Deviated nose surgery: Cut the bone or hide it? How to choose the surgical method based on the degree of deviation

The surgical method for deviated nose surgery varies depending on whether the primary site of deviation is bone or cartilage, and how much of the nasal bridge shape can be preserved. If the bone is deviated, bone cutting is an option; if the nasal septum (the partition inside the nose) is deviated, septal correction is an option; and if there is mild irregularity, adding cartilage to conceal it is an option — most cases combine multiple approaches[1][2]Even with the same "deviated nose," there are reports showing that surgical outcomes differ depending on whether the deviation is linear, C-shaped, or S-shaped[3]、knowing your own type of curvature becomes the starting point for choosing the right approach.

What types of deviated nose surgery are there?

Broadly speaking, there are 3 approaches: methods that conceal the deviation, methods that decompose and reconstruct, and a combination of both. Research following curved nose correction over the long term divides treatment philosophy into camouflage (adding cartilage to hide irregularities), complete anatomical reconstruction, and combined use. At the authors' facility, reconstruction is the foundation, with camouflage added as needed.[2]。

Reconstruction consists of a combination of techniques for each anatomical region. Textbooks organize it into 5 elements: bone cuts for bone displacement, septal correction, correction of the upper lateral cartilage (cartilage in the mid-dorsum), tip and columella correction, and management of the internal nasal fold (inferior turbinate).[1]Since which of these 5 elements are used varies from person to person, you cannot understand the actual procedure from the surgical name alone.

How do results differ depending on the type of curvature?

Reports indicate that the combination of deformity type and surgical technique affects the range of improvement in nasal airflow and appearance. A study examining 78 patients who underwent surgery for deviated noses, divided into straight type (I-type), curved type (C-type), and twisted type (S-type), found that both the deformity type and surgical method were factors influencing improvements in nasal obstruction assessment (NOSE) and appearance satisfaction (ROE).[3]。

This study was a retrospective review of records and was not a randomized controlled trial.[3]Nevertheless, it provides a basis for the concept that "different surgical approaches suit different types," so there is considerable value in asking about your own type during consultation.

How do bone-cutting methods differ?

Osteotomy is a technique that makes incisions in the nasal bones to align their position and orientation, and is essential for correcting bone displacement.[1]For convex deviated nasal bones, the procedure begins with medial osteotomy, followed by lateral osteotomy, and for cases with large displacement or wide nasal root, a strip-shaped bone removal method is indicated.[1]。

Even with the same osteotomy, whether or not the periosteum (the membrane covering the bone) is elevated affects postoperative swelling. A pooled analysis of 6 randomized trials involving 208 patients showed that the group with periosteum elevation before lateral osteotomy had more postoperative lid ecchymosis and swelling within 3 days, with no difference in swelling at day 7.[4]The method of preserving the periosteum may result in less early-stage ecchymosis and swelling.[4]。

Refinements to improve cutting precision have also been reported. In a report of 10 patients who underwent nasal bone osteotomy using a 3D-printed guide, the average deviation from the planned line was 0.48 mm.[5]However, this demonstrates the accuracy of the cutting technique and does not assess resistance to relapse.[5]。

Which surgical technique that "preserves" the nasal bridge is suited for whom?

This method is suited for post-traumatic deviated nose without a dorsal hump, where the nasal bridge shape is originally well-aligned. Over the past 20 years, nasal surgery has shifted from the concept of reducing height by shaving bone and cartilage to the concept of preserving the original shape and reinforcing weak areas.[6]As part of this trend, a method has been reported in which bone is cut from inside the mouth and fixed with a plate, straightening the nose while leaving the nasal bridge structure virtually untouched.[7]。

However, the physician who reported this method themselves has added the condition that it is limited to people whose nasal bridge shape is anatomically suitable.[7]Cases with a dorsal hump, or where the nasal bridge itself is significantly deviated, fall outside the scope of this method.

Why is it said to be prone to relapse?

The cartilage's tendency to return to its original shape and the contraction that occurs during wound healing push the corrected position back.[2]Correction of a deviated nose is known to have more relapse than other nasal surgeries.[2]Overall nasal surgery reports a complication rate of 8–15%.[8]。

On the other hand, there are reports showing long-term stability when reconstruction is thorough. In a study following 360 patients who underwent surgery by the same surgeon from 2014 to 2020 over 2 years or more, the difference in measurements between 1 month and 24 months post-operatively was minimal, and only 1 patient required revision surgery due to partial relapse.[2]This research is the result from a single experienced surgeon, and the numbers will not be the same if the facility or surgeon differs.[2]。

If your nose was just struck, when should surgery be performed?

There is the option of performing correction together with reduction immediately after fracture. In a report of 45 patients who underwent reduction and nasal reconstruction simultaneously for acute nasal bone fracture, the average physician satisfaction was 7.62 out of 10 and average patient satisfaction was 8, with no difference based on fracture type.[9]。

In case of young age, the principle is to wait for growth to complete. Domestic guidelines state that secondary correction to hard tissues such as the nasal septum and nasal bone should be performed as a final procedure after the age when nasal growth ends (age 15 for females, age 17 for males).[10]。

What to confirm during consultation

What you want to determine is whether the main location of the deviation is bone, cartilage, or both; what type your deviation is; and which elements to combine and how. The open approach (a method of cutting and opening the columella) is said to offer a wide field of view and make it easier to correct the distorted structure as is.[11]Also ask about the location and reasoning behind the incision.

If you have nasal obstruction, having a physician confirm during examination whether its cause is septal deviation will provide material for determining the surgical technique. The possibility of relapse and how to manage it if relapse occurs are also points you should discuss with your surgeon before the operation.