A Surgical Algorithm Using Open Rhinoplasty for Correction of Traumatic Twisted Nose

Abstract

Hsiao and colleagues have presented a simple, clear, and effective algorithm for managing the traumatic twisted nose. Their results are excellent and exemplary of a sound approach to a difficult problem. Their argument for the management of these cases using an open approach is sensible and in line with the practice of many rhinoplasty surgeons. The results for 92 patients who underwent open rhinoplasty for correction of a twisted nose are presented. It is not surprising that 95% of the patients were male, indicating that men pursue a riskier lifestyle than women. All the patients underwent a complete history and physical examination including preoperative photo documentation of the nose. Frontal, basal, lateral, and oblique views were recorded. An additional view that proves to be helpful in assessing the twisted nose is the frontovertex view, with the nasion proximal and the tip distal taken from the top of the head. It is the same view the surgeon has from the head of the operating table, and it offers an excellent way to asses the curvature of the nose. The authors infiltrate the nose with the minimum amount of local anesthetic to avoid distortion. This is especially meaningful for a patient population that tends to have thick soft tissue coverage of the bony and cartilaginous framework. In these cases, it can be very helpful to tattoo the midline of each nasal segment (upper, middle, and lower) before injection. These tattoo marks then can be used to assess nasal curvature during surgery. When the three dots are in alignment, straightening has been achieved. The authors algorithm for straightening the twisted nose makes sense and incorporates a top to bottom anatomic approach. Management should start with the bony nasal pyramid, then proceed to the septum, the tip cartilage, the skin and soft tissue, and finally closure. This approach takes into account open exposure of all anatomic landmarks in an effort to correct curvature in a stepwise pattern, with reassessment performed after each anatomic site has been addressed. I agree with the surgical techniques described and offer two points of advice for anyone considering correction of the twisted nose. First, in the case of a deviated nasal pyramid with asymmetric nasal bones, bilateral medial and lateral osteotomies should be undertaken with caution, especially in patients with a flattened nasal dorsum. In performing medial and lateral osteotomies, care must be taken to avoid a ‘‘floating’’ nasal bone that has been completely osteotomized from any bony attachment. This bone can collapse entirely and then be very difficult to restore to an anatomic location.