The crooked nose: principles of treatment.

Correction of the crooked nose is one of the most challenging procedures in rhinoplasty. The goals of the surgery are creation of a rigid and straight cartilaginous L-strut, correction of the deviated bony structures, and improvement of the nasal airway. Curvatures of the dorsal septum can be corrected with several techniques. Spreader grafts, cartilage batten grafts, or ethmoid bone grafts can be utilized for internal stenting to straighten the dorsal deviations. The surgical treatment for a deformed caudal septum with the most predictable and successful outcome is resection and replacement with a straight septal cartilage graft. In severe deviations of septum cartilage involving both dorsal and caudal portions of the L-strut, extracorporeal reconstruction of the septal cartilage may be the required method. For correction of the deviated bony pyramid, several osteotomy methods can be employed. Medial osteotomy, low-to-low or low-to -high internal lateral osteotomy, double-level lateral osteotomies, and external lateral osteotomy are the options, depending on the deformity. Dorsal onlay grafts can provide camouflage for any residual asymmetries after septal reconstruction or can be applied for dorsal augmentation.