straight septum, crooked nose: an overlooked concept

ORIGINAL ARTICLE AESTHETIC

Straight Septum, Crooked Nose: An Overlooked Concept

Farhad Hafezi • Bijan Naghibzadeh •

Abbas Kazemi Ashtiani • Bahman Guyuron •

Amir Hossein Nouhi • Ghazal Naghibzadeh

Received: 15 February 2013 / Accepted: 6 September 2013 / Published online: 20 November 2013

� Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2013

Abstract

Introduction Asymmetric facial skeletal growth is a

common finding in the rhinoplasty patient population. This

common abnormality affects all facial components,

including the upper lateral cartilages (ULCs). The asym-

metric growth also may produce uneven thickness, con-

sistency, curvature, and elastic recoil of the ULC. Ignoring

this asymmetry may have a marked impact on the outcome

of any rhinoplasty operation, especially in the management

of crooked noses.

Materials and Methods The files of 89 consecutive rhi-

noplasty patients who underwent surgery by a single sur-

geon were reviewed for deformities of the middle vault and

to tabulate the procedures performed in each individual

case.

Results Of the 89 rhinoplasty cases, 72 (81 %) had

asymmetric ULCs. Approximately 30 % (27/89) of the

cases had a straight septum with asymmetric ULCs which

required appropriate correction.

Conclusions Awareness of an asymmetric ULC in a

crooked nose and an attempt to correct this condition in

addition to straightening of the septum is key to decreasing

postoperative residual or recurrent mid-vault deviation.

Level of Evidence IV This journal requires that authors

assign a level of evidence to each article. For a full

description of these Evidence-Based Medicine ratings,

please refer to the Table of Contents or the online

Instructions to Authors www.springer.com/00266.

Keywords Crooked nose � Upper lateral cartilage �Postoperative deformities

Introduction

The middle third of the nose is the prevailing site of

postrhinoplasty aesthetic and functional deformities [1].

Although the upper lateral cartilage (ULC) has a primary

role in the creation of aesthetic dorsal lines and the

maintenance of a laminated airflow, few authors have

published papers addressing the anomalies and variations

of this structure [2–5].

By removal of the hump, the ULC is separated from the

septum, and the tripod integrity of the nasal dorsum is lost.

This manipulation jeopardizes the integrity of the middle

vault as a functional and aesthetic unit (Fig. 1).

An imbalance in the facial skeleton and soft tissue

growth produces facial asymmetry, which affects all the

facial elements (Figs. 2, 3, 4, 5I). These effects include

deflection of the nasal skeleton, nasal septum, and middle

F. Hafezi (&)

Burn Research Center, St. Fatima Hospital, Tehran University of

Medical Sciences, 172 Zafar St., Suit 9, Tehran, Iran

e-mail: [email protected]

B. Naghibzadeh

Loghman Hakim Hospital, Shahid Beheshty University of

Medical Sciences, Tehran, Iran

A. K. Ashtiani

St. Fatima Hospital, Tehran University of Medical Sciences,

Tehran, Iran

B. Guyuron

Department of Plastic Surgery, Case Western Reserve University

and University Hospitals Case Medical Center, Cleveland, OH,

USA

A. H. Nouhi

Kowsar Laboratory, Tehran, Iran

G. Naghibzadeh

Tehran University of Medical Sciences, Tehran, Iran

123

Aesth Plast Surg (2014) 38:32–40

DOI 10.1007/s00266-013-0230-1

http://www.springer.com/00266

third and the ULCs toward the shorter side of the face [6–

8]. The asymmetry of ULCs also can contribute to a

middle-vault deformity.

An asymmetric middle vault and asymmetric ULCs

require particular attention, particularly after their separa-

tion from the septum and during removal of the dorsal

Fig. 1 a Asymmetric upper

lateral cartilages (ULCs) and

minimal septal deviation

(arrow). b Autospreader flaps or

spreader grafts alone are not

sufficient to correct all these

anomalies. All available

resources should be used to

correct this type of asymmetry.

Arrows indicate severely

asymmetric ULCs

Fig. 2 a, b Asymmetric upper

lateral cartilages (ULCs) are

much more severe in cleft lip

nose deformities due to the

disproportionate skeletal and

soft tissue growth on the sides

of the face. The arrows show the

asymmetric ULCs

Fig. 3 a Preoperative photo

showing a minimal left supratip

depression. b The deformity is

more apparent after removal of

the hump. The arrow shows the

concave left upper lateral

cartilage (ULC) accompanying

the C-shaped septum

Aesth Plast Surg (2014) 38:32–40 33

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hump. This study aimed to investigate the frequency by

which the mid-vault asymmetry can be present without a

gross septal deviation and to emphasize the rule of elimi-

nation of this abnormality in successful correction of the

nasal deviation.

Materials and Methods

The files of 89 primary rhinoplasty patients who underwent

rhinoplasty between March 2011 and April 2012 were

reviewed for deviations or asymmetry of the middle vault.

The pathology and operative procedures for correction of

the septum and ULCs were reviewed in detail.

Results

Autospreader flaps were used on the right in 57 patients

and on the left in 51 patients, 49 of which were bilateral.

Spreader grafts were used on the right in 35 patients and on

the left in ten patients, one of which was bilateral

(Table 1).

Our analysis showed that only 11 % (10/89) of the

patients had a straight septum and symmetric ULCs,

requiring no intervention for either the septum or the

ULCs. However, 50.5 % (45/89) of the routine rhinoplasty

cases had significant dorsal septal deviation that required

septal straightening in addition to correction of the ULC

asymmetry (Figs. 8, 9). Only 8 % (7/89) of the patients

benefited from septal straightening alone (Table 2).

The interesting finding was that approximately 30 %

(27/89) of the patients had a straight septum with asym-

metric ULCs (Figs. 6, 7I). Long-term postoperative views

of two patients with 12- and 13-month follow-up periods

respectively are shown in Figs. 5 and 7.

Discussion

The classic correction of a crooked nose includes removal

of the hump if present, separation of the ULCs,

Fig. 4 a Crooked nose in 19-year-old boy. The arrow shows the

depressed left lateral wall. b–d Although the septum is almost

straight, upper lateral cartilage (ULC) asymmetry is conspicuous. The

arrows indicate a depressed left ULC compared with the right side.

Ignoring this deformity will result in a crooked nose postoperatively

34 Aesth Plast Surg (2014) 38:32–40

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straightening of the septum, and nasal bone osteotomies

[6]. However, persistent deviation of the mid-vault is a

fairly common source of patient and physician discontent

after this routine.

The hump anatomically comprises a wing-shaped

framework of the integrated septum and ULC. In the

keystone area, the ULC remains low and extends for

6–8 mm under the nasal bone. It extends caudally beneath

the lower lateral cartilage in the scroll area [9]. In addition

to the vertical components, the cephalic part of the hump

has a horizontal element worthy of attention [10, 11]. This

structure is permanently changed by removal of the hump

or by separation of its frame components from each other

[12] (Fig. 9). These changes include inferomedial reposi-

tioning of the ULC and an overall weakening of the mid-

dle-vault structures.

Additionally, hump removal can damage internal nasal

valve integrity and function, which may create static and

dynamic airway obstructions [13, 14]. By the same token,

preserving the T shape (transverse portion) of the ULC is

mandatory for keeping the internal nasal valve open, pre-

venting the inverted-V deformity and maintaining the

dorsal aesthetic lines [9, 15].

In the past three decades, the reduction-only philosophy

has been replaced gradually with the addition of autologous

tissues and augmentation for the correction of crooked

noses [6, 7, 16]. The spreader graft introduced by Sheen

[17] helped to correct inverted-V deformities. Before

popularization of the autospreader flap by Byrd et al. [18]

and Gruber et al. [19], ULCs were incised and trimmed,

and the excess portion was discarded.

Despite the remarkable benefits of the spreader flap, it

has a few shortcomings [20]. Its irregularity and asym-

metry in shape and its disparity in length and width are

crucial problems that may result in visible dorsal irregu-

larities and asymmetries.

Despite meticulous correction of the deviated septum

with different techniques, including asymmetric spreader

grafts and batten grafts, a high rate of postoperative mid-

vault deformities still occur [16, 21], especially in

Fig. 6 a Straight nose. b In

spite of a straight septum, the

cone-shaped upper lateral

cartilage (ULC) on the left side

(arrow) became apparent after

removal of the hump and

separation of the ULC from the

septum. c Correction of

asymmetry by a bilateral

autospreader flap and a

unilateral right-side spreader

graft (arrow) to minimize the

right ULC concavity

Fig. 5 Ia Minimal right supratip depression (arrow). Ib The middle

vault before the separation of its elements maintains its integrity may

appear to be straight. Ic After separation from the septum, the arrow

shows an anomalous upper lateral cartilage (ULC) on the right side. IIThe procedure for this patient was a bilateral autospreader flap plus a

right-side spreader graft. The photos show views before and

12 months after the rhinoplasty

b


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congenital, nontraumatic cases. The authors believe that

one of the major reasons for the high postoperative middle-

vault asymmetry after the correction of a crooked nose is

an overlooked asymmetric ULC. Attention to this entity

may reduce the incidence of incompletely corrected dorsal

asymmetry.

During the past few decades, nasal surgery has under-

gone an extensive evolution. Numerous papers have

reported the classification and anatomy of the deviated

septum, but we could not find any reports that explain or

classify ULC deformities and asymmetries as a cause of

mid-vault deviation.

Facial asymmetry is very common in the normal pop-

ulation. This asymmetry, which most likely is controlled

genetically, has a substantial effect on the total facial

skeleton [8]. The nasal skeleton usually deviates toward the

shorter, less developed side of the face [8]. This asym-

metric facial growth affects all the nasal structures

Table 1 Operative procedures performed

No. of patients Septal deviation, septoplasties Autospreaders Spreaders ULC resections ULC incisions Asymmetric ULCs

Right Left Right Left Right Left Right Left

89 52 57 51 35 10 0 21 4 15 72

ULC upper lateral cartilage

Fig. 8 a Severely crooked nose with depressed right lateral wall

(arrow) without any history of trauma in a 40-year-old man. b A

minimal septal deviation but a concave right upper lateral cartilage

(ULC) is compatible with deformity in the preoperative photo

(arrow). c Autospreader flaps are prepared by a longitudinal cut on

the upper border of the ULCs (arrows). d A right-sided spreader graft

is added to straighten the septum and to decrease the right ULC

concavity

Fig. 7 Ia Obvious nasal deviation to left side in a 21-year-old

woman. Ib Concave right upper lateral cartilage (ULC) is noticeable

(arrow). Ic After hump removal, the dorsum integrity is lost, and

although the septum is almost straight, the ULCs are exceedingly

unequal in shape (arrows). This result indicates that a dorsal septal

deviation is not the only etiology of the crooked nose and that ULCs

also should be considered. Surgery removed 1 mm of dorsal thickness

of the left ULC, and a bilateral autospreader flap procedure was

performed. A 2 9 15-mm spreader graft was added on the right side.

II The photos show views before and 13 months after rhinoplasty and

advancement of genioplasty in the patient

b


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including the nasal bone, septum, and lower lateral carti-

lage. Soft tissue also is involved in this process, which may

present as the asymmetric alae base. The ULC is no

exception to this rule. It has a significant anatomic and

physiologic role in the form and function of the nose. The

thickness, curvature, consistency, and elastic recoil of the

ULC can differ between the two sides of the nose, with a

marked effect on the outcome of any rhinoplasty operation,

particularly in the case of crooked and deviated noses.

The integrated T-shape structure of the nasal dorsum

may obscure the extent of a ULC’s asymmetry, but when

the ULC separates from the septum, as in hump removal,

this structural integrity is lost (Figs. 7I, 9). The recoil and

elastic forces of the septum and the ULCs that have been

neutralized by the opposing forces are released, and the

true shape of these three structures is seen (Figs. 5I, 6, 9).

The classic ULC management has been dorsal and

caudal trimming of this crucial structure. Although these

maneuvers minimize the asymmetry, the physiologic con-

sequence of this action is a respiratory problem, and the

anatomic consequence is an inverted-T deformity.

Preservation of the ULC during the modern rhinoplasty is

the rule, but keeping a malformed asymmetric structure has its

own consequences. A crooked nose may result from a previ-

ously straight nose, or some nasal asymmetry may occur in a

nose with a septum that has been diligently and meticulously

straightened if the ULC is not assessed and corrected pru-

dently. Paying special attention to the ULC including its

curvature, thickness, and recoil forces and ensuring that these

elements are symmetric and straight are mandatory, and this is

a crucial step in correcting a crooked nose.

The best time to diagnose an asymmetric ULC is during

the preoperative examination. An accurate observation,

Fig. 9 a Straight nose in

21-year-old woman. b Before

removal of the hump and

elimination of its integrity, the

middle vault appears to be

straight. c Septal deviation and

asymmetric upper lateral

cartilage (ULC) are shown after

a dorsum reduction (arrow)

Table 2 Anatomic findings during the operation

No. of

patients

Deviated

septum,

asymmetric

ULCs

Deviated

septum,

symmetric

ULCs

Straight

septum,

asymmetric

ULCs

Straight

septum,

symmetric

ULCs

89 45 7 27 10

ULC upper lateral cartilage


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especially palpation of the nasal lateral walls during the

physical examination, may disclose some of these asym-

metries preoperatively. Overhead-view photography is

valuable for detecting the asymmetry. The deformity

becomes more evident intraoperatively after separation of

the ULCs from the ULC-septal junction.

An unequal spreader graft and flaps have been recom-

mended by many authors for correction of disequilibrated

skeletal and soft tissue forces as well as middle-vault

deformities [15, 22]. These anatomic structures have been

promising and helpful, but despite all the classic proce-

dures, the revision rates in surgery for crooked noses

remains high [21], with a 9.8 % reoperation rate reported

by some authors [16].

Precise alignment of the middle vault and the ULCs to

rebuild the frame in a manner that tolerates the redraped

envelope and healing forces is mandatory [1]. The T-shape

framework at the keystone area is of primary importance in

any rhinoplasty procedure, but providing symmetry in this

important structure usually is overlooked.

Proper treatment consists of folding the spreader flaps

and suturing them together. This approach may decrease

the asymmetry of ULC to some extent in cases involving

minimal deformation. A complete or partial incision on the

dorsum of the ULC flap creates differential bending and

changes the cartilage recoil forces. Placement of an addi-

tional spreader graft on the thinner or weaker side is the

most frequently practiced technique. Septal straightening

also may help to some extent. Minimal resection of the

thicker side is the last choice and sometimes is inevitable in

exaggerated asymmetric cases (Figs. 6, 8).

Conclusion

The common purpose of ULC manipulation is to produce an

open septal ULC angle (inner valve,[10–15�) for normal air

flow that is a wide enough horizontal element to prohibit the

formation of an inverted-V deformity, but care should be

exercised to make it as symmetric and equal on both sides as

possible. The ULC is an important structure in the nasal

skeleton that needs special attention not only to maintain its

functional role but also to maintain its effect on the aesthetic

outcome of the anteriorly deviated nose.

Regarding the high percentage of asymmetric ULCs and

the impact on a postrhinoplasty crooked appearance, the

authors recommend considering asymmetric folding of

spreader flaps, complete or partial incision on the dorsum of

the ULC flap to create differential bending, additional sprea-

der graft on the thinner or weaker side, septal straightening,

and minimal resection of the thicker side as the last choice to

create more natural aesthetic dorsal nasal lines.

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straight septum, crooked nose: an overlooked concept

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