The Clinical Problem ( Fig. 17.1 )
The deviated nose presents significant problems to the aesthetic surgeon and is one area in which revisions for residual deviation or asymmetry are common. Synonyms for the deviated nose include crooked, S -shaped, and twisted. Deviated noses can be defined when the nasal axis is displaced from the midline. Sometimes defining the midline can be a problem, because more than 90% of patients presenting for rhinoplasty surgery have some degree of facial asymmetry. It takes a fraction of a second to scan the face perceptively—starting across the eyes, passing down the nose to the mouth, and then back up to the eyes. It is therefore important in an asymmetric face to try and choose the visual axis that aligns as closely as possible with the philtrum and the upper dental midline smile.
Deviation of the nasal septum can be the result of developmental deformity. The addition of trauma in the developing nose or after nasal maturity contributes to displacement of the septum or outer pyramid. It is important when evaluating the causation of the deviation to inquire about trauma, even relatively insignificant trauma in early childhood. Trauma can occur at birth with septal dislocation, which will spontaneously correct in most cases. However, it is often associated with a posterior septal vomerine spur, which may result in a displacement from the maxillary crest and a contralateral caudal septal dislocation from the spine with continued growth.
The nose develops from a cartilaginous capsule that extends to the skull base. Subsequent ossification from cranial to caudal results in the cap of the nasal bones, lateral K area, and central keystone area. The former equates to the junction of the quadrilateral cartilage and the perpendicular plate of the ethmoid, the latter refers to the connection between the upper lateral cartilage and the nasal bone cap.
Clinical Assessment
External Nose
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Upper third—this is predominantly bony, and may be central, to the left or right format for the lower third.
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Middle third—the cartilaginous vault may be similarly described but is more prone to asymmetry or collapse from loss of height of the septum.
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The lower third—symmetry determined by the orientation of the tip cartilages over the septum and lateral cartilages. It is here that the greatest variability occurs.
Internal Nose
Intranasal visualization is essential to understand the problem. A palpating thumb can push back the nasal tip to expose the lower septum, and a speculum allows direct viewing of the deep septum. Ideally, a nasoendoscope is available. This allows for full determination of nasal septal deformities and nasal valve function. Palpation of the external nasal pyramid produces further information, such as the presence of one vertical nasal bone or one oblique bone. The resilience and support of the tip cartridges can easily be ascertained. Finally, it is important to walk around the back of the patient with her or his head tilted backward to make a final assessment of the axis of the nose.
Nasal Septum
The nasal septum is the key structure in the deviated nose. It is a supporting structure, particularly for the lower two-thirds of the nose. Together with the conjoint upper lateral cartilages, it forms a fixed tripod. Floating over this fixed tripod is the so-called floating tripod of the lower lateral (alar) cartilages, attached by various ligaments. These include the lateral scroll ligament and interdomal sling, supported by muscular structures such as the dilator nasi, pyriform ligament, and transversalis muscles. Without a proper foundation, with a central septum supported by upper lateral cartilages, there is little hope of achieving a symmetric and stable nose.
The concepts of septal surgery have evolved considerably since its first modern description by Cottle. An overriding principle is that all cartilage anterior to a line drawn through the nasal spine to the bone and cartilage junction of the central K area must be preserved ( Fig. 17.2 ). Septal resection, leaving an L -shaped strut harvested from the nasal septum to support the nose, can weaken the septum. This is far from ideal because the least supported and most vulnerable part of the septum is exposed to the deforming forces of postrhinoplasty wound healing and any direct trauma. In a personal series of revision rhinoplasty, a fracture of the L strut was found in nearly 40% of patients. If a cartilage graft is required, the shape of the septal resection behind the supporting line should be in an arch rather than L shape to avoid fracture.
