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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
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