Rhinoplasty Dr Bashar Bizrah Article on: The Crooked Nose Part 3: Postoperative Care

IV. Postoperative Care:

1. Nasal pack removed after 24 hours.
2. Patient is discharged home on the following day.
3. Patient reviewed in the clinic one week later for removal of the plaster (Special nose massage instructed). (Fig. 2 – 6,7)
4. Three weeks follow-up.
5. Two months follow-up.
6. Six months follow-up.
7. Follow-up at patient’s request.

V. Hints to remember with Crooked Nose:

1. Small and intermediate humps are best left to the end of the operation, after tip correction. This is due to the fact that there is always mild collapse in crooked noses following septoplasty and osteotornies, so it is important to preserve bone and cartilage.

Fig. 9 - 11. Classical and medial and lateral osteotomies may not be adequate to achieve straight, well oriented nasal bones. If doing
lateral and medial osteotomies alone, the concave and convex margins, the author means, the banana shape will slightly shilt from a lateral to a more central position, preserving the banana shape. Therefore, an intermediate osteotomy is essential to break the banana shape and to achieve full mobilization and accurate repositioning of the nasal bones in a straight and symmetrical manner. Again, w hen deviation starts from the root of the nose (nasion), a transverse osteotomy is mandatory in order to straighten the deviated nasal bones.

2. Ensure that you leave behind symmetrical and normal anatomically shaped upper lateral cartilages. If there is any depression on the cartilage, augment with cartilage at the end of the procedure.
3. Ensure that you leave behind bilateral symmetrical alar cartilages.
4. Be conservative when trimming the lateral crura and upper lateral cartilage. This should be a gradual process, taking away a little at a time. If too much cartilage is removed, one will need to augment, which later causes problems related to grafting.
5. Intermediate and transverse osteotomies may be needed to achieve good repositioning of the nasal bones, make sure that the bones are freely mobilized without any tension pulling on either side.
6. Try to preserve septal cartilage in order to use it for augmentation. If this is not adequate, use conchal graft.
7. Correction of the caudal septal dislocation by conservative trimming of the caudal septum may be, in some cases adequate to correct the deviation of the cartilagenous component of the nose.
8. To prevent supratip collapse and columellar retraction, the integrity of the L-shaped septal strut should be strengthened and framed by supratip grafts and columellar grafts.
9. Following septorhinoplasty most of the factors achieving tip support are interrupted, therefore, compensatory measures for tip support should be considered (new dome creation, suture fixation, scoring, columellar strut and tip graft).
10. Ensure that the dressing and plaster of paris are applied perfectly. Check the plaster the next operative day before the patient is discharged and if it is loose change it.
11. Large hump and crooked nose. (Fig. 9 -13)
    In a crooked nose, the lateral walls of the nose are asymmetrical. Therefore, when removing a large hump with I-shape osteotome, the osteotome should not be parallel to the face, but positioned slightly in an oblique way away from the deviated side. This is done in order to leave wherever possible, equal nasal lateral bony walls, thus avoiding overlapping of the bone after approximation.
12. Remember, the main problems following poorly performed septorhinoplasty are:
    – Persistent crooked nose
    – Nasal collapse and saddling
    – Loss of tip support: dropped wide tip

Fig. 9 - 12. Trimming of caudal end of septum in order to correct caudal dislocation.

Fig. 9 - 13. Large hump and crooked nose The osteotome should not be parallel to the face. It should be positioned slightly in an oblique way away from the deviated side. This is done in order to leave as much as possible equal bony walls, in order to avoid overlapping of the bone a~er approximation.

Fractured nasal bone

Fig. 9 - 14. Reduction of fractured nose:
      First: Elevate the non-depressed bone
      Second: Elevate the depressed bone
      Third: Approximate the nasal bones

Pollybeak

• Tip asymmetry
• Columellar retraction
• Flaring of the alar rim
• Wide bony pyramid
• Open roof deformity
• Hanging columella
• Impaired airways

All of the above mentioned problems would be avoided by performing adequate septorhinoplasty: Preservation of L-shaped strut, conservative hump removat adequate osteotomies, dorsum overlay graft, spreader grafts and compensatory measures to achieve tip support (new dome creation, suture fixation, scoring, columellar strut, tip graft and lateral crura overlay technique).