Çankaya, Ankara, Turkey

Ultrasonic Structural Rhinoplasty and Secondary Rhinoplasty

€6,000 - €14,000

Treatment Procedure and TechniqueAdvanced Surgery Techniques
Ultrasonic Structural Rhinoplasty6.000 Euro - 8.000 Euro
Secondary Rhinoplasty8.000 Euro - 16.000 Euro
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What is Nasal Deviation? How is it Corrected?

Shaping a crooked nose is significantly more challenging than shaping a straight one. Surgeries for crooked noses demand greater surgical expertise, and even in the most experienced hands, dissatisfaction and revision rates remain relatively high.

But why is it difficult? What do we mean by "difficult"?

The challenges of nasal surgery stem from the numerous variables involved in the surgery and the limitations, coupled with the high expectations of perfection from both patients and surgeons. Crooked noses form a "more difficult" subset within an already complex surgery. This is because there is often an expectation that a structurally asymmetric nose should become completely symmetrical after surgery, which is a significant challenge.

Contents

  1. Basic Information about Nasal Deviation
  2. Causes of Nasal Deviation
  3. Surgery for Nasal Deviation

Basic Information about Nasal Deviation

When we refer to a crooked nose, we mean a nose that appears to tilt to the right or left when viewed from the front, with the right and left halves of the nose being asymmetric concerning the midline of the face.

Crooked noses usually have internal deviations that match their external appearance, often accompanied by airway problems and breathing difficulties.

When correcting nasal deviations, the entire nose must be considered as a structural whole. It's not sufficient to fix the inside and leave the outside unchanged, or to make aesthetic adjustments externally without addressing the internal structures (at least not in modern rhinoplasty).

Nasal deviation and nasal asymmetry are often observed together but are fundamentally different concepts. Understanding the difference between deviation and asymmetry is crucial for developing realistic expectations. Deviation means that the midline of the nose differs from the midline of the face, whereas asymmetry refers to differences in size and shape between the right and left sides of the nose. Often, deviation and asymmetry coexist, but it's important to understand that a nose can be asymmetrical without being crooked.

For instance, imagine a perfectly symmetrical nose with no deviation. If we inject 1 cc (milliliter) of filler into one side of the nose, it would appear asymmetrical and crooked, even though the nose is structurally straight.

This concept also applies when evaluating issues that persist after surgery. Even after correcting the nasal deviation—aligning the nasal midline with the facial midline—the nose may still appear crooked due to asymmetry between the right and left nasal walls. As a rule, the human face is asymmetric, and the nose is no exception.

The nasal skeleton consists of paired structures. The right and left components of all the structural subunits (bones and cartilages) that form the nose may differ in size, shape, flexibility, and thickness, even in normal individuals.

Causes of Nasal Deviation

The most common cause of nasal deviations we encounter is trauma during early developmental stages. Sometimes the individual may not even remember the trauma, such as a swing hitting them when they were three years old. Blows to the nose can break the cartilaginous wall in the middle of the nose. This cartilaginous wall is the growth center of the nose, and as the individual grows, the nose may develop asymmetrically over the years, resulting in a noticeable deviation. Long-term developmental asymmetries may lead to the bones and cartilages of the right and left sides of the nose having completely different lengths, thicknesses, and concave/convex shapes. Nasal deviations can also occur following traumatic injuries in adulthood.

Developmental issues in the facial bones also affect the nose. For example, if the upper jaw is crooked, tilted, or developmentally asymmetric, the nose must also be crooked because it sits on an uneven platform. For instance, children with cleft lip and palate may develop complex nasal deformities due to underdevelopment of the upper jaw on the side of the cleft.

As you can see from these descriptions, nasal deviations can be congenital, developmental, or acquired, and they are quite complex problems.

Surgery for Nasal Deviation

One of the most critical issues in crooked noses is cartilage memory. Even if you make the elastic septal cartilage wall in the middle of the nose perfectly straight during surgery, this cartilage, being a living and biological material, can bend again in the long term due to the healing forces. Various suturing techniques and cartilage weakening techniques have been described to overcome cartilage memory in crooked nose surgeries. Unfortunately, they do not consistently produce stable results. In structural rhinoplasty, we use cartilage-based columns and beams, known as structural grafts, to correct the curvature. In crooked nose surgeries, structural grafts can be placed asymmetrically to neutralize the deviations.

In cases of advanced deviation, where the internal nasal cartilages are curved in two different axes, and the deviation originates from the junction of the bony wall at the back of the nose and the cartilage, it may be necessary to remove the nasal septum entirely, reshape it on the operating table, and then reinsert it into the nose. This approach is known as extracorporeal septoplasty. Such a surgery will take much longer than a standard nasal surgery, may require the use of external cartilage sources, and will involve a different follow-up and long-term treatment plan. As a result, the cost will be higher than routine rhinoplasty.

One of the developments that have significantly strengthened our hand in crooked nose surgeries in recent years is ultrasonic bone shaping technology (also known as piezo). Ultrasonic bone cutting technology uses precise micro saws to abrade the bone with sound waves. This allows us to shape nasal bones with a thickness of 1-4 millimeters without fully fracturing them or to create very delicate greenstick fractures that enable us to change the shape and angle of the bone.

Patients with crooked noses must understand that some degree of curvature will remain after surgery and that the nasal structures on the right and left sides of the midline will not be perfectly symmetrical. A "perfect symmetry expectation" will only lead to disappointment. There are clinical case examples where noses that were severely crooked before surgery become nearly straight and almost symmetrical after surgery. I have such examples in my archive, and we can look at them together when you come, but you should know that these examples do not set a standard for the clinical outcomes that can be achieved in crooked nose surgeries.

Some patients with crooked noses struggle to find a doctor willing to perform the surgery, while others face high surgical costs quoted by the doctors they consult. The primary reasons for the increased cost of these surgeries include hospital costs, potential revision costs, the additional cost of the extended surgical time, increased surgeon experience, and fewer surgeon options.

The information provided here about crooked noses was not written to cause concern. Today, in Turkey, one out of every three patients we operate on presents with significant nasal deviations. Generally, patients with crooked noses benefit the most from surgery and experience the most significant changes. However, a perfectionist expectation of flawless symmetry before surgery can lead some patients in this group to focus on minor post-operative issues and become unhappy despite the remarkable changes they have achieved. The only essential precondition for achieving happy patients in plastic surgery is starting with accurate and realistic expectations before the surgery. This article was written with that purpose in mind.

Assoc. Prof. Dr. Ozan Bitik

Çankaya, Ankara, Turkey

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