Surgical Correction of the Crooked Nose: A Procedure Proposal

Summary:

A crooked nose, resulting from the collapse of cartilaginous and/or bony support, often presents with depression of the nasal tip and middle third. This condition is frequently associated with septal deformities that impair breathing and cause damage to the upper lateral cartilages and bony framework. Traditional surgical techniques typically involve septal correction and the use of cartilage grafts to restore structure and projection, though such methods carry a risk of fibrosis and recurrent deformity. We present an alternative surgical approach that reconstructs the nasal pyramid without the use of tissue grafts, which begins with transcartilaginous and transfixion incisions, followed by a subperichondrial dissection extending beneath the cartilaginous vault. The upper lateral cartilages are separated from the septum, and fibrotic tissue on the concave surfaces is removed. A standard septoplasty using the Killian method straightens the septum. Scar tissue from contractures is released through complete subperichondrial dissection on the mucosal side and partial dissection on the cutaneous side. To support healing and preserve dorsal projection, radiographic film strips or sterile silicone bands are applied in a sandwich-like configuration and removed after 5 days; the external splint is removed after 10 days. This technique avoids grafts by relying on intrinsic nasal structural elements. In 70% of cases, satisfactory anatomical correction is achieved without further intervention, whereas 30% require minor refinements. Importantly, no postoperative respiratory impairment has been observed, underscoring the technique’s effectiveness in both aesthetic and functional nasal reconstruction.

Takeaways.

Question: How can the structural and functional deformities of the crooked nose be corrected without using cartilage grafts?

Findings: A graft-free technique using subperichondrial dissection and internal splinting with radiographic films can be useful in restoring nasal projection and straightening the septum.

Meaning: This technique offers an effective, graft-free option for reconstructing the crooked nose, preserving nasal function and avoiding donor site morbidity.

INTRODUCTION

A crooked nose results from the collapse of cartilaginous support, bony support, or both.¹ Cosmetically, the condition is characterized by a lack of projection in the nasal tip and middle third of the nose, with septal deformity and a risk of nasal obstruction.² This condition is usually caused by frontal trauma or surgery involving impact to the nasal pyramid, when the resulting injury not treated.

Observations in cases of crushed nose suggest that contracting fibrosis, which develops around the perichondrium of the upper lateral cartilages, is a major factor contributing to severe septal deformity.³ We propose a surgical technique that restores the anatomical shape of the components of the nasal pyramid without the need for tissue grafting.

The procedure begins with a transcartilaginous incision (used in 11 patients treated since 1994), followed by a transfixion incision of the nasal septum. A subperichondrial dissection is then performed, extending beneath the cartilaginous vault up to the origin of the upper lateral cartilages. The soft tissues are carefully separated from the nasal dorsum.

Next, the upper lateral cartilages are detached from the septum at the level of the hump down to the synchondrosis. The anterior portion of the deformed septum is straightened after dissection of the contracting fibrotic tissue found on the concave surfaces. A septoplasty is then performed using the Killian technique.

To correct the collapsed upper lateral cartilages, a complete subperichondrial dissection is carried out on the mucosal side, whereas a partial dissection is performed on the cutaneous side (Fig. 1). This step releases contracting scar tissue responsible for nasal pyramid collapse, which develops at the site of posttraumatic cartilaginous disruptions in the upper lateral cartilage.

Fig. 1.

Preoperative images. A, Lateral view. B, Frontal view. The first case was performed using the technique described in 1994: the patient sustained nasal trauma while playing soccer at the age of 17 years, which was left untreated.

Following this, if necessary, any excess upper lateral cartilage and septal cartilage in the hump can be evaluated and removed. If nasal bones are deviated and require cosmetic realignment, the bone callus is smoothed using a diamond rasp or treated with lateral osteotomies.

A crucial part of this procedure involves the placement of 2 radiographic film strips or sterile silicone bands, cut into bean shapes. These are positioned in a “sandwich” configuration on the septal mucosa and secured with 2 resorbable stitches (Vicryl Rapid 3/0). The silicone bands must be aligned with the anterior nasal spine and pressed against the nasal vault, projecting the nasal dorsum and reducing the dead space between the cartilaginous structures. The septal films are removed after 5 days, whereas the external nasal splint is taken off 10 days postoperatively.

DISCUSSION

Several surgical techniques have been proposed to correct the crooked nose deformity.^4–7 Most authors emphasize the importance of correcting septal deformities as a key step in nasal reconstruction.^2,5 This can be achieved by either removing or weakening the deviated portion of the septum through incisions.⁶ Alternatively, the entire septum can be excised, reshaped, and repositioned to provide adequate structural support for the nasal pyramid.⁷ To address soft-tissue deformities, some authors recommend partial resection of the upper lateral and alar cartilages, combined with a cartilaginous graft placed over the upper lateral cartilages.⁸

Many surgical techniques proposed by different authors^4–9 involve resecting deviated cartilaginous structures and restoring nasal projection using homologous or alloplastic grafts on the nasal dorsum and tip. However, studies of direct and secondary complications associated with autologous or alloplastic grafts¹⁰ for nasal dorsum reconstruction have led us to seek an alternative solution. Bone or cartilage grafting is indicated when structural elements are absent due to excessive resection; however, in our experience, it is not appropriate in cases where the anatomical structures are preserved but malpositioned.

The patients included in this study predominantly presented with frontal trauma resulting in crushing of the middle and lower thirds of the nose, with collapse of the cartilaginous portion of the nasal pyramid. In contrast, patients who sustain lateral trauma to the nasal pyramid require treatment based on the same underlying principle, but performed at a different anatomical plane.³

Computed tomography imaging enables more precise characterization of traumatic lesions and scar retraction. However, in the early phase of our experience, patient evaluation and surgical planning were based exclusively on clinical assessment.

Our approach is based on the principle that all the structural components of the deformed nasal pyramid remain present, restoring nasal shape without additional scars in donor areas. Patients can be treated at least 1 year after the trauma, once the scar tissue has matured. Before this point, posttraumatic swelling can lead to a suboptimal result.

Cartilage memory, which contributes to recurrent soft-tissue deformities, is primarily caused by localized scarring within the perichondrium. By releasing these scars, the thin upper lateral cartilages can be straightened effectively. A key element of the technique is maintaining a strictly atraumatic subperichondrial plane. When this avascular layer is respected, bleeding is minimized, hematoma formation is avoided, and blood circulation to the mucosal flaps is preserved.¹¹ This aspect is crucial, as postoperative hematoma represents a major trigger for secondary fibrosis and recurrent contracture.

Splinting is not intended to counteract persistent mechanical tension, but rather to stabilize the repositioned structures during the first 72 hours, when tissue apposition and initial neovascularization take place.¹² In the absence of hematoma formation, this temporary stabilization is sufficient to permit healing in the corrected anatomical position.

With this technique, we have successfully restored the natural projection of the nasal dorsum and tip by repositioning the nose’s anatomical structures in 70% of cases (n = 11) (Figs. 1, 2). (See figure, Supplemental Digital Content 1, which displays a follow-up image [frontal view] 29 years after surgery, https://links.lww.com/GOX/A29.) (See figure, Supplemental Digital Content 2, which displays a follow-up image [lateral view] 29 years after surgery, https://links.lww.com/GOX/A30.) Minor surgical refinements (typically revision surgery due to the presence of osteomas/bone callus at the junction between the cartilage and nasal bones) may be required in 30% of patients after 6–8 months to achieve optimal cosmetic results. Importantly, no interference with breathing, as evaluated using patient-reported outcome measures, has been observed.

Fig. 2.

Postoperative images. A, Lateral view. B, Frontal view.

A limitation of the study may be the small number of patients, mainly due to improvements in the acute management of nasal trauma, which have reduced the incidence of this type of sequelae. Another limitation of the technique is its reduced effectiveness in cases of major trauma: in cases of comminuted fractures, the outcomes are poorer, and alternative procedures are required.

Given the controversial nature of this topic, the present study should be viewed as a contribution to surgical innovation rather than a definitive alternative to established techniques. Its aim is to introduce a concept that may complement current approaches, not replace them. At the same time, further comparative studies are necessary to better define its indications, limitations, and clinical outcomes, particularly in cases where the technique alone does not provide satisfactory correction.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

Patients provided consent for the publication of the case.