REPAIRING THE TWISTED NOSE

RHINOPLASTY AND SEPTOPLASTY,PART I zy 0030-6665/99 $8.00 + .OO REPAIRING THE TWISTED NOSE Raj P. TerKonda, MD, and Jonathan M. Sykes, MD, FACS zyxw zyxwv The severely twisted nose represents a complex deformity that often involves multiple anatomic components. The significantly deviated nose often produces a cosmetic and functional deformity. Correction of the deviated nose presents a challenge to even the experienced rhinoplastic surgeon. A detailed understanding of the anatomy of the nose is necessary to accurately diagnose and treat the cause of the nasal deformity. Surgical repair of the twisted nose requires careful structural realignment of each component of the nasal framework. In that any anatomic part of the nose-the nasal septum, the nasal bones, or the upper or lower lateral cartilages-may cause deviation, precise analysis of the cause, or causes, of the deviation is essential to successful treatment. This article describes the etiology, analysis, and surgical treatment for the severely twisted nose. The applied anatomy of the deviated nose is discussed in detail. Finally, a graduated approach to surgical management is described. ETIOLOGY Most twisted noses are secondary to trauma. Attempted closed nasal reductions for severe fractures are often unsatisfactory, particularly when the septum is displaced off of the maxillary crest. Deviations can become From the Department of Otolaryngology-Head and Neck Surgery, University of Florida College of Medicine, Gainesville, Florida (RPT); and the Department of Otolaryngology-Head and Neck Surgery, University of California-Davis, Sacramento, California OMS) zyxwvut OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA VOLUME 32 NUMBER 1 * FEBRUARY 1999 53 54 zyxwvutsr zyxwvutsr TERKONDA & SYKES more apparent as edema subsides, and wound contraction and fibrosis occurs. Less common causes of the twisted nose are iatrogenic, congenital deformity, and infection.’ Patients who have had a deviated nose ”all of their life” may have had a birth canal injury or unrecognized trauma early in childhood. These injuries may not manifest until puberty, when the nose and face undergo significant growth. From rabbit models, the integrity of the attachment of the upper lateral cartilages (ULC) to the septum is crucial for satisfactory nasal growth. Nasal projection is dependent on the ULC, whereas dorsal length is dependent on the growing cartilaginous septum. Maldevelopment of the ULC-septa1 complex results in nasal bone and vomerine abnormalities? zyxwv SURGICAL PATHOLOGY OF THE TWISTED NOSE The twisted nose deformity can range from a subtle unilateral dislocation of the ULC to an entire deviation of the nasal bones, ULC, nasal tip, and septum. Ellis and Gilbert defined the crooked nose as a “nose which is displaced from the midline without tissue loss of the supporting framework,” whereas the pseudocrooked nose describes a nose ”centered in the midline plane where soft tissue or bony loss produces the illusion of a crooked nose.”2The definition can be simplified as any nasal deformity that results in a deviated appearance to the nose. The external nose can be divided into upper, middle, and lower one thirds. The upper one third consists of the nasal bones. Deviations of the nasal bones often involve depression of one bone accompanied by elevation of the opposite bone, resulting in lateral displacement of the entire bony pyramid. Severe deviations of the middle one third of the nose usually are associated with high septal-ULC deformities. Less severe deformities in the middle one third may be secondary to dislocation of the ULC from the nasal bone, giving the appearance of a curved dorsum. Lower one third, or tip, deformities are often accompanied by caudal septa1 deviations, as well as displacement of the lower lateral cartilages (LLC). Fractures of the nasal septum are common with the twisted nose. The classic C-shaped septum results in displacement of the inferior septum from the maxillary crest into the nasal cavity (Figs. 1A and B). This displacement often is contralateral to the external convexity. Any combination of spurs, twists, deflections, duplications, and deviations may occur. Deviations along the caudal or dorsal septum (L-strut) result in lateral or side-to-side displacement of the nose. A fracture at the keystone area of the septum can result in an angulation of the middle and lower thirds of the nose. Loss of dorsal height is the result of displacement of the nasal zyx REPAIRING THE TWISTED NOSE zy 55 zyxwvuts zyxwvut Figure 1. Full face (A) and close up (6) AP views of a patient 6 months post-trauma with a depressed nasal fracture and concavity of the left middle third of the nose causing twisting and deviation of the nasal dorsum. septum off of the maxillary crest or posterior displacement of the septum (duplicated septum). The combination of internal and external deformities can result in nasal valvular narrowing. When the caudal or dorsal septum is deviated, the narrowing is usually on the convex side. When the ULC is dislocated from the nasal bones, the valve is narrowed on the concave side of the twist. Hypertrophy of the inferior turbinates also can contribute to narrowing of the nasal airway. Preoperative recognition of valvular narrowing is essential for satisfactory postoperative functional results. 56 zyxwvutsr zyxwvutsr zyxwvuts zyxw TERKONDA & SYKES PHYSICAL EXAMINATION AND ANALYSIS A thorough history and physical examination should be performed. The timing and mechanism of injury, as well as other facial injuries such as a frontal sinus or nasoethmoid fractures, should be ascertained. Nasal obstruction and changes in appearance must be documented. Previous attempts at correction decrease the likelihood of a satisfactory result. Photographs of the patient before the injury are helpful to determine any premorbid deformities, and provide an aesthetic goal for the patient and the surgeon. Physical examination consists of inspection and palpation of the external nose. The relationship of the nasal size to the face should be determined. Specifically, attention should be given to the horizontal thirds and vertical fifths. A midline plane from the glabella to the central incisors should be envisioned, and deviations from the midline are noted. Occlusion and chin position are determined. Bony step-offs and nasal tip support should be assessed. Palpation of a displaced anterior septal angle indicates a severe septal deviation. A prominent dorsal hump or saddle deformity should be noted. Intranasal examination consists of anterior rhinoscopy, indirect visualization of the nasopharynx with a mirror, and, when indicated, nasal endoscopy. Careful examination of the nasal septum, nasal valves, and turbinates is performed before and after decongestion. Caudal deflections of the septum and displacement of the septum off of the maxillary crest should be noted. The anatomy of the nasal valves should be inspected at rest and with deep inspiration. Persistent turbinate enlargement after decongestion implies enlargement of the bony turbinate. Preoperative photographs in the following six views are essential: frontal, left and right obliques, left and right laterals, and basal views. Photographs often are required for insurance preauthorization for posttraumatic deformities. The computerized video imager can be helpful for analysis, preoperative planning, and patient education. TIMING OF SURGERY If the trauma is recent, restoring the pretraumatic condition may require only closed reduction and splinting of nasal and septal injuries. Closed nasal and septal reductions should be performed within 10 days of the injury. External casts and intranasal silastic stents are placed for 1 week. If the nose remains twisted after closed nasal reduction, definitive septorhinoplasty can be performed as early as 6 weeks after the failed reduction. If the deformity is severe, a closed reduction may not be ben- zy zyx zyxwvu REPAIRING THE TWISTED NOSE 57 eficial, and a planned septorhinoplasty is performed 6 weeks after the injury. SURGICAL TECHNIQUE Septoplasty Correction of the nasal septum is important to attain satisfactoryaesthetic and functional results. This often is performed through an open approach. Deviations along the dorsal septum, which are common with the twisted nose, are difficult to correct through routine intranasal (transfixion) incisions. In the past, the septoplasty was performed through a hemitransfixion incision. Endonasal exposure, however, is often inadequate to straighten dorsal septal deviations and to place and secure cartilaginous support grafts. Diagnosis and treatment of dorsal septal deviations usually is facilitated through the open approach. Excellent exposure can be gained by using the open approach and accessing the septum "from above," at the junction of the nasal septum and the upper lateral cartilage (Fig. 2). A second method using the open approach is to separate the LLCs and enter the submucoperichondrial plane at the caudal septum. This change in surgical approach has decreased operating time and improved functional and aesthetic results for the twisted nose. After the skin-soft tissue envelope (skin-STE) is elevated through marginal and transcolumellar incisions, the interdomal ligaments are incised and the LLCs are retracted caudally to gain exposure of the anterior zyxwvu z zyxw Figure 2. A, Approach to the nasal septum by way of an open rhinoplasty at the junction of the upper lateral cartilages and the nasal septum. B,Approach to the nasal septum by way of an open rhinoplasty by separating the intracrural ligament between the medial crura of the lower lateral cartilages and entering at the caudal septum. 58 zyxwvutsr zyxwvutsr TERKONDA & SYKES septal angle. The ULCs are separated sharply from the septum and the submucoperichondrial plane is identified. Depending on the deformity, unilateral or bilateral mucoperichondrial flaps are elevated and the septum is exposed as in a routine septoplasty. Usual techniques, such as scoring and removal of deviated cartilage and bone, are performed. One-centimeter dorsal and caudal struts of the cartilaginous septum are required to provide support for the nasal dorsum and tip, respectively. A large piece of cartilaginous septum can be removed for structural grafting (Fig. 3). The resected cartilage is usually large enough to provide spreader and tip grafts and columellar strut. After the posterior aspect of the septum is straightened, attention is turned to the caudal septum. The caudal aspect of the nasal septum is commonly subluxed off of the maxillary crest, causing deviation of the septum and asymmetry of the nasal base. To straighten this portion of the nose, an inferior wedge of septal cartilage must be removed (Fig. 4A). The caudal septum is then mobilized, repositioned, and anchored to the periosteum of the premaxilla with a #4-0 monofilament absorbable suture (Fig. 4B). The goal of the septoplasty is to make it is as straight as possibleoften a difficult task in the severely twisted nose. To prevent the septum from returning to its twisted form, cartilaginous or bony struts are placed along the dorsum unilaterally or bilaterally, similar to placement of spreader grafts. Bony struts fashioned from the ethmoid perpendicular zyxw z r 'Columellar graft 'Spreader grafts Figure 3.Sagittal view of the nasal septum with the dotted line showing the amount of septum that can be removed to achieve straightening and cartilage harvest for grafting of the nasal dorsum and tip. The inset shows the usual areas used for carving a nasal tip graft, bilateral spreader grafts, and a columellar strut. REPAIRING THE TWISTED NOSE zy zy 59 zyxwvut zyxw z Figure 4. A, Resection of the inferior aspect of the nasal septum to achieve mobilization of the caudal nasal septum. B, Suture fixation of the caudal nasal septum to the periosteum overlying the premaxilla. plate provide excellent support for twists at the keystone and caudal areas without causing widening of the nose. A fine drill, such as a skeeter drill, is used to make perforations in the bone. The strut is sutured into position with a horizontal mattress suture (4-0 nylon or PDS) that goes through both ULCs, the strut (unilateral or bilateral), and the dorsal nasal septum. Hump Reduction If a large dorsal hump is present, the hump is removed in an oblique or asymmetric fashion, so that a greater amount of cartilage and bone is removed from the depressed or concave side when compared with the elevated or convex side. When osteotomies are performed near the end of the procedure, this maneuver allows formation of a symmetric bony pyramid. Middle Third of the Nose After the septoplasty and hump reduction, the middle one third of the nose should be addressed. Deviations of this area are common. Shaving of the convex aspect of the dorsal septum will give partial correction of the deformity3 The concave side is augmented with a combination of cartilaginous spreader grafts and onlay grafts. Repositioning of the ULC is difficult, and, therefore, camouflage techniques often must be used to mask the concavity. Spreader grafts are grafts placed between the nasal septum and the ULC to improve aesthetic appearance and nasal function. Spreader grafts are indicated when the nasal valve is compromised or when the middle one third of the nose requires widening. The grafts are placed in a submucosal plane and sutured into position using 5-0 mono- 60 zyxwvutsrq zyxwvutsr zyxwvut zyxwv TERKONDA & SYKES filament absorbable suture (Figs. 5 A and €9.When the dorsum is twisted secondary to middle third asymmetry, unequal sized cartilaginous grafts may be placed to improve function and camouflage the external deviation. These grafts can be layered on top of the bony ethmoid struts. Onlay grafts are useful for augmenting (and camouflaging)a depressed nasal sidewall subunit. After feathering the edges of the cartilaginous onlay grafts, these should be sutured in place through the open approach (Fig. 5C). When the nose has an isolated depression in the middle third of the nose, an onlay graft can be placed into a precise pocket (without anchoring sutures) through an intercartilaginous or a marginal incision. This is an effective and simple maneuver, and avoids the more extensive dissection associated with the open approach. zy Tip Modifications Deviations of the nasal tip and caudal septum often are accompanied by a loss of nasal tip support and projection (Fig. 6A). The foundation of moving the tip to the midline is straightening the caudal septum using zyxw Figure 5. A, Approach to the nasal septum between the upper lateral cartilages and dorsal nasal septum. The dotted line indicates full submucosaldissection on the concave side of the septum allowing approach to the entire septum on this side. The dotted line on the other side shows a limited approach for placement of a spreader graft. B, Submucosal placement of bilateral asymmetric spreader grafts with a larger spreader graft being placed on the patient’s left than the right to improve concavity on this side. C,Axial cross section illustrating bilateral spreader grafts with a larger spreader graft being placed on the concave side of the middle third of the nose. zyxw zy zy REPAIRING THE TWISTED NOSE 61 zyxwvuts zyxwvut zyxwv Figure 6. A, A deviated nasal tip secondary to trauma and asymmetric buckling of the nasal tip cartilages. B, Stabilization of the nasal base and tip after placement of a columellar cartilaginous strut graft. This graft should create improved three dimensional symmetry of the nasal base. C,Vertical cartilage division of the nasal tip bilaterally. Note that the division on one side is lateral to the dome secondary to lack of projection on this side. This asymmetric vertical division will improve nasal tip symmetry. 0,Cartilage reconstitutionwith 5-0 monofilament absorbable suture. f,Placement of a nasal tip graft for improved tip definition, tip projection, and camouflage of tip deformities. F, Alar concavity secondary to weak lateralcrus of the lower lateral cartilage. G, Improved alar based symmetry after placement of an alar batten graft to improve the concavity. 62 zyxwvutsr zyxwvutsr TERKONDA & SYKES zy zy the techniques previously described. The maneuvers to reconstruct a symmetric nasal tip are similar to those used in aesthetic rhinoplasty. Removal of the cephalic edge of the lateral crura is performed when indicated. A columellar strut placed between the medial crura will improve nasal tip support and three-dimensional symmetry of the columella (Fig. 6B). Intradomal sutures or vertical cartilage division with reconstitution of the LLC will narrow each dome, as well as increase tip projection if a portion of the lateral crus is used to lengthen the medial crus (Figs. 6C and D). A tip graft may be sutured to the domes and medial crura with 6-0 clear monofilament suture to increase tip support, and to control tip projection and rotation (Fig. 6 E ) . Residual concavities of the lateral crura can be camouflaged with onlay cartilaginous batten grafts (Figs. 6F and G). Turbinate Reduction Unilateral or bilateral turbinate reduction is necessary for hypertrophic turbinates. Submucous reduction or intramural cauterization with therapeutic outfracture of the turbinates is performed by the authors. Turbinate reduction also is necessary for persistent caudal septa1 deformities or when the placement of spreader grafts is inadequate for opening the nasal valve. SUMMARY zyxwv Correction of the deviated nose is a challenging task. To be successful, attention must be given to careful diagnosis and restructuring of the underlying deformity. Figure 7 A through F shows pre- and postoperative views of a patient after internal and external nasal reconstruction after an open approach, asymmetric osteotomies, and placement of a unilateral cartilaginous spreader graft. The important aspects of repairing the twisted nose include good exposure for accurate diagnosis, meticulous straightening of the nasal septum, and judicious use of functional cartilage grafts. If these principles are used, a high success rate of straightening the nose can be achieved. zyxwvuts zyxwvu zyx Figure 7. PreoperativeAP (A), oblique ( B ) ,and basal views (C) of a patient 6 months after trauma to the nose with deviation of the nose to the left side of the face. D-F, Six months postoperative photographs after an open rhinoplasty approach with nasal septoplasty,asymmetric osteotomies, placement of a columellar strut and nasal tip graft, and placement of an asymmetric right sided spreader graft. REPAIRING THE TWISTED NOSE zyx zy 63 zyxwvu Figure 7. See legend on opposite page 64 zyxwvutsr zyxwvutsr zyxwvuts zyx zyxwvut TERKONDA & SYKES References 1. Dingman RO, Natvig P: The deviated nose. Clin Plast Surg 4:145,1977 2. Ellis DAF, Gilbert RW Analysis and correction of the crooked nose. J Otolaryngol20:14, 1991 3. Toriumi DM, Ries WR: Innovative surgical management of the crooked nose. FacialPlastic Surgery Clinics of North America 1:63,1993 4. Venvoerd CDA, Verwoerd-Verhoef HL: Developmental aspects of the deviated nose. Facial Plastic Surgery 6:95,1989 Address reprint requests to Raj P. TerKonda, MD Department of Otolaryngology University of Florida College of Medicine Box 100264 Gainesville, FL 32610-0264