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Page 2 of 9 Morisada et al. Plast Aesthet Res 2024;11:35 https://dx.doi.org/10.20517/2347-9264.2023.119

ANALYSIS OF THE TWISTED NOSE
The first step in addressing the crooked or twisted nose starts with a thorough physical examination to
understand the factors contributing to the patient’s deformity and allow for the creation of an accurate
surgical plan. Baseline facial analysis and asymmetry (e.g., hemifacial microsomia) should be assessed and
pointed out to the patient, as this may contribute to the perception of a crooked nose. Symmetry in both the
vertical and horizontal dimensions should be scrutinized closely. For vertical symmetry, using the midline
teeth, lip, or glabella can help to determine any discrepancy and degree of deviation. The patient’s skin type
and thickness should be noted, since thicker skin tends to better camouflage cartilage irregularities. Noting
areas of scarring, contracture, and contour irregularities can give insight into what may have been
previously resected or missing from the native structure. Observing both normal and then more forceful
inspiration may reveal the presence of dynamic nasal valve collapse . The external nasal appearance should
[1]
be analyzed and broken down by upper, middle, and lower thirds [Table 1]. Both the side of deviation and
the shape of the deformity can help one to predict the underlying cartilage contour. The base view is then
analyzed with attention to nostril asymmetry and the presence of caudal septal deviation. Nostril asymmetry
is often a difficult problem to correct and can be the result of soft tissue, lower lateral cartilage crural size or
shape, or caudal septal deviation. Manual palpation of the caudal septum aids in identifying the shape and
strength of the caudal septal strut. Intranasal examination is useful for analyzing the nasal airway including
any septal deviation or nasal valve narrowing that contributes to nasal obstruction. The modified Cottle
maneuver is performed by placing an instrument gently under the upper lateral cartilage caudal edge and
lifting superiorly and laterally. It should be noted that only gentle support of the nasal sidewall rather than
dramatic and overaggressive lateralization should be performed for the most accurate assessment and to
provide realistic expectations for improvement with surgical intervention. Patients who subjectively report
improved airflow during the modified Cottle maneuver may benefit from grafting to open and/or stiffen the
nasal valve. Finally, preoperative photographs should be obtained of the frontal, oblique, lateral, and base
views . These photos may reveal subtle deformities overlooked during the initial physical examination, can
[1]
be reviewed pre- and postoperatively by the surgeon and/or patient, and are used for medicolegal
documentation. The use of anatomic landmarks to ensure photos are taken straight and without slight
tilting or turning of the head can aid in determining the degree of asymmetry or deviation. Many patients
learn to turn their heads to make photos more favorable, but this can preclude accurate assessment and
counseling. Candid discussion and appropriate expectations should be established with the patient
preoperatively.

TECHNIQUES TO ADDRESS NASAL DEVIATION BY SUBSITE
Correction of upper third
Correction of the upper “bony” third has been classically based on osteotomies for control and
manipulation of the bony pyramid to create smooth brow-tip aesthetic lines . Thorough evaluation with
[2]
both visual inspection and palpation of nasal bone contour differences, irregularities, asymmetry, and prior
fracture lines can help with planning the osteotomies. When there is a significant discrepancy in the length
of the nasal sidewall, multiple lateral osteotomies or an intermediate osteotomy is useful on the longer nasal
bone or to correct a convex shape . In our practice, we utilize the “high-low-high” lateral osteotomy
[3,4]
technique with subsequent digital manipulation and molding . The initial “high” cut is started high on the
[5]
pyriform aperture to preserve Webster’s triangle and avoid nasal airway collapse. The angle of the hand is
then dropped for the “low” portion which is well within the maxillary groove to avoid palpable osteotomy
step-offs. Finally, the last “high” angle is curved superiorly again toward the nasofrontal suture line. Medial
osteotomies can be performed in order to control the back fracture and are sometimes completed prior to
open septoplasty to avoid destabilizing the dorsal septal keystone region. Occasionally, a percutaneous
transverse osteotomy aimed caudally from the nasal root, in addition to bilateral lateral osteotomies, can