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PROFILES Modern Rhinoplasty Textbook

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The Twisted Nose

Written by Dr. Litner and Dr. Solieman

Treatment of Broken, Crooked Noses

Functionally, in treating the twisted nose, Drs. Litner and Solieman have the knowledge and experience to evaluate and treat a variety of complex deformities ranging from the S- shaped septum to complete valve avulsion (separation) and collapse. In fact, septal deviation is ubiquitous in this patient population and its correction, in large measure, determines the long-term success in treatment of the associated cosmetic deformities.

While a discussion of the embryology of nasal development is outside the scope of this site, Drs. Solieman and Litner try to impress upon you, their patient, that even minor trauma, when it causes cartilaginous injury, can lead to progressive deformation with time. The reaction of growing cartilage to injury can lead to a variety of deformities ranging from bowing of the septal cartilage (resulting from cartilaginous overgrowth) to retraction of the columella and loss of tip support arising from caudal septal hypoplasia (failure of cartilaginous growth).

Oftentimes, surgeons treating the crooked nose fall into one of two camps, those who attempt to “camouflage” existing deformities, and those who believe in “aggressive reconstruction.” Occasionally, following acute trauma where minimal functional disturbances are present, Drs. Litner and Solieman may indeed use dorsal onlay grafts to restore the pre-injury appearance. These thin slices of cartilage are placed over areas of depression or curvature to hide the contour irregularities. The irregularities themselves are left uncorrected. However, while camouflage techniques preserve maximal support, they may require aesthetic compromises that lead to a nose that is overly prominent and wide. On the other extreme, there are those patients presenting with vague histories of childhood trauma who are noted on exam to have a severely S- shaped dorsum and caudal septal deviation. Aggressive reconstruction provides optimal aesthetics in these cases but may risk compromising structural supports. Drs. Solieman and Litner approach their patients with a balanced reconstructive approach that in turn addresses each anatomical concern while maintaining and reconstituting key structural elements in order to maximize long-term support.

Male face, before Fat Grafting treatment, front view, patient 1Male face, after Fat Grafting treatment, front view, patient 1BeforeAfter
Male face, before Fat Grafting treatment, Left side view, patient 1Male face, after Fat Grafting treatment, Left side view, patient 1BeforeAfter

Preoperative Evaluation and Discussion

In general, most patients with twisted noses present with functional complaints as their primary concern, and subsequently ask if the accompanying external deformity can be simultaneously corrected. The preoperative consultation at Beverly Hills Profiles therefore addresses all functional and cosmetic concerns.

As always, thorough examination and visual inspection is an essential component of diagnosis and treatment planning. With the twisted nose, assessment of the external appearance of the nose is obviously of primary importance. Drs. Solieman and Litner will note and point out all external deviations and deformities. They will then thoroughly evaluate the bony vault (the orientation of the nasal bones are assessed). Profile evaluation will then detail the presence of any dorsal hump or evidence of saddling (scooping out of the nasal bridge). The middle vault will then be evaluated for asymmetries, evidence of cartilage avulsion or collapse, as well as an overall assessment of width should camouflaging spreader or batten grafts become necessary. Finally, attention will be directed toward the lower third (tip) of the nose.

Frequently, any septal deflection, usually present, can cause tip and nostril asymmetries. Anterior rhinoscopy (visualization of the nasal interior) allows Drs. Solieman and Litner to make a complete assessment of the septum, the inferior turbinates, and the nasal valve. Finally, before completing the preoperative consultation, our doctors will have a candid discussion with you regarding the difficulty in obtaining a perfectly straight nose. You should be made aware that the primary goal of surgery is functional restoration of the nasal airway but that all attempts will be made toward correction of the external deformities. The possibility of future changes that might necessitate minor revisions must also be understood and accepted. All of your concerns will be addressed during your visit, and Drs. Litner and Solieman will give you ample time to answer your questions to your satisfaction.


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