Crooked Or Deviated Nose
The deviated or twisted nose can be seen due to nasal trauma or accidents or it maybe congenital. A twisted nose may also be associated with other syndromes such as cleft lip or palate. The complexity of the surgical repair of the twisted nose depends on the location of the deformity- whether it involves the cartilage dorsum or bony dorsum, whether the upper lateral cartilages and lower lateral cartilages are involved, if the nasal septum is also deviated and is contributing to the twisted nose, if the deviation also involves a twisted nasal tip. The deviated or twisted nose can usually be improved but perfection in creating a perfectly straight nose is sometimes impossible due to the many interconnecting parts creating the nasal structure and to complicate this further these interconnecting parts are made of different materials-bone, cartilage and soft tissue.
The severely deviated or "twisted" nose is a complex problem with both functional and cosmetic implications. According to Dr. Sam Rizk, a NYC nose job or rhinoplasty surgeon, when a nose is crooked or "twisted", it is important to determine whether the deviation is in the bony portion of the nose or the cartilage region of the nose. Very often the deformity in the nose is a complex bony deviation associated with a deviated cartilage part and a collapse in one segment of the cartilage. The bony part of the nose is the upper part of the bridge in between the eyes and a little lower and the cartilage part of the nose is the part of the dorsum above the nasal tip and extends and connects with the bony segment. The cartilage part of the nasal dorsum consists of the dorsal septum and the two upper lateral cartilages and according to Dr. Sam Rizk, deviations of the septum can lead to a deviated lower 2/3 of the nasal dorsum since part of the septum forms the bridge of the nose. The bony dorsum consists of 2 nasal bones that meet in the middle with the bony part of the nasal septum. So to summarize this anatomical description, Dr Sam Rizk believes that the deviated nose or Twisted nose is a complex deformity of the nasal septum, the upper lateral cartilages (ULC), and the bony pyramid. This results in a cosmetic deformity as well as a functional airway problem. Correction, according to Dr. Sam Rizk requires a three-dimensional understanding of the pathology discussed above, and hence Dr. Rizk pioneered and emphasizes the importance of using 3d high definition endoscopic tools during the surgery to correct this problem.
Many approaches of correction of the deviated nose have been described and they range from septal and bony reconstruction to septoplasty, bone osteotomies, cartilage grafting including spreader and camouflage grafts to correct indentations and collapsed regions of the nose. Dr. Rizk feels all approaches need to be customized to the patient because the deformities can be quite different from patient to patient.
Etiology of the deviated or twisted nose
The deviated nose may result from nasal trauma but may also be present from birth or associated with a cleft nose/palate syndrome. Nobody has a perfectly straight nose and most noses and faces in general have some degree of asymmetry. The surgeon should strive to correct as much as possible the deviation or twisting of the nose but perfection is sometimes impossible. In most cases, however, nasal trauma results in the deviated nose. Acute injuries are addressed differently from injuries sustained in childhood accidents and the patient presents later in life. Minor cartilage trauma early in life can lead to marked deformation with continued cartilage growth. Repetitive fractures represent a different scenario of chronic cartilage changes in which cartilage has had time to grow in an abnormal direction. Some twisted noses that are not resulting from trauma present similar anatomical abnormalities as those resulting from trauma.
Functional Breathing Problems
It is important not to overlook the functional component present when evaluating the twisted nose. In addition to airway blockage by the deviated nasal septum, the collapse of the mid-nasal vault can both cause airflow problems. Dr. Sam Rizk, a New York nose job specialist, points out as well that the collapses of the external and internal nasal valves sometimes are missed in evaluating airflow in the nose and even if one corrects a deviated nasal septum in the presence of a missed nasal valve collapse, the patient will still experience airway obstruction. The internal nasal valve, formed by the junction of the septum and the upper lateral cartilages, should have an angle of at least 10-15 degrees to maintain normal airflow. Traumatic alterations of the normal anatomy can cause breathing problems and should be corrected when the cosmetic deformity is addressed. Spreader grafts or other methods may be used to correct the internal nasal valve.Batten grafts may be used to correct the external nasal valve. The external nasal valve collapse is diagnosed with the patient being asked to breathe in quickly from his nose and noting the area lateral and superior to the nostril collapse in during inspiration.The area of maximal collapse is then marked and this is the area which is corrected during the rhinoplasty.
Concepts important to understand and Correct the Nasal Deformity
An understanding of cartilage healing characteristics helps in the repair of septal deviations. Cartilage has a very low metabolic rate and heals by scar formation. The current methods of dealing with misshapen cartilage include excision, incision, or swinging door flaps, morselization and crosshatching.Excision of the deformed septal segment may be the easiest method for isolated deformities. The only caveat to excision is that adequate should be left for support. A standard submucous resection (SMR) resulting in an L-shaped strut of dorsum and caudal septum for dorsal and caudal support. Dr. Sam Rizk leaves approximately 1.5cm of dorsal septum and 1.5cm of caudal septum for dorsl and caudal support in the nose. If the caudal septum is dislocated or twisted, Dr. Sam Rizk, a New York rhinoplasty surgeon, prefers to either morselize it or flip it on either side of the nasal spine, usually on the opposite side of the original deviation. Swinging door flaps are full-thickness incisions of cartilaginous segments used to reposition angulated portions. Ideally, one mucoperichondrial side is left intact to preserve the cartilaginous blood supply. Various back-cuts may be needed to restore a straight septum depending upon the angulation. Prolonged postoperative septal splinting is essential to long-term success. Morselization is the crushing of the deformed septal segment so that it can heal in a straightened position. Postoperative spliinting to stabilize the cartilage is needed. The disadvantage of morselization is the weakening effect upon the cartilage and the unpredictability of the result. Carved cartilage curves towards the side of intact perichondrium. This finding can be used to help shape bent cartilage by crosshatching one side and leaving the opposite mucoperichondrium intact. The healing cartilage must be splinted to maintain position. This method leaves a stronger cartilage segment than morselization.
Dr. Sam Rizk, an NY nose job expert, states that there is often an interrelated complex deformity of the nasal bones, ULC's and septum. If the problem is a broken down and analyzed with a 3dimensional model,it would be easier to understand and more accurately repaired surgically with the 3d high definition technology Dr. Rizk has pioneered.
Nasal Bone problems.
Analysis of nasal bones include symmetry, size, and presence of a dorsal bump or hump. Dr. Rizk points out that when an injury occurs in the nasal bones, a bump tends to form from a normal healing process of depositing calcium at the injury site to heal the bone. In contrast, when an injury occurs in the cartilage portion of the nasal dorsum, it tends to collapse. Large nasal bones or hump can hide an underlying high septal deformity. Removal of the hump or bump and standard infracture may correct the problem by removing both problems, hump and high septal deformity. This technique may be combined with the septoplasty to correct the internal airway problem. After hump removal, replacement of some of that tissue may be needed with a spreader graft if an internal valve narrowing or middle nasal vault collapse is present. Nasal bone deviation may be corrected visually by asymmetric hump resection and infracture. This can straighten and align the nasal bones if a significant high septal deformity is not present following hump resection. Camouflage of nasal bone asymmetry with cartilage or bone graft is another option if a septal deformity does not impede airflow or if the septal problem can be addressed separately. Osteotomies or comminution of the nasal bones may be performed if there is a significant nasal bone deviation not amenable to midline repositioning. This method will not realign any septal deviation, however, and long-term results may be affected if the septum is not repaired at the same time. According to Dr. Sam Rizk, a NYC nose job expert, better long term results are achieved when the deviated nasal septum is repaired along with the deviated nose at the same time.
Upper Lateral Cartilages
The Upper lateral cartilages are affected to a greater degree than the nasal bones by high septal deviations. Collapse of the upper Lateral Cartilages may follow trauma to the nasal bones and can manifest as a dent or deviation in the mid portion of the nasal dorsum. To correct such a deformity requires separation of the Upper Lateral Cartilages from the septum and precise placement of a spreader graft on the side of the indentation or collapse. A camouflage graft may also be needed on the outside portion of the upper lateral cartilage in addition to the spreader graft between the upper lateral cartilage and the nasal septum. Dr. Sam Rizk, who performs rhinoplasty on twisted noses on a regular basis, uses the 3d high definition endoscopic approach to achieve precise placement of spreader and camouflage grafts. The placement of spreader and camouflage grafts can be performed through an endonasal as well as an open rhinoplasty approach.
The previously mentioned approaches to cartilage alteration can be used and combined with a septoplasty to correct a deviated nasal septum. The specific corrective technique for septoplasty will depend on the location of the septal deformity. Low septal deformity impllies a dislocation from the vomerine groove. This can result from a displaced vomer or a displaced septum or both. Correction is performed by repositioning the septum on the vomer. If the vomer is the problem, excision or alteration of the vomer portion of the septum can be performed. Septal angulation is most easily accomplished by a "swinging door" flap.
If the caudal or lower portion of the septum is deformed or dislocated, it often leads to a crooked nasal tip and asymmetrical nostrils. The side the caudal septum is deviated towards results in a smaller nostril. Caudal septal deformity can be corrected with a swinging door flap. If the caudal septum needs shortening, excision to the point of angulation may be appropriate. Excision of the caudal septum usually necessitates adding a columellar strut graft and suturing it to the medial crura portion of the lower lateral cartilages to support the nasal tip. Another option is morselization or other weakening procedures and external splinting if there is a curved caudal septal deformity. Often, morselization can be combined with excision of a portion of the caudal septum.
Mid-septal deviation can be readily seen on intranasal examination. In the absence of other septal deviation, mid-septal deformities can be managed by excision, cartilage weakening and splinting, or a swinging door approach.
High septal deformities can be missed if a detailed intranasal examination is not performed. The septum can exert pressure on the Upper lateral cartilages and nasal bones, and can cause long term problems and twisting of the nose. Correction may be difficult and requires analysis in the context of the rest of the nasal deformity. A coexisting dorsal hump and high septal deformity can be corrected simultaneously by excision of the septal defiation and the hump. Infracture of the nasal bones then can be performed to close the open roof deformity. It is important to consider internal valve narrowing and correct it with a spreader graft if the potential for valve narrowing exists.
The previously mentioned analysis for repair of the nasal septum by site is useful in approaching a twisted nose, but in reality the twist nose is a very complex deformity made up of multiple areas of deviation-not all of which are entirely correctable 100%. This is why it is vital to advise the perspective patient that improvements can be made but 100% correction is not possible. A patient should have realistic expectations in order to prevent disappointments in results. Scar tissue factors into the deviated nose and the skin also may have conformed to the twisted nose over time and may not readjust to the new structure so readily. With so many variables such as interconnecting cartilage and bone, scar tissue, subcutaneous tissue, skin, and mucous membranes, a surgeon cannot predict 100% correction of a deviated nose. Dr. Sam rizk, a nyc nose job surgeon and double board certified facial plastic surgeon, operates on a deviated nose only when a significant improvement is possible. Reliable and long-term correction of the severely deviated nose is still a difficult problem. Factors that may lead to incomplete correction or recurrence are:
1. Insufficient nasal bone and septal mobilization
2. Incomplete scoring of the anterior caudal portions of the septum.
3. Insufficient stabilization of the septum
4. Warping or partial absorption of the grafts used.
5. Scar tissue or skin not conforming to new straighter structure from inelastic skin.
6. Differing shapes of the nasal bones on the right and left side of the nose (One nasal bone may be more convex/concave than the other).
Adequate treatment of deviated nose requires a detailed internal and external evaluation of the nose and the deformity present. The isolation and evaluation of each component of the nose to determine which component is deviated is essential to allow the detection and correction of all areas of cartilage and bone deviation. Internal and external nasal valve narrowing or collapse must be corrected at the same time as a deviated nose to establish long term support and correction of the deviated nose. A deviated nasal septum should be corrected at the same time as a deviated nose for better long term cosmetic and functional breathing improvement. Cartilage grafting is often necessary in the collapsed areas of the cartilaginous portion of the nose to give a straighter looking nose. Osteotomies or nasal bone fractures are often needed to straighten the deviated portion of the nasal bones.
24 year old female who wanted a straighter nose from the front view and a slightly lower bridge from the profile. Patient did not want much change in her tip. The patient had a collapse on the left part of the nose from an injury and also had a deviated nasal septum to the right. The patient underwent a very conservative rhinoplasty and septoplasty and use of septum cartilage as grafts on the left part of her nose to make it appear straighter. The profile was also lowered very conservatively.
25 year old male with multiple nasal injuries who also could not breathe. Patient had multiple collapsed areas in his nose and a saddle nose deformity. Patient is shown 2 weeks after rhinoplasty and septoplasty using the 3d-open approach with multiple cartilage grafts to collapsed areas.