General Considerations
The crooked nose is neither a single entity nor a specific description. Crooked noses represent a spectrum of nasal deformities, most commonly of traumatic origin, that are associated with a deviated or irregular appearance to the nose. For the casual onlooker, the crooked nose may be unsettling because of its disharmony with the rest of the face, much like a picture frame that sits askew on a wall. In common usage, “crooked” connotes not only a lack of straightness but also traits of dishonesty or unsavory character, as contrasted to the forthright person who is “playing it straight.” The term “crooked nose” is thus apt because it not only captures the distinctive external appearance of a misaligned, deviated nose but also suggests the potential for social stigmatization. The surgeon should thus be attentive to not only the anatomic characteristics of the crooked nose but also the potential effects of this deformity on the patient’s self-image.
Correction of the crooked nose remains a notoriously difficult challenge for the rhinoplasty surgeon. The complex interplay of functional and aesthetic considerations is coupled with the predilection of this deformity for gradual recurrence, often despite initially successful surgical treatment. The contracture forces of scar formation combined with cartilage thickening and deformation may resist definitive correction. Cartilage’s elastic memory, the progressive formation of adhesions, and the collapse of a weakened septum are all contributory factors. An understanding of the relevant anatomy and pathogenesis of the deformity informs the surgical approach. This chapter covers the etiology, analysis, and surgical correction of the crooked nose.
Anatomy of the Crooked Nose
The anatomy of the crooked nose is best understood relative to the constituent components of the osseocartilaginous framework. The upper third of the nose comprises the bony pyramid with its paired nasal bones and ascending processes of the maxillae. Bone thickness tapers along the nasal bones’ caudal aspect. The lower two thirds of the nose are cartilaginous, including the nasal septum, the paired upper lateral cartilages, and the alar cartilages. The cartilage of the septum is relatively wide along the floor of the nose, flattens in the midportion, and is thickest near the dorsum, adjacent to the takeoff of the upper lateral cartilages.
Crooked noses exhibit greater diversity in their patterns of deformity than do isolated bony fractures. This heterogeneity is a reflection of the ability of cartilage to not only fracture but also twist, bend, and remodel in response to injury. The nasal septum behaves much like the rudder of a boat that both acutely and chronically guides the direction of the external nose, lending credence to the surgical maxim, “Where the septum goes, so goes the nose.” Traumatic injury may cause angulation, telescoping, stepoffs, flattening, or splaying of the framework of the nose. The entire nasal pyramid may be deviated to one side, or a canted bony pyramid may be at an angle with the mid vault or lower third of the nose.
Classification of the Crooked Nose
The common patterns of crooked or deviated noses are the C-, S-, and I-type deformities shown in Figure 22-1 . The C-shaped deformity usually begins cephalad at the nasal dorsum, proceeds posteroinferiorly through the perpendicular plate of the ethmoid, and then extends into the cartilaginous septum. The S-shaped deformity is characterized by a serpentine twisting of the external nose, usually with corresponding septal deviation. The I-shaped deformity corresponds to a deviation of the entire nasal pyramid. The nose is considered truly deviated if it departs from the midline position, with or without curvature. These deformities are associated with varying degrees of nasal obstruction.
Not all crooked noses fit neatly into this classification scheme. Prior rhinoplasty, pathologic disease processes, and saddling may all produce unpredictable patterns of asymmetry. Some noses that appear crooked do not have a true deviation. For example, when a laterally directed force causes unilateral collapse of a nasal bone, the resulting concavity makes the nose appear deviated to the opposite side. Unilateral infracture of the bony pyramid side wall is often not associated with displacement of the septum. This infracture injury has a more favorable long-term prognosis with surgery and requires less extensive reconstruction than does a true deviation.
Etiology and Pathogenesis of the Crooked Nose
Traumatic Causes
The nasal bones are the most commonly fractured bones in the face, and nasal injury is the most common cause of the crooked nose. True deviation is indicative of a high energy injury and requires greater force than an isolated nasal bone depression or fracture. Usually a significant frontal vector is required for deviation to occur. With trauma, the nasal septum is often fractured or displaced from the maxillary crest. Because the nasal framework becomes more ossified and brittle with age, younger patients tend to have larger fracture segments than older patients, who are more prone to nasal bone comminution. As a general rule, nasal trauma associated with septal fracture requires extensive reconstruction and is unlikely to be adequately treated with closed reduction. The surgeon should also consider psychological repercussions of the incident; such factors may influence the patient’s readiness to undergo an elective surgical intervention.
The crooked nose deformity may reflect either the acute outcome of a traumatic episode or a remote injury that has been compounded by years of scarring and soft tissue contracture. The cartilaginous septum is the primary shock absorber of the nose, with lesser contributions from the upper lateral cartilages, alar cartilages, and bony components. Patients with untreated or inadequately reduced nasal fractures may develop a crooked nose gradually, with surface irregularities and asymmetries becoming more conspicuous with the passage of years. Cartilage has a low metabolic rate and frequently heals with scar formation. In cases of remote trauma, the patients may recount a worsening of the deformity with time, often associated with progressive nasal airway obstruction due to disruption of nasal support mechanisms. Repetitive fractures may cause profound structural deficiency, and comminution often will induce aberrant growth.
Many patients with a crooked nose do not remember the inciting traumatic injury. The patient with a severely twisted nose and without history of antecedent trauma is likely to have sustained a childhood injury that was overlooked. Relatively minor cartilage trauma may lead to dramatic deformation over time with chondrocyte growth. The pediatric nose lacks a well-developed bridge and is capable of absorbing substantial energy without showing irregularity until later in life. Children’s noses are mostly cartilaginous and are susceptible to injuries that produce progressive deformation over subsequent years of growth. In some cases, septal subluxation or fracture may have occurred during birth. Forceps delivery and breach delivery are risk factors, although the head is also subjected to powerful compressive forces during normal passage through the birth canal. Such early deformities may first become evident during adolescence, as shown in Figure 22-2 .
Iatrogenic Causes
Prior nasal surgery is an important cause of the crooked nose. Asymmetric or incomplete osteotomies often result in deviation and step-off deformities of the upper third of the nose. With green-stick fractures, the bony vault may be subject to residual memory and deviating forces from scarring. Alternatively, if adequate osteotomies are performed but the underlying septal deformity is not addressed, the nasal pyramid will often regress to its original, deviated position. Removal of a dorsal hump in the nose with a straight dorsum and a caudal deviation may unmask an underlying deformity that was not previously visible. Closed reduction of a nasal fracture may result in persistence or creation of a crooked nose if the fracture is not adequately reduced.
Reduction rhinoplasty deserves special consideration due to its potential for creating severe asymmetries that usually become apparent years after surgery. Resection of the nasal osseocartilaginous framework disrupts nasal support mechanisms, often with insidious destabilizing effects. Over the course of years, the contractile forces of scar formation, gravity, and aging conspire to warp and collapse the attenuated nasal scaffold. Such distortions may require major reconstruction years later to address progressive disfigurement and impairment of nasal function. Most rhinoplasty techniques have effects in adjacent zones of the nose during healing. Thus, unexpected deviations often occur from manipulations elsewhere, for example mid vault narrowing and upper lateral cartilage collapse occurring after dorsal hump reduction.
Diseases Involving the Septum and Internal Nose
Several relatively rare pathologic processes may lead to a crooked nose. The surgeon should inquire about symptoms of nasal obstruction and history of epistaxis, allergy, and systemic disease. Autoimmune or immunologically mediated diseases may cause resorption of bony or cartilaginous nasal structures. Granulomatous disease, such as Wegener’s granulomatosis or sarcoidosis, and collagen vascular/connective tissue disorders are important diagnostic considerations, particularly in patients with nasal septal perforation or saddling. A history of inhalant abuse, such as cocaine, oxymetazoline, nasal steroids, or NeoSynephrine use, should be considered in cases of mucosal atrophy, ulceration, or nasal perforation. The surgeon should also be alert to infectious etiologies such as tuberculosis, syphilis, and HIV infection. Sinonasal polyposis or neoplastic disease may also induce remodeling and/or splaying of nasal framework.
Evaluation
Physical Examination and Nasal Analysis
The physical examination begins with an assessment of overall facial symmetry to ensure that all nasal pathology is viewed in relation to facial asymmetries. Many patients are unaware of asymmetry of the facial bones or soft tissues that may influence the perceived straightness of the nose. One of the defining features of the crooked nose is disruption of the brow–nasal tip aesthetic line, a line that runs from the medial brow to the ipsilateral nasal tip defining point. Identification of a break in this contour line helps localize the site of fracture or deformity that will require correction. Visual inspection and palpation are complementary in the nasal analysis.
The bony pyramid, nasal mid vault, and lower third of the nose are then systematically evaluated. The bony pyramid may be canted or have palpable surface irregularities. Angulation is often present at the transition of the upper and lower two thirds of the nose. Careful examination of the mid vault region will differentiate true deviation from isolated unilateral collapse of a nasal bone and/or upper lateral cartilage. The nasal tip is assessed for asymmetry, deviation, presence of bossae, and alar retraction. Poor recoil of the tip to gentle finger pressure is indicative of compromised tip support. The anterior septal angle is palpated for its location and orientation. Basal view demonstrates caudal septal deviation and subluxation of the caudal septum off the maxillary crest. The anterior nasal spine serves as an anchoring point for the septum. Malposition of the septum due to prior trauma or surgery will alter nasal alignment and is best appreciated upon inspection of the nasal base.
Internal nasal examination is crucial from both a functional and aesthetic standpoint because septal deformity is the primary driver of the external appearance of the crooked nose. The nose should be examined both before and after constriction of the nasal mucosa to visualize potential sites of obstruction. The nasal lining will provide clues as to the extent of scarring and inflammation. Septal fractures, spurs, deviations, and other deformities are noted. The attachment of the upper lateral cartilage to the septum should create an angle of at least 10 to 15 degrees to avoid internal nasal valve collapse. The Cottle maneuver, performed by retracting the cheek soft tissues laterally, decreases the nasal obstruction from internal nasal valve collapse. Dynamic alar collapse with inspiration indicates external nasal valve collapse. Recurvature of the lower lateral cartilage into the nasal airway makes an often unrecognized contribution to airway narrowing and is an impending source of deformity following tip surgery. Turbinate hypertrophy may require a reduction or submucosal resection.
Photography is necessary in all patients with crooked nose, including those with purported interest in the relief of nasal obstruction only. Photography allows for precise recording of deformities and for computer imaging during patient consultation. In addition to the standard 7 rhinoplasty views (frontal, base, bilateral three-quarters, bilateral side, and lateral smiling views), the authors find it helpful to include a helicopter or sky view from above the nose highlighting any twisted configuration. Analysis of the patient followed by review of photographs taken in these views will assist the surgeon to determine whether camouflaging, structural reorientation, or both are needed.
Selection of Surgical Approach
The decision to undertake anatomic reconstruction (structural reorientation) versus masking of the deformity (camouflage) will dictate the surgical approach. Camouflage techniques will best preserve existing structural support but fail to introduce new support and often involve some compromise in the aesthetic outcome. In contrast, structural reorientation can achieve excellent contour and can correct airway obstruction but does so at the expense of more extensive surgery and the potential risk for collapse if support mechanisms are not reconstituted. In performing nasal analysis, the surgeon should differentiate between the intrinsic forces and extrinsic forces that contribute to the nasal deformity. Intrinsic forces are due to aberrant growth and development of the cartilaginous septum. Extrinsic forces result from deviation of the nasal pyramid. Extrinsic forces are transmitted to the nasal septum through attachments to the nasal bones, the upper and lower cartilages, the vomer and perpendicular plate, and the maxillary crest. For more severe deformities, especially those with airway compromises, we often use a combination of structural realignment and camouflage of residual minor deformities.
When nasal airway obstruction is present or when there is concern for impending nasal airway compromise, a structural reorientation approach is preferred. This approach involves release and deconstruction followed by rebuilding of structural elements of the osseocartilaginous skeleton. In such cases, an open rhinoplasty approach is advised. Camouflaging methods, which create the illusion of correction without actual manipulation of the deviated framework, do not influence nasal airway patency. In the absence of nasal obstructive complaints, camouflage alone may be adequate for correcting limited deformities. Camouflage techniques, when used in isolation, are usually conducive to an endonasal approach. It should be kept in mind that this method may only partially correct the crooked appearance and grafts may become visible in patients with thin skin. In some cases, it is desirable to use both techniques, as shown in Figure 22-3 .
The Role of Closed Reduction
Closed reduction is best reserved for simple nasal fractures resulting from lateral forces. With such injuries, the nose may appear deviated but the actual deformity is usually limited to a single depressed bone fragment of the nasal side wall. The ipsilateral upper lateral cartilage may also be pulled medially. The casual observer will often erroneously perceive the nasal dorsum to being deflected to the opposite side. With either closed reduction or rhinoplasty, this type of injury carries a favorable prognosis. Closed reduction should be performed within 24 hours of the injury, prior to the onset of edema, or at 10 to 21 days, by which time soft tissue edema has resolved. For unilateral nasal bone fracture, the Boies elevator usually suffices to restore the bone to its native position. Closed reduction is also useful in the neonatal period, when a difficult delivery is associated with a displaced septum and can be reduced with blunt forceps.
Unfortunately, the aesthetic outcomes following closed reduction are frequently unsatisfactory for the deviated or crooked nose. Closed reduction has limited precision in realigning bony and cartilaginous structures that are askew, telescoping, or markedly displaced. Walsham and Asch forceps are designed to reduce the displaced septum and impacted nasal bones, respectively. However, revision rates after closed reduction are unacceptably high when significant septal pathology is present. Another drawback is the possibility of mucosal crushing injuries, synechia formation, and septal hematoma. In general, closed reduction can be unsatisfying for traumatic deformities that have bony comminution, extensive cartilaginous injury, or septal fracture.
If one chooses to perform a closed reduction, assessment of postreduction fragment stability is essential. Most fractures are, in fact, comminuted injuries that tend to collapse readily with minimal pressure. In adults, we often wait 10 to 21 days following their injuries when the fragments start to get “sticky.” In this early phase of healing, the fragments are more stable. In addition, we will often support unstable fragments with a section of compressed cellulose sponge that can be wedged beneath the mucosal surface of the bone and anchored with absorbable sutures. The sutures are passed through the dorsal fracture fragments and nasal skin and then taped to the dorsum. These splints eliminate the need for traditional nasal packing and are removed within 5 to 7 days.
External Approach to the Crooked Nose
Much debate has centered on the indications for use of external versus endonasal approaches in rhinoplasty. In the authors’ opinion, the preferred surgical approach is the one that confers the highest likelihood of a successful and durable surgical outcome. The literature confirms that the columellar scar from the external approach is a concern in less than 1% of patients. This figure is quite small compared to the overall published revision rates for rhinoplasty. Therefore, we use the external approach whenever improved exposure and precise graft placement can provide a meaningful advantage. These two criteria are met in the majority of patients with crooked noses.
The external approach affords the surgeon unparalleled exposure for counteracting the intrinsic and extrinsic forces responsible for cartilaginous septal deviation. Release of diffuse scar tissue, realignment of collapsed or twisted lateral cartilages, and repair of septal deviations involving the dorsal or caudal septum are all cumbersome through intranasal incisions. Using the external approach, the surgeon can expose the septum from the dorsum to the maxillary crest and from the caudal margin back to the anterior face of the sphenoid. As a result, structural reorientation involving graft placement under direct visualization and precise suture fixation is possible. In our experience, placement of spreader grafts after dividing the upper lateral cartilages through an external approach results in far more predictable results than endonasal placement. In addition, the lower third of the nose is seen in broad relief and easily manipulated, providing the best opportunity for achieving symmetry in the deviated or twisted nasal tip.
Endonasal Approach to the Crooked Nose
The endonasal approach is useful for a more limited subset of crooked noses. One of the most significant advantages of this approach is that is allows for precise pocket preparation for camouflage grafts. In addition, this approach decreases operative time, avoids a columellar incision, may decrease postoperative edema, and obviates the need to reconstitute the structural elements disrupted by the open approach. An intercartilaginous incision allows for camouflage techniques in the middle third of the nose, as well as conservative hump reduction and osteotomies, provided the nasal airway remains widely patent. Grafts are placed immediately above perichondrium or deep to periosteum to minimize the risk of visible or palpable grafts. Although the delivery approach has proven very useful in refinement of the bulbous nasal tip, correction of tip asymmetries is less reliable endonasally.
Selection of Graft Material
Septal cartilage is the grafting material of choice because of its versatility, ease of harvest, and minimal donor site morbidity. When adequate septal cartilage is not available, usually auricular cartilage or costal cartilage may be used. Autologous tissues have long track records of success and are associated with low risks of infection, extrusion, and resorption. Conchal cartilage is best for alar batten grafts and for filling small dorsal concavities, whereas costal cartilage is often necessary for correction of a saddle deformity or when previous surgery has reduced other grafting options. Crushing cartilage significantly improves camouflage and malleability but may predispose to resorption if chondrocyte viability is impaired by excessive trauma. We rarely use calvarial or other bone grafts due to the favorable attributes of cartilage, which include its natural feel and facile harvest, carving, and fixation. Acellular dermal matrix may be used selectively for camouflage of minor irregularities, although we prefer autologous fascia, perichondrium, or fibroconnective tissue for this purpose.
When costal cartilage is required, we prefer to use the “floater” tenth rib as a dorsal onlay graft. Harvesting from this site decreases pain, carving time and risks of flail chest and pneumothorax. Harvesting additional cartilage from other ribs may be necessary if additional grafting material is needed. The floater rib has less curvature than attached ribs and contains both bone and cartilage, thus mimicking the structural elements to be replaced. The bony portion of the graft is cantilevered on the rasped bony foundation of the upper third of the nose to promote a bony union. If cartilage is harvested from the seventh or eighth ribs, the grafts should be taken from the center of a relatively straight cartilage segment to decrease risk of warping.
Dorsal costal cartilage grafts serve to provide sufficient structure to recreate a straight dorsal line and simultaneously camouflage and modify irregularities. Costal cartilage dorsal grafts are not immune to distortion during or after surgery, and a few pearls may decrease the risk of warping. Carving the graft symmetrically by trimming from both lateral edges and placing a Kirschner wire in the middle of the graft has been recommended. We routinely place the dorsal graft along the entire dorsum, from the radix to the supratip to avoid distortion that can occur if a graft ends at the rhinion. In the uncommon case where a patient is unwilling or unable to undergo costal cartilage harvest, homologous irradiated rib graft is useful. It is readily carved and compares favorably with the commercially available alloplastic implants.
Numerous fixation techniques have been used to secure dorsal grafts. Our preferred method is to suture the caudal portions of the graft to the dorsal edges of the upper lateral cartilages, as in an onlay spreader graft and anchor the cephalic end to the bony dorsum with one or two percutaneous Kirschner wires that are removed in 3 weeks as a minor office procedure that rarely requires even local anesthesia. Lag screw fixation, although preferred by some, has been unsatisfactory for use due to the tendency for the screw to extrude long term.
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