A suture suspension technique for improved repair of a crooked nose deformity.

Repair of a crooked nose deformity can be a formidable task. The correct cause must be established in order to achieve a successful correction. Too often, a well-intentioned surgeon will perform an osteotomy of the ascending process of the maxilla in an attempt to shift the nasal pyramid into a central position. However, this procedure is doomed to fail in cases where the deformity is caused by a septal misdirection rather than a bony deviation.

Caudal or inferior septal deflections are routinely approached and successfully treated through a closed endonasal approach without disrupting the dorsal nasal septum. However, if a crooked nose is influenced by a proximally deflected dorsal septum, it is necessary to treat this portion of the septum directly in order to achieve a correction.

The senior author (S.H.D.) has developed a suture-suspension technique to correct a proximally deviated dorsal septum. An external rhinoplasty approach is used to facilitate adequate exposure. Wide undermining of the skin soft-tissue envelope and septal mucoperichondrium is performed in order to achieve complete exposure of both the nasal bones and the deflected septum. The deflected dorsal segment of the septum is then divided from the upper lateral cartilages in a submucoperichondrial plane. The free but distorted dorsal septum is vertically transected through the deviated segment with a Converse scissors (figure 1, A).

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Next, a 3.0-mm Skeeter drill (Xomed Medtronic; Jacksonville, Fla.) is used to drill two small holes into the nasal bone on the side opposite the direction of the septal deflection (figure 1, A). The distal segment of the divided septum is then brought into a midline position with a horizontal mattress suture (4-0 polydiaxanone [PDS]) that extends from its dorsal border to the holes drilled through the nasal bones (figure 1, B). Finally, a unilateral spreader graft that spans the transection is placed along the cut dorsal septum on the side opposite the suture. The graft provides support to the dorsal septum.

Thus far, the senior author has performed this technique on 12 patients. On 24-month follow-up, straight nasal alignment with improvement in nasal airflow has been maintained in each (figure 2). In 8 of the 12 patients, this technique has been used in conjunction with osteotomy, and there have been no complications or failures.

[FIGURE 2 OMITTED]

Other authors have previously described placement of unilateral and bilateral spreader grafts as a means of correcting the crooked nose deformity. We present an alternate technique that provides an additional mechanism for straightening the septum.

A crooked nose deformity is a common entity that can be caused by various anatomic factors. The suture-suspension technique described here corrects high proximally oriented deviations of the dorsal septum and provides enough stability to resist septal cartilage memory.

Suggested reading

Rohrich RJ, Gunter JP, Deuber MA, Adams WP. The deviated nose: Optimizing results using a simplified classification and algorithmic approach. Plast Reconstr Surg 2002;110;1509-23; discussion 1524-5.

TerKonda RP, Sykes JM. Repairing the twisted nose. Otolaryngol Clin North Am 1999;32:54-64.

Toriumi DM, Ries WR. Innovative surgical management of the crooked nose. Facial Plast Surg Clin North Am 1993;1:63-78.

From the Division of Facial Plastic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Illinois at Chicago.