On Deviated Noses
3 December 2019 onur
Shaping deviated noses is much more difficult than sculpting non-deviated noses. Rhinoplasty on deviated noses is typically more difficult and requires more experience, with dissatisfaction and revision rates being quite high even in the most experienced hands. But why is it so difficult? What do we mean by ‘difficult’?
What makes rhinoplasty “difficult” is the expectation of excellence in patients and physicians, despite the multiplicity of variables in surgery and the limitations of the surgical operation. Deviated noses form a “more difficult” cluster for an already-difficult operation. This is because there is a great expectation that a structurally-asymmetrical nose will be perfectly symmetrical after surgery.
By deviated nose, we mean noses where the nose diverges to the right or left when viewed from the front, and the right and left halves of the nose are asymmetrical compared to the midline of the face.
Deviated noses are usually deviated inside as well, and the deviation is almost always accompanied by airway problems and breathing difficulties.
When correcting deviations in the nose, the entire nose must be considered as a structural whole. It is not possible to correct the deviation inside and leaving the external deviation untouched or making aesthetic interventions on the outside and not touching the inside (at least not in modern rhinoplasty).
Deviation and nasal asymmetry are concepts that are frequently observed together but are fundamentally different from each other. Understanding the difference between deviation and asymmetry will also be very helpful in developing correct expectations.
Deviation means that the midline of the face and the midline of the nose are on different axes. Asymmetry, on the other hand, is that the right and left sides of the midline are of different sizes and shapes.
As I said, deviation and asymmetry are often observed together.
However, what you should particularly understand is that a non-deviated nose can be asymmetrical.
For instance, consider a completely symmetrical nose with no deviation. Imagine that 1 cc (milliliter) of filler is injected into one side of this nose. In that case, the nose will appear asymmetrical even though it is not structurally deviated.
A similar situation arises when evaluating persistent post-operative problems.
After the deviation in the nose is corrected, that is, the midline of the nose overlaps with the midline of the face, the nose may still appear to be deviated due to the asymmetry between the right and left side walls of the nose.
As a rule, the human face is asymmetrical, and the nose is no exception.
The nasal skeleton consists of pairs. All structural sub-units (bones and cartilages) that make up the nose have right and left parts. These parts can be different from each other in size, shape, flexibility and thickness in developmentally-normal individuals.
The most common cause of deviation is traumas in the early developmental period. Sometimes people don’t even remember traumas. For instance, when they were 3 years old, a swing hit them in the face.
Blows to the nose break the cartilaginous wall in the middle of the nose. This cartilaginous wall is the growth center of the nose, and as the person grows, the nose develops asymmetrically over the years. Due to that asymmetry, the nose gets noticeably deviated. Long-term developmental asymmetries are such that the right and left nasal bones and cartilages can be of completely different lengths, thicknesses and concave/convex shapes. Even if you position these structures symmetrically by taking the midline as the guide, the differences between their shapes will persist after surgery.
Problems in the facial bones are also reflected in the nose. For instance, if your upper jaw is curved, tilted or developmentally-asymmetrical, the nose must also be deviated due to the curved structure of the platform on which it stands. Furthermore, in children with cleft lip and palate, a complex nasal deformity occurs because the upper jaw will develop less on the side where the lip and palate are cleft.
Another issue with deviated noses is “cartilage memory”. Even if you perfectly straighten the elastic septal cartilage wall in the midline of the nose, this cartilage may deviate again in the long run under the effect of healing forces, since it is a living and biological material.
As you can see from the definitions and descriptions above, nasal deviation may be congenital, developmental or acquired and is quite a complex problem.
Now let’s get into the details of surgery:
It is imperative for patients with deviated noses to know that some deviation will remain after the operation and that when the nasal midline is drawn, the nasal structures on the right and left of this line cannot be completely symmetrical. Other than that, an “expectation for perfect symmetry” will only disappoint you. There are clinical case examples where noses that were severely deviated before surgery got almost straight and symmetrical after surgery. I have such examples in my archive, too. We can look at them together when you come visit me, but you should know that these examples do not set a standard in terms of the possible clinical results in rhinoplasty for deviation.
In rhinoplasty for deviation, the remaining deviation and asymmetry after the surgery will/should be much less noticeable than before the surgery. That is, deviation and asymmetry can be significantly improved, but not completely corrected.
In cases where nasal cartilages deviate in two different axes and the deviation starts from the junction of the bone wall at the back of the nose with cartilage, it is necessary to completely remove the midline cartilage of the nose, shape it on the operating table and re-position it in the nose. We call this approach ‘extracorporeal septoplasty’. Without doing this, it is almost impossible to correct the deviation effectively, permanently and consistently. This type of surgery will take much longer than a standard rhinoplasty and will require a different follow-up as well as a long-term treatment. Therefore, it can be several times more expensive than routine rhinoplasty.
Ultrasonic bone shaping technology (aka piezo) is one of the developments that have strengthened our hands in deviation rhinoplasty in recent years. In ultrasonic bone cutting technology, we use precision micro-saws that abrade the bone with sound waves. This has made it possible to shape nasal bones with a thickness of 1-4 mm without breaking them completely, or to change the shape and angulation of the bone by creating very sensitive greenstick fractures.
Some patients with deviated noses complain about not being able to find a doctor to perform the surgery, and some suffer from high surgical costs demanded by the surgeons they see. The hospital costs for these surgeries, the costs of possible revisions in the ensuing period, the additional costs of the long duration of operation, the increase in the experience of the physician, and having fewer alternatives of physicians are the main reasons why the price of such surgeries increase.
I have not written these on deviated noses to worry you, readers. Today, one out of every three patients we operate in Turkey already presents with prominent nasal deviation. Generally speaking, patients with deviated noses form the group that benefits most from surgery and enjoys the most significant changes. However, the expectation for a perfect symmetry/perfection before the surgery causes some of the patients in this group to focus on the minor problems in the nose and grow unhappy instead of focusing on the tremendous change they have had and being happy about it. The only indispensable prerequisite for happy patients in plastic surgery is to set out with correct/realistic expectations before the surgery. This article was written to serve that purpose.
If you have complaints for deviation in your nose and seek more detailed information about it, you can contact me.
Take good care…
… of yourself and your beauty.