Treatment of the Middle Third and Septal Deformity: A Trizonal Approach

Genetic, developmental, traumatic factors can produce a wide variety of nasal septal deformities in caudal–cephalic/dorsal–maxillary planes alone or in combination. These can be corrected by an endonasal approach through a transfixion incision by resecting, transposing, or utilizing principles of cartilage biomechanics. The authors are proposing a “Rosetta Stone” based on a trizonal analysis of the deviated nose that considers the contribution of each region to the deformity. Clinical assessment of the deviated nose should be segmental as well as global. Surgical correlation of the nasal bones, perpendicular, and quadrilateral plates, lateral cartilages, and turbinates may be necessary to achieve a satisfactory cosmetic and functional results.

Indications for Preservation Rhinoplasty: Avoiding Complications

Nasal dorsal preservation surgery was described more than 100 years ago, but recently has gained prominence. Our objective is to show the surgical technique, the main indications and counterindications, and the complications. It is a technique that does not cause the detachment of the upper lateral cartilage (ULC) from the nasal septum, and has the main following sequence: preparation of the septum and its resection can be at different levels (high or low, i.e., SPAR [septum pyramidal adjustment and repositioning] A or B); preparation of the pyramid; transversal osteotomy; lateral osteotomy(s); and septopyramidal adjustment. The result is a nose with a lower radix than the original, a deprojection of the nasal dorsum tending to maintain its original shape; an increase in the interalar distance (IAD) and enlargement of the nasal middle ⅓; and loss of projection of the nasal tip and roundness of the nostrils. Thus, the ideal candidate is the one who benefits from such side effects, that is: tension nose, that is, high radix with projected dorsum, projected anterior nasal septal angle (ANSA), narrow middle ⅓, narrow IAD, thin nostrils and straight perpendicular plate of the ethmoid (PPE), and, depending on the characteristics, the deviated nose. The counterindications are low radix, irregularities in the nasal dorsum, ANSA lower than rhinion, and a wide middle ⅓. And the main stigmas are: a nose with a very low radix, middle ⅓ enlarged, residual hump, and saddling of the supratip area. Other issues of this technique are: the shape of the radix; the need or not to remove PPE; wide dorsum; irregular dorsum; ANSA lower than rhinion; weak cartilages; long nasal bone; deviated PPE; and obsessive patient. We conclude that this is a great technique for noses with characteristics suitable to it; care must be taken with the stigmas it can cause.

Extracorporeal Septoplasty for anterior septal deviation and deviated nose

Background: Deviated nose and septum is challenging, which results in functional and cosmetic problems. It blocks the nose and makes person ugly. The classical septoplasty approach becomes unsuitable for such severe deviations. Extracorporeal septoplasty is a surgical technique for correcting a severely deviated nasal septum, which also corrects the aesthetic part of the nose. The objective of this study was to describe extracorporeal septoplasty for Deviated nose and anterior septal deviation. Methods: A prospective observational outcome study was done in patients with Deviated nose and anterior septal deviation who underwent extracorporeal septorhinoplasty. Preoperative and postoperative evaluation was performed using a photographs, computerized tomography (CT) scan, and Nasal obstruction symptoms evaluation scale. Results: A total of 38 consecutive patients were enrolled, out of which majority were male (24, 63.2%) with only 14 (36.8%) female. The ratio of male female was 1.7:1. All the subjects had deviated nasal septum. Among these, nose deviation was externally noticeable in 20 (52.6%) cases, whereas in remaining cases it was inconspicuous. There were 21(55.3%) patients where Nasal Septum was deviated to the right side followed by 17(44.7%) with left side deviation. There was a significant improvement in mean nasal obstruction symptoms evaluation postoperatively (71.2 versus 22.7 with p value equal to 0.01). According to the pre and postoperative photographs 17(44.7%) patients had good improvement, nine (23.6%) showed excellent improvement and the result was fair in six (15.7%) patients. Conclusions: Extracorporeal septoplasty is effective in improving both nasal airway function and aesthetics in patients with severe Nasal Septal deviation.

Anthropometric Evaluation of Photographic Images Before and After Functional Nasal Surgery in Patients With Deviated Noses

Background Numerous techniques for correction of deviated noses have been described. Nevertheless, surgical management is challenging even for experienced rhinosurgeons. Often, a “residual deformity” after functional septorhinoplasty (SRP) due to a deviated pyramid syndrome may remain. Objective Therefore, the purpose of this study was to determine how frequent functional SRP in patients with a deviated nose results in “successful” straightening of the external nose based on standardized angle measurements. Possible influences having a positive or negative effect on the surgical success were identified. Methods Photo documentation of 607 patients with deviated noses (304 women, 303 men, median age 30 years) before and after nasal surgery were retrospectively analyzed using standardized angle measurements. The pre- and postoperative photos of the faces were anthropometrically measured. The median follow-up was 6 months. Results A “straight” deviated nose (I-type) was present in 225 patients (37%), a C-shaped nose (C-type) in 382 patients (63%). More than 75% of the patients presented a facial asymmetry. Based on angle measurements alone, a total of 452 (75%) noses were straightened or postoperatively improved. 155 noses (25%) still showed a biometric deviation. The I- or C-type had no relevant influence on outcome. Conclusion A purely biometric analysis of crooked noses is difficult and its importance is limited due to commonly pre-existing facial asymmetries. The risk of a “residual deviation” after rhinoplasty in patients with deviated noses must not be underestimated. This fact should be addressed as part of the informed consent. In particular, it should be mentioned that the surgical outcome can remain well below the patient’s aesthetic expectations. Not rarely, a revision surgery may be necessary.

Deviated nose: Physiological and pathological changes of the nasal cavity

Deviated nose is highly challenging in rhinoplasty since the surgeon should consider both aesthetic and functional aspects of the nose. Deviated nose correction is surgically complex, and a thorough understanding of the mechanical and physiological changes of intranasal structures, including the septum and turbinates, is necessary for functional improvement.

Correction of bony deviation in rhinoplasty

In rhinoplasty, osteotomy is becoming more and more frequent as a way to achieve aesthetically pleasing and functional results, as well as patient satisfaction. In procedures to correct a deviated nose, osteotomy to correct the bone plays an essential role in addition to correction of the septum and cartilage, and osteotomy can reduce the wide nose bridge and give a slightly higher appearance in Asian rhinoplasty. However, osteotomy is relatively invasive, and the nasal bones of Asians are often low and thick, so bleeding or swelling during surgery can be somewhat more severe, and a stuffy nose can occur after surgery if osteotomy is performed incorrectly. Since side effects are possible, it is necessary to have a precise understanding of the relevant anatomy and technique. Several articles have described nasal bone osteotomy in rhinoplasty, and this review article introduces the methods presented in various articles, describes indications and limitations, and reviews the relevant anatomical structures and techniques in an accurate manner. We introduce a method that can increase patients’ satisfaction and the completeness of surgery through accurate osteotomy, as well as reducing the risk of side effects.