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Page 8 of 9 Morisada et al. Plast Aesthet Res 2024;11:35 https://dx.doi.org/10.20517/2347-9264.2023.119

RISK FACTORS FOR PERSISTENT DEVIATION
Many risk factors can predispose patients to a persistently twisted or crooked nose. Assessment of baseline
facial asymmetry should be performed and, if present, should be discussed with the patient to establish
appropriate expectations prior to surgical intervention. Congenital or acquired irregularities of the nasal
bones, cartilage, or soft tissue envelope make the deviated nose more challenging to correct. Severe
deviation of the dorsal or caudal septal strut that is not adequately released and reinforced will often
succumb to the memory of its native state and is a common site of failure in primary rhinoplasty due to the
use of more conservative techniques.

Postoperative infection or wound healing issues may lead to an increased risk of graft failure or
insufficiency; infections are often more severe in revision surgeries with poorly vascularized wound beds
and plentiful cartilage grafting. Meticulous postoperative care and aggressive treatment of early post-
surgical infection should be performed to avoid compromise of the underlying structure. Postoperative
infection can be observed as early as a few weeks after surgery and, in our practice, is most often seen in
high-risk patient populations such as healthcare workers with increased risk for colonization by drug-
resistant microorganisms or in patients requiring copious costal cartilage grafting. These patients are started
on early oral antibiotic treatment, with the most severe, resistant infections possibly necessitating
intravenous antibiotics and additional surgical intervention for infection debridement and drainage.

CONCLUSION
Failure to recognize the true site and degree of nasal deviation often leads to inadequate release and
reconstruction of the deviated portions of the nose. While an endonasal approach for intranasal septal
deviation may suffice in most patients with nasal obstruction, open approaches are frequently preferable for
more complex, and particularly revision, situations. The authors strongly advocate for the use of costal
cartilage that expands graft options and increases rigidity. Treatment of the crooked nose tests the skills of
the surgeon and frequently requires multiple techniques to achieve success.

DECLARATIONS
Authors' contributions
Conception and design of the manuscript, writing of the manuscript: Morisada MV
Conception and design of the manuscript, reviewing and editing of the manuscript, contribution of images:
Humphrey CD
Conception and design of the manuscript, reviewing and editing of the manuscript, contribution of images:
Kriet JD

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable. Given that this article is not a research study but rather an overview of techniques
incorporated, IRB approval was not obtained prior. We have obtained explicit written and verbal approval