Crooked & Twisted Nose

CROOKED & TWISTED NOSE RHINOPLASTY (Washington DC, Virginia & Chevy Chase Maryland)

Some say, “The essence of beauty is symmetry.”  But in reality, symmetry is more an aspired ideal than a realized actuality.  In fact, symmetric human faces are extremely rare.  Over 85% of people have significant facial asymmetry. That is the norm.  The eyes are almost never at the same level.  The cheekbones are usually not at the same height or width.  The mid part of the forehead does not often line up with the mid portion of the lips.

And the nose is not perfectly symmetric from side to side.  These are all widespread norms of the human visage.  It is extremely rare to find a very symmetric nose.  How could the nose, a midline anatomic structure, be perfectly symmetric when the two sides of the face are almost never perfectly even?  “If you were to build a house on uneven grounds, most certainly the house would be tilted.”

Classic anatomic studies have taken one side of the face, copied it, then flipped and used it to create a mirror image for the other side, and vice versa.  Consistently, these two resultant faces, made from each left and right halves, have shown to be very different indeed.  These studies highlight the significant, normal asymmetries of the human face, where the left half and the right half vary greatly.  But these same studies have also shown that the asymmetric original face is often aesthetically more pleasing to the human eye than the perfectly symmetric left- or right-based versions.

So asymmetry is a part of the human face and a reality.  A perfectly symmetric nose on an asymmetric face would not look right.  It all has the blend and it all has to fit.  A face can be asymmetric, yet balanced, harmonious and attractive.  In fact, some of the most famous and attractive celebrities have extremely asymmetric faces (Tom Cruise, Shannen Doherty, Keira Knightley, etc).  When the nose is awkwardly twisted, tilted, or crooked, it may draw excess attention to itself, relative to the rest of the face, creating an aesthetic problem.

Anatomic reasons for a crooked nose or a twisted nose or a C-shaped nose are:

  • Asymmetric nasal septum (deviated septum)
  • Asymmetric nasal bones
  • Asymmetric middle vault cartilages (Upper Lateral Cartilages)
  • Asymmetric tip cartilages (Lower Lateral Cartilages)
  • Asymmetric alar rim length (nostrils)
  • Significantly asymmetric facial bones

Clinical reasons for a crooked nose or a twisted nose or a C-shaped nose are:

  • Congenital / Developmental
  • Trauma
  • Poorly performed previous Rhinoplasty
  • Poorly healed previous Rhinoplasty

Lets briefly discuss healing after a Rhinoplasty and why healing forces may create asymmetries:

    • Some surgeons prefer to create very strong and prominent post Rhinoplasty noses, using lots of rib cartilage to place 10 to 20 grafts in the nose.  Such strong and wide noses withstand the healing forces and scar tissue contracture better than average.  But most patients do not like having a larger, wider, stronger nose after a Rhinoplasty.  Most patients will not want to wait 3-5 years for the rib cartilage to melt and mold before their nose looks aesthetically acceptable.  Most patients prefer aesthetic, beautiful, natural and refined noses.  Most patients want to see immediate improvements after a Rhinoplasty and be able to enjoy their new nose even the week after a Rhinoplasty.  If a post Rhinoplasty nose looks significantly better as early as 7 to 10 days after a Rhinoplasty, patients will enjoy and witness the rest of the refinement and healing over the following 1 to 3 years.   But patients should not have to wait for 3 years to start enjoying their new nose after a Rhinoplasty.  However, there is a trade off and each patient has to make a decision between wanting a “cuter” nose or a stronger nose that withstands scar tissue forces.  Either is fine as long as the patient is fully informed, and an active part of the decision making.
    • To understand scar tissue after a Rhinoplasty lets use an analogy in carpentry:  Imagine you hire a carpenter to shave down the wooden legs of your dining room table, to create a more refined shape.  The newly refined table would look great, forever, if it weren’t for weight exerted on the tabletop.  The problem will be if someone comes along and sits on the new more slender looking dining room table.  At that point, the smaller, sleeker wooden legs may not be able to withstand this new weight and will buckle or break.  If the table is analogous to the nose, then the weight on the newly modified table is scar tissue after a Rhinoplasty.  Scar tissue is what changes the nose after a Rhinoplasty.  Scar tissue is inevitable.  It will occur.  And it will change the results of the Rhinoplasty from week, to month to year to decade.  But good a-traumatic technique can minimize scar tissue.  Good technique also involves good judgment in creating a more refined nose but also one that can decently withstand the healing forces of scar tissue contracture after a Rhinoplasty.   Scar tissue forms after any surgery but with the nose, it is especially important.  Scar tissue forming deep inside the abdomen after bowel surgery is not visible (although it can create its own specific set of problems).  But scar tissue on the 3-dimensional nose can distort things while the nose heals.  Stronger, larger, thicker noses with more cartilage and thicker skin, will withstand the twisting forces of scar tissue.  There will always be scar tissue but stronger noses will not be influenced as much.   However, scar tissue should never scar or deter a realistic patient from undergoing a Rhinoplasty. As long as a patient understands that a Rhinoplasty Specialist Surgeon can improve the nose significantly, then slight changes to the nose as it heals, over the life of the patient, should not matter.  Perfection is an ideal but not a reality.  Significant improvement is the actual goal of Rhinoplasty. The nose should not become worse but rather it should be greatly improved after a Rhinoplasty.  In experienced, skillful and artistic surgical hands, this is very possible.  Realistic patients should take comfort in this fact.  But more importantly, a patient who accepts nothing less than “perfection” or demands “100% symmetry,” is not a candidate for elective Rhinoplasty.
  • Scar tissue is the enemy after a Rhinoplasty

    ✓ A non operated nose does not have scar tissue acting upon it

    ✓ A post Rhinoplasty nose has scar tissue forces acting upon it for months and years.

    Scar tissue is inevitable

    ✓ Scar tissue takes 2-3 years or even longer to mold and mature

    Scar tissue contracts and shrinks as it matures.  These forces can pull the nose from side to side.

    ✓ A post Rhinoplasty nose is often smaller, weaker and more susceptible to forces exerted by scar tissue and healing.

Rhinoplasty techniques for correction of a crooked nose or a twisted nose or a C-shaped nose are:

  • Septoplasty to correct a deviated septum.  The inside and outside of the nose are intimately connected.  When one is deviated, it often “pulls” the other with it and vice versa.  Correction of a deviated septum occasionally requires correction of a deviated external nose.  Correction of a deviated external nose often requires correction of a deformed septum.
  • Osteotomies to correct asymmetric nasal bones.  Asymmetric osteotomies are often needed: Double osteotomies on the longer nasal bone.
  • Correction of asymmetric Upper Lateral Cartilages or dorsal septum using spreader grafts.
  • Correction of asymmetric Lower Lateral Cartilages with proper grafting and suture tip techniques.
  • Alar augmentation, reduction or support to correct asymmetric alar rim length (nostrils).
  • Surgery to correct or augment significantly asymmetric facial bones

Cartilage sources for grafting are septal cartilage, ear cartilage and rib cartilage.