Crooked Nose Research Articles

Oblique Split Rib Graft Surgery in Primary and Secondary Septorhinoplasty.

BACKGROUNDRib cartilage is an outstanding material in reconstructive septorhinoplasty, especially in revision surgery with a low rate of complications compared to other materials. In this study, the results of oblique splitting of rib grafts were evaluated in 25 patients operated for primary and secondary septorhinoplasty.METHODSThe prospective case series were undertaken on 25 patients of saddle or crooked nose that referred to the senior author’s private office between January 2015 and November 2017. They had primary and secondary septorhinoplasty using autologous costal cartilage carved by the oblique split method (OSM). The postoperative follow-up period ranged from 3 to 36 months (Mean follow up of 19 months).RESULTSThe problems seen in patients were saddle-nose deformity in 16 cases, crooked-nose deformity in 3, crooked nose and saddle nose in 3 and implant infection, inverted V-pinch, destruction of septum in 3 more cases. After oblique split rib grafts surgery and 3-36 month follow-up (an average of 19 months), the operative outcomes were successful and no severe resorption, infection, warping or displacement were observed related to graft and patients were also satisfied, and there was no complication of the donor-site. The patients did not have any post-operative complications and no complain of nasal distortion during follow up period.CONCLUSIONOSM allowed obtaining large quantities of graft material without the risk of warping due to inclusion of both peripheral and central portions of the rib cartilage.

A comparison study of insertion of spreader graft in the convex side in patients with deviated nose undergoing open septorhinoplasty

Background: Correction of a crooked or deviated nose is a major challenge for rhinoplasty surgeons. In the present study we proposed to compare the aesthetic and functional results of unilateral grafting using spreader grafts on the convex side of the nasal deviation with those used on the concave side.
 Methods: In this study, the technique and aesthetic and functional outcomes of the correction of crooked noses with spreader graft placement at either convex or concave side of the nasal deviation are presented.
 Results: Unilateral spreader graft was used in 66 patients with C-type deviated nose. At the discretion of the rhinoplasty surgeon, the spreader graft was placed in the convex side of the nasal deviation in 33 patients (group A) and in the concave side of the nasal deviation in the remaining 33 patients (group B). During an average following-up period of 18 months (ranged from 8 to 36 months), there were no complications, infection, or graft extrusions. Functional evaluation was performed using a visual analog scale before and 4 months after surgery. Patients were asked to score their nasal breathing on a scale from 0 to 10. In group A (convex group), the mean preoperative score was 6.32+/-1.02 (ranging from 2 to 8), and the mean postoperative score was 2.03+/-1.01 (ranging from 0 to 4). In group B (concave group), the mean preoperative score was 6.76+/-1.10 (ranging from 2 to 8), and the mean postoperative score was 3.67+/-1.80 (ranging from 2 to 7). Patients with spreader graft at the convex side showed higher increase in angle measurements as compared to the patients with spreader graft in the concave side. Moreover, patients with spreader graft at the convex side were more likely to have excellent or good surgical outcomes (according to the degree of correction in the angle of deviation) as compared to patients with spreader graft in the concave side.
 Conclusion: The use of the spreader graft is a safe and effective method for correction of crooked noses. We showed that speeder graft at the convex side of C-type nose deformity provided better aesthetic and functional results as compared to the placement of the speeder graft in the concave side of the nasal deformity.
 

Esthetic and functional result of crooked nose treatment; internal microperforating osteotomy and subtotal septal reconstruction

Crooked nose is mostly characterized by a deviation of both the bone and the cartilaginous parts of the nose. In order to obtain proper functional and improved esthetic results, both of these parts have to be corrected. The objective of this study is to evaluate the esthetical and the functional outcomes following correction procedures of the bone pyramid through internal microperforating technique and the cartilaginous part through subtotal septal reconstruction. The medical records of 158 patients who have undergone through primary septorhinoplasty for crooked nose treatment during the period of 21 June 2016 and 31 July 2017 have been reviewed. Functional results have been evaluated using the Nasal Obstruction Symptom Evaluation (NOSE) scores and the esthetical results through Rhinoplasty Outcome Evaluation (ROE) scores. The observation times have been arranged preoperatively as 6 months–1 year (group 1) and 1–2 years (group 2). Septorhinoplasty procedure has been performed on 158 patients with crooked noses. Out of this number, 104 of the patients (65.8%) were women and 54 were men (34.2%). The average age of the patients was 31.59 (9.3%), all of who have undergone this procedure. There was a significant improvement (P < 0.001) in the NOSE and the ROE scores of group 1 and group 2, which was statistically significant. There was no difference between group 1 and group 2. In crooked nose treatment, correction of the deviated bone pyramid using internal microperforating osteotomy and correction of the severely deviated septum using subtotal septal reconstruction yield improved functional and esthetic results. Level of Evidence: Level V, therapeutic study.

Correction of the Crooked Nose.

Successful management of the crooked nose can be a formidable task and requires a systematic approach that begins with an understanding of the patients' aesthetic desires, expectations, and functional symptoms. Dividing the nose into thirds and organizing a plan to correct each region individually can simplify the preoperative planning. There are two broad philosophical strategies of surgical management: engineering (reconstructive) and artistic (camouflaging). While the camouflaging technique is helpful for minor asymmetries, protrusions, and depressions, the engineering approach is best for more extreme corrections. The surgeon must be skilled in both approaches as either one or a combination of the two may yield the best results. Once corrected, postoperative care is essential to obtain optimal outcomes.

Comparison of nasal obstruction symptom evaluation, peak nasal inspiratory flowmeter, and rhinomanometry in patients with nasal deformities

Nasal obstruction is the most common symptom in daily otolaryngology practice that correlates with quality of life. Nasal obstruction etiology is multifactorial and can result from mucosal or structural factors. Subjective and objective evaluation approaches are a significant challenge in its diagnosis. This study aimed to evaluate correlations among the nasal obstruction and symptom evaluation (NOSE) and peak nasal inspiratory flowmeter (PNIF) scores and active anterior rhinomanometry values for nasal obstruction diagnosis in subjects with nasal deformities including crooked nose, saddle nose, nasal valve incompetence, and deviated septum. Furthermore, the correlation of nasal obstruction with sleep-disordered breathing was evaluated. Data in this cross-sectional analytical study in 52 consecutive subjects with nasal deformities and 10 consecutive normal subjects were analyzed with the bootstrapping method. Mean nasal resistance in normal subjects and those with nasal deformities were 0.172 and 0.173 Pa/cm3/s, respectively, on 75 Pa. The NOSE score was not significantly correlated with the PNIF score or the nasal airflow resistance determined by rhinomanometry. However, there was a significant correlation between PNIF and nasal airflow resistance.

Combined Nasal Osteotomies With Caudal Transverse Osteotomy and Their Effect on Dorsal Geometry

Congenital, traumatic, or developmental bony vault deformities may require additional interventions rather than classical osteotomies to correct the surface structure or angulations of the nasal bones in rhinoplasty. The aim of the study was to determine the effects of the additional osteotomies applied for the correction of the nasal vault asymmetries retrospectively. Twenty-one patients among 512 primary rhinoplasty cases between 2011 and 2016 with bony vault asymmetries were included in the study. Three patients had bilateral convex, 6 patients had unilateral convex, and 7 patients had unilateral concave surface deformities. Five patients had concave deformity on one side and convex deformity on the other side. Double-layer lateral osteotomies and caudal transverse osteotomies were conducted for the correction of the severe surface anatomy deformities of the nasal bones. The caudal transverse osteotomy was delicately performed with a special osteotome, which was designed to protect inner periosteum and mucosa of the nasal bone, and to prevent uncontrolled fracture formation with thinned edge. Twenty patients (95.2%) had favorable results with restoration of a symmetric bony and cartilaginous nasal vault configuration. None of the bone fragments showed any rotation or malposition. One (4.8%) patient with a crooked nose had suboptimal dorsal geometry without requiring revisional surgery at the level of the cartilaginous nasal vault. The author described the morphology, clinical relevance, and correction methods of the nasal vault and the changes that occur in this area during rhinoplasty in patients with concave, convex, or combined three-dimensional nasal bone deformities. Level of Evidence: 4.

Endonasal endoscopic assisted extracorporeal septoplasty in aesthetic reconstruction of crooked nose

Endonasal endoscopic assisted extracorporeal septoplasty in aesthetic reconstruction of crooked nose

Is Osteoplasty With Unilateral Osteotomy Effective in the Correction of the Crooked Nose?

The crooked nose is frequently observed, and a significant number of correction methods have previously been described. Nevertheless, the condition remains a challenging problem for rhinoplastic surgeons. Here, the authors present a technique that the authors have used to correct a crooked nose in selected patients. A total of 23 patients underwent surgery for a C-shaped crooked nose, and were followed up for an average of 11.4 months. Pre- and postoperative photographs were taken, and these were analyzed to evaluate the results. Osteoplasty and unilateral osteotomy were carried out in all 23 patients and a spreader graft was contralaterally placed. Unilateral osteoplasty was conducted in 17 patients, while bilateral osteoplasty was performed in 6 patients. In 19 patients, a single spreader graft was sufficient, but it was necessary to use a double spreader graft in 4 patients. In summary, 23 C-shaped crooked noses were corrected with osteoplasty plus unilateral osteotomy. Osteoplasty plus unilateral osteotomy, combined with a contralateral spreader graft, is an efficient method that can be safely used in the correction of a C-shaped crooked nose.

Discussion on the micro-plastic operative treatment of nasal-septum deviation combined with crooked nose

To explore the micro-plastic operative treatment of deviated nose combined with nasal septum deviation. We designed the incision at the caudal side of the nasal septum. The three-line reduction method for correcting nasal septum deviation was performed. The connection of the caudal nasal septum and the anterior nasal spine was reposited. The micro-plastic surgery with fixed suture was used to correct the deviated nose. After the surgery, the nasal septum deviation was corrected, whose nasal function and symptoms improved without nasal adhesion, nasal septum perforation or other complications. Meanwhile, the nasal tips were in the middle place and nasal dorsums were straight. The aesthetic outcome was satisfactory. Compared to the traditional orthopedic technique, the micro-shaping technique can be used for the homochromous operation of crooked nose combined with nasal septum deviation with less injury and lower risk. We suggest this micro-shaping technique be used in a rational way.

Invited Commentary: Outcome of In Situ Septoplasty and Extracorporeal Subtotal Septal Reconstruction in Crooked Noses: A Randomized Self-Controlled Study.

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Suture under tension across cartilage in the application of the crooked nose surgery

Objective:Observing the effect of maintain tension across suture between cartilages to fix new nasal structure on balance the asymmetric strength of the two sides of the cartilage and the recurrence of the postoperative crooked nose.Method:A L-shaped struct made of the nasal septum cartilage were fixed to maintain tension across structure between cartilage during rhinoplasty in 39 patients with crooked nasal deformity. Of 21 cases were type I deviation, of 12 cases were C-shaped deviation,and of 6 cases were S-shaped deviation.Result:A 1-5 years follow-up were performed. The effects were divided into three degrees: 30 cases excellent (76.92%), 6 cases good (15.38%) and 3 cases acceptable (7.69%).The rate of excellent and good was 92.31%(36/39). The type I improvement rate was 80.3%,the rate of type C was 83.6% and the improvement rate of type S was 84.1%,the overall improvement rate was about 81.9%.Conclusion:Suture under tension across cartilage can fix reconstruction of nasal structure effectively,improve the postoperative effect, reduce recurrence of crooked nose. The operation is simple and is an essential part of the nasal deformity correction technique.

The Learning Curve in Surgical Practice and Its Applicability to Rhinoplasty.

The learning curve as a concept has been considered, discussed and debated in medical education and healthcare for over two decades. The precise usage has been recognised in surgical disciplines both broad specialties and sub-specialties. Rollin Daniel in his book stated that, rhinoplasty is the most difficult of all cosmetic operations for three reasons, (a) nasal anatomy is highly variable, (b) the procedure must correct form and function and (c) the final result must meet the patients expectations. With this in mind a study was carried on the perception of learning curve in rhinoplasty based on a surgeon questionnaire at Marien Hospital, Stuttgart, Germany under Prof. Gubisch. Aims of the study were, (1) to extract the perception of learning curve of Rhinoplasty from surgeons across a spectrum of experience, i.e. less experienced to experienced, (2) To calculate the perception of learning curve in rhinoplasty as for other surgical procedures i.e. minimum number, interquartile range, surgical time, accelerators, (3) To chart-out a road-map for a novice rhinoplasty surgeon for continued improvement in surgical skills and ability. The conclusion derived was the concept of learning curve in rhinoplasty cannot be applied to the operation of Septo-Rhinoplasty as a whole because the two factors i.e. interquartile range and minimum number to achieve proficiency have a wide range and cannot be generalized. It is thought that each type of Rhinoplasty should be dealt with separately and learning curve calculated accordingly, i.e. hump reduction, crooked nose and augmentation rhinoplasty.

Minimally Invasive Technique In Correcting Crooked Nose

Minimally Invasive Technique In Correcting Crooked Nose

Septoplastia extracorpórea para la correción nasal en casos complejos. Resultados en 16 pacientes

ObjectiveSeptal deviation is one of the main causes of respiratory nasal insufficiency and external asymmetry. Septorhinoplasty, either open or closed, is sometimes unable to achieve good results, mostly due to a severe deviation of the anterior part of the septum. The results of extracorporeal septoplasty in the management of difficult cases of septonasal deviations are presented. Material and methodsAn analysis was performed on 16 consecutive extracorporeal septoplasties. The technique consisted of a complete dissection of bony and cartilaginous septum, followed by complete septal resection and reconstruction «on the table» of a new anterior «L strut». This strut was then sutured to the K area, superior nasal cartilages, and anterior nasal spine. Other rhinoplasty steps were done as necessary. A review is presented of the clinical charts and pre- and post-surgical photographs. ResultsMain indications for surgery have been a severely crooked nose (9 cases), followed by nasal sequelae of cleft lip and palate (2 cases). Three patients had a previous septorhinoplasty performed (one of them plus orthognathic surgery). Comminute cartilage fracture was the most common intra-operative finding.All patients have reported a significant relief of their nasal obstruction, and a clear improvement of their aesthetics. The photographs showed a significant improvement in nasal symmetry and enhancement of dorsal, tip, and columellar projection when indicated. ConclusionsExtracorporeal septoplasty is very useful in difficult cases of septorhinoplasty and has few complications. Technical details are described.

Osteoplasty in Crooked Nose Deformity: A Novel Approach.

Crooked nose deformity is one of the most difficult issues to correct by rhinoplasty, as it can result in undesired late sequelae. Revision rates are often high, and numerous operational techniques have been tested. This study describes a crooked nose rhinoplasty technique that reduces the need for a double osteotomy in the long nasal bone. This study included 26 patients with an I-shaped crooked nose deformity. In the surgical correction of the crooked nose deformity, previously defined techniques were applied to the cartilage identically. However, the traditional double osteotomy of the long nasal bone was not performed. Instead, the bone protruding laterally from the long nasal bone was narrowed by rasping with a file or burr, and this section was delivered to the maxilla accordingly. Angle values were measured preoperatively and postoperatively. Two lines were used to measure the angle: The first was drawn from the midpoint of the glabella to the midpoint of the upper lip, while the second, representing the nasal dorsal axis, consisted of both the osseous and cartilaginous parts from the nasion to the anterior nasal spine. The angle between these two lines was taken as the angle of deviation from the median line. Postoperatively, patients' angle values were significantly smaller than preoperatively. After 1year, no persistence was observed. In crooked nose deformity surgery, the osteoplasty technique applied to the lateral protrusion of the long nasal bone described here was as successful as a double osteotomy. Thus, certain complications of a double osteotomy can be avoided. In addition, as no greenstick fractures were induced, the long-term persistence risk was also reduced. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Treatment of the Crooked Nose

Perfection is sometimes approached in treatment of the crooked nose today but not fully achieved due to the continued existence of flaws. While the traditional surgical algorithm envisages the use of 2 series of procedures to straighten the nasal bones and cartilaginous septum, the addition of a third appears very useful with a view to obtaining truly excellent results, above all in the case of marked deviation. The authors present their experience in the use of certain procedures designed to correct asymmetry of the upper lateral and lower lateral cartilages, as well as the soft covering tissues where necessary.A retrospective study was carried out on 105 patients treated for crooked nose over a 3-year period, 90% of the patients being due to trauma and the remaining 10% to congenital malformation. All the patients involved severe deviation of the nasal pyramid.The mean follow-up period was 18 months (range: 8-36 months). The use of these additional surgical procedures made it possible to obtain excellent final results in 83 (97.6%) patients with crooked nose of traumatic origin and in 17 (85%) patients with crooked nose due to congenital malformation. No major complication was registered, although 3 patients did present minor complications not connected with the nasal deviation.In conclusion, more modern approach to correction of the crooked nose should involve not only realignment of the osteocartilaginous axis but also treatment of the neighboring structures.

Caudal Septal Stabilization Suturing Technique to Treat Crooked Noses.

To rotate the nasal axis and septum to the midline using an L-strut graft and a novel caudal septal stabilization suturing technique to treat crooked noses. Thirty-six patients were included in the study. First, an L-strut graft was prepared by excising the deviated cartilage site in all patients. Second, multiple stabilization suturing, which we describe as a caudal septal stabilization suturing technique with a "fishing net"-like appearance, was applied between the anterior nasal spine and caudal septum in all patients. This new surgical technique, used to rotate the caudal septum, was applied to 22 I-type and 14 C-type crooked noses. Correction rates for the crooked noses were compared between the 2 inclination types with angular estimations. Deviation angles were measured using the AutoCAD 2012 software package and frontal (anterior) views, with the Frankfurt horizontal line parallel to the ground. Nasal axis angles showing angle improvement graded 4 categories as excellent, good, acceptable, and unsuccessful for evaluations at 6 months after surgery in the study. The success rate in the C-type nasal inclination was 86.7% (±21.9) and 88% (±16.7) in the I-type. The overall success rate of L-strut grafting and caudal septal stabilization suturing in crooked nose surgeries was 87.5% (±18.6). "Unsuccessful" results were not reported in any of the patients. L-strut grafting and caudal septal stabilization suturing techniques are efficacious in crooked noses according to objective measurement analysis results. However, a longer follow-up duration in a larger patient population is needed.

Correcting the Alar Base Retraction in Crooked Nose by Dissection of Levator Alaque Nasi Muscle

Nasal base retraction results from cephalic malposition of the alar base in the vertical plane causing disharmonies in the alar base. In literature, there are some excisional procedures to correct this deformity, but it may result to nostril distortion, stenosis, or upper lip elevation. Here, a new technique is reported for the correction of nasal base retraction in crooked nose by manipulating the levator labii alaeque nasi muscle. Sixteen patients, 6 women and 10 men ranging in age from 21 to 42 years, who have alar retraction with crooked nose, were operated, with a follow-up period of 12 months. Preoperative and postoperative frontal, profile, base, and oblique base views in a standard manner were taken and analyzed with Image software. Comparison of preoperative and postoperative photographs demonstrated that nasal base retractions were corrected in all cases without distortion and recurrence. Nasal obstruction was reduced after surgery, and self-evaluation of nasal patency scores significantly increased in all patients (P < 0.001). Functional and aesthetic outcomes were satisfactory for surgeons and the patients. Careful analysis to identify the deformity and proper selection of the technique will ensure a pleasing outcome. The new techniques presented for the correction of nasal base retraction and prevention of the recurrence of the dorsal deviation will help rhinoplasty surgeons obtain pleasing outcomes.

Forty-five degree cutting septoplasty

Background The crooked nose represents a challenge for rhinoplasty surgeons, and many methods have been proposed for management; however, there is no ideal method for treatment. Accordingly, the 45° cutting septoplasty technique, which involves a 45° cut at the junction of the L-shaped strut and repositioning it to achieve a straight septum is proposed. Methods From October 2010 to September 2014, 43 patients underwent the 45° cutting septoplasty technique. There were 28 men and 15 women, with ages ranging from 20 to 58 years (mean, 33 years). Standardized photographs were obtained at every visit. Established photogrammetric parameters were used to describe the degree of correction: Correction rate = (preoperative total deviation - postoperative residual deviation)/preoperative total deviation x 100% was proposed. Results The mean follow-up period for all patients was 12.3 months. The mean preoperative deviation was 64.3° and the mean postoperative deviation was 2.7°; the overall correction rate was 95.8%. One patient experienced composite implant deviation two weeks postoperatively and underwent revision rhinoplasty. There were no infections, hematomas or postoperative bleeding. Conclusion Based on the clinical observation of all patients during the follow-up period, the 45° cutting septoplasty technique was shown to be effective for the treatment of crooked nose.

An often neglected area in crooked nose: middle turbinate pneumatization

IntroductionCrooked or deviated nose is a deviation of the nose from the straight vertical position of the face. Extensive pneumatization of the middle turbinate, also called concha bullosa or bullous middle turbinate (BMT) is known to be one of the possible etiologic factors in nasal obstruction, recurrent sinusitis, and headache. There is no study concerning a link between BMT and crooked nose. ObjectiveTo investigate the association between crooked nose and the presence of a BMT. MethodsA total of 199 patients who underwent open septorhinoplasty were retrospectively analyzed. Preoperative paranasal Computerized Tomography (CT) findings, preoperative photodocumentation, and anterior rhinoscopic examination findings were documented. Of the 199 patients, 169 were found to meet the criteria and were included in the study. CT scans were examined to note the presence of BMT, inferior turbinate hypertrophy, and septum deviation (SD). SDs and crooked noses were classified. ResultsNinety-four of 169 patients (56%) presented a crooked nose deformity and seventy-five of 169 patients (44%) presented a straight nose. While 49 (52%) crooked nose patients had a bulbous and extensive BMT, 20 patients with straight nose (26.6%) had a BMT. A statistically significant relationship was found between the presence of crooked nose and BMT, regardless of the side of the disease (p=0.011). ConclusionThis study revealed a link between crooked nose and BMT.