Atlas of Asian Rhinoplasty (Volume 3) – Tác giả chưa rõ – Hướng Dẫn Giải Phẫu & Phẫu Thuật Mũi (file pdf)

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Fig. 13.53 Footplate
approximation
Correction of the Footplates
Correction of the lateral angulation of footplate (i.e., approximation of the footplates) can narrow the wide columella base,
move the columella base (subnasale) caudally, and project and rotate the tip cephalically (Fig. 13.53).
To avoid fullness of subnasale, the soft tissue between the footplate can be excised. Alternatively, the lateral portion of
footplate can be resected. Footplate approximation is considered to increase medial crural stability.
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Further Reading
1. Constantian MB, Hanover NH. The boxy nasal tip, the ball tip, and alar cartilage malposition: variations on a theme – a study in 200 consecu-
tive primary and secondary rhinoplasty patients. Plast Reconstr Surg. 2005;116:268–81.
2. Gunter JP, Rohrich RJ, Friedman RM. Classification and correction of alar-columellar discrepancies in rhinoplasty. Plast Reconstr Surg.
1996;97(3):643–8.
3. Guyuron B. Alar rim deformities. Plast Reconstr Surg. 2001;107(3):856–63.
4. McKinney P, Stalnecker ML. The hanging ala. Plast Reconstr Surg. 1984;73(3):427–30.
5. Kim HS, Roh SG. The alar extension graft for retracted ala. J Korean Soc Plast Reconstr Surg. 2009;036(01):66–74.
6. Jang YJ, Kim SM, Song SY, et al. Correction of alar retraction by Conchal cartilage extension grafts. Arch Plast Surg. 2016;43(6):564–9.
7. Kriedel RWH, Chiu RJ. Management of alar columellar disproportion. Fac Plast Surg Clin Am. 2006;4:313.329.
8. Joseph EM, Glasgold AI. Anatomical considerations in the management of the hanging columella. Arch Facial Plast Surg. 2000;2(3):173–7.
9. Alexander AJ, Shah AR, Constantinides MS. Alar retraction: etiology, treatment, and prevention. JAMA Facial Plast Surg. 2013;15(4):268–74.
10. Losquadro WD, Bared A, Toriumi DM. Correction of the retracted alar base. Facial Plast Surg. 2012;28(2):218–24.
11. Yap E. Improving the hanging ala. Facial Plast Surg. 2012;28(2):213–7.
12. Rohrich RJ, Afrooz PN. Components of the hanging columella: strategies for refinement. Plast Reconstr Surg. 2018;141(1):46e–54e.
13. Suh MK. Asian rhinoplasty. Seoul: Koonja; 2012. p. 341–2.
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© Springer Nature Singapore Pte Ltd. 2018
M. K. SUH, Atlas of Asian Rhinoplasty,
Correction of Nostril and Alar Base
The ideal outline of alar rims and columella should resemble a seagull in flight (Fig. 14.1). From basal view, ideal shape of
the nostril is oval shape. The outline of nasal base should resemble an equilateral triangle with lobule-to-nostril ratio of 1:2
(Fig. 14.2).
The width of alar base should be 1/5th of the facial width (Fig. 14.3) and be approximately equal to or 2 mm wider than
the intermedial canthal distance.
14
Fig. 14.1 The ideal alar rim and columella profile resemble the seagull outline

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Fig. 14.3 Ideal width of alar base
Fig. 14.2 Ideal shape of the nostril from basal view
14 Correction of Nostril and Alar Base

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Alar Base Reduction
Compared to Caucasians, the ala base is usually wider in Koreans. Among Asians, the nostril and ala are wider for Southeast
Asian patients than in East Asian patients. For this reason, alar base reduction is more popular among patients from Southeast
Asian countries. Because of the difference in nasal anatomy between Caucasian and Asian patients, alar base surgery cannot
be performed according to those criteria developed from within Western countries, and any alar base operation should pre-
serve the ethnic identity of a given patient while achieving a harmonious relationship between the nose and face. Among
Asians, the wide intercanthal distance is relatively common. As such, the intermedial canthal distance may not provide an
accurate reference distance. In addition, ala base reduction can result in the side face appearing wider in a patient with wide
face. Instead of absolute criteria, alar base reduction should be performed to achieve a harmony to the remainder of face.
Causes and Types of Wide Alar Base
Most cases of wide alar base are congenital in nature. Common non-congenital causes of wide alar base and upturned tip are
two jaw surgeries including maxillary advancement.
There are several pathologic anatomic features that lead to wide alar base (Fig. 14.4):
1. Horizontally long lateral alar wall, with or without alar flaring*
2. Wide nostril
3. Thick alar base
4. Wide columellar base
*Alar flaring is defined as lateral excursion of the alar wall that extends beyond the alar-facial groove.
In most cases, a wide alar base is caused by a combination of these factors (Fig. 14.5), which dictate the operative tech-
nique to be employed.
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644
Fig. 14.5 Wide alar base from the combination of wide nostril
floor, alar flare, and thick alar base
a
b
c
e
d
Fig. 14.4 Pathologic anatomic features of the wide alar base. (a) Normal. (b) Long lateral alar wall with alar flares. (c) Wide nostril. (d) Thick
alar wall. (e) Wide columellar base
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Operative Technique
The operative technique used to address alar base reduction is determined by the causative factor mentioned above.
1. Horizontally long lateral alar wall with/or without alar flaring: This is a very common type of wide alar base among
Asians. It is corrected by wedge resection of external alar base (Weir excision). This type is commonly observed by thick
alar base, which will require an addition of thinning operation.
2. Wide nostril floor is addressed with nostril floor resection.
3. The combination of long lateral ala wall (with/or without alar flaring) and wide nostril floor is the most common type of
wide alar base, which is addressed Weir excision and nostril floor resection.
4. Thick alar base can present by itself but can also be accompanied by long lateral alar base or hanging ala. For correction,
an elliptical-shaped excision is performed at the thick portion of the caudal surface of alar rim.
5. Wide columellar base is addressed by soft-tissue excision between the footplates with placement of interfootplate suture.
Wedge Resection of External Alar Base (Weir Excision)
Weir excision is performed for alar flaring, and the external alar base is excised in a wedge shape (Fig. 14.6).
The incision is better if it is placed 1–1.5 mm anterior to the alar-facial crease, which facilitates the suture process. It
avoids obliteration of ala-facial groove, with better quality for resulting scar. However, cephalic end of the incision should
be closer to the alar-facial groove so that it is less conspicuous.
The incision should be carried down to the muscle but not into the mucosa. The most common width of excision is
2–4 mm (Fig. 14.7). Excessive amount of excision is usually the main cause of obliteration of the natural alar-facial groove
(Fig. 14.8).
Readers should know that this technique results in a decrease in alar flaring with no true decrease in the width of alar base.
To decrease the alar base width, nostril sill should be excised as described below.
In most cases, the resulting scar is inconspicuous. However, the incision can leave a suture mark or bumpy scar for oily
skin with larger pores. CO2 laserbrasion can be beneficial in these cases. A depressed scar will require scar revision.
Fig. 14.6 Wedge resection of external alar base
Alar Base Reduction

646
a
c
d
f
b
e
g
Fig. 14.7 Wedge resection of external alar base. (a, b) Design for wedge resection of external alar base. (c) Immediately after excision and wound
closure. (d, e) This patient with wide alar base and alar flaring underwent tip projection and wedge resection of external alar base. (f, g) Postoperative
photograph
14 Correction of Nostril and Alar Base

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Fig. 14.8 Obliteration of the natural alar-facial groove can result from
excessive amount of external excision
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Fig. 14.9 Nostril base resection
Nostril Base Resection
This technique decreases the alar base width by the resection of nostril sill and nostril floor (Fig. 14.9). However, this does
not address the alar flare.
The area to be excised is marked along the nostril sill. Incisions should be placed in the horizontal portion of the sill,
preserving the lateral corner of the nostril to prevent notching deformity of nostril sill or letter Q-deformity (Fig. 14.10).
Furthermore, a triangular resection should be designed on the inside of nostril floor. The amount of planned sill resection is
made symmetrical by the use of a caliper for measurement. To avoid dog-ear formation, the incision should be extended into
the alar-facial groove. This extension should become longer for greater amount of nostril sill excision.
Incision with No. 15 blade is done and excess nostril floor is resected. Lateral flap is dissected and elevated, releasing the
alar nasalis muscle. Two deep cinching sutures are used to draw the lateral flaps closer together. This decreases the tension
on the skin edges, bunches the subcutaneous tissue, and elevates the wound to prevent wound inversion. It also minimizes
the risk of notching deformity at the junction of the ala and sill. The incision at alar-facial groove is closed with a subcutane-
ous suture and skin suture using 6-0 nylon. Nostril floor suture is performed using 6-0 Vicryl suture; special caution should
be paid to evert the wound vertical mattress suture. This is important in preventing the inversion of wound margin in this area
and the letter Q-deformity.
Fig. 14.10 Letter Q-deformity of the left nostril
after alar base reduction
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649
Combined Technique: Wedge Resection of External Alar Base and Nostril Base Resection
The presence of both alar flaring and wide nostril floor will require wedge resection of external alar base and nostril base
resection (Fig. 14.11). This technique combines an external alar wedge resection which decreases the alar flaring, with an
internal nostril base resection that approximates the alae, thus decreasing the width of the nasal base (Fig. 14.12).
Two deep cinching sutures are used to draw the lateral flap towards each other, reducing the tension on skin edges. The
incision at alar-facial groove is closed with a subcutaneous suture and skin suture. The nostril floor is sutured using the
method described above, to avoid inversion of wound.
In most Southeast Asian patients, the alar base reduction will require this specific combination of techniques (Figs. 14.13
and 14.14).
Fig. 14.11 Wedge resection of external alar base
with nostril base resection
Alar Base Reduction

650
a
b
c
d
e
f
g
h
j
k
i
Fig. 14.12 Wedge resection of external alar base with nostril base resection. (a, b) Preoperative design. (c) Resection of external alar base and
nostril base. (d) Key suture is placed to pull the alar base flap medially. (e) Trimming of the flap. (f) The wound is closed with 6-0 Vicryl subcutane-
ous suture and 6-0 nylon skin suture. (g) The nostril floor wound should be repaired in eversion to prevent depressed scar. (h, i) Preoperative
photographs. (j, k) Postoperative photographs
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a
c
b
d
Fig. 14.13 Reduction of external alar base and nostril base. (a, b) This patient with wide alar base underwent wedge resection of external alar
base and resection of nostril base, in addition to implant augmentation and tip plasty (transdomal suture, spanning suture of lateral crura, and
conchal cartilage onlay graft). (c, d) Postoperative photographs
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652
a
b
c
d
Fig. 14.14 Reduction of external alar base and nostril base. (a, b) This patient with wide alar base and retracted ala underwent wedge resection
of external alar base and resection of nostril base and alar rim graft, in addition to dorsal augmentation (silicone implant), tip plasty (caudal septal
shortening, columellar strut graft, and septal cartilage onlay graft). (c, d) Postoperative photographs demonstrate decreased alar base width and
improved alar retraction
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Thinning of Thick Alar Base
For the correction of thick ala, an elliptical incision is performed at the thick portion of the caudal surface of basal alar rim
(Fig. 14.15). The skin and subcutaneous tissue within the nostril wall are excised. Subcutaneous tissue excision should be
performed wide and deeply for better result. Soft silicone sheets are applied externally and internally to compress the dead
space after wound repair.
This procedure is commonly performed along with nostril base reduction or external alar base reduction (Fig. 14.16).
Fig. 14.15 Operative design for thinning of alar
base and reduction of external alar base
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654
a
b
c
e
d
Fig. 14.16 Thick alar base is frequently accompanied by inverted triangular shaped nostril. This patient with thick alar base, alar flare, and
inverted triangular shaped nostril (A) underwent external reduction of alar base, thinning of thick alar base (B, C, D), and tip plasty with the colu-
mellar strut graft. Postoperative photograph demonstrates improved nostril shape and alar base (E)
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Alar Cinching
This suture technique uses nonabsorbable suture to decreases ala width without any tissue excision (Fig. 14.17). It is a simple
technique that does not leave any incisional scar. However, a major disadvantage of this technique is the high recurrence rate.
Fig. 14.17 Alar cinching
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656
Alar Release with Medialization
Normally, alar base is wider at the caudal portion than at the cephalic portion (Fig. 14.18). Thus, the alar axis is directed
inferiorly and laterally. If a vertically oriented alar axis (Fig. 14.19) has alar resection, then the alar axis is likely to direct
inferiorly and medially, which is called a bowling pin deformity. To avoid this deformity, both cephalic and caudal regions
should be made narrower. This is accomplished by alar release with medialization (Fig. 14.20).
Reported by Santana et al., this technique is useful for alar base reduction in a nose with vertically oriented alar axis and
reduces both the cephalic and caudal aspects of the ala. The technique detaches the ala from the maxilla. The freed ala is
mobilized medially and secured using interalar sutures.
a
b
c
Fig. 14.18 Various types of alar axis. (a) Normal alar axis with infero-
laterally oriented axis. (b) Vertically oriented alar axis. (c) Inferomedial
alar axis (bowling pin deformity)
Fig. 14.19 A patient with vertically oriented alar axis
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Fig. 14.20 Alar release with medialization. Alar release includes the periosteum of the anterior maxilla including the pyriform ligament (above,
left), periosteum posterior to the pyriform rim (in the nasal vault) (above, right), and tissues of the horizontal pyriform rim (below, left). The needle
of a 3-0 polydioxanone suture picks up the dermis of one alar incision site, passes to the other side, picks up the dermis there, and returns to the
original site where the knot is tied (below, right) (illustration and legend from Gruber RP, Freeman MB, Hsu C, Elyassnia D, Reddy V. Nasal base
reduction: a treatment algorithm including alar release with medialization. Plast Reconstr Surg. Feb 2009;123(2):716-725)
Alar Base Reduction

658
A Joseph periosteal elevator is inserted through an incision at the ala-sill junction. The alar is released from the perios-
teum of the anterior maxilla (including pyriform ligament), periosteum posterior to the pyriform rim, and tissues of the hori-
zontal rim. The soft tissues are freed off the anterior maxilla about 2–3 cm lateral to the pyriform rim. The elevator is used
to push the ala medially so that all fibers are ruptured along the anterior surface of the vertical component of the pyriform
rim. This will allow the ala to mobilize freely.
Interalar suture is placed using 2-0 nylon, to maintain medial mobilization of the whole ala base.
Depending on the nose, this technique can be performed by itself or in conjunction with other procedures.
Alar base reduction can also worsen a congenital bowling pin deformity (Fig. 14.21). In a patient with this deformity, alar
base resection should not be performed no matter how much the patient wants the procedure. Alar release and alar cinching
(between cephalic portion of the alar base) mentioned above are more appropriate solutions.
Fig. 14.21 Bowling pin deformity
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659
a
d
b
e
c
f
Fig. 14.22 Effect of tip projection on wide alar base. (a–c) This patient with wide alar base and tip drooping underwent nasal tip projection with
columellar strut graft using septal cartilage. (c–e) At 5 weeks after operation, her alar base appears less wide, as if she had undergone alar base
reduction
Effect of Tip Projection on Wide Alar Base
Nasal tip projection can decrease the alar base width or give the illusion of decreased width (Fig. 14.22). If a patient
requires both nasal tip projection and alar base reduction, the nasal tip projection should be performed prior to alar base
reduction.
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Effects of Alar Base Reduction on the Tip and Alar Rim
A significant amount of alar base reduction can slightly decrease the tip height. Ala base reduction can improve a bit of alar
retraction (Fig. 14.23). Nostril floor reduction will medialize the lateral segment, which will mobilize the alar rim in caudal
direction.
a
c
b
d
e
f
Fig. 14.23 Effect of alar base reduction on alar rim. (a–d) This patient underwent alar base reduction. (e, f) At 5 months after operation, the alar
retraction appears improved
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Correction of Narrow Alar Base
Narrow alar base can be caused by congenital problem, trauma, infection, over-resection of ala base/nostril during prior
rhinoplasty, and overprojection of tip by the suspension technique of the lower lateral cartilage, such as fixed columellar strut
graft or septal extension graft.
If a narrow alar base is caused by overprojection of the tip, lowering the tip can easily restore the alar base to a normal
width.
Other causes of narrow base can be corrected by composite graft or with alar base island flap. Constantian designed the
island flap as a crescent adjacent to the alar base. The flap elevated and transposed on subcutaneous and musculocutaneous
perforators can correct the nostril stenosis and reposition the alar base simultaneously.
Correction of Cephalically Malpositioned Alar Base
If the alar base is wide with cephalic malposition, the alar base is mobilized medially and caudally. If the alar base is not wide
but has cephalic malposition, however, alar base lowering is performed by a crescent-shaped excision of upper lip skin below
the alar base, which pulls the nasal base caudally when the wound is closed (Fig. 14.24).
Fig. 14.24 Correction of cephalically malpositioned alar base
Correction of Cephalically Malpositioned Alar Base

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Correction of Caudally Malpositioned Alar Base
Caudally malpositioned alar base is corrected after an elliptical excision of the superior ala-facial groove (Fig. 14.25).
Fig. 14.25 Correction of caudally malpositioned
alar base
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663
Correction of Unpleasing Nostril Shape
From worm’s-eye view, the nostril should be of equilateral triangle shape, and the height of infratip lobule should be one-
third of the distance from alar base to the tip (Fig. 14.2). This harmony between the nostril and infratip lobule is essential for
aesthetics of nasal tip.
Short Nostril
A nostril that is disproportionately short in relation to lobule length will appear imbalanced and in disharmony from basilar view.
The pathology of vertically short nostril lies with the short columella and small lower lateral cartilage (Fig. 14.26). For a
nose with short nostril and low tip, simple onlay graft or shield graft will cause a discrepancy between the nostril length and
tip height. In such a case, the short nostril should be lengthened in addition to correcting the nasal tip height.
The following procedures increase the nostril length:
1. Medialization of lateral crura.
2. Approximation of the footplates.
3. Alar rim graft.
4. Suspension of whole lower lateral cartilage: fixed-type columellar strut graft, L-shaped columellar strut graft, or septal
extension graft.
5. Partial excision of redundant soft triangle lining: This provides a very robust nostril-lengthening effect.
In a nose with redundant soft triangle lining, the nostril apex is far from the caudal border of dome. Partial removal of this
redundant tissue can increase the nostril height. Previously, incision into the soft triangle was thought to cause notching from
scar contracture, and procedures involving the soft triangle have been controversial. However, Guyuron reported that partial
excision of the soft triangle lining and approximation of the alar rim to the lining under the dome elevate the nostril apex and
elongate the nostril (Fig. 14.27).
Excision of redundant soft triangle lining is performed as the final step after all other procedures have been performed
(e.g., interdomal suture, transdomal suture, medialization of lateral crura, or columellar strut graft). A crescent-shaped piece
of redundant soft triangle lining is removed with a pair of iris scissors, and then the nostril rim is approximated to the lining
under the domes. The amount of excision should be made conservative because excessive excision can lead to nostril notch-
ing, while a conservative excision allows for additional excision.
In a nose with wide alar base and short nostril, the alar base reduction should be performed simultaneously with a nostril-
lengthening procedure to obtain aesthetically pleasing outcome (Fig. 14.28).
Fig. 14.26 Short nostril with small lower lateral
cartilage, short columella, and redundant soft
triangle lining
Correction of Unpleasing Nostril Shape

664
Fig. 14.27 Partial excision of soft
triangle
a
b
Fig. 14.28 A short nostril with wide alar base should be
addressed by nostril-lengthening procedures as well as
with alar base reduction
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Small Nostril
Primary small nostril not only represents an aesthetic complaint but can also be a cause for functional airway issue. Small
nostril is caused by small lower lateral cartilage, thick ala rim, and/or laterally overprojected footplates. The problem is cor-
rected by nostril height lengthening (columella strut graft or septal extension graft), alar rim thinning, and/or approximation
of laterally projected footplate.
Inverted Triangular Shaped Nostril
This congenital abnormal nostril shape is not a rare occurrence among Asians. The most typical example is the inverted tri-
angular nostril, which is often accompanied by thick alar base and retracted ala (Fig. 14.29).
Correction of this deformity consists of increasing the nostril height and lowering of alar rim. The nostril height is
increased using a combination of the techniques mentioned above for short-nostril correction. Alar rim graft can be employed
to lower the alar rim (Fig. 14.30).
Fig. 14.29 Inverted triangular nostril
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666
a
b
c
d
Fig. 14.30 Correction of inverted triangular nostril. (a, b) This patient with short nose and conspicuous inverted triangular nostril underwent
septal extension graft and alar rim graft using the septal cartilage. (c, d) At 5 months, the nostrils assume the normal upright triangular shape with
decreased nostril show
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Further Reading
1. Constantian MB. An alar base flap to correct nostril and vestibular stenosis and alar base malposition in rhinoplasty. Plast Reconstr Surg.
1998;101(6):1666–74.
2. Guyuron B, Ghavami A, Wishnek SM. Components of the short nostril. Plast Reconstr Surg. 2005;116(5):1517–24.
3. llenbogen R, Blome DW. Alar rim raising. Plast Reconstr Surg. 1992;90(1):28–37.
4. Ohba N, Ohba M. Preservation of nostril morphology in nasal base reduction. Aesth Plast Surg. 2016;40:680–4.
5. Foda HMT. Nasal base narrowing: the combined alar base excision technique. Arch Facial Plast Surg. 2007;9:30–4.
6. Gruber RP, Freeman MB, Hsu C, Elyassnia D, Reddy V. Nasal base reduction: a treatment algorithm including alar release with medialization.
Plast Reconstr Surg. 2009;123(2):716–25.
7. Santana PSM. Treatment of the Negroid nose without nasal alar excision: a personal technique. Ann Plast Surg. 1991;27:498–506.
Further Reading

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© Springer Nature Singapore Pte Ltd. 2018
M. K. SUH, Atlas of Asian Rhinoplasty,
Deviated Nose Correction
and Functional Rhinoplasty
Deviated nose refers to the displacement of nose from the vertical midline of the face and is also called crooked nose. In
addition to the aesthetic problem, it can lead to functional problems including nasal obstruction.
For successful correction of deviated nose, the operator must understand anatomic structure and physiology of the nose.
He/she must have an accurate preoperative assessment of the patient and be experienced in rhinoplasty techniques. Because
of this, deviated nose correction is one of the more challenging areas within the field of rhinoplasty.
Causes of Nasal Deviation
Trauma
The most common site of facial fracture is the nasal bone. Most instances of deviated nose are caused by traumatic nasal
bone fracture.
Commonly deviated nose deformity is obvious after traumatic nasal bone fracture, septal fracture, or dislocation from the
maxillary crest. In a small subset, however, the nasal deviation may not be so conspicuous immediately following a facial
trauma. Instead, development of fibrosis and scar contracture increases the amount of deviation over the course of several
months or several years. This is especially the case for patients with a history of traumatic impact to the nasoseptal growth
center at an early age.
Also, closed reduction of nasal bone fracture can be followed by gradual deviation. This is because closed reduction does
not ensure complete reduction and because of secondary remodeling of the nasal bone and soft tissue.
Diseases
Congenital and developmental issues in the skull and facial bone can lead to deviated nose. In addition, nasal deviation can
be caused by less frequent causes that destroy the septum and internal nose, such as Wegener’s granulomatosis, autoimmune
diseases (e.g., sarcoidosis), and infectious diseases (e.g., syphilis and HIV).
Iatrogenic Causes
Failed rhinoplasty is a common cause of deviated nose. Incorrectly performed osteotomy can result in nasal bone asymmetry.
This is especially the case with incomplete greenstick osteotomy, for which the residual osteoconductive memory allows the
nasal bone to return to its original shape. If such bone remodeling occurs differently across the midline, the resulting nasal
bone will be asymmetric, with the overall nose becoming deviated.
Even with accurate osteotomy, deviated high septum or hypertrophied turbinate can push the unilateral bony segment
laterally into original asymmetric position and result in the deviated nose again.
15

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Pathophysiologic Consideration and Classification of Deviated Nose
Nasal deviation can occur in any part of the nasal structure: nasal bone, upper lateral cartilages, and lower lateral cartilages
and septum (Fig. 15.1). In most cases, the deviation occurs in all of these structures. In addition, most deviated noses are
accompanied by tip and nostril asymmetry (Fig. 15.2).
A deviated nose can be classified according to the shape of deviation from frontal view.
I: Linear deviation (Fig. 15.3)
Nasal bone and upper lateral cartilage (ULC) are deviated to the same side.
II: C-type deviation (concave dorsal deformity) (Fig. 15.4)
The nasal bone and ULC are deviated in opposite direction. The C-type deviation is further divided according to the ULC
deviation. IIa: All of ULC is displaced to the side opposite of nasal bone deviation. IIb: The cephalic portion of ULC is dis-
placed to the same side of the nasal bone deviation, while the caudal portion is to the opposite side.
III: S-type deviation (Fig. 15.5)
The nasal bone and upper lateral cartilages are displaced from midline in S-shape.
a
b
Fig. 15.1 Deviated nose. Nasal deviation can occur in any part of the nasal structure: nasal bone, upper lateral cartilages, lower lateral cartilages,
and septum
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b
a
Fig. 15.2 Most deviated noses are accompanied by tip and nostril asymmetry
a
b
Fig. 15.3 Linear deviation
Pathophysiologic Consideration and Classification of Deviated Nose

672
a
b
c
Fig. 15.4 C-shaped deviation
a
b
c
Fig. 15.5 S-shaped deviation
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IV: Cartilage deviation only (Fig. 15.6)
In this type of deviation, the bony pyramid is uninvolved with the deviation solely in the ULC.
Not all cases of deviated nose can accurately be described by this classification scheme. Among the deviation types,
C-type deviation is the most common. Outside of the classified types, nasal tip asymmetry due to caudal septal deviation can
make the whole nose appear deviated.
From the frontal view, the direction/shape of nasal bony deviation does not always coincide with that of the septal devia-
tion. However, the direction of deviation is always the same for upper lateral cartilage and dorsal septum. Columellar devia-
tion coincides with caudal septal deviation, and this defines the asymmetry in the nostril.
Several authors have suggested different classifications for septal deviation. However, not every septal deviation can be classi-
fied as a single type, and specific classification of septal deviation may only complicate the decision-making process for operative
planning. As such, the author believes that septal deviation should be classified in the simplified manner described below (Fig. 15.7).
I: Cartilage or bony spur without curvature: This type is defined by a local protrusion in the cartilage or bony septum, which
is a cause for nasal obstruction (Fig. 15.7a).
II: Linear septal deviation without curvature: The entire septum is dislocated from the maxillary crest (Fig. 15.7b).
III: Mid-septal deviation (Fig. 15.7c)
IV: Caudal septal deviation (Fig. 15.7d)
IVa: Caudal septal deviation without dislocation (Fig. 15.7d), which can assume a C- or S-shape.
IVb: Caudal septal deviation with dislocation from ANS (Fig. 15.7e)
Fig. 15.6 Cartilage deviation only
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a
b
c
d
e
f
Fig. 15.7 Types of septal deviation. (a) Cartilage or bony spur without curvature. (b) Linear septal deviation without curvature. (c) Mid-septal
deviation. (d) Caudal septal deviation without dislocation (C- and S-shaped). (e) Caudal septal deviation with dislocation from ANS. (f) Dorsal
septal deviation with or without curvature
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V: Dorsal septal deviation with or without curvature (Fig. 15.7f): anteroposterior C- or S-shaped, cephalocaudal C- or
S-shaped
Septal deviation can be accompanied by deviation of the ANS.
Correction of septal deviation is important not only for restoring symmetry to the external nose but is also required for
functional improvement.
Septal deviation can change airflow dynamics, which can lead to various functional symptoms. Most common symptom
is nasal obstruction. Most cases of nasal obstruction in deviated nose are due to septal deviation. Other causes include hyper-
trophied turbinate, collapsed internal valve, and collapsed external valve. Anterior and posterocaudal septal deviations tend
to affect nasal airflow more significantly compared to deviations in the posterocephalic septum or bony septum. The anterior
and posterocaudal areas represent areas of highest resistance, and this is the reason why small deviations in the anterior sep-
tum are more symptomatic than large deviations in posterior position.
Other symptoms of deviated septum are snoring, headache, rhinorrhea, sneezing, hyposmia, and epistaxis.
In deviated nose, the septum is the most important anatomic structure in functional problem, but the turbinate cannot be
overlooked. The three turbinates are attached to the lateral wall of nasal cavity along the path of nasal airflow (Fig. 1.58).
Among these, the inferior turbinate is the largest and is composed of bone and mucosal tissue. The turbinate mucosa alter-
nates between congestion and shrinkage through autonomic nervous system. More than 2/3 of population has nasal cycles
where the congestion alternates between the two nasal cavities.
Inferior turbinate has the function of regulating the humidity and temperature of the inspired air. Allergic rhinitis is
accompanied by inferior turbinate hypertrophy.
In the presence of septal deviation, the inferior turbinate of opposite nasal cavity is hypertrophic, which is referred to
compensatory hypertrophy (Fig. 15.8). In deviated nose, septal deviation and inferior turbinate hypertrophy both contribute
to the nasal obstruction. Correction of deviated septum will require simultaneous reduction of hypertrophied turbinate.
Otherwise, septal mobilization will cause the septum and the hypertrophied turbinate to come into contact, which will
become a new source of obstruction.
Other structures that cannot be overlooked in the discussion of nasal obstruction are internal nasal valve and external nasal
valve. Internal nasal valve is defined by the angle between nasal septum and caudal margin of the upper lateral cartilage. This
angle is 10–15°, represents the narrowest cross-sectional area through the nasal cavity, and contributes close to half of the
total airway resistance. High septal deviation and upper lateral cartilage collapse can both contribute to decreased internal
valve angle and nasal obstruction.
External nasal valve collapse is not typical of deviated nose and is caused by facial palsy, trauma, and failed rhinoplasty
(e.g., over-resection of the lateral crus of the lower lateral cartilage, pinched deformity from the inappropriate cartilage workup).
Fig. 15.8 Septal deviation
with compensatory
hypertrophy of left inferior
turbinate
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Preoperative Evaluation
History and Physical Examination
A patient with deviated nose should be evaluated for history of facial trauma and septal or sinus surgery. A thorough trauma
history should obtain information regarding age at injury, injury mechanism, and facial shape prior to injury.
Nasal function should be evaluated for symptoms of obstruction. For patients with nasal obstruction, the cause should be distin-
guished between anatomical abnormalities (e.g., septal deviation) or inflammatory disease (e.g., allergic rhinitis and sinus infection).
In the presence of nasal deviation, it is also important to examine the overall asymmetry of the face. Clinical photograph can be
helpful in objective assessment of the deviated nose and facial asymmetry. Each photograph should be evaluated for chin position,
location of left and right mouth corners, location of vermilion, midline of the upper and lower incisors, and occlusion plane.
The patient should also be evaluated for facial palsy.
The shape of nose is not only inspected but also be palpated to evaluate for symmetry of nasal bone and of the cartilages,
as well as deviation of the nasal tip. A deviation should be distinguished between a true deviation and unilateral depression
of nasal bone and upper lateral cartilage.
The basal view allows evaluation of nostril asymmetry and dislocation or deviation of caudal septal cartilage. Using a
nasal speculum or an endoscope, the internal nose is examined for septal deviation, septal spur, turbinate hypertrophy, polyp,
or mass. This is especially important in patients with prior history of septal surgery, in whom the septum must be evaluated
for perforation and synechiae.
Incompetency of internal and external nasal valves is not easily evaluated by simple inspection. Instead, functional issues
should be evaluated under forced inspiration. Suspected valve incompetence is evaluated using Cottle test or modified Cottle
test (Figs. 1.69 and 1.70).
Radiologic Examination
Both plain X-rays and CT are helpful in assessing nasal deviation. Computed tomography can reveal any septal deviation, turbinate
hypertrophy, and atrophy. Concha bullosa and septa bullosa cannot be examined directly and require the use of CT imaging.
Preoperative Plan and Explanation
Preoperative planning and consultation are determined through physical examination and evaluation. The surgeon must determine
whether the patient expectation is realistic. Deviated nose correction cannot achieve completely straight nose with perfect symme-
try. With asymmetry of the overall face, correction of deviation may not provide the desired outcome by the patient. If needed, a
patient may require facial bone surgery or fat injection to the face, and the patient must be made aware of the underlying asymmetry
in his/her own face. Patients must also understand the possibility of incomplete correction and recurrence of nasal deviation.
For functional septorhinoplasty, the surgeon must explain that about 20% of patients will continue to experience nasal
obstruction after the operation.
Operative Techniques of Deviated Nose
The purpose of deviated nose correction is aesthetic and functional improvement.
For aesthetic improvement, all deviated structures (nasal bone, upper lateral cartilages, and lower lateral cartilages) should
be moved from the asymmetric deviated position to straight symmetric orientation. For functional improvement, asymmetry
of the internal nose should be corrected (septal deviation and hypertrophied turbinate). Deviated nose correction is not sim-
ply a matter of repositioning the nasal bone through an osteotomy. Instead, deviations should also be straightened in the
upper lateral cartilage and the septum for optimal result.
The core nasal asymmetry is the crooked septum. Mid-vault deviation (upper lateral cartilage deviation) is related to dor-
sal septal deviation. Deviation of the tip/columella and asymmetry of the nostril are most commonly associated with caudal
septal deviation. For all of these reasons, the correction of septal deviation is a key element of deviated nose correction.
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In addition to septal deviation, nasal obstruction is also caused by deviated nasal bone and deviated upper and lower lat-
eral cartilages. Because of this relationship between internal and external elements, aesthetic correction and functional cor-
rection cannot be clearly separated.
Deviated nose correction consists of the following five procedures:
1. Correction of bony deviation by osteotomy
2. Correction of septal deviation
3. Correction of upper lateral cartilage deviation by dorsal septal manipulation
4. Correction of tip and columella deviation by manipulation of lower lateral cartilages as well as dorsal and caudal
septum
5. Manipulation of inferior turbinate
The midline reference used for correction of deviated nose should not use the midpoint between eyebrows but should
instead use the midpoint between the medial canthus, to avoid problems arising from asymmetric eyebrows.
Approach and Dissection
Endonasal approach is feasible for the following cases:
1. Mild deviation that can be corrected using camouflage technique.
2. Mild deviation with straight cartilaginous dorsum and tip that can be addressed only with nasal bone osteotomy or sub-
mucosal resection (SMR) of septal cartilage.
3. Medial and lateral osteotomy is possible through endonasal approach, but spreader graft and clocking suture are difficult
to place in Asian patients with small nostrils. Open approach is recommended if suture techniques are needed for upper
lateral cartilages.
For septal deviation correction, transfixion incision provides the best endonasal access.
Open rhinoplasty approach is necessary for severe deviation that also involves cartilaginous dorsum or severe asymmetry
of tip. In such cases, the benefits to be gained from open approach far outweigh the columella scar. The open approach is
made in the following manner.
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Incision
The access is created by mid-columellar incision and inframarginal incision.
Dissection
The dissection is carried in the supraperichondrial and subperiosteal planes. To facilitate dissection, the operator must under-
stand the anatomic characteristics of the septum. As mentioned in Chap. 1, the septum is composed of quadrangular cartilage,
perpendicular plate of the ethmoid bone, vomer, and maxillary crest (Fig. 15.9). The quadrangular cartilage connects end to
end with the perpendicular plate and vomer, and is covered by mucoperichondrium on both sides. The quadrangular cartilage
articulates with the maxillary crest via a tongue-and-groove joint. At the joint, a portion of the perichondrium is continuous
with the periosteum of maxillary crest, and another portion passes through the articulation and meets the contralateral peri-
chondrium (Fig. 1.53). This crossed configuration of fibers and tongue-and-groove articulation creates for a tough dissection
in this area.
For deviated nose correction, the intercrural approach is used to expose the septum. Mucoperichondrial flaps are elevated
from both sides. The flap is easier to elevate from the concave side of septum. Flap elevation of the concave side first mini-
mizes the mucoperichondrial tearing, with the convex side dissected second. For each side, the mucoperichondrial elevation
is begun in the caudal portion of septum and advanced in the cephalic direction. At the starting area, the dissection should be
made carefully because the perichondrium is tightly adherent. The flap elevation is continued along the dorsal border in the
cephalic direction. The upper lateral cartilage is separated from the dorsal septum. The flap elevation is then carried in the
cephaloposterior direction towards the dorsal and middle septum, where mucoperichondrium adheres less tightly to the car-
tilage. The flap elevation can be directed anteriorly towards the maxillary crest to decrease dissection time with lower risk of
flap tearing (Fig. 4.14).
In the presence of bony deviation, the flap should be elevated beyond the bony deviation.
ANS
upper lateral
cartilage
nasal bone
sphenoid sinus
perpendicular plate
of ethmoid bone
nasal crest of maxilla
nasal crest of
palatine bone
vomer
septal
cartilage
Fig. 15.9 Components of
the nasal septum
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Correction of Deviated Nasal Bone
Camouflage Technique
Nasal bone deviation is usually bilateral but can occasionally be unilateral. In the absence of functional impairment, camou-
flage technique may be appropriate for a unilateral deviation and also for mild instances of bilateral deviation.
The discrepancy in nasal bone is addressed by the placement of cartilage onlay graft (septal or conchal cartilage) on the
side of sunken nasal bone (Fig. 15.10). The graft margin is tapered thin to a beveled edge and crushed to minimize the visible
irregularity. The onlay graft needs to be inserted below the periosteum to minimize graft visibility and mobility. In lieu of
cartilage, the graft can be prepared from temporal fascia or dermal allograft, though with less predictability due to
resorption.
Convexity in the contralateral nasal bone will need to be filed down with a rasp.
a
b
c
Fig. 15.10 Camouflage technique for minimal deviation of nose. (a) The convex side of nasal bone is filed with a rasp, and a cartilage onlay graft
is used to augment the depressed nasal bone. (b) This patient with minimal deviation of the nose has convexity of the left nasal bone and concavity
on the right. (c) Photographs after nasal bone filing and cartilage graft shows adequate camouflage of deviation
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680
Osteotomy Technique
Definite correction of deviated nasal bone requires osteotomy. During deviated nose correction, the timing of osteotomy var-
ies widely across surgeons. The author recommends the osteotomy after detachment of upper lateral cartilage from dorsal
septum, SMR (submucosal resection of septum), and turbinate reduction. The turbinate reduction and submucosal resection
are performed first to create room for subsequent osteotomy and inward mobilization of the nasal bone. The osteotomy alters
the position of nasal bone and upper lateral cartilage, and this can improve dorsal septal deviation. As such, dorsal and caudal
septal deviation should be addressed after the osteotomy.
The periosteal elevation should be kept to the absolute minimal area that allows mobilization of the osteotomy fragments
while maintaining the stability of bony segment after the operation.
The osteotomy consists of medial and lateral osteotomy. At times, intermediate osteotomy may also be required.
The concave side of deviated nose should be osteotomized first because this affords the space needed for medialization of
the bony segment from the convex deformity.
Osteotomy for Concave Side
Concave depressed bone is accompanied by medial transposition of upper lateral cartilage, which can be associated with
internal valve collapse.
To laterally mobilize the concave nasal bone, the lateral osteotomy is performed first, followed by medial osteotomy. The
purpose of lateral osteotomy is purely to divide the bone into segments, and no force should be applied to create in-fracture.
For intranasal continuous lateral osteotomy, a small vestibular incision is made lateral to the insertion of inferior turbinate. The
periosteum is elevated with Joseph’s periosteal elevator along the osteotomy line. High-low-high lateral osteotomy is performed,
followed by medial osteotomy for out-fracture of nasal bone. The reason for initiating the lateral osteotomy high on pyriform aper-
ture is to avoid medial movement of inferior turbinate. The low position for midportion of osteotomy line can prevent the step
deformity, and high position of osteotomy at the level of medial canthus can prevent lacrimal sac injury and excessive narrowing at
the root of the nose. With wide bony base, the lateral osteotomy should follow the low-to-high or low-to-low osteotomy path.
The concave bony segment is out-fractured from the endpoint of medial osteotomy, which lateralizes the previously con-
cave bony surface (Fig. 15.11). The lateralization of the bony segment leaves behind a bony gap. This space should be occu-
pied with a long extended spreader graft to prevent the lateralized bone from returning to its original position (Fig. 15.12).
Fig. 15.11 Osteotomy on the concave side of nasal bone
a
b
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681
c
Fig. 15.11 (continued)
Fig. 15.12 After medial osteotomy and out-fracture,
the spreader graft should be made long enough to
reach the bony gap
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682
All of the maneuvers to mobilize and stabilize the concave bone in a lateral position will place enough lateral traction on
the upper lateral cartilage, which could improve internal valve function. In this context, the spreader graft serves to fill the
bone gap, spread out the concave ULC, and improve the internal valve insufficiency.
It is possible to manage the concave nasal bone without lateral osteotomy, using just medial osteotomy and out-fracture
(Fig. 15.13).
If the bony base on concave side is also sunken, the bony segment needs to be pushed outward after the osteotomies. This
can be accomplished by performing the medial osteotomy first and then the “inside-out” perforating lateral osteotomy tech-
nique, which allows the inwardly displaced lateral nasal bony sidewall to be moved outward (Fig. 15.14).
a
b
c
d
Fig. 15.13 Medial osteotomy and long spreader graft for the concave nasal bone. (a) This patient has a C-shaped nasal deviation. (b) Operative
design for the medial osteotomy and long spreader graft on the left side and the lateral and medial osteotomies on the right side. (c–e) Stepwise
illustration of the osteotomy technique used in this patient. (f, g) Intraoperative photographs. (h) Photograph at 2 months demonstrates correction
of the nasal deviation
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f
g
e
h
Fig. 15.13 (continued)
Fig. 15.14 Inside-out perforating lateral osteotomy
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684
Osteotomy for Convex Side
For the convex side of deviated nasal bone, the medial osteotomy is performed first, followed by lateral osteotomy (Fig. 15.15).
If a significant amount of bone needs to be moved or if the roof of nasal bone is wide, a strip resection of nasal bone may be
required (Fig. 15.16).
Excessive convexity of the lateral wall of nasal bone can be addressed by the addition of an intermediate osteotomy.
An osteotomy should be made through the full thickness of the bone. An osteotomy that results in greenstick fracture is
highly likely to allow the nasal bone to return to its original position. After osteotomy, the bone segment should be able to
move freely but not require manual traction for the bone to stay in its desired position, to minimize the risk of recurrent
deviation. If the medial osteotomy and lateral osteotomy do not connect with each other, a percutaneous osteotomy can be
added to complete the bone segmentation.
a
b
c
Fig. 15.15 Osteotomy on the convex side of nasal bone
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685
a
b
c
Fig. 15.16 Strip resection of medial bone. Strip resection of medial bone is required for significant displacement of bony segment and for wide
roof of nasal bone
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686
Combined out-fracture and in-fracture via medial and lateral osteotomy allows for correction of complex nasal deviation
(Fig. 15.17).
If SMR and complete osteotomy do not allow adequate mobilization of the bony segments to the intended position, the
following factors are responsible for limiting the movement.
First, the bony portion of high septum (i.e., perpendicular plate of vomer) remains in a deviated configuration. In most
cases, the remaining L-strut after SMR is deviated at the cartilage-bony junction. Correction of high septal deviation will be
discussed during the correction of septal deviation.
Second, a hypertrophied inferior turbinate may also prevent mobilization of the septum. Manipulation of inferior turbinate
will be discussed in the next chapter.
a
b
c
d
Fig. 15.17 Out-fracture and in-fracture by medial and lateral osteotomies for deviated nasal bone. (a) A patient has nasal deviation with concavity
on the patient’s right and convexity on the left. (b, c) Illustration of the out-fracture on the right side and in-fracture on the left. A long spreader
graft is placed between the septum and the right ULC. (d) Postoperative photograph
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687
Unilateral Osteotomy
Not all deviated nose correction requires bilateral osteotomy. Nasal bone deviation can be caused by concavity or convexity
in only one of the two nasal bones, with the contralateral nasal bone being relatively straight. In such a case, the deviated
nose can be addressed by unilateral osteotomy (Fig. 15.18).
If a C-shaped convex deviation is present unilaterally, an osteotomy by itself will not be adequate in correcting the devia-
tion. In such cases, the convexity can be decreased with a double-level osteotomy or by fracturing and flattening the convex
portion of the bone using a bone bender.
A focal depression from an old fracture cannot be managed by the usual combination of lateral and medial osteotomies.
Camouflage technique using cartilage graft can be helpful. Another method is to elevate the depressed portion of the bone
after dissecting the underlying mucosa. The depressed portion of the bone from old fracture is often healed by fibrous union,
which allows for an easier elevation of the fragment without any osteotomy. The elevated nasal bone fragment can be sup-
ported by intranasal packing.
a
b
c
d
e
f
g
Fig. 15.18 Unilateral osteotomy. (a, b) This male patient has a deviation and saddle-nose deformity from a nasal trauma. (c) Operative design for
unilateral osteotomy on right side. (d) Exploration reveals caudal and dorsal septal deviation. (e) An extended spreader graft (costal cartilage,
tongue-and-groove pattern) was used to correct septal deviation and reconstruct the collapsed mid-vault. The patient also underwent radix augmen-
tation using costal cartilage. (f, g) Postoperative photographs demonstrate straightened nasal axis and added definition to the radix and supratip
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688
Correction of Mid-Vault (Cartilaginous Dorsum) and Deviated Septum
Mid-vault deviation is due to deviation of upper lateral cartilages, and it is synonymous with dorsal septal deviation.
Correction of septal deviation is the most important aspect of deviated nose correction because the deviated septum is the
core pathologic structure that is responsible for deviated mid-vault as well as deviated tip and columella. Maurice Cottle best
explained the importance of septum by the adage, “As the septum goes, so goes the nose.” The crooked septum is central to
the crooked appearance of external nose. If the septal deviation is not adequately corrected, the deviation of external nose
cannot be corrected in a complete manner.
Additionally, septal deviation is a main cause behind the airway obstruction. Therefore, correction of septal deviation is
essential for straightening the dorsum and correction of deviated tip/columella, as well as functional improvement.
The goals of septal correction are as follows:
1. To centralize the septum as a foundation to correct the deviations in the cartilaginous dorsum and columella
2. To improve nasal airflow (i.e., nasal obstruction)
3. To provide the cartilage graft needed for spreader graft and additional tip plasty
Approach to the Septum
If a mid-septal or caudal septal deviation corrected solely for correction of nasal obstruction, the endonasal approach is
appropriate, using Killian (or modified Killian) approach, transfixion, or hemitransfixion incision.
However, the open approach is more useful for the addition of dorsal septal deviation and tip plasty. In this case, the inter-
crural (anterior) approach is used to access the septum.
In the manner described above, the mucoperichondrial is elevated from the anterosuperior septum to the midportion, the
cephaloposterior septum, and to the cartilage/vomer junction. During this maneuver, a D-knife or scalpel is used to separate
the upper lateral cartilages from the dorsal septum.
The mucoperichondrium adheres tightly to the posterocaudal septum. If this area is approached from the nostril, the
mucosa can easily be torn. A safer direction would be to approach from the cephaloposterior septum to the caudal portion.
The mucoperichondrial attachments must be widely released. If the deviation is present in the caudal septum, the dissection
should extend to the anterior nasal spine (ANS).
Correction Principle of Septum
Once the septum has been freed from the upper lateral cartilages and the mucoperichondrium, the operator can assess the true
extent of the curvature in the septum (i.e., intrinsic component of septal deviation).
The deviation can be present in any area of the septum: the mid-septum, dorsal septum, and caudal septum (Fig. 15.19).
In addition, there are various configurations of septal deviation, including septal tilting, bony spur, focal deviation, C-shaped
deviation, and S-shaped deviation.
Regardless of the type of deviation, the author observes the following principles in correcting the septum.
The septal deviation is corrected in the order of submucosal resection (SMR), correction of caudal septal deviation, and
correction of dorsal septal deviation.
Detachment of the upper lateral cartilages and SMR removes the extrinsic factors for septal deviation, which will remove
a significant degree of dorsal and causal septal deviation. In this state, correction of the caudal septal deviation can often be
enough to straighten the dorsal septum. Any remaining deviation in the dorsal septum can be removed as the last step.
SMR is the only maneuver that needs to be performed before nasal bone osteotomy. The remaining steps for septal cor-
rections are performed after the osteotomy.
15 Deviated Nose Correction and Functional Rhinoplasty