The Crooked Nose

The desire to straighten a crooked nose can elude even a master rhinoplasty surgeon. I am delighted and honored by Dr. Sclafani's invitation to assemble this issue of Facial Plastic Surgery, revisiting the current thinking and techniques for repairing the crooked nose. As surgical technology and experience advance, the potential for new surgical options and outcomes will be introduced. By integrating and sharing the tried-and-true surgical approaches to the crooked nose with current innovations and trends, we, as facial plastic surgeons, will continue to stand upon the shoulders of those who came before us and lead the way for those who will follow.

The literature is rich with many algorithms and choices attesting to the complexity of the problem that is the crooked nose. Although no two noses are the same, identifying similar patterns of deformity and the underlying etiologies can be used as a guide to finding more and more reliable and successful solutions for improved function and cosmesis when repairing the crooked nose. Documentation, dating back to the early 20th century, indentified areas of obstruction from the septum to the nasal valves. For example, descriptions of caudal septal deflections and the corresponding surgical repairs have been continually modified from Dr. Metzenbaum to Dr. Pastorek, improving surgical outcomes when approaching this component of a crooked nose. Dr. Cottle, in the 1940s and 1950s, nicely outlined and identified the areas of the internal nose and how they contribute to airway obstruction. Although airway obstruction doesn't necessarily equate to an externally crooked nose, as the saying goes, the crooked nose regularly follows the crooked septum.

Improved comprehension of nasal biomechanics, from the nasal tip support structure to the septal L strut, has helped to validate current surgical techniques and guide more innovative approaches. It is through the examination and implementation of evidence-based medicine that surgeons can consistently reconstruct and reinforce support for the soft tissue and osseocartilaginous framework of the nose. The recent advent of polydioxanone (PDS) foil, used to reconstruct septal structures after significant septal trauma, represents another step forward in the surgeon's armamentarium. The growing area of bioengineering, of both autogenous cartilage and other tissue fillers of varying modalities, may minimize the need to obtain autologous grafting materials. The ultimate goal of this issue of Facial Plastic Surgery is to serve as a resource for all rhinoplasty surgeons confronted with a crooked nose.

I would like to acknowledge the time and effort of the contributing authors. I hope you find their insight and management of this difficult issue helpful in your surgical approach and management of the crooked nose.