The Crooked Nose

The correction of the crooked nose, is undoubtedly, the most difficult and challenging clinical situation in cosmetic and functional nasal surgery.
In crooked noses, there is deviation, depression, collapse of cartilagenous and bony compartments, airways obstruction and occasional hump. It is quite obvious that the correction of these deformities, requires outstanding and distinguished surgical skills. The surgeon should always aim to achieve a well projected, profound, oriented, strong, straight, symmetrical and supported bony and cartilagenous compartments with patent airways. The use of intermediate and transverse osteotomies, together with the recent advances in tip surgery and dorsum augmentation, have certainly upgraded and promoted our end results. The transverse and intermediate osteotomies have achieved more mobilization and accurate repositioning of the nasal bones, spreader grafts have obtained a straight cartilagenous dorsum and the improved tip support techniques have accomplished more tip symmetry, elevation and projection.The key manoeuvres are lateral, medial osteotomy, intermediate and or transverse osteotomy, new dome creation, scoring, suture fixation, columellar strut, tip graft and as needed, augmentation by means of dorsum graft, supratip graft, spreader graft, Batten graft and or upper lateral cartilage onlay graft.Classifications:

  1. Deformities of external nasal skeleton.
  2. Deformities of inner nasal skeleton.
  3. Deformities of external and inner nasal skeleton.

Aetiology Factors: Trauma

  1. Trauma as the head passes through the birth canal.
  2. Trauma in early childhood.
  3. Trauma at puberty.
  4. Trauma after puberty.
  5. Iatrogenic:
    • Poorly performed osteotomies
    • Poorly performed septoplasty
    • Poorly performed tip surgery
    • Malpositioned sutures
    • Poorly applied nasal dressing

Fig. Above 22-year-old man with a severely crooked nose. Management plan was: septoplasty, right spreader grafts, medial, lateral and intermediate osteotomies, new dome creation, suture fixation, columellar strut, tip graft, septocolumellar sutures and correction of caudal dislocation.

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