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.