Correction of Severe Nasal Deviation in a 4th Revision Rhinoplasty Patient
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| Complex Crooked Nose Correction After Multiple Failed Rhinoplasties |
Surgical Challenges in Fourth Revision Rhinoplasty
When performing rhinoplasty for the fourth time, we generally do our best to make the procedure as less traumatic as possible. This is because repeated surgical trauma, grafting, and suturing cause changes in all nasal tissues. We need to discuss the potential for reduced circulation and infection risk with our patients beforehand. The patient I'm sharing with you here has undergone three previous surgeries, and after the last surgery, suffered diagonal trauma to the nose, resulting in a "crooked nose deformity". In the patient's image, the tip of the nose is turned to the left, and the nasal bone is turned to the right.
Structural Weakness and Loss of Native Cartilage
As observed during the patient's operation, there was insufficient natural cartilage tissue inside the nose, and particularly weak cartilage tissue prone to collapse was detected both in the nasal valve area and in the area of the upper lateral cartilages. This structural weakness and altered anatomy made the operation more complex and difficult.
Severe Septal Deviation and Memory Effect
Following nasal trauma after the patient's third surgery, a "C-shaped nose" became more pronounced, and cartilage memory and bone memory were altered. The patient was informed before the operation that "even if complete symmetry is achieved during surgery, due to the effects of cartilage and bone memory, asymmetry may occur, albeit less severe than before, once healing is complete". The patient also had a severe nasal septum deviation narrowing the right nasal cavity and a right nasal valve collapse.
Asymmetric Nasal Bones and Upper Lateral Cartilages
Examination of the patient's preoperative photographs reveals that the left nasal bone lamellar structure is collapsed inward, the right nasal bone wall is displaced outward, the nasal tip is turned to the left, and the left upper lateral cartilage is weakened and collapsed inward. In crooked nose deformity, asymmetry is present in all three areas of the nose (nasal bone, supratip, and tip region). This patient requires separate procedures and cartilage graft placement for each of these areas.
Limitations Due to Previous Surgical Interventions
Following repeated rhinoplasty operations, due to factors such as excessively altered nasal anatomy, weakened cartilage and supporting tissues, the presence of areas covered with fibrotic scar tissue, and suture reactions, careful attention is required during the procedure to minimize surgical trauma. In some patients, when the skin is lifted, it becomes very difficult to distinguish which tissue is cartilage, which is subcutaneous tissue, and which is scar tissue. The nasal skin and subcutaneous tissue may have transformed into a thick, cardboard-like structure. Even dissection alone can lead to a risk of skin injury.
Use of Cartilage Grafts (Costal / Auricular / Residual Septal)
In patients with C-shaped nasal deformities who have undergone previous recurrent rhinoplasty, cartilage grafts can be used to treat the existing deformity, support the nasal valve and upper lateral cartilage area where collapse occurs, and conceal sunken areas with a camouflage effect. For this purpose, the patient's own costal cartilage, auricular cartilage, residual septal cartilage, or cadaveric rib cartilage can be used. In some patients with significant irregularities on the nasal dorsum, a temporal fascia graft may also be used.
Correction of the C-Shaped Deformity
Correction of C-shaped nose deformity can involve a diverse procedure including unilateral spreader graft placement, various osteotomy techniques, dome point modification at the nasal tip, alar batten graft, marginal rim graft, and alar plasty techniques. I generally prefer using an ultrasonic device and micromotor for bone shaping. In this patient, a left spreader graft and various osteotomy techniques were used. Alar cartilage lateral crus graft was used to improve the symmetry of the patient's nasal wings. The columella was shaved to treat the affected columella. Scar tissue from the previous surgical incision was resected.
Unexpected Anatomical Distortions
In this patient, who underwent a fourth revision rhinoplasty and also had a history of nasal trauma, the surgery was like "opening a surprise box." The patient's existing nasal anatomy and the insufficient cartilage tissue could only be understood during the surgery itself. Surgeons performing such complex rhinoplasty operations must always be prepared for the worst and most difficult scenarios. They must know and inform the patient beforehand that it may be necessary to harvest cartilage from the patient's ribs or temporal fascia from the temple area.
Osteotomy Strategy in Crooked Nose Revision
In this patient, the right nasal septum was closer to the outside and the left nasal septum closer to the inside. A low-to-high osteotomy was performed specifically on the right nasal bone, and additionally, the nasal bone was reduced using micromotor techniques. The patient already had a poorly defined nasal hump. Only a minimal hump reduction was performed.
.JPG) |
| Complex Crooked Nose Correction After Multiple Failed Rhinoplasties |
.JPG) |
| Complex Crooked Nose Correction After Multiple Failed Rhinoplasties |
.JPG) |
| Complex Crooked Nose Correction After Multiple Failed Rhinoplasties |
.JPG) |
| Complex Crooked Nose Correction After Multiple Failed Rhinoplasties |
.JPG) |
| Complex Crooked Nose Correction After Multiple Failed Rhinoplasties |
Search result link where you can find articles prepared by Dr. Murat Enöz about "crooked nose" and published on this website (you can also reach previous articles by clicking "more posts" at the end of the page) >> https://www.ent-istanbul.com/search?q=crooked+nose
Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
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