New York Crooked Nose Correction Surgery
An asymmetric or crooked nose poses one of the greatest challenges in cosmetic surgery of the nose. An anatomically crooked or twisted nose can negatively affect both facial symmetry and nasal function as well as nasal appearance. As a skilled NY rhinoplasty surgeon, Dr. Oleh Slupchynskyj has vast experience in the correction of crooked noses, and can help his patients achieve the appearance and function they desire.
What Causes a Crooked Nose?
The underlying causes of the crooked nose most commonly include:
- nasal or traumatic injury
- at birth (e.g., forceps-assisted or breech delivery)
- childhood (e.g., direct frontal injury or nasal trauma associated with septal fracture)
- specific developmental abnormality or disease
- autoimmune or immunologic diseases resulting in septal injury
- mucosal atrophy and septal perforation (due to drug abuse and neoplastic processes).
Anatomy of a Crooked or Twisted Nose
Typically, the crooked nose involves several components–a bony deviation, defective upper or lower lateral cartilages, or a combination thereof. In general, traumatic injury may result in deviation of the upper nasal bones and upper lateral cartilages. While additional developmental defects may involve the upper lateral cartilage, deformation or displacement of the lower lateral cartilages during traumatic injury is also possible. Surgical evaluation of the deviated nose for lateralization of the nasal bones and cartilage responsible for asymmetries in the middle-and upper-third regions of the nose is essential.
The upper lateral cartilages are two triangular-to-trapezoidal cartilages flanking the cartilaginous septum that extends from the nasal bones in the midline above to the bony septum in the midline posteriorly, then down along the bony floor. They are fused to the dorsal septum in the midline and attached with the help of ligaments to the bony margin of the aperture. There is an internal area or angle formed by the septum and upper lateral cartilage.
The lower lateral cartilages, often mobile, lie beneath the upper lateral cartilages. They extend from structures called the medial crura to an intermediate crus area.
The upper lateral cartilages provide structural support for the nose. The upper lateral and the lower lateral cartilages play a significant functional role: The association of the upper lateral cartilage with the middle septal cartilage forming an angle at the internal nasal valve helps with breathing. Impairment or obstruction of this nasal valve can cause nasal obstruction and breathing difficulties. An internal valve collapse may be suspected if a positive Cottle maneuver, performed by retracting the cheek skin laterally, relieves obstruction. Septoplasty can correct any associated defects.
The dorsum, sidewalls, hemilobules, alae, soft triangles, and columella constitute different components of the nasal anatomy. They account for different nose shapes and sizes externally in different ethnicities including Caucasian, African American and Hispanic.
The portion of the internal nasal valve, which comprises the septal cartilage and the upper lateral cartilage is also important from a cosmetic viewpoint especially after fracture, as the upper lateral cartilages are also connected to the upper nasal bone. Fracture or disruption due to a previous Rhinoplasty in this area can lead to deviation of the nasal bone. It can also cause deviation and fracture of the upper lateral cartilage resulting in nasal bone deformity, a critical aspect of the crooked nose. These defects require careful evaluation to enable accurate nasal reconstruction and Revision Rhinoplasty.
The external nasal valve is the portion of the nose where the upper lateral cartilage and lower lateral cartilages meet. This portion of the interior of the nose can also be disrupted of the trauma or previous surgery.
Revision Rhinoplasty reconstruction can correct most of these defects.
What do Older Rhinoplasty Techniques have to do with Nasal Valve Collapse?
Nasal valve collapse may also result from a previous over-resection or over-removal of the lower lateral cartilage. This procedure was commonplace in the '80s, removing large portion of lower lateral cartilage, resulting in collapse of the internal nasal valve. Removal of the upper lateral cartilage from this area can lead to eventual scarring and fibrosis, down the internal nasal valve resulting in a pinched nose appearance. In addition, the nasal valve collapse can cause severe internal obstruction of the nose. As an excessive amount of lower lateral and dorsal septal cartilages is scooped out resulting in a pinched appearance, Revision Rhinoplasty is warranted.
The procedures are known to be associated with severe collapse of the external nasal valve, resulting in severe nasal obstruction. A collapsing ala, which impedes air entry during inspiration, is a sign of external valve collapse, especially in patients with a history of previous aggressive reduction rhinoplasty. Many of these patients currently require reconstruction of the external nasal valve. These earlier procedures also caused the characteristic ski slope nose, the pinched look or even the characteristic nose drop look, resulting in the need for Revision Rhinoplasty today.
What Surgical Procedures Can Repair a Crooked Nose?
Upper Cartilage Repair
Revision Rhinoplasty is used when the crooked nose or the nasal obstruction involves the nasal bone and the upper lateral cartilage, either on one side or both sides. It can repair the nasal bone and also the collapsed upper lateral cartilage.
Septoplasty Surgery is the most common procedure to correct a collapsed upper lateral cartilage using spreader grafts. Spreader grafts measure 8-25 mm in length, 3-6 mm in height, and 1-4 mm in thickness. It entails carving a tiny piece of cartilage from the septal cartilage to position exactly between the upper or dorsal portion of the septal cartilage and the upper lateral cartilage, where the cartilage has been fractured off. The cartilage graft is inserted in between the upper lateral cartilage and the upper septal cartilage and sutured in place. This procedure not only stabilizes the upper lateral cartilage with the septal cartilage, but also the angle of the upper lateral cartilage. The intervention increases internal valve angle, opens the airway, and provides symptom-free breathing. In addition to correcting a collapsed upper lateral cartilage, this procedure widens the middle third of the nose and repairs the cosmetic deformity.
Indeed, spreader grafts can serve several different purposes: they can be used to widen the middle third of the nose cosmetically, as well as to open the internal nasal valve by relieving nasal obstruction. Spreader grafts are strongly indicated for stabilization of the internal nasal valve and dorsal onlay grafts to prevent dorsal irregularity.
What is an Osteotomy? When is this Procedure Required?
In addition to placement of the spreader graft, osteotomies may be required to straighten the nasal bones in the event of nasal deviation. For minimal trauma, a Z-shaped asymmetric hump resection combined with unilateral osteotomy can safely be used to correct deviated nose.
The Importance of Suture Techniques and Butterfly Grafts
Other methods of opening middle third or upper lateral cartilages of a nasal valve include suture techniques and butterfly grafts.
The Conchal Cartilage "butterfly" graft is indicated for patients presenting with nasal obstruction after Rhinoplasty that are frequently found to have collapse or weakening of their upper lateral cartilages and associated nasal valve dysfunction. The butterfly graft uses the cartilages from the external ear in the external nasal valve. It is then sutured in place in order to open and reinforce the internal nasal valve. It has predictable functional and cosmetic results with minimal morbidity.
When considering Revision Rhinoplasty or functional reconstruction of the nose, the following components of the cartilaginous bony and soft tissue structures must be evaluated:
- the upper nasal bones, which comprise the upper third of the nasal anatomy;
- the middle third, which comprises the upper lateral cartilages; and
- the lower third, which comprises the lower lateral cartilages.
In addition, there is a midline structure, the septal cartilage or septum consisting of an internal cartilage and posterior bone. The cartilage and bone are fused.
The soft tissue covering the nasal valve includes a deep muscular layer known as the SMAS (Submuscular Aponeurotic System), which is continuous with the Submuscular Aponeurotic System of the face. There is also a functional muscle layer, which controls the functional and cosmetic movements of the nose. As well, there is a fatty fibrous or fatty subcutaneous tissue layer, which in Afro-Americans and Ethnic noses tends to be thicker and more fibro-fatty that in Caucasian noses. And finally, the dermis and epidermis also vary in thickness depending on the ethnicity–Caucasian, Afro-American versus other ethnicities.
An External Rhinoplasty approach is indicated for a deviated tip or severely obstructed nose requiring reorientation of underlying support structures, and may facilitate placement of grafts and stabilizing sutures.
Lower Cartilages and Crooked Noses
The internal nasal valve and lower cartilage and can also contribute to crookedness of the nose. During the reconstruction of the external nasal valve using the cartilage grafts or butterfly graft, adjustments are made using cartilage grafts to realign the lower lateral cartilages, so that they can be straightened down to the middle line of the nasal septal cartilage.
Reorientation of Support Structures
A reorientation of support structures in order to increase nasal support to alleviate or prevent symptoms may be required in the event of valve collapse or suspicion of impending nasal airway obstruction. If performed incorrectly, the procedure carries the risk of worsening deviation and nasal obstruction.
Camouflaging Technique, involving implants placed into a well-defined deformity, may be indicated in isolated deformities without nasal obstruction. It carries the risk of residual deformities and graft visibility.
The endonasal approach to repair the twisted nose is indicated in the absence of airway compromise, and the deviated nose confined to upper- and middle-third regions of the nose, using an inter-cartilaginous incision. It is also indicated for nasal obstruction associated with middle vault or bony deviation, although the technique requires considerable skill to avoid overdeveloped or misplaced pockets while placing cartilage spreader grafts.
Open Rhinoplasty Septal Reconstruction for the correction of the markedly deviated nasal septum entails fixation of the straightened and replanted septum at the nasal spine and dorsal septum border with the upper lateral cartilages.
The photograph above shows septal cartilage spreader graft sutured in place and also images (before and after the intervention) of a patient, who had a spreader graft placed for widening of the middle third of the nose.
Relieving Nasal Valve Collapse
Restoration of breathing ability and correction of the nasal valve collapse via nasal valve reconstruction, is typically performed with cartilage grafts, which replace the cartilage that has been removed in the area between upper and lower lateral cartilages. It also involves widening and enlarging the internal valve area, as well as re-supporting the internal valve, to restore its integrity and thereby improve the aerodynamics of nasal air flow during breathing.
What Implant Materials are Available? What offers the best outcome with the least amount of risk?
View more information and a comprehensive guide to the safest implants.
Septal Cartilage is Dr. Slupchynskyj's implant of choice, but may be substituted with auricular (ear) cartilage when adequate supplies are unavailable or limited.
Curved Conchal (Ear) Cartilage may be used for alar batten grafts and for filling dorsal concavities. Crushing the cartilage sometimes allows the cartilage to conform to existing structures.
Autologous Costal (Rib) Cartilage (either from the confluence of the sixth, seventh, and eighth ribs or from the ninth, tenth, and eleventh ribs), calvarial bone (from the the parietal scalp), homologous irradiated rib graft material can be used to replace major support structures of the nose. The potential benefits must be weighed against the risk of morbidity with any of these grafts.
Acellular Dermis (AlloDerm™) has been used to camouflage minor irregularities of the dorsum, when autologous fascia or soft tissue is limited.
Alloplastic materials, specifically Medpor can carry the risk of extrusion and infection Since Medpor allows for tissue in-growth, it is extremely difficult to remove should a patient decide for any reason to do so. Surgical removal runs the attendant risk of causing trauma to and deformity of the surrounding tissue. Gore-Tex, although safe and user-friendly, also allows for tissue ingrowth and is associated with rejection, infection, and extrusion.
While biodegradable polymers, such as polylactides, are stable for at least 7 months, they are associated with the risk of extrusion and infection.
The SLUPimplant™ is Dr. Slupchynskyj's custom carved silastic implant is used to elevate and raise the dorsum and nasal-frontal angle in Ethnic and African American Rhinoplasty and Revision Rhinoplasty.
In conclusion, the success of Revision Rhinoplasty for a crooked nose largely depends on the degree of nasal valve collapse, septal deformity, tip status and surgical expertise. It can be accomplished with a combination of appropriate techniques including camouflaging and/or structural reorientation following accurate diagnosis centered on the upper-third region as well as the lower two thirds of the nose. The choice of implant cannot be overstated. In African American Rhinoplasty at least, the SLUPimplant™ is preferred for dorsal and nasal frontal angle deviations. The cutting-edge procedure is currently available with the New York-based Rinoplasty Surgeon, Dr. Oleh Slupchynskyj.
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African American Revision Rhinoplasty. Available at: http://www.africanamericanrhinoplasty.com/ethnic-rhinoplasty-revision-photos.htm.
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