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Introduction

The principles of preservation rhinoplasty are to respect conserve or restore the soft tissue envelope ligaments, minimize the resection of cartilage through reorientation and to keep the dorsal continuity of the patient’s own bridge. The origins of the operation date back to the beginning of the 20th century.¹ Although initially described as an endonasal procedure, preservation rhinoplasty can be performed via open or closed approaches.

Crooked or deviated noses pose a specific challenge, as many of the elements in a deviated nose are not symmetric and therefore not ideal for preservation techniques.2-4 Indeed, deviated noses are often where there is a hybridization between preservation and structural rhinoplasty.

The first question to ask is whether the deviation is part of a facial asymmetry – that is, the underlying foundation of the nose (maxilla) is different between left and right sides either in left to right vertical height or anterior posterior discrepancy. This is usually obvious by looking at the orbit or brow position, the insertion of the alar base of the cheek, the cant of the smile, and the dentition if the patient has not undergone orthodontic treatment. It is easy to assess bony asymmetries by using a head down frontal photograph or by walking round behind the patient to examine the nose from above. This ascertains whether the deviation involves predominantly the bony pyramid, the cartilaginous part of the nose, or the whole nasal structure. It also permits assessment of asymmetries in the nasal sidewalls and the tip. The axis of a nose can be straight but sidewall asymmetry can create the appearance of deviation.

Trauma in childhood often results in a similar growth-related disorder to the developmentally deviated nose without a history of injury, except here there will be evidence of the previous injury with angulations in the cartilaginous and bony dorsum. The septum has a major role to play in deviated or crooked noses particularly as it may contribute to a dysfunctional airway due to compromise of the nasal valve – anywhere from the front of the nostril to behind the head of the inferior turbinate. The secondary changes in the turbinate size or shape usually demand that lateral nasal wall surgery will be combined with rhinoplasty or endoscopic sinus surgery.

This makes an external and internal and functional assessment so important in deciding the appropriate procedure. Careful palpation of the nasal pyramid and CT scanning is highly recommended in evaluating the underlying architecture nose and septum plus examination of the nose by endoscopy (Fig. 1).

Crooked or Deviated Noses

The working definition for deviation can be any deviation of the nasal form from a vertical line dropped from the midpoint of the intercanthal distance.2 This of course is an approximation as in facial asymmetry the midline between the eyes, the philtrum the dental midlines and the chin point may not lie on the same vertical axis. However, we assume that the nose is the central feature about which we evaluate the whole face; however, this seems to vary between Western and Asian cultures. For facial learning and recognition, westerners focus more on the eyes and mouth in a triangular pattern, whereas Eastern Asians rely more on the central face, mainly the nose. So the perception of facial deformity and tolerance of deformity particularly with respect to the nose may differ between different cultures.6

Axial CT of nasal pyramid with deviation

Fig. 1. Axial CT of nasal pyramid with deviation, different bone thickness, septal deviation, and pneumatized expansion of the left middle turbinate.

In Western noses which in general are slimmer with a higher dorsum and have more projection, deviation of the nose creates very different profiles particularly in the three-quarter view often leading to the adoption of ‘head tilt’ – an adaptive mechanism whereby an individual often subconsciously presents the perceived least deformed side in pictures or face-to-face meetings.

These variations in perception may need to be accounted for in a patient’s acceptance of improvement over perfection – something that is very difficult to achieve in deviated noses, that is, an improvement is possible, symmetry is not, especially from all the different angles. A straighter nose is possible on an asymmetric face.

In the history of preservation rhinoplasty, one of the reasons dorsal preservation may not have been adopted for deviated or crooked noses was the inability to correct a deformed or twisted bridge and for the need to correct a complex septal deformity. There may be several reasons why preservation techniques are now being reapplied to deviated noses. The first is the ability to accurately image by CT or cone-beam CT, the second is the ability to reshape and move nasal bones using the piezoelectric technology, and the third is a reappraisal of the management of the nasal septum in deviated noses, moving away finally from the ‘L strut’. Fundamentally therefore, the ability to change the foundation of the nose (maxilla) or the roof (dorsal profile) safely and predictably means the preservation techniques can be applied to noses other than those that have existing pleasing dorsal aesthetic lines. The basis of a straight nose is to have a central septum fixed to a midline nasal spine and equal sidewall slopes in terms of angulation, if not length. Creating more symmetric dorsal aesthetic lines but perhaps not symmetric lateral aesthetic lines is probably a realistic goal in correcting nasal deviations by preservation. Additional augmentation of one side of the maxilla is possible with diced cartilage or fat transfer.

The Skin Envelope

Developmentally deviated noses invariably have differences in the size of the soft tissue envelope – not only skin but also the muscles and ligaments. The soft tissue envelope has an ability to adapt or contract there is often considerable dif- ference in the healing response from a deception in the subperichondrial/periosteal plane compared with the sub-SMAS. Although it may be possible to preserve many of the ligaments in deviated noses, some may have to be modified. In particular, the position of insertion of the vertical scroll ligament on the short side of the deviated nose will be different with the repositioned nasal pyramid. Release of certain ligaments, for example, the pyriform ligament and adjacent upper lateral/nasal junction may be necessary to create length on the short side of the nose. When an overprojected deviated nose is reduced, however, there will be a relative excess of the envelope. If there is little need to adjust the profile, a straight nose that has axis deviation to one side may not need a soft tissue dissection over the upper laterals or nasal bones and shifting the pyramid to one side can readily correct minor axis deviations (Fig. 2).

In general, it is the author’s preference to undertake a subperichondrial/periosteal dissection especially in the middle and upper third of the nose. Wide dissection down to the face of the maxilla is required for piezo sculpting. A limited dissection or sometimes no soft tissue elevation is required for simple rotation of the pyramid through a closed approach

The Dorsum: Bony Pyramid/Bone Cap Cartilage Complex

CT scanning can be very helpful in determining, first, the slope angle of each nasal sidewall and second, the shape of the sidewall being straight convex or concave.

Straightening an axis deviation

Fig. 2. Straightening an axis deviation without dorsal soft tissue elevation.

Straight bones that lean to one side lend themselves ideally to a preservation technique, whereby the osteotomy on the more oblique bone is combined with an ostectomy in the nasomaxillary groove (Fig. 3A). A sagittal lateral osteotomy having removed Webster’s triangle with elevation of the internal periosteum will create the space allowing the bony sidewall to slide down on the inner aspect of the piriform aperture. On the opposite more vertical nasal bone, a transverse cut is made without internal mucoperichondrial elevation allowing this side to be a hinge, as the oblique side impacts downward on the inner aspect of the piriform aperture. The transverse osteotomy between the lateral and the radix cuts may be performed percutaneously with a 2-mm chisel, with a powered instrument or hand saw. The radix cut is usually perpendicular to the nasal bone connecting the transverse cuts (Fig. 3B, C). An oblique radix cut may be used to create a rotational hinge of the dorsum, therefore preventing posteriorly displacement of the radix point.

If the dorsal aesthetic lines are already slim, this is a very effective way of treating a nasal dorsum that has purely axis deviation, combined with a reposition of the nasal septum to the midline affixing it to the spine with a secure suture through a drill hole (Fig. 4).

With increasing degrees of axis displacement, not only is there a discrepancy in the anterior/posteriorly length of the nasal bones but also in the length vertically of each nasal sidewall.

Without compensating for this, there is a limit to how far the whole dorsal unit can just be aligned by osteotomies. More severe asymmetries occurring in the middle third cartilaginous portion additional maneuvers may be necessary to lengthen one side compared with the other.

Partial release of the upper lateral/bony junction known as the lateral K area can gain the required length to achieve symmetry. The pyriform ligament is sectioned and released across the mucosal space of the nose. Sharp dissection of the upper lateral, nasal bone overlap parallel to the upper lateral cartilage and extending up to within 5 mm of the dorsum will allow the vertically short side to elongate minimizing the risk of redeviation. This will almost always be necessary in concert with repositioning of the quadrangular cartilage of the septum (Fig. 5 A,B).

Rhinosculpting

Modifying the shape of asymmetric nasal bones has a limited value in achieving a straighter looking nose and depends on the thickness and shape of the bone. CT scanning is an important investigation in ascertaining the limits of rhinosculpting. Thicker convex bones can be thinned but not to the point where there is a risk of fracture. An alternative way to change the convexity of a nasal bony sidewall is to perform a series of criss-cross cuts using the fine piezo saw but not damaging the deep mucoperiosteum. This is analogous to a series of tiles on a flexible backing and will allow sub- tle convexity is to be flattened without performing longitudinal or transverse osteotomies using osteotomes. In the same degree, modification of the bony nasal can be performed by local rasping or contouring with powered instruments and this may be all that is necessary in a post-traumatic nose correction that involves the rhinion.

Schematic for preservation osteotomies in a deviated nose

Fig. 3. Schematic for preservation osteotomies in a deviated nose.

The septal cuts for a low strip preservation rhinoplasty

Fig. 4. The septal cuts for a low strip preservation rhi- noplasty with deviation. The vertical cut is made at the maximum convexity of the rhinion and the caudal septum advanced and sutured to the spine moving the whole axis to the midline.

The Cartilaginous Vault

Distortions in the cartilaginous vault are difficult to correct in dorsal preservation – marked twists in this area invariably need release of the upper laterals from the septum possibly with spreader graft or flap reconstruction.

Section of the pyriform ligament

Fig. 5. Section of the pyriform ligament (cross hatched) and separation of the lateral keystone will allow a rotational lengthening of a short middle third. (B) Rotation of the whole dorsum impacting the longer wall inside the pyriform aperture.

Where the upper laterals are of a similar length but displaced along with the dorsal more caudal septum, the middle third of the nose can be controlled by a complete release of the septum via a low strip section from the vomer and release from the perpendicular plate of the ethmoid together with if necessary resection of a triangular piece of perpendicular plate under the nasal bones. This allows the septum and the cartilaginous vault as one unit to be rotated back to the midline. This may also be facilitated by removal of the bony cap, still preserving the whole cartilaginous dorsum intact (see Fig. 4).

A variation of preservation rhinoplasty called ‘spare roof technique’ allows the dorsal cartilage vault separation from the septum after removal of the bone cap.7 By releasing the cartilaginous vault completely including a lateral K area dissection, the bony sidewalls can be treated by paramedian and lateral osteotomies to narrow the bony base. The cartilage roof is either pushed down or centralized and then reattached to an independently repaired septum by suturing. This almost certainly requires an open approach, as there is frequently a widening effect in the middle third which will need suture control ideally with a criss-cross technique to achieve the correct contour. It must be inserted behind the W point to avoid valvular narrowing (Fig. 6). This has an advantage insomuch as it will minimize the risk of further axis displacement by overriding segments of the neodorsum on an underlying unfavorable high septal deformity and overcomes the limitations of high strip excision in preserva- tion rhinoplasty where extensive septal surgery is required – an extracorporeal septal reconstruction is possible before replanting and fixation at the nasal spine and to the upper lateral ‘roof’ (Fig. 7 reproduced by permission M GF).

Criss-cross suture fixation.

Fig. 6. Criss-cross suture fixation.

Soft Tissue Ligament Repair

The reliance on the support of the soft tissue ligaments, for example, scroll ligament the deep and superficial medial SMAS after rhinoplasty for a deviated nose is still unclear.8 It is the authors’ experience that in correcting some deviated noses, it has been preferable to excise the sesamoid cartilages in the scroll and not reattach the ligament particularly on the shorter side. First, the discrepancy in the skin envelope may recreate a deformity and second, the scroll cartilages may displace cranially producing an unfavorable supratip bulge which can need to be excised endona- sally in a minor revision procedure. Where a caudal septal reconstruction with an extension graft or strut is used to support the nasal tip, there is little point in re-establishing the deep medial SMAS. However, refixation of the dorsal perichondrium/periosteal flap by fixation to the anterior septal angle and repair of the superficial medial SMAS to help suspend the upper lip in an open approach are advocated. Fig. 8. The periosteal/ perichondrial flap tensioning is analogous to plicating or tightening the SMAS in a facelift and has a considerable effect in helping the soft tissue envelope redrape as well as closing dead spaces.

Fixation of the cartilage vault to

Fig. 7. Fixation of the cartilage vault to the lowered septum. Note the lateral K release to allow flattening of the rhinion. The bone cap has been removed creating a near complete cartilaginous dorsum.

Retensioning the deep soft tissues

Fig. 8. Retensioning the deep soft tissues to close a dead space.

The Nasel Tip

Developmentally deviated noses will invariably have a degree of asymmetry in the nasal base in a vertical or an anteroposterior plane. There may be pre-existing nostril asymmetry and a need for differential alar base reduction. In prin- ciple, the more vertical side of the nasal tip will need to be lengthened to allow the dome to be approximated in the midline with its opposite number. A form of lateral crural steal on one side or release at the junction of the AE – A1 cartilage supported with a lateral crural strut graft or rim graft may be required. The use of a lateral crural strut together with sectioning of the levator labii alaeque nasi muscle can lower high insertion of the alar on to the cheek skin. In all these instances, there is a departure from pure preservation rhinoplasty and in general a form of hybrid operation is invariably performed but with the principles of suturing and reorientation with minimum cartilage resection.

The use of a septal extension graft attached to the midline septum is an excellent anchor point for creating tip symmetry, and although there is a tendency to stiffness in the nasal tip, this is preferable to recurrence of deviation. Release of the nasal tip from the muscles around the piriform aperture may be required together with augmenta- tion of the premaxilla under the alar using free seg- ments of cartilage or diced cartilage injected via an incision in the floor of the nasal vestibule in a similar fashion to augmenting a depressed alar sidewall in a cleft nose.

Otherwise the principles of preservation by min- imum cephalic resection, lateral crural underlay techniques, dome suturing and lateral crural flare sutures are used to build a symmetric tip on a stable midline medial crural column.

Summary

Although it is clear that the most deviated or twisted noses will require a reconstructive approach to septorhinoplasty, the principle of deep dissection in a subperichondrial periosteal plane in the upper two-thirds and the realigning of a mild axis deviated nose via transverse lateral and radix osteotomies are all achievable goals following the goals in preservation techniques.9 Therefore, apart from simple axis deviation of the nose with good aesthetic lines, corrections of deviated noses tend to need a hybrid approach often with minor grafting.

Clinic Care Points

  • Ostectomy and saggital osteotomies allow impaction techniques in preservation rhinoplasty.
  • Lateral K release permits lengthening of a short midvault and permits flexion of the cen- tral K area.
  • Fixation of the quadrangular cartilage on the centralised nasal spine is key to stability.

Disclosures

None.

References

1. Goodale JL. The correction of old lateral displace- ments of the nasal bones. Boston Med Surg J 1901; 20:538–9.
2. Ellis D, Gilbert R. Analysis and correction of the crooked nose. J Otolaryngol 1991;20(1):14–8.
3. Preservation Rhinoplasty, 2019 Saban Y, Cackir B,Daniel R, Palhazi P. ISBN 978-605-5322-49-6.
4. Kosins A, Daniel RK, Nguyen DP. Rhinoplasty: The asymmetric deviated nose-an overview. Facial Plast Surg 2016;32(4):361–73.
5. Daniel R, Palhazi P. Rhinoplasty. An anatomical and clinical Atlas. Springer; 2018.
6. Blais C, Jack R, Christoph S, et al. Culture shapes how we look at faces. PLoS Journal, San Francisco 2008;3(8):e3022.
7. Ferreira MG, Monteiro D, Reis C, et al. spare roof technique: middle third new technique. Facial Plast Surg 2016;32(1):111–6.
8. Palhazi P, Daniel R, Kosins A. The osseocartilagenous vault: anatomy and surgical observations. Aesthet Surg J 2015;35(3):242–51.
9. Cakir B, Ali Riza O, Teoman D, et al. A complete sub- perichondrial dissection technique for rhinoplasty with management of the nasal ligaments. Aesthet Surg J 2012;32(5):564–74.

Floor 3, 9 Harley Street, London W1G 9QY
+44 (0) 20 3196 0130

Tempus Belgravia, 11a West Halkin Street, London SW1X 8JL

Floor 3, 9 Harley Street, London W1G 9QY
+44 (0) 20 3196 0130

Tempus Belgravia, 11a West Halkin Street, London SW1X 8JL

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