Deviated nose (crooked nose)

The visible lean is only the surface of the problem. Different parts of the nose can be deviated separately or together, and each layer is managed on its own terms.

The bony bridge — high deviations. This is one of the more challenging areas to address. High septal deviations that involve the whole nasal pyramid used to leave limited options if the bridge also needed to stay narrow. Ultrasonic rhinoplasty has made this more manageable. The instrumentation lets us reshape and reposition bone with more control than a conventional split, and offers a better chance of improving alignment and symmetry while preserving a narrow nasal bridge.

The middle vault. This part of the nose is supported by cartilage. The septum plays a significant role in the deviation here — a bent septum pushes the middle third off the midline and can narrow one airway while leaving the other relatively open.

The nasal base and tip. These are influenced by the lower part of the septum, by the configuration of the tip cartilages and their asymmetry, and by the direction of the anterior nasal spine. A tip that points one way while the bridge points another is a common pattern, not a single problem with a single manoeuvre.

A crooked nose can sit on an otherwise well-proportioned framework, or it can sit on a nose that is also too large, too wide, or under-projected. When size or projection also needs to change, the alignment work is planned with a reduction rhinoplasty or an augmentation rhinoplasty rather than treated as an isolated straighten-the-nose exercise.

This page is for an established deviation: a developmental lean, or an injury that has already healed into a new shape. It is not the same problem as an acute nasal fracture. Deviations of the bones and cartilages can be reset with a relatively good success rate within the first week to ten days after injury. After that window the tissues have begun to set, and elective rhinoplasty is the route — planned, not an emergency manipulation.

It is a suitable conversation when:

• The front view shows a lean of the bridge, the tip, or both.

• Breathing is restricted on one side, or both, in a nose that also looks off-axis.

• An old injury has left a step, a twist, or a collapse of support.

• A previous operation has left residual deviation — that work then sits closer to secondary rhinoplasty, with the same alignment principles.

It is not a suitable conversation when the only wish is a perfectly straight nose on a face that is itself asymmetric. Faces are scoliotic to a variable degree in everyone. The nose has to find a position that belongs to that face. Computer simulation is useful here precisely because it shows the limit as well as the opportunity.

Moderate asymmetries in previously un-operated noses can typically be managed by reshaping and reconfiguring the bone and cartilage support that is already there.

Severe asymmetries, or those resulting from injury that has also damaged the supporting structures, benefit from additional cartilage grafts sourced from outside the nose. Ear cartilage can supply smaller, curved pieces. When the framework itself has to be rebuilt or strongly braced, we favour rib cartilage — autologous or preserved donor — because the structural support sits at a higher level than septal or ear cartilage can usually provide.

A grafted framework is also the reason some of these operations are planned as an overnight stay: a course of intravenous antibiotics over the first twenty-four hours helps to reduce the risk of infection around the graft. Infection remains possible even with that precaution.

If the patient’s own rib is harvested there is normally a scar of approximately 2.5 cm in the crease under the breast for women, or slightly lower on the front of the chest for men. Preserved donor cartilage avoids a chest scar. The choice is made in consultation against the scale of the reconstruction, previous surgery, and the condition of the remaining septum.

Planning uses computer simulation, from standard photographs and, when it adds something, from 3D images. The simulation is a planning tool. It is not a photograph of the outcome. What it does well is show how a change in one third of the nose reads against the others, and how a “straight” nose would sit on an asymmetric face — which is often less attractive than a small residual lean.

Cone beam CT scan imaging is more frequently beneficial in preparation for these interventions than it is for a straightforward reduction. It helps us understand the anatomy of the inside of the nose and the characteristics of the paranasal sinuses, and it shows how a high septal deviation relates to the bony pyramid before the day of surgery. It is not required in every case.

The open approach is favoured in this practice so that the correlation between the preoperative plan and the surgical work stays as close as the tissues allow. Ultrasonic instrumentation is the standard of care here for bony work.

The surgery is carried out under general anaesthetic and generally takes between two and three hours, longer when a graft harvest and a more extensive reconstruction are part of the same sitting. It is most frequently a day-case procedure. An overnight stay is used when a twenty-four-hour course of intravenous antibiotics is judged useful — typically when extra-nasal cartilage is being placed.

The sequence is built around the layers that are actually off-axis:

• The septum is straightened or reconstructed so that it no longer drives the middle vault and the tip off the midline, and so that both airways have a designed path.

• The bony pyramid is repositioned and contoured with ultrasonic instruments, with particular attention to high deviations and to keeping the bridge width that the plan requires.

• The middle vault is braced where it would otherwise collapse or twist as the septum is moved.

• The tip cartilages and the anterior nasal spine are reconfigured so that the base of the nose follows the new axis rather than fighting it.

• Where the existing support is not enough, rib or ear cartilage is added as a structural graft rather than as a camouflage on top of a still-crooked framework.

Alar base reduction can be included when nostril width is part of the imbalance. A good airway has to be designed in at the same time as the visible alignment. Straightening a nose without thinking about the internal valve is how an aesthetic gain becomes a functional loss.

The consultation is where the mechanism is identified — developmental, injury, or both — and where we decide whether the existing framework can be reshaped or whether extra-nasal cartilage is required. Medical history and current medicines matter. The weight, when considering this surgery, sits on blood thinners and on raised blood pressure: both increase bleeding risk and have to be managed before a date is set. Previous nasal surgery, a septal perforation, chronic sinus disease and a history of nasal infection all change the plan.

Bring a clear sense of which view is the problem: a lean on a front photograph, a twist that shows on three-quarter view, a tip that points away from the bridge, breathing that is worse on one side, or an old injury whose step is still visible. Fees are discussed in consultation rather than published as a single figure, because a primary reshape of an intact framework is a different piece of work from a grafted reconstruction after injury.

A cast and sutures come off at one week. Recovery from surgery is usually:

• 1 week for removal of the cast and sutures, and return to work from home.

• Typically 2 weeks for return to work in an office.

• 3 weeks before returning to light exercise.

• Approximately 5 to 6 weeks for returning to normal-intensity exercise.

Glasses stay off the bridge for about a month; contact lenses are safe from the start. Sleep on the back. Side-lying puts pressure on a newly aligned pyramid and can re-introduce a lean while the bones are still setting. Do not blow the nose for the first three weeks; saline rinses are the usual way to keep the lining comfortable.

Early breathing often feels tighter, as it does with a cold — usually swelling of the lining rather than a structural blockage. The visible alignment at cast removal is not the final shape. Swelling at the junction of the side walls and the cheeks, and in the tip, takes longer to settle than the first week of social recovery implies.

Surgery for a deviated nose carries the risks of any operation under general anaesthetic, and some that belong specifically to alignment work and to grafted support:

• Anaesthetic risk, bleeding, infection, pain and visible scars — the columellar scar of an open approach, the fine scars of an alar base reduction when that is included, and a chest scar of approximately 2.5 cm when the patient’s own rib is harvested.

• Residual or recurrent deviation. A perfectly straight nose is not a realistic target on an asymmetric face, and cartilage has a memory. Some lean can return as swelling settles and as grafts take.

• Infection around a graft. This is why some patients stay overnight for intravenous antibiotics. Infection remains possible even with that precaution, and can threaten the graft.

• Donor-site problems when autologous rib is used — pain, a visible scar, contour irregularity of the chest wall, and, uncommonly, issues related to the chest cavity itself. These do not apply when preserved donor cartilage is used.

• Airway change in either direction. The operation is often planned to improve breathing; swelling, internal scarring or a poorly braced middle vault can leave restriction. Persistent blockage needs review.

• Graft warping, visibility or absorption, particularly in thin skin over a reconstructed bridge.

• Asymmetry of the nostrils, numbness or stiffness of the tip, and the possible need for further surgery.

• Donor-site and graft issues do not apply when the existing framework is simply reshaped. That is why the consultation has to establish which operation is actually being discussed.