Crooked Nose

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.