Crooked noses or deviated noses are among the most challenging to fix. Sometimes they are due to previous trauma, mostly though its just a developmental growth issue.

They often resist good repair and straightening unless the surgeon uses specific techniques. I find I get the best results if I follow these steps:

First as in all noses I analyze. Is the crooked shape or deviation from bone or cartilage or both? Is the deformity external only, or internal as well? If each area that is affected is not addressed then its unlikely to get a good result.

With bony deviations I like to use a “turn the page of a book technique”. What that means is that instead of a routine procedure when one is just trying to narrow the bony width from the outside by bringing the bones together, you have to modify what you do. To explain further, if the nose is deviated off to the right side of the face, I start by releasing the left nasal bone in the middle and then on its outside. This allows me to “turn the page” and rotate the bone from the right side of the face to the center or left of center. I then follow with the same procedure on the left bone which allows me to turn it towards the middle and “close the book” with the nasal bones in the center of the face.

If the cartilage is deviated this is also challenging. Cartilage is flexible and has memory and so will often resisit efforts to straighten it.  I often find it necessary to use a variety of techniques to get it to sit straight such as scoring to “break the spring”, adding cartilage as “braces or struts” to splint it in the new shape or camouflage curvatures and different types of suture placements.

Internally the nasal septum is integrally connected to the external profile. If the septum is deviated (often in an opposing direction to the external curve) it must also be corrected. If not the external result will often be compromised. This also holds true when dealing with a nose that initially appears straight. If the surface (dorsum or profile) is reduced or altered and a crooked septum is not addressed the end result may be a crooked nose which had started out straight.

One of the tradeoffs of having to do so much bone and structural work is that the surgery takes a little longer and patients often have more bruising post operatively than routine rhinoplasty. However the bruising goes away and I’ve never had anyone complain about it or longer surgery when the nose is sitting straight. I’ve spent a lot of time consulting with people who’ve gone through procedures and are still frustrated by having a crooked nose. Both of us would rather have spent the extra time in the OR and not talking after.