Discussion
Crooked nose deformity is the vertical axis deviation of the nasal
pyramid to the left or right on the basal or frontal view. Generally, it
occurs due to trauma during the early childhood or adolescence period
and is accepted as a challenging problem to solve. Many authors have
claimed that the etiologic reasons for the crooked nose are unnoticed
trauma during birth or early childhood and insufficient correction of
nasoseptal fractures (13,14).
There are both functional and esthetic problems in crooked nose
deformities, and achieving a successful result is possible with
appropriate preoperative analysis. Detailed examination of frontal,
basal and helicopter views and analysis of the reason for deviation are
crucial for a correct preoperative plan and for ultimately successful
postoperative results.
The use of spreader grafts is a classical and useful method for the
correction of septal deformities in classical structural rhinoplasty
approaches but may not be sufficient to solve the problem in some
patients (15,16). The location, number and thickness of spreader grafts
may be different from patient to patient. Generally, spreader grafts are
placed on the concave side of the deformity, but asymmetric locations
and different numbers of spreader grafts on both sides may be used in
patients with crooked nose deformity (17). However, the use and benefits
of spreader grafts are limited in the case of bony pyramid deviations.
Asymmetries in the lower parts of the lateral nasal bones in maxillary
regions cannot be solved with classical single osteotomies; in contrast,
using spreader grafts can make the asymmetries more pronounced during
the classical structural rhinoplasty approach.
Extracorporeal septal reconstruction (ECSR) is another and generally
accepted final reconstruction method for severe crooked nose
deformities. In the ECSR technique, the septum is totally mobilized and
removed from the nose, reconstructed as an L-shaped strut and
repositioned into the midline of the nose (18). The main challenge is
achieving a straight L-shape and stabilization of the new septum.
Because of the highly deformed septal cartilages, achieving a straight
septum is an important problem that can be solved only with costal
cartilage harvesting in a significant number of patients. Many authors
have hesitated to use this technique because of the risk of
destabilization and technical difficulty. Additionally, combinations of
different techniques, such as asymmetric osteotomies, ostectomies and
spreader grafts, have been described in the literature, and the
deformities have been solved (19-21).
When the nasal pyramid is considered in three dimensions, it can be
easily seen that the lateral nasal bones do not lie in a straight plane.
For example, the lateral nasal bone is generally convex in its upper
parts close to the eye and concave in the lower parts in the maxillary
region. This situation becomes much more pronounced in patients with
crooked nose deformities. In our technique, to correct this
3-dimensional asymmetry in the lateral nasal bone, the dimensions of the
lateral bone were measured and equalized, and a mobile bony cap was left
to hide the slight asymmetries below. First, osteotomies were localized
2-3 mm below the bony cap and were an average of 8 to 10 mm in size, and
their connection with the upper lateral cartilages was preserved on both
sides. Mobilization of the bony cap allows the dorsal septal cartilage
to move freely, and this maneuver helps the correction of the middle
third deviation. Lateral nasal bones were left 15 to 18 mm in length,
and the excessive bone just below the lateral nasal bone from the lower
maxillary nasal bone junction was removed. Thus, we obtained a straight
and more symmetric nasal bony structure assessed by 3-dimensional
examination on both sides. Bony pyramid deviation is corrected with this
asymmetric reduction of the bone on both sides, and the important point
is that the residual bone size and shape left in the patient should be
equal for symmetry.
Nasal bones become fully mobile as in the structural rhinoplasty
approach. In addition to the advantages of the structural approach, more
bone must be removed from the hump, but asymmetry in the base remains.
In the structural rhinoplasty approach, the nasal bones are brought
closer together and lowered. Since there is remaining asymmetry at the
base, the preoperative asymmetry can be felt again while the bone is
rebonded in postoperative follow-ups. In the let-down procedure,
asymmetries in the nasal maxillary junction at the base can be resolved,
but since the dorsum remains as one piece, asymmetries are eliminated
only by removing the asymmetrical bone at the base, and deviation to one
side at the K-point can still be felt. In our technique, we correct
asymmetries at the lower maxillary nasal junction, such as in the
Let-down approach, as well as asymmetries at the K-point, such as in the
structural approach. Thus, we combine the advantages of both techniques.
We believe that complete mobilization rather than green-stick fractures
and measurement and equalization of all bony fragments on each side is
essential for successful postoperative results. In addition, the
mobile-bony cap left on the patient is very useful for releasing the
tension of the septal dorsum and hiding slight asymmetries remaining
below in the patients. This presented technique may be an alternative
technique for crooked nasal deformities.