Tuesday, July 23, 2013

Deviated Septum vs Crooked Nose

All crooked/twisted noses have an underlying septal deformity that requires correction and reconstruction to achieve and maintain a long term straightening of the deviated septum.  It is not uncommon for both septal  and pyramid deviations to be corrected at the same time A deviated septum  is corrected by having a septoplasty to improve breathing. This is normally addressed by  correcting the abnormal curvature of the nasal wall consisting of the septal cartilage (the quadrangular cartilage) and bones at back (vomer and ethmoid bone).  This can be done with a closed (endonasal) approach. A localized deviation or spur is purely a functional problem and has no translation to the external shape of the nose.  A crooked/twisted nose usually involves more then just surgical repair or partial removal of the inner quadrangular septal cartilage . Having a septoplasty alone does not mean you will see a external physical change regarding the asymmetry of your nose. A crooked/twisted nose could involve many or all components of the nose cartilage and bone structures from the top/down (cephalic/caudal) region of the nose this would involve anything from the bony pyramid (upper third of your nose) all the way down to the caudal septum (deviation in this region is known as having a caudal deflection), nasal spine & maxillary crest. From the front/back (anterior/posterior) region of the nose this would involve anything from the side of the bridge (medial section of the bony pyramid) of the nose to the most lateral aspect of the nasal bones, or to where the quadrangular cartilage adjoins to the maxillary crest, nasal spine, vomer and perpendicular plate of the ethmoid bone. Sometimes the aforementioned bones need to be corrected to assist with aligning the nasal wall. . The pair of upper lateral and lower lateral cartilage, and medial cartilage are usually evaluated and those which are found asymmetrical after all other corrections to the septum has been made will be modified in this type of surgery. Technically this is referred to as having a septorhinoplasty because there will be a visible cosmetic change to the external shape of your nose.

Pietro Palma M.D. and Paolo Castelnuovo M.D.Chapter 29 p. 320 Correcting the crooked nose from textbook Advanced therapy in Facial Plastic & Reconstructive surgery edited by T. Regan Thomas M.D

Authors classify crooked noses in three basic variations. However, it is important to realize that any of these three categories may be found in various combinations with each other.

Type 1: Single Opposing Convexity/Concavity

The C-shaped and inverted C-shaped noses represent the paradigmatic expression of type 1 deformity. The midnose is invariably involved. Tip-definition point and nasion can be correctly located on the midline axis.

Type 2: Double Opposing Convexity/Concavity

Type 2 crooked nose includes S-shaped and inverted S-shaped. The three framework arches (bony vault, cartilaginous dorsum, and inferior nasal third ) are the most frequently involved with variable combinations of convexity/concavity. Interdomal midpoint and midline rhinion are often out of the midsagittal axis.

Type 3: Laterally Deviated Noses

The typical laterally deviated nose appears straight in terms of alignment of the nasal structures but presents different heights of the two halves. The interdomal midpoint is invariably displaced off center of the midline axis. The angulation may start at the nasion or the rhinion. When the angulation is located at the nasion the halves of all three nasal arches present different heights. Angulation starting at the rhinion implies a straight or near-straight bony pyramid.

Some other major findings which the authors point out are:

  • The crooked nose should be considered an anatomical 'three-level unit": skin-soft tissue envelope (SSTE),bony- cartilaginous framework, and internal lining. Each of these 3 layers plays a specific role for making the nose appear crooked.
  • Total septal reconstruction of the quadrangular cartilage maybe required in severe cases where there is extensive post traumatic or iatrogenic alteration of the cartilage. According to above authors reshaping techniques under those conditions provides poor long term functional and cosmetic results because the original deformities tend to reoccur. 
  • Camouflage procedures are used to achieve better symmetry of the nasal contour anatomy  &/or emphasis some crucial surface landmarks (rhinion, tip definition points, pronasale, colemellar break, subnasale). Autogenous softly crushed septal cartilage, remnants of the cephalic alar resections, & mature scar tissue are the authors preferred additive camouflage material. 
  • The poor success rate of septum surgery reported by many studies is probably due to the failure to treat concomitant valve derangement & alterations of the lateral nasal wall. In fact, concomitant surgery on the nasal lateral wall is often required for a satisfactory functional outcome.  
  •  Precise mini-invasive endoscopic procedures on turbinates and ostiomeatal complex produce excellent functional results.
  •  Conventional osteotomy techniques do not always accomplish what was intended. Double and in special cases, triple osteotomies are necessary to mobilize completely the bony pyramid and change excessive broadness, convexity, or bowing of the nasal lateral walls.  
  • An often neglected region is the premaxillary area including the inferior nasal spine and the premaxillary wings. 
For further reading on chapter by above mentioned authors


Additional reading sources







Saturday, June 22, 2013

Identity Loss Syndrome after rhinoplasty

One of the possible unexpected  psychological effects patients may experience after having rhinoplasty can be a sense of loss of identity. This occurs when one experiences a disconnect with their new physical appearance which they either can't accept or takes a long transition period to get accustomed to.One who undergoes a multitude of  initial cosmetic procedures at once or within a short period of time, are more  prone to suffer from this syndrome, versus someone who has a single or few minor cosmetic changes. However the nose is a prominent feature of the face, and therefore a very large proboscis that is dramatically reduced or reshaped after initial rhinoplasty can have dramatic psychological effect creating a self identity crisis. For example pre-rhinoplasty I had a very large hooked crooked nose. After my initial rhinoplasty i ended up with a over shaved bridge, which created a ski sloped nose with a over projected tip. The look (which was very contrasting with my original nose) never fitted in with  my round face, and looked unnaturally long resulting in a Cyranno type appearance. Others who may likely experience this syndrome are those belonging to certain ethnicity, race or have a family physical trait. A middle eastern person or a descendant of, may want to keep a more rounded profile or lowered tip then a 'perfectly' straight septum, or a Colored or Asian individual may want a wider nose then the Caucasian standard ideal nose. Another group who would be susceptible to this identity loss syndrome (I.L.S.) would be those who feel a reduction in their gender defined degree of physical characteristics. A male may feel emasculated if he always had a more rugged 'Roman like' shaped nose , and then after rhinoplasty ended up with more feminine looking nose (more obtuse nasolabial or nasofrontal angle). Same could hold true for women who have petite features and end up with a more masculine nose, due to more acute tip angle, or increase in size/shape of their new nose due to cartilage replacement grafts. Another subgroup are those who feel a disharmony between their physical appearance and their personality type. This  can occur where one ends up with a  nose shape that makes them look rugged/ more aggressive looking or weaker/softer looking  which is in disharmony with their  type of personality.  A person may also associate and develop a strong negative feeling  with their new look not based on gender issue's but because their new look simply resembles a character type they view negatively or very foreign. One other group who may experience  I.L S. are people who have become very accustomed to their facial imperfection (i.e.slight deviated septum, or asymmetric nose), which had become subconsciously a personal identity marker. This is why it is critical for the surgeon and patient to be on the same page, as to what result the patient is seeking. However a patient seeking primary rhinoplasty may not know what they really want.  It may be wise for the surgeon to have a questionnaire that can address these questions, and issue's, just before consult, so the surgeon can further explore these possible issue's that even the patient may not of been cognizant of prior to making the appointment. A follow up appointment may be needed to give time to the patient to be more specific about what cosmetic change their seeking, and to figure out what they like and don't like about their nose. The use of a picture or computer imaging is very useful to experiment with different looks at different angle views to give the patient an idea of how they may appear post rhinoplasty. Young patients may need to realize and be counseled that their favorite celebrities nose(s) may look totally wrong with their facial features.


Sunday, January 13, 2013

Anatomic reconstruction of the alar cartilages in secondary or revision rhinoplasty

In my October 22, 2012 post i discussed if there is a surgical decision point such as a  50% rule relating to  missing cartilage where some surgeons decide to  rebuild the alar cartilages or other nasal cartilage in general instead of using an assortment of different individual grafts and fillers. While still not knowing the precise answer to that question, the following article which i discovered after writing that article sheds some light on the issue, and it seems a bit more complicated then that. It emphasizes the advantage of anatomic reconstruction of the nasal tip cartilages instead of using nonanatomic cartilage tip grafts.


   Most techniques for secondary rhinoplasty assume that useful residual remnants of the tip cartilages remain but frequently the alar cartilages are missing- unilaterally, bilaterally, completely or incompletely- with loss of the lateral crura, middle crura, and parts of the medial crura. In such severe cases, excision of scar tissue and the residual alar remnants and their replacement with nonanatomic tip grafts have been recommended. Multiple solid, bruised or crushed cartilage fragments are positioned in a closed pocket or solid shield-shaped grafts are fixed with sutures during an open rhinoplasty. These onlay filler grafts only increase tip projection and definition. Associated tip abnormalities (alar rim notching, columella retraction, nostril distortion) are not addressed. Problems with graft visibility, an unnatural appearance or malposition have been noted.

   Fortunately, techniques useful in reconstructive rhinoplasty can be applied to severe cosmetic secondary deformities. Anatomic cartilage replacements similar in shape, bulk, and position to normal alar cartilages can be fashioned from septal, ear and rib cartilage, fixed to the residual medial crura &/or a columellar strut, and bent backward to restore the normal skeletal framework of the tip. During an open rhinoplasty, a fabricated and rigid framework is designed to replace the missing medial, middle, or lateral crus of one or both alar cartilages. The entire alar tripod is recreated. These anatomic alar cartilage reconstructive grafts create tip definition and projection, fill the lobule, and restore the expected lateral convexity, position the columella and establish columellar length, secure and position the alar rim, and brace the external valve against collapse, support the vestibular lining, and restore a nostril shape. The anatomic form and function of the nasal tip is restored. This technique is recommended when alar cartilages are significantly destroyed or absent in secondary or reconstructive rhinoplasty and the alar remnants are insufficient for repair.

   Anatomically designed alar cartilage replacements allow an aesthetically structured skeleton to contour the overlying skin envelope. Problems with displacement are minimized by graft fixation. Graft visibility is used to surgeon's advantage. A rigidly supported framework with a nasal shape, can mold a covering forehead flap ro the scarred tip skin of a secondary rhinoplasty and create a result that may approach normal.

   Anatomic alar cartilage reconstructions were used in 8 reconstructive and 8 secondary rhinoplasties in the last 5 years. Their use in the repair of postrhinoplasty deformities is emphasized. (Plast, Reconstr. Surg. 104: 2187, 1999.)