3rd Female Micromotor-Assisted Revision Rhinoplasty Operation for Crooked Nose

Precision Correction of Crooked Nose in Female Patient: Micromotor-Assisted Revision Case

I would like to share another challenging revision rhinoplasty operation with you. We performed a micromotor-assisted open technique revision rhinoplasty on a female patient with crooked nose features, irregularities on the nasal bridge when viewed from the front, and who had undergone rhinoplasty twice in other clinics. The results were quite good.

The image above shows the change in the nasal axis before and after the operation.

A C-shaped nose is a type of nasal deviation characterized by a curve in one direction when viewed from the front. Its clinically and surgically significant features are:

🔹 Key Features of a C-Shaped Nose

Unidirectional curvature: The nasal bridge curves to the right or left in a "C" shape.

Asymmetrical nasal axis: The nasion-tip line is not parallel to the midline of the face. As shown here, the direction of the arrows indicates that the nasal tip has a curved light reflection in a C-shape from right to left.

Dorsal concavity-convexity: One side of the curvature is concave, and the opposite side is convex.

Nasal tip deviation: The tip usually deviates in the opposite direction of the dorsal curvature. Arrows are used to show the nasal tip deviating forward.

🔹 Cartilage and Bone Structure Characteristics

Septal deviation: The septum is usually deviated in the direction of the C-shaped curvature. Since this patient had undergone surgery twice, the septal deviation was not very pronounced, but the nasal valve area was narrow on both sides.

Upper lateral cartilage asymmetry: A depression may be seen on one side and a protrusion on the opposite side. Unfortunately, although the patient's nasal skin is thin, which is advantageous in terms of healing speed and edema, the camouflage effect is minimal, and it cannot prevent all the reflections of the underlying asymmetrical cartilage-bone structure from being visible from the outside.

Nasal bone asymmetry: Rotation of bone segments may occur, especially if there is a history of previous trauma or surgery.

🔹 Functional Findings

Unilateral nasal obstruction is common.

Nasal valve stenosis: Constriction of the inner nasal valve may develop on the concave side.

Generally, when the nasal tip is directed to one side, the nasal valve area on the opposite side narrows.

Compensatory turbinate hypertrophy is common: Inferior turbinate hypertrophy on the opposite side may be present. This is due to the emergence of significant asymmetry between the intranasal air passages.

🔹 Aesthetic Features

Disharmony with the midline of the face

Asymmetrical nasal wings

Irregularities on the nasal dorsum (especially noticeable in patients with thin skin)

🔹 C-Nose in Revision Rhinoplasty

Frequently seen due to cartilage memory, scar tissue, and loss of support after previous surgeries.

There is a high risk of recurrence; Therefore, strong septal correction, spreader grafts, and precise bone shaping are required.

The use of micromotors and tungsten burrs offers advantages, especially in C-shaped nose cases with thin skin and irregular dorsum.

In the image above, a significant difference in size between the nostrils is seen before the operation; after the operation, the nostrils are much closer in size and shape. The patient underwent left alarplasty (alar base resection was also performed).

In the image above, a significant difference in size between the nostrils is seen before the operation; after the operation, the nostrils are much closer in size and shape. The patient underwent left alarplasty (alar base resection was also performed). The patient's preoperative nasal axis is noteworthy.

The image above shows an underprojected nose tip, a slightly prominent nasal hump, and a slightly hanging columella before the operation. These problems were resolved after the surgery.

The Role of Tungsten Burrs in Creating a Smooth Nasal Dorsum

If you examine the two images below, you will see that the patient's nasal bridge skin is thin, and irregularities in the nasal bone and cartilage structure are easily noticeable from the outside. In this patient, the thinness of the skin on the nasal bridge, and perhaps the irregularity of the skin due to repeated surgical trauma, may mean that a camouflage graft such as "temporal fascia" was needed during the operation. The patient was informed about this before the surgery. During the patient's surgery, the nasal bridge was smoothed using a tungsten probe, and no metal files or traumatic techniques were used. A very smooth nasal bridge was obtained after the surgery. Bilateral low-to-high osteotomies were performed simultaneously, and a unilateral spreader graft was placed. Unilateral upper lateral cartilage volume was reduced.

Preoperative Assessment of a Rough and Irregular Nasal Bridge
As easily seen in the patient's photo above, the nasal bridge is irregular and the skin is thin. In this patient, even with the use of a device like a micromotor, if "sufficient smoothness" could not be achieved, the placement of a temporal fascia graft on the nasal bridge would have been planned.

The image above shows an underprojected nose tip, a slightly prominent nasal hump, and a slightly hanging columella before the operation. These problems were resolved after the surgery.

Reasons for High Revision Rates in Crooked Nose Deformity

This nasal deformity means there is asymmetry in all areas of the nose. Especially in cases that occur before nasal development is complete, or after nasal trauma, the "asymmetrical nose" presents a surgeon with many nasal areas that need correction.

Septal Cartilage and Nasal Bone Memory and Recurrence Tendency

In C-shaped nasal deformity, the septal cartilage exhibits a strong memory towards the direction of the curvature. Asymmetrical junctions are usually present at the cartilage-bone junctions and in other areas. Inadequate mobilization, scoring, or resection can lead to a tendency for the septum to return to its original position in the postoperative period. Similarly, the nasal bone lamellae are usually at different angles and widths. Despite ultrasonic or micromotor-assisted bone shaping procedures, bone and cartilage memory can affect the outcome. This biomechanical characteristic is one of the most important reasons for the need for revision surgery.

Asymmetric Surgical Trauma and Asymmetric Healing Tissue

In patients with C-shaped noses, roughly one side receives more surgical trauma while the other receives less. For example, more work is done on the side where the bone is on the outside; the patient's body and healing system perceive this as an "asymmetric and larger wound," and can produce correspondingly asymmetric healing tissue. Conversely, in symmetrical noses, the healing characteristics of symmetrical surgical traumas should also be roughly symmetrical.

Asymmetric Force Distribution Among Nasal Structures

C-shaped noses are not limited to septal deviation; the upper lateral cartilages, nasal bones, and nasal tip supports are all affected. Correcting some of these structures while neglecting others leads to the inability to permanently stabilize the nasal axis. For example, if the upper lateral cartilage dimensions are not equalized, nasal deformity may reappear over time.

Insufficient Septal Support and Excessive Tissue Resection

Excessive resections of the septum in primary rhinoplasty weaken the supporting system of the nasal skeleton. Loss of support over time leads to restancing of the nasal axis, tip deviation, and functional impairments. This situation particularly increases the risk of revision in C-shaped nasal deformities.

Insufficient or Asymmetrical Use of Spreader Grafts

In C-shaped nasal cases, spreader grafts should be planned asymmetrically, not symmetrically, according to the direction of the deformity. Insufficient or incorrectly positioned grafts cause internal nasal valve stenosis and the continuation of aesthetic axis distortion. When placing these grafts, it is necessary to plan the placement and size of the spreader graft by looking at the patient's head from above and following light reflections.

Prominence of Dorsal Irregularities in Patients with Thin Skin

Even minimal bone or cartilage irregularities are easily noticeable from the external contour in C-shaped nasal patients with thin skin. Clinically minor asymmetries cause aesthetic dissatisfaction and increase the demand for revision.

Scar Tissue and Soft Tissue Contraction

In revision rhinoplasty cases, scar tissue can pull nasal structures back towards the curvature during the healing process. This contractile effect increases the risk of recurrence, especially in unidirectional deformities.

Persistence of Functional Problems

Even if the aesthetic appearance is acceptable, the persistence of nasal obstruction or internal nasal valve stenosis leads to patient dissatisfaction and a request for a second surgery.

Camouflage Approach in Primary Surgery

Performing dorsal filing or grafting solely for camouflage purposes without correcting the true cause of C-shaped nasal deformity leads to the recurrence of the deformity in the long term. This approach is a significant factor that increases the need for revision surgery.

The main reason for the high revision rates in C-shaped nasal deformity is that the deformity exhibits a multi-layered and biomechanically resistant structure. For lasting success, septal correction, bone reconstruction, and asymmetric support techniques must be applied together.

Generally, many surgeons achieve results that are close to perfectly symmetrical in pre- and post-operative images. However, after 6 months and 2 years, due to the reasons mentioned above, deviations from this symmetrical midline can appear even if no surgical errors are made.

You can click here to read previously prepared articles on "Crooked Nose" by Dr. Murat Enoz on this website.

[Link to search results page (click "more posts" at the bottom of the page to access other articles and patient images)] >> https://www.ent-istanbul.com/search?q=crooked+nose

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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