1

Introduction

Correction of the twisted or deviated nose, a complex anatomic deformity, remains a big challenge for the rhinoplasty surgeon to achieve consistent long term success in aesthetic and functional outcome. A thorough understanding of nasal anatomy, physiology, an accurate preoperative and intra-operative analysis and biomechanics of soft tissue and cartilage healing is required . The underlying anatomic deformity involves osteo-cartilaginous and soft tissues, usually of traumatic origin in which all nasal osteocartilaginous components play a role in deviations including soft tissues . Both intrinsic and extrinsic forces in osteocartilaginous pyramid produce nasal and septal deviations . Extrinsic forces are secondary to deviation of nasal pyramid, scar contractures and attachments of upper and lower lateral cartilage and forces from injury or deviation to the vomer, perpendicular plate of ethmoid, maxillary crest and septal deviation. Intrinsic deforming forces within cartilage cause misdirected growth of septum following injury .

Many surgical techniques/algorithms using either closed or open structure approach have been described for the correction of deviated nose deformities . With the evolution of modern rhinoplasty techniques and use of structural grafts, anatomic reconstruction using open approach has become the standard line of management for deviated nose . In a review of literature most of surgical techniques for deviated nose and results have been published in Caucasian or Asian noses. Except for anecdotal cases, not many studies have been done in the Arabic nose. The Arabic or Omani nose has special characteristics. The goal of our study was to critically analyze the cause for recurrence of deformity with respect to surgical technique used especially osteotomies and use of structural-spreader grafts in twisted or deviated nose deformity. Our second goal was to evaluate the functional and aesthetic outcome in severely twisted or deviated nose deformity in Arabic (Omani) nose with open structure rhinoplasty.

2

Materials and methods

A retrospective chart review of two hundred consecutive patients with deviated or twisted nose deformity who underwent corrective septorhinoplasty during the period of 2 years between January 2009 and December 2010 was done. Approval of the institutional ethic committee before conducting the study was obtained. The inclusion criteria were all cases operated on as primary or secondary surgery for deviated nasal deformity with open rhinoplasty approach. We excluded those cases which were operated on by closed approach and also cases operated on only for aesthetic concerns.

Out of total 201 cases operated on during the period, 179 cases of deviated or twisted noses were finally analyzed. Twenty-two cases that were operated on by closed technique were excluded from the study. The age group of the patients was between 16 and 55 with a mean age of 27.3 years. There were 43 females and 136 males. All patients had functional and cosmetic deformity and desired correction. A thorough medical record review was conducted on each patient to identify preoperative complaints, surgical maneuvers performed, surgical complications and clinical follow-up. All patients had a detailed physical examination and preoperative photography, consisting of frontal, basal, lateral, and oblique views. With respect to median axis on frontal plane, the deviated or twisted nose was divided into three types:

• Type1.
  

  Cartilaginous deviation—lowers 2/3rd of nasal pyramid

  
  
• Type II.
  

  Deviation of whole nasal pyramid away from midline axis to either side

  
  
• Type III.
  

  C shape or reverse C shape. This group included cases with the following characteristics.

  
  
  
  
  • a.
    

    Severe lateral wall asymmetries

    
    
  • b.
    

    Deviation with hump deformity

    
    
  • c.
    

    Broad asymmetric nose with or without hump deformity

  
  

All cases were operated on with open septorhinoplasty approach via an inverted V-shaped trans-columellar incision and a standard marginal incision. The nasal suprastructure was exposed under SMAS layer and skeletonization of cartilaginous and bony framework was performed under direct visualization and structural asymmetries were noted. All cases had septal reconstruction with dorsal approach. Selections of osteotomies were based on type of deformity. Structural grafts especially spreader grafts were applied whether unilateral or bilateral based on the severity of septal deformity especially dorsal septal deviation, and condition of upper lateral cartilage and lateral wall asymmetry. The reconstruction of nasal tip especially projection was the last step of reconstruction based on the height of nasal dorsum.

The patients’ follow-up visits were recorded at 1 week, 4 weeks, 3 months, 6 months 12 and 24 months later. Their functional and aesthetic assessment clinically and with pre- and post-operative photographs in standard – frontal, basal, profile and oblique – views were evaluated. Those patients who did not have sufficient post-operative visits were contacted by phone to determine their aesthetic and functional improvement and satisfaction.

2

Materials and methods

A retrospective chart review of two hundred consecutive patients with deviated or twisted nose deformity who underwent corrective septorhinoplasty during the period of 2 years between January 2009 and December 2010 was done. Approval of the institutional ethic committee before conducting the study was obtained. The inclusion criteria were all cases operated on as primary or secondary surgery for deviated nasal deformity with open rhinoplasty approach. We excluded those cases which were operated on by closed approach and also cases operated on only for aesthetic concerns.

Out of total 201 cases operated on during the period, 179 cases of deviated or twisted noses were finally analyzed. Twenty-two cases that were operated on by closed technique were excluded from the study. The age group of the patients was between 16 and 55 with a mean age of 27.3 years. There were 43 females and 136 males. All patients had functional and cosmetic deformity and desired correction. A thorough medical record review was conducted on each patient to identify preoperative complaints, surgical maneuvers performed, surgical complications and clinical follow-up. All patients had a detailed physical examination and preoperative photography, consisting of frontal, basal, lateral, and oblique views. With respect to median axis on frontal plane, the deviated or twisted nose was divided into three types:

• Type1.
  

  Cartilaginous deviation—lowers 2/3rd of nasal pyramid

  
  
• Type II.
  

  Deviation of whole nasal pyramid away from midline axis to either side

  
  
• Type III.
  

  C shape or reverse C shape. This group included cases with the following characteristics.

  
  
  
  
  • a.
    

    Severe lateral wall asymmetries

    
    
  • b.
    

    Deviation with hump deformity

    
    
  • c.
    

    Broad asymmetric nose with or without hump deformity

  
  

All cases were operated on with open septorhinoplasty approach via an inverted V-shaped trans-columellar incision and a standard marginal incision. The nasal suprastructure was exposed under SMAS layer and skeletonization of cartilaginous and bony framework was performed under direct visualization and structural asymmetries were noted. All cases had septal reconstruction with dorsal approach. Selections of osteotomies were based on type of deformity. Structural grafts especially spreader grafts were applied whether unilateral or bilateral based on the severity of septal deformity especially dorsal septal deviation, and condition of upper lateral cartilage and lateral wall asymmetry. The reconstruction of nasal tip especially projection was the last step of reconstruction based on the height of nasal dorsum.

The patients’ follow-up visits were recorded at 1 week, 4 weeks, 3 months, 6 months 12 and 24 months later. Their functional and aesthetic assessment clinically and with pre- and post-operative photographs in standard – frontal, basal, profile and oblique – views were evaluated. Those patients who did not have sufficient post-operative visits were contacted by phone to determine their aesthetic and functional improvement and satisfaction.

3

Case representative

N.B: Patients were consented for publishing their cases and photos.

3.1

Case 1

A 19-year-old male had deviated nose deformity with progressive bilateral nasal obstruction following childhood nasal trauma. On clinical examination he had type III deviated nose deformity with asymmetric lateral wall, hump deformity, and drooping under projected nasal tip with gross deviated nasal septum to the left obstructing nasal passages completely ( Fig. 1 ). He underwent corrective septorhinoplasty with open approach. He had asymmetric hump removal, extra-mucosal separation of both upper lateral cartilages and modified extracorporeal septal reconstruction. Bilateral spreader grafts were placed to correct the deviated dorsal septum ( Figs. 2 and 3 ). Multiple osteotomies – bilateral lateral, transverse (percutaneous), and intermediate – on the left-side dome to mobilize the deviated pyramid were performed. Tip reconstruction was done with suture technique incorporating columellar strut and Shield graft. Eighteen months postoperatively, he had a straight nose with well projected nasal tip and complete relief of nasal obstruction and septum in midline ( Fig. 1 ).

Case 1. (A, B) A 19-year-old ASM male, type III. Frontal view shows severe twisted deviated nasal deformity. Pre- and postoperative views. (C, D) Basal pre- and postoperative view. (E, F) Profile pre- and postoperative view.

Extramucosal dissection, separation of both upper lateral cartilages and hump reduction.

(A, B) Application of asymmetric bilateral spreader graft.

3.2

Case 2

A 20-year-old male had presented with deviated nose deformity. He was not happy with the shape of his nose. There was no history of nasal trauma. Clinically he had type II, deformity with twisted broad nasal dorsum with linear axis of deviation to the right from radix to the tip, and broad and bulbous nasal tip. Septorhinoplasty with open approach was performed. He had unilateral spreader graft application on the right side and septal reconstruction and multiple osteotomies – paramedian, lateral, left intermediate, transverse and root osteotomies – to straighten the nose at radix. At 2-year postoperative follow-up, he was satisfied and happy aesthetically with a straight nose and patent nasal airway ( Fig. 4 ).

Case 2. (A, B) Type 2 deviated nasal deformity. Pre- and postoperative 24 months after.