The crooked nose is not just one deformity, and therefore, it must not be assumed that there is a single surgical technique or set of surgical steps that can be universally applied. As a consequence, analysis is of fundamental importance to understanding the patient’s anatomy and directing a surgical plan. It’s critical to recognize that the crooked nose can often be associated with complex deformities involving multiple components of the nasal skeleton, skin soft tissue envelope, and mucosal lining. These anatomical elements may not just be displaced but also remodeled if there is a history of trauma. Furthermore, patient’s expectations should not be assumed in advance. Functional as well as aesthetic improvement may need to be addressed.

The patient’s motivation for surgery may also be complex. Special attention should be given to psychological issues not only in the patient requesting cosmetic change for congenital nasal deformity but also in those who’ve had nasal trauma, for example, the patient with a history of having been assaulted who hopes their nose can be returned to its premorbid appearance. The surgeon must be sensitive to patients’ psychological concerns, must be capable of recognizing and understanding a wide range of anatomical deformities, and must be competent with a wide range of surgical techniques for all elements of the nasal skeleton and soft tissues.

A medical history should be approached in a standardized format of medical conditions, surgical interventions, current prescriptions and allergies, as well as a general examination. A rhinoplasty history should start with an open question asking the patient what they hope to achieve from the consultation and from any future surgery. It is important to establish what the patients’ main hopes are. Subsequently, the patient can be guided with questions specifically addressing their aspirations and expectations with regard to both nasal function and appearance as well as their expectations as to how surgery will help them make progress generally. It is also important to ask the patients about their concerns and worries. Whether previous nasal trauma including iatrogenic has occurred should be investigated as this may warn the surgeon of increased unpredictability during any subsequent rhinoplasty. It should, however, be remembered that trauma could have occurred in childhood, and the patient may have no recollection of this event. If the patient presents after trauma, it’s important to ascertain whether the patient is hoping for their preinjury nasal shape and function to be restored or whether they’re looking for additional improvement. Preinjury photographs can be helpful in understanding what the patient wants. If the patients’ nasal deformity was acquired through trauma, it is important to determine whether there is any pending or continuing litigation, frustration, or anger present in the patient as this could adversely affect the current doctor-patient relationship and even lead to transference of anger and disenchantment.

As with any surgery aimed at altering the shape of the nose, it’s important to be sure there is no significant psychological morbidity or personality disorder. Even though at this stage the patient may not know what is
possible from surgery, it’s important to reflect on whether the patient’s expectations are generally reasonable and whether they are embracing surgery as a positive step or not.

The operative plan should take into account the foremost of the patient’s aims. These must be considered alongside the surgical options and possibilities with their risks and limitations and the surgeon’s level of experience. Aesthetically, special attention is given individually to the dorsum and to the lateral nasal walls. I aim to correct the position of the dorsum with regard to the midline and the shape of the dorsum, if curved. Symmetry of the dorsum is also carefully assessed, with consideration given to correction of bony and cartilaginous humps and irregularities. The length of the nasal bones is assessed. Short nasal bones increase the risk of septal disarticulation with osteotomies. The relationship of the dorsum to the lateral nasal wall—both bony and cartilaginous—is determined. The contour of the lateral walls is determined as well as their length from the dorsum to the naso-facial junction. The longer lateral wall, from dorsum to naso-facial junction, in a deviated nose may need an additional intermediate osteotomy for correction. A convex lateral wall may also need an intermediate
osteotomy to break the curvature. The position of the lateral walls in relation to the midline is assessed when deciding on lateral, superior transverse, and medial osteotomies (Figs. 15.1, 15.2 and 15.3). The half basal view is helpful in analyzing the contour and position of the lateral nasal walls, and the head down view is very helpful for assessing the position and shape of the dorsum.

Septal surgery is invariably necessary in the treatment of the crooked nose for functional and aesthetic reasons. When planning correction of the septum, particular attention is given to the position and shape of the caudal and dorsal edges of the quadrilateral cartilage. While the caudal and dorsal edges may be repositioned or reshaped, a contiguous 10-mm caudal and dorsal cartilaginous strut must be left in place. In cases of nasal blockage, particular attention must be given to the internal valves. Narrowing at this site will require high dorsal septal and upper lateral cartilage reconstruction. The position of the bony septum must be noted during planning as deviation here will influence the position of the quadrilateral cartilage. Care must be taken in planning for resection of the bony septum especially if bony hump reduction and osteotomies are required as the risk of septal disarticulation is higher. As I mentioned above, this risk is greater in the presence of short nasal bones.

The position and symmetry of the tip cartilages are also noted. Deviation of the tip may be intrinsic, thus requiring surgery to the lower lateral cartilages, or extrinsic, due to displacement secondary to septal deviation. Planning for correction of tip cartilage asymmetries must consider resection of segments of excessively long crura or grafting of short crura. Repositioning sutures may be required as may onlay grafts inserted into precise pockets to camouflage depressions.