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.

This week I worked on two patients who really illustrated the interface of cosmetic and reconstructive rhinoplasty.

One patient had been asssaulted and had his face smashed with a baseball bat. Having completed restoration of his upper jaw and teeth it was time to rebuild his nose. Unlike routine rhinoplasty where there is bone and cartilage to reshape, everything had been smashed and crushed leaving little to work with. After adding in the resultant scar tissue it left the patient with a collapsed, shapeless and nonfunctional nose. The challenge was met by going to one of our natural spare parts boxes, in this case the patient’s rib cartilage. After harvesting this new supply of firm, supportive cartilage all the building blocks to create an aesthetic and functioning nose were carved and shaped and then implanted and grafted.  This is one of the most diificult of all challenges in rhinoplasty.

The second patient presented with what is often called “finesse” rhinoplasty. An attractive young woman who only desired modest refinement of her profile and nasal width. The challenge (and sometimes trap) for the surgeon here is to resist the temptation to do to much. The over zealous surgeon  who wants to use all the great (or usual) techniques he knows or does on every patient ends up altering a pretty face when only subtle refinement is needed or has been requested. Such a result can be devastating for a patient.

Each of these cases represent polar opposites in planning, approach and execution to achieve the desired result.The sum of these two cases together remind me why I love doing this procedure-even after twenty years you still are challenged by every patient. It is never routine. You can’t do the same procedure on every patient. You have to be skilled in a wide variety of techniques but only use what’s needed for each individual case. The results will be right out there for everyone to see, not hidden under clothes or makeup. It can only come from you, it’s not an implant or a technology that anyone can buy.  Nothing is more rewarding or humbling then being trusted by patients with this responsibility and being able to help them meet their goals.

This week I met with a 14 year old girl and her parents. She was playing on a trampoline and had broken her nose. It was obviously out of place and the parents were concerned about the proper course of action. Should they leave it alone until she was older? Should they have it fixed and try to have a rhinoplasty now? If they have it fixed now will that prevent the need for a rhinoplasty in the future? These were all good questions.

I recommended that she have what is known as a closed reduction. This is a simple procedure (20 min) which will reposition the nasal bones into a more normal location. She is to young to undergo a formal rhinoplasty as she is still growing and besides wants to still play sports and may break it again! It will not prevent the need for a more aesthetic rhinoplasty in the future but will certainly make it easier if you don’t start with a crooked and deviated nose.

Fortunately they came to see me promptly as there is only a 10-14 day window from the time of injury for which this option is available.