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WHAT IS NASAL DEVIATION? HOW IS IT CORRECTED?

Shaping a crooked nose is significantly more challenging than shaping
a straight one. Surgeries for crooked noses demand greater surgical
expertise, and even in the most experienced hands, dissatisfaction and
revision rates remain relatively high.

But why is it difficult? What do we mean by "difficult"?

The challenges of nasal surgery stem from the numerous variables
involved in the surgery and the limitations, coupled with the high
expectations of perfection from both patients and surgeons. Crooked
noses form a "more difficult" subset within an already complex
surgery. This is because there is often an expectation that a
structurally asymmetric nose should become completely symmetrical
after surgery, which is a significant challenge.

CONTENTS

	* Basic Information about Nasal Deviation
	* Causes of Nasal Deviation
	* Surgery for Nasal Deviation

BASIC INFORMATION ABOUT NASAL DEVIATION

When we refer to a crooked nose, we mean a nose that appears to tilt
to the right or left when viewed from the front, with the right and
left halves of the nose being asymmetric concerning the midline of the
face.

Crooked noses usually have internal deviations that match their
external appearance, often accompanied by airway problems and
breathing difficulties.

When correcting nasal deviations, the entire nose must be considered
as a structural whole. It's not sufficient to fix the inside and leave
the outside unchanged, or to make aesthetic adjustments externally
without addressing the internal structures (at least not in modern
rhinoplasty).

Nasal deviation and nasal asymmetry are often observed together but
are fundamentally different concepts. Understanding the difference
between deviation and asymmetry is crucial for developing realistic
expectations. Deviation means that the midline of the nose differs
from the midline of the face, whereas asymmetry refers to differences
in size and shape between the right and left sides of the nose. Often,
deviation and asymmetry coexist, but it's important to understand that
a nose can be asymmetrical without being crooked.

For instance, imagine a perfectly symmetrical nose with no deviation.
If we inject 1 cc (milliliter) of filler into one side of the nose, it
would appear asymmetrical and crooked, even though the nose is
structurally straight.

This concept also applies when evaluating issues that persist after
surgery. Even after correcting the nasal deviation—aligning the
nasal midline with the facial midline—the nose may still appear
crooked due to asymmetry between the right and left nasal walls. As a
rule, the human face is asymmetric, and the nose is no exception.

The nasal skeleton consists of paired structures. The right and left
components of all the structural subunits (bones and cartilages) that
form the nose may differ in size, shape, flexibility, and thickness,
even in normal individuals.

CAUSES OF NASAL DEVIATION

The most common cause of nasal deviations we encounter is trauma
during early developmental stages. Sometimes the individual may not
even remember the trauma, such as a swing hitting them when they were
three years old. Blows to the nose can break the cartilaginous wall in
the middle of the nose. This cartilaginous wall is the growth center
of the nose, and as the individual grows, the nose may develop
asymmetrically over the years, resulting in a noticeable deviation.
Long-term developmental asymmetries may lead to the bones and
cartilages of the right and left sides of the nose having completely
different lengths, thicknesses, and concave/convex shapes. Nasal
deviations can also occur following traumatic injuries in adulthood.

Developmental issues in the facial bones also affect the nose. For
example, if the upper jaw is crooked, tilted, or developmentally
asymmetric, the nose must also be crooked because it sits on an uneven
platform. For instance, children with cleft lip and palate may develop
complex nasal deformities due to underdevelopment of the upper jaw on
the side of the cleft.

As you can see from these descriptions, nasal deviations can be
congenital, developmental, or acquired, and they are quite complex
problems.

SURGERY FOR NASAL DEVIATION

One of the most critical issues in crooked noses is cartilage memory.
Even if you make the elastic septal cartilage wall in the middle of
the nose perfectly straight during surgery, this cartilage, being a
living and biological material, can bend again in the long term due to
the healing forces. Various suturing techniques and cartilage
weakening techniques have been described to overcome cartilage memory
in crooked nose surgeries. Unfortunately, they do not consistently
produce stable results. In structural rhinoplasty, we use
cartilage-based columns and beams, known as structural grafts, to
correct the curvature. In crooked nose surgeries, structural grafts
can be placed asymmetrically to neutralize the deviations.

In cases of advanced deviation, where the internal nasal cartilages
are curved in two different axes, and the deviation originates from
the junction of the bony wall at the back of the nose and the
cartilage, it may be necessary to remove the nasal septum entirely,
reshape it on the operating table, and then reinsert it into the nose.
This approach is known as extracorporeal septoplasty. Such a surgery
will take much longer than a standard nasal surgery, may require the
use of external cartilage sources, and will involve a different
follow-up and long-term treatment plan. As a result, the cost will be
higher than routine rhinoplasty.

One of the developments that have significantly strengthened our hand
in crooked nose surgeries in recent years is ultrasonic bone shaping
technology (also known as piezo). Ultrasonic bone cutting technology
uses precise micro saws to abrade the bone with sound waves. This
allows us to shape nasal bones with a thickness of 1-4 millimeters
without fully fracturing them or to create very delicate greenstick
fractures that enable us to change the shape and angle of the bone.

Patients with crooked noses must understand that some degree of
curvature will remain after surgery and that the nasal structures on
the right and left sides of the midline will not be perfectly
symmetrical. A "perfect symmetry expectation" will only lead to
disappointment. There are clinical case examples where noses that were
severely crooked before surgery become nearly straight and almost
symmetrical after surgery. I have such examples in my archive, and we
can look at them together when you come, but you should know that
these examples do not set a standard for the clinical outcomes that
can be achieved in crooked nose surgeries.

Some patients with crooked noses struggle to find a doctor willing to
perform the surgery, while others face high surgical costs quoted by
the doctors they consult. The primary reasons for the increased cost
of these surgeries include hospital costs, potential revision costs,
the additional cost of the extended surgical time, increased surgeon
experience, and fewer surgeon options.

The information provided here about crooked noses was not written to
cause concern. Today, in Turkey, one out of every three patients we
operate on presents with significant nasal deviations. Generally,
patients with crooked noses benefit the most from surgery and
experience the most significant changes. However, a perfectionist
expectation of flawless symmetry before surgery can lead some patients
in this group to focus on minor post-operative issues and become
unhappy despite the remarkable changes they have achieved. The only
essential precondition for achieving happy patients in plastic surgery
is starting with accurate and realistic expectations before the
surgery. This article was written with that purpose in mind.


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