig. 19.2e , and Fig. 19.2f are follow-up views taken 2 years after revision surgery.
Surgical Procedure
Operative details: closed approach, resection of the medial crural footplates, submucous septoplasty, and dislocation of the alar cartilages with lateral sliding. Medial and lateral curved osteotomies were performed on both sides, with a double osteotomy and wedge resection on the right side and a single osteotomy on the left side ( Fig. 19.2g, h ).
Psychology, Motivation, Personal Background
The patient was highly motivated to have his overprojected nose straightened and deprojected.
Discussion
The decision for a closed approach was based on the symmetrical nasal tip and the anticipated effects of the endonasal manipulations.
Case 15
Introduction
A 25-year-old woman presented with the desire to have her nose straightened. She also wanted a nasal hump removed to harmonize her profile. She had breathing issues as well, particularly on the left side. One year after primary rhinoplasty she presented again with the concern of an asymmetrical nasal dorsum.
Initial Findings
Frontal view before primary rhinoplasty ( Fig. 19.3a ) shows asymmetry of the nasal dorsum with convexity on the right side and concavity on the left side in the supratip area. Profile view ( Fig. 19.3b ) shows overcorrection of the dorsum with a scooped appearance. Basal view ( Fig. 19.3c ) shows slight widening of the nasal tip. Fig. 19.3g , Fig. 19.3h , Fig. 19.3i , and Fig. 19.3j were taken 2 years after revision surgery.
Surgical Procedure
Primary rhinoplasty: hemitransfixion incision, submucous septoplasty, splitting approach, en bloc resection of the bony and cartilaginous hump, medial and lateral curved osteotomies with a double osteotomy on the left side.
Revision rhinoplasty: lysis of dorsal scars and adhesions, additional cephalic alar cartilage reduction, and augmentation of the opposite side with the removed cartilage. Augmentation of the supratip area.
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