"Every time I'm in a photo, the line of my nose bothers me" — for many who come to our clinic with this worry, not only the appearance but also the bone, cartilage, and septum (the partition of the nose) are distorted together[1,5]. Just "making it look straight" carries the possibility of reverting. We share the blueprint of the treatment.
The most common question at consultations is this.
"Can this only be fixed with surgery?"
To give the conclusion first,for a crooked nose accompanied by distortion of the septum, surgical correction is the central option[5,6]. However, how to fix it changes with the "type of crookedness"[3].
Why does the nose become crooked — the "quirks" of the 4 cause types
Conclusion: Behind a crooked nose lurks a collapse of any one (or several) of the bone, cartilage, and septum[1,4].
"I don't even remember hitting it, but it's crooked" — this voice is truly common. The causes can be organized into 4.
1. Trauma to the face / nasal bone
Facial trauma and nasal bone fracture are consideredone of the most frequent causesof a crooked nose[2].
It is not rare for it to go unnoticed at the moment of impact due to swelling, and for nasal congestion to strengthen later[2]. The nose that has lost its support is pulled by scarring (the hard tissue of a scar), and it is reported that asymmetry or collapse of the internal/external nasal valve may occur[2].
2. The "silent" distortion of the growth period
A child's nose is made mainly of cartilage, and the nasal bone is also small and soft, so it is thought to often absorb the force of an impact andmanage to avoid breaking[2]. Even without breaking, if the growth center is disturbed, asymmetry gradually surfaces toward puberty[2]. Birth trauma at delivery or intrauterine pressure are also sometimes cited as causes[2].
3. It became crooked after surgery (iatrogenic)
"I feel like it started bending after my last surgery" — this voice is also not few.
Excision of the septal cartilage and osteotomy are operations that weaken the support of the nose's framework[3]. In a state where the support has weakened, there is a possibility of being pulled in a hard-to-predict direction during the healing process[3].
4. The "apparent crookedness" where only one side caves in under low impact
A weak lateral force can sometimesmake only one nasal bone cave in[2]. Even if the septum is uninjured, it can look as if it has shifted to the opposite side — it looks crooked in appearance, but in fact only one side is caved in; this is that type[2].
In short: the causes are the 4 systems of trauma, development, surgical history, and one-sided caving. Next is the viewpoint for telling "which type you are."
The "horizontal three-division" diagnosis to know your own crookedness
Conclusion: It is the standard approach to consider a crooked nose by dividing it into three sections, the upper 1/3, middle 1/3, and lower 1/3[3].
You slice the nose horizontally and divide it into three sections, and diagnose by combining which section has shifted to which side[3]. Based on this three-division way of thinking, it is reported that27 kinds of crookednesscan be organized[3].
A form in which one side of the nasal dorsum is caved in and the other side bulges is calledthe C type, and a method of putting a slightly thicker spreader graft (the supporting cartilage of the dorsum) on the caved-in side to correct the asymmetry is reported[5].
"Crooked nose," "deviated nose," "scoliotic nose" — though the names differ, they are a word that groups together multiple deformities[6]. Discerning the type becomes the starting point of treatment[6].
In short: depending on where and how the three sections are crooked, the treatment changes. Next we organize the "schools of how to fix it."
The 3 schools of treatment — hide? rebuild? mix?
Conclusion: There are 3 ways of thinking in surgery for a crooked nose, and the philosophy of the result changes depending on which you take as the basic axis[4].
We talk about the "philosophy" first, not the "surgical method." Depending on which school your attending physician leans toward, the postoperative image differs considerably.
Even if the schools differ, what is common is one point —not sacrificing the support of the nose in order to "look straight"[4]. A design that prioritizes only the linearity of the appearance may affect long-term stability[4]. How to reconstruct the support becomes the axis of the procedure choice.
In short: there are 3 schools, and the common principle is "support first." Next we peek into the 6 judgments made in the actual operating room.
What is done in the actual surgery — the 6 crossroads
Conclusion: Surgery for a crooked nose is designed by the combination of the following 6 checkpoints[2,5].
It gets a little technical, but these are precisely the items you want to confirm at the consultation.
(1) "Opening widely with the open method" at the center
To reliably fix a crooked nose, theopen method (external rhinoplasty), which adds a small incision to the columella (the pillar between the two nostrils) and widely deploys the whole nose, is considered the most reliable deployment method[2,5]. It is said that the wider the field of view, the more you avoid overlooking the cause of the distortion and the easier it is to precisely adjust the left-right cartilage balance[2].
(2) "Releasing" the septum from its surroundings
The process of firstreleasing the septum from the distorted nasal bone, lateral cartilage, and major alar cartilageis considered important[5]. Moderately excising the central part of the cartilage also weakens the intrinsic bending force from the perpendicular plate of the ethmoid and the vomer[5].
(3) Leaving the "pillars" of the dorsum and tip
When straightening the septum, removing all of it is a no-go. It is the principle toalways leave the strutson the dorsal side and the caudal side[5]. The struts left behind protect the height of the nasal tip and the airway of the nose[5].
(4) Filling the asymmetry with a spreader graft
For a C-type bend, a device of putting a slightly thicker spreader graft on the caved-in side and a slightly thinner graft on the opposite side to correct the asymmetry of the dorsum is reported[5].
(5) Stabilizing the nasal tip with a columellar strut
As support for the nasal tip, a method of placing acolumellar strutbetween the medial crura (the cartilage on the inner side of the two nostrils) is also combined[5]. The point is to not abut it directly against the nasal spine, but to fix it tucked into a pocket a little in front[5].
(6) Adjusting the contour of the bone with an appropriate osteotomy
The asymmetric contour of the nasal bone is adjusted in its positional relationship by osteotomy[5]. It is recommended to consider separately which distortion to fix with osteotomy and which distortion with cartilage grafting[3].
In short: the choice of the 6 crossroads changes the result. Next we talk honestly about "to what extent can this surgery be expected?"
The reality of surgery — not "100 points," but "70 to 90 points you can accept"
Conclusion: The correction of a crooked nose is a high-difficulty area even within cosmetic surgery[5,6].
"How straight will it become?" — honestly speaking,this is not a surgery that can promise a 100-point straight line[6]. It is reported that even an experienced operator may have a remaining difference in the result in both the functional and cosmetic aspects[6].
In a report of 79 cases, while everyone felt an improvement,7 cases had a residual deviation seen from the front, and of those, 3 chose reoperation, it is recorded[4]. The attending physician is questioned on the soundness of the procedure of "processing each distortion factor one by one while leaving the support"[4]. If you place the purpose of the surgery only on "the straightness of the appearance," the nose that has lost its support may revert over time[4].
However, raising both the function (nasal airflow) and the cosmetics (the asymmetry of the line)to some degreeis realistically possible[5]. Whether you aim for a "perfect straight line" or a "natural line without discomfort," the satisfaction changes accordingly[3].
In short: crooked-nose surgery is a tough challenge, but raising the function and appearance at the same time is possible. Next is "what you should talk about" at the consultation.
What you should confirm at the consultation — can "making the outside smaller" and "improving the airflow" both be achieved?
Conclusion: The alignment of goals governs the result[3].
A common one is a mismatch like this.
"I want to make the outside of my nose a little smaller. But I also want the airflow of my nose to be better."
These twocan sometimes go in opposite directions, and the technique chosen changes depending on which is prioritized[3].
At the first examination, the following information becomes the basis for organization[1,2].
- Past trauma (including in childhood)
- Nasal congestion, snoring, difficulty breathing
- The presence and content of any nasal surgery received so far
- Since when the crookedness began to bother you (suddenly? gradually?)
- Constitution such as a tendency to bleed easily or bruise easily
One more thing. You also want to confirm whether the attending physician is making a proposal leaning only toward "the linearity of the appearance." A plan that lacks talk of the support (structure) may leave anxiety about long-term stability[4].
In short: the prior alignment is 70% of it. Next we answer common questions all at once.
Q&A — the 5 commonly asked questions
Q1. If the septum is not bent, is the surgery light?
It is reported that in almost all cases of a clearly crooked nose, the septum is also distorted[5]. A severely deviated nose is often accompanied by a large deformity of the septum[2], and it is rare for surgery that does not touch the septum to complete it.
Q2. Can it be fixed just by cutting the cartilage?
It is summarized that, even if excision alone can release the "force that causes the distortion," in many cases thework of supporting a straight nosebecomes separately necessary afterward[5]. Reinforcement with suturing or grafting is generally used together[5].
Q3. If I have surgery, will it definitely become straight?
It is reported that residual deviation or functional dissatisfaction can arise at a certain frequency[4,6]. Some people choose reoperation[4]. It is recommended to set, as a realistic goal, a "natural-looking line" rather than a "perfect straight line."
Q4. Is revision of a nose that has had surgery before difficult?
A nose whose framework is unstable due to past septal excision or osteotomy tends to have a more complex revision[3]. The preoperative interview and structural analysis become especially important[1].
Q5. I'm only bothered by the asymmetry. Can't it be done lightly?
If it is an "apparent crookedness" where a weak lateral force has only caved in one nasal bone, it can sometimes be improved with a relatively limited response[2]. However, the actual diagnosis requires assessment by the three-division and confirmation of the septum[3].
In short: almost every crooked nose involves the septum. Next is the final summary.
If you find yourself thinking, "What about my case?"
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Summary — your case, which type is it?
Having read this far, you already understand the basics of a crooked nose.
- The causes are the 4 types of trauma, development, surgical history, and one-sided caving[2]
- The standard is athree-division diagnosisof the upper 1/3, middle 1/3, and lower 1/3[3]
- The treatment philosophy is the 3 schools of "hide, rebuild, mix," and the common principle isnot sacrificing the support[4]
- Because almost every case involves the septum, it is rare for a method that does not cut to complete it[5]
- Rather than a "perfect straight line,"achieving both a natural line and nasal airflowis the realistic goal[6]
From here on,which type your nose is, and which combination achieves the best balance — no one can answer without seeing it in person[1].
Our clinic's free consultation has no pushy sales whatsoever.You are welcome to come just for the judgment of "whether surgery is necessary". If there is anything that concerns you, please first come to hear about it.
References
- Cerkes N. The Crooked Nose: Principles of Treatment. Aesthetic Surgery Journal. 2011 https://doi.org/10.1177/1090820X10394167
- Stepnick D, Guyuron B. Surgical Treatment of the Crooked Nose. Clinics in Plastic Surgery. 2010 https://doi.org/10.1016/j.cps.2009.12.001
- Roofe Scott B., Murakami Craig S.. Treatment of the Posttraumatic and Postrhinoplasty Crooked Nose. Facial Plastic Surgery Clinics of North America. 2006 https://doi.org/10.1016/j.fsc.2006.06.003
- Pontius Allison T., Leach Joseph L.. New Techniques for Management of the Crooked Nose. Archives of Facial Plastic Surgery. 2004 https://doi.org/10.1001/archfaci.6.4.263
- Okur E, Yildirim I, Aydogan B, et al. Outcome of Surgery for Crooked Nose: An Objective Method of Evaluation. Aesthetic Plastic Surgery. 2004 https://doi.org/10.1007/s00266-004-0001-0
- Jang Yong Ju, Wang Jong Hwan, Lee Bong-Jae. Classification of the Deviated Nose and Its Treatment. Archives of Otolaryngology–Head & Neck Surgery. 2008 https://doi.org/10.1001/archoto.2007.46