Intraoperative Details:A crooked nose is almost always associated with a crooked septum.
Deviating cartilage not included in the vital 1.5 cm dorsal caudal L strut can be resected without concern for loss of middle-vault support. Bony obstruction and deviations of the perpendicular plate of the ethmoid and vomer may be rongeured gently.
The caudal anterior septum is often displaced off the maxillary crest, which results in tip deviation. Corrective efforts include swinging the septum back onto its pedestal. This is performed by excising a triangular wedge of cartilage from the inferior septum at the posterior septal angle. The septal base is then stabilized to the maxillary crest periosteum with a strong, permanent suture.
Deviating cartilage not included in the vital 1.5 cm dorsal caudal L strut can be resected without concern for loss of middle-vault support. Bony obstruction and deviations of the perpendicular plate of the ethmoid and vomer may be rongeured gently.
The caudal anterior septum is often displaced off the maxillary crest, which results in tip deviation. Corrective efforts include swinging the septum back onto its pedestal. This is performed by excising a triangular wedge of cartilage from the inferior septum at the posterior septal angle. The septal base is then stabilized to the maxillary crest periosteum with a strong, permanent suture.
recorrction through endonasal approach
In cases in which a twisted nose is accompanied by a lateral wall defect causing obstruction, treatment may be performed via the endonasal approach.
Although visualization is less than with the external rhinoplasty approach, combination of structural stenting and camouflaging may be adequate to achieve a straight dorsum. This approach allows for functional improvement without disrupting a well-supported tip.
Management of a crooked bony dorsum
Although visualization is less than with the external rhinoplasty approach, combination of structural stenting and camouflaging may be adequate to achieve a straight dorsum. This approach allows for functional improvement without disrupting a well-supported tip.
Management of a crooked bony dorsum
A 2- or 3-mm straight osteotome is desirable; however, this small of an instrument has an associated learning curve. The 4-mm guarded osteotome is effective for lateral osteotomies and can be used with minimal trauma, especially when the guard is placed on the inner surface of the pyramid.
When indicated, medial osteotomies are performed before lateral osteotomies. This provides a safe back fracture and allows for a complete break. Incomplete breaks or green-stick fractures lead to bony irregularities and postoperative shifting of the bones. Medial osteotomies are performed with the aid of a 6-mm curved osteotome placed at the junction of the nasal bones and septum. The osteotome is directed 25° lateral from the midline. Medial osteotomies, however, are not always needed. If a large open roof exists following hump resection, bony walls may be mobilized fully with lateral osteotomies alone.
Lateral osteotomies are usually performed in a high-low-high direction. This path allows for protection of the nasal airway at the nasal base by initiating osteotomy at an elevated (high) position on the pyriform aperture. This leaves a triangle of bone at the base of the pyriform aperture (Webster triangle), avoiding compromise of the nasal airway width. The osteotome then travels in a low path along the mid dorsum to maximize narrowing and then back high to prevent over-narrowing of the nasal root. If the nasal bones do medialize, internal stabilization with splints may be necessary to prevent support without outward migration.
When indicated, medial osteotomies are performed before lateral osteotomies. This provides a safe back fracture and allows for a complete break. Incomplete breaks or green-stick fractures lead to bony irregularities and postoperative shifting of the bones. Medial osteotomies are performed with the aid of a 6-mm curved osteotome placed at the junction of the nasal bones and septum. The osteotome is directed 25° lateral from the midline. Medial osteotomies, however, are not always needed. If a large open roof exists following hump resection, bony walls may be mobilized fully with lateral osteotomies alone.
Lateral osteotomies are usually performed in a high-low-high direction. This path allows for protection of the nasal airway at the nasal base by initiating osteotomy at an elevated (high) position on the pyriform aperture. This leaves a triangle of bone at the base of the pyriform aperture (Webster triangle), avoiding compromise of the nasal airway width. The osteotome then travels in a low path along the mid dorsum to maximize narrowing and then back high to prevent over-narrowing of the nasal root. If the nasal bones do medialize, internal stabilization with splints may be necessary to prevent support without outward migration.
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