The Laryngoscope
C 2013 The American Laryngological,
V
Rhinological and Otological Society, Inc.
Deviated Nose Correction: Different Outcomes According
to the Deviation Type
Gye Song Cho, MD; Yong Ju Jang, MD, PhD
Objectives/Hypothesis: The present study analyzed 631 deviated nose cases to determine the overall success rate of
correction, the treatment outcomes according to the different types of deviation, and the revision rate.
Study Design: Case series study.
Methods: We reviewed 631 patients who underwent rhinoplasty for correction of a deviated nose with a minimum
follow-up of 18 months. Surgical outcomes were classified as excellent, good, fair, or no change. Deviations were classified
into five types: type I, a straight tilted bony pyramid with straight tilted cartilaginous vault in the opposite direction; type II,
a straight tilted bony pyramid with concavely or convexly bent cartilaginous vault; type III, a straight bony pyramid with
tilted cartilaginous vault; type IV, a straight bony pyramid with bent cartilaginous vault, and type V, a straight tilted bony pyramid and tilted cartilaginous dorsum in the same direction.
Results: Postoperative assessment showed that 80.2% of the 631 patients had successful (excellent or good) outcomes,
and 19.8% had unsuccessful (fair or no change) outcomes. Deformities of types I through V occurred in 169 (26.8%), 139
(22.0%), 150 (23.8%), 101 (16.0%), and 72 (11.4%) patients, respectively, of whom 34 (20.1%), 39 (28.1%), 11 (7.3%), 11
(10.9%), and 30 (41.7%) had unsuccessful outcomes. Analysis showed that the frequency of unsuccessful outcomes differed
according to the deviation type (P < .001). Forty-one patients (6.5%) required revision rhinoplasty owing to dissatisfaction.
Conclusions: An unsatisfactory surgical outcome is a significant risk following surgical correction of a deviated nose.
The type of deviation affects the likelihood of a successful outcome.
Key Words: Rhinoplasty, deviation, nose, treatment, outcome.
Level of Evidence: 4
Laryngoscope, 123:1136–1142, 2013
INTRODUCTION
The deviated nose is a common deformity encountered in rhinoplasty, and yet it remains one of the most
difficult and challenging pathologies to treat, even for
experienced surgeons.1 Although numerous surgical
approaches have been documented in the literature,
there is still no technique that can guarantee a successful outcome, and no technique has a clearly lower
revision rate. To enable more accurate diagnosis and
treatment of deviated noses, some studies have created
criteria by which to categorize deviations.2,3 We
described a new classification system in 2008, which
placed external nose deviations into five categories
depending on the relationship between the bony pyramid
and the cartilaginous vault.4
From the Department of Otolaryngology, Asan Medical Center,
University of Ulsan College of Medicine, Seoul, South Korea.
Editor’s Note: This Manuscript was accepted for publication December 16, 2011.
Presented at the American Academy of Facial Plastic and Reconstructive Surgery Fall Meeting, San Francisco, California, U.S.A., September 8–11, 2011.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Yong Ju Jang, MD, PhD, Department of
Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, South Korea.
E-mail: [email protected]
DOI: 10.1002/lary.23195
Laryngoscope 123: May 2013
1136
In deviated nose correction, unsatisfactory cosmetic
outcomes lead to high failure and revision rates. Many
surgeons believe that the risk of an unsatisfactory outcome is linked to the type of deviation. However, few
studies have examined outcomes of extensive case series
and analyzed success rates according to the types of
deviated nose. The present study analyzed outcomes in
631 deviated-nose patients treated by a single surgeon.
We evaluated the overall success rate of deviation correction, treatment outcomes according to the type of
deformity, and revision rate.
MATERIALS AND METHODS
Study Design and Patients
This study was approved by the institutional review board
of the Asan Medical Center in Seoul, South Korea. The study
involved 631 patients (489 males and 142 females) who underwent rhinoplasty for correction of a deviated nose between
November 2003 and February 2010. All operations were performed by one surgeon (Y.J.J). Patient ages ranged from 13 to 68
years (mean, 32.4 years). Follow-up ranged from 18 to 74
months, with a mean of 34.7 months.
Classification of Deviated Noses Into
Five Categories
Deviated noses were categorized according to our previously published classification system4: type I ¼ a straight tilted
bony pyramid with a straight tilted cartilaginous vault in the
Cho and Jang: Treatment Outcome of the Deviated Nose
Fig. 1. Five classifications of deviated nose. Depending on the orientation of two horizontal subunits (the
bony pyramid and the cartilaginous
vault) with respect to the facial midline, the nasal deviations are classified into five types. From Jang
C 2008 American
et al.5 Copyright V
Medical Association. All rights reserved. Reprinted with permission.
[Color figure can be viewed in the
online issue, which is available at
wileyonlinelibrary.com.]
opposite direction; type II ¼ a straight tilted bony pyramid with
a concavely or convexly bent cartilaginous vault; type III ¼ a
straight bony pyramid with a tilted cartilaginous vault; type IV
¼ a straight bony pyramid with a bent cartilaginous vault; and
type V ¼ a straight tilted bony pyramid and a tilted cartilaginous dorsum in the same direction (Fig. 1).
Surgical Techniques
Surgery was performed via an endonasal or external rhinoplasty approach. An endonasal approach is performed in
selected cases; however, in most patients, an open approach is
preferred to provide better exposure. When we correct the deviated nose, the general surgical principles suggested by previous
researchers are followed.4 The surgical sequence was septal correction, separation of both upper lateral cartilages from the
septum, and bony pyramid manipulation after osteotomy. The
deviated nose management algorithm according to each classification is shown in Figure 2. For correction of the deviated bony
pyramid, several osteotomy combinations (medial, lateral, percutaneous root osteotomy) were used to straighten the bony
vault.5 Curvatures of the dorsal septum were corrected with
several grafts such as spreader, septal batten, and septal bone
grafts.6 In some patients with type III and V deviations in
which a straight septal tilt was present, we severed the dorsal
strip of the L-strut and overlapped the proximal and distal segments, and then we fixed them together using 5-0
polydioxanone sutures.7 In cases with severe deviations of the
Laryngoscope 123: May 2013
septal cartilage involving both dorsal and caudal portions of the
L-strut, extracorporeal reconstruction of the septal cartilage
was used.8 When there was convexity in the caudal septum, a
swinging-door maneuver and fixation suture or septal batten
graft were used.9
Assessment of Surgical Outcomes
Surgical outcomes were assessed by two otolaryngologists
who were not involved in any of the surgeries. Assessment was
based on reviews of preoperative and postoperative photographs
taken at the last follow-up. Based on their consensus, they
determined ideal vertical midline plane. The pre- and postoperative deviation from the ideal midline was compared, providing
a success rate that was divided into four categories.10,11 The
postoperative outcome in terms of deviation correction was classified as excellent, good, fair, or no change. If the correction
ratio was 90% to 100%, the result was accepted as excellent. If
the ratios were 70% to 89%, 50% to 69%, or <50%, the results
were accepted as good, fair, and no change, respectively (Fig. 3–
Fig. 6). Fair and no change were considered unsuccessful
outcomes.
Statistical Analysis
The association between unsuccessful outcome and deviation type was examined using Pearson v2 tests. Statistical
analyses were performed using SPSS software version 12.0
(SPSS, Inc., Chicago, IL). P < .05 was considered to indicate a
significant difference.
Cho and Jang: Treatment Outcome of the Deviated Nose
1137
Fig. 2. Algorithm for deviated nose
classification and management. This
algorithm guideline shows the deviated nose treatment according to
different types of deviation.
Fig. 3. Example of an excellent surgical outcome. Preoperative frontal
view (A) of a 20-year-old man with a
deviated nose. Fifteen-month postoperative view (B) after surgical
treatment with a medial and lateral
osteotomy and bilateral spreader
graft. [Color figure can be viewed in
the online issue, which is available
at wileyonlinelibrary.com.]
Laryngoscope 123: May 2013
1138
Cho and Jang: Treatment Outcome of the Deviated Nose
Fig. 4. Example of a good surgical
outcome. Preoperative frontal view
(A) of a 27-year-old man with a
deviated nose. Thirteen-month postoperative view (B) after surgical
treatment with a medial and lateral
osteotomy, dorsal L-strut cutting
and suture, and bilateral spreader
graft. [Color figure can be viewed in
the online issue, which is available
at wileyonlinelibrary.com.]
RESULTS
Of the 631 patients, 578 (91.6%) were undergoing
primary rhinoplasties, and 53 (8.4%) were undergoing
secondary rhinoplasties (i.e., had undergone previous
rhinoplasty at other hospitals).
Consensus ratings by two independent surgeons
found that surgical outcomes for the 631 patients were
excellent in 289 (45.8%), good in 217 (34.4%), fair in 111
(17.6%), and no change in 14 (2.2%) (Fig. 7). Therefore,
125 (19.8%) patients were deemed to have had unsuccessful outcomes (i.e., fair or no change).
Deviations were classified based on our previously
published system.4 There were 169 (26.8%) type I, 139
(22.0%) type II, 150 (23.8%) type III, 101 (16.0%) type
IV, and 72 (11.4%) type V deformities (Table I). Therefore, type I was the most common deformity, followed by
type III, type II, type IV, and type V.
We assessed surgical outcome according to deviation
type (Table I). For the 169 type I deviations, there were
52 (30.8%) excellent, 83 (49.1%) good, 31 (18.3%) fair,
and three (1.8%) no change outcomes. For the 139 type
II deviations, there were 42 (30.2%) excellent, 58 (41.7%)
good, 35 (25.2%) fair, and four (2.9%) no change outcomes. For the 150 type III deviations, there were 105
(70.0%) excellent, 34 (22.7%) good, 10 (6.7%) fair, and
one (0.6%) no change outcomes. For the 101 type IV
Fig. 5. Example of a fair surgical
outcome. Preoperative frontal view
(A) of a 33-year-old woman with a
deviated nose. Sixteen-month postoperative view (B) after surgical
treatment with a medial and lateral
osteotomy and spreader graft.
[Color figure can be viewed in the
online issue, which is available at
wileyonlinelibrary.com.]
Laryngoscope 123: May 2013
Cho and Jang: Treatment Outcome of the Deviated Nose
1139
Fig. 6. Example of a no-change surgical outcome. Preoperative frontal
view (A) of a 37-year-old man with a
deviated nose. Five-month postoperative view (B) after surgical
treatment with a medial and lateral
osteotomy, dorsal L-strut cutting
and suture, and spreader graft.
[Color figure can be viewed in the
online issue, which is available at
wileyonlinelibrary.com.]
deviations, there were 73 (72.3%) excellent, 17 (16.8%)
good, 11 (10.9%) fair, and zero (0%) no change outcomes.
For the 72 type V deviations, there were 17 (23.6%)
excellent, 25 (34.7%) good, 24 (33.3%) fair, and six (8.4%)
no change outcomes.
We examined whether the type of deformity had an
effect on the unsuccessful outcome rate. The rates of
unsuccessful outcomes for each deformity were 20.1% (n
¼ 34) for type I, 28.1% (n ¼ 39) for type II, 7.3% (n ¼
11) for type III, 10.9% (n ¼ 11) for type IV, and 41.7% (n
¼ 30) for type V (Fig. 8). Analysis showed that the frequency of unsuccessful outcomes differed according to
the type of deviated nose (P < .001).
Of the 631 patients, 41 (6.5%) patients required revision rhinoplasty owing to dissatisfaction. Of those 41
patients, 19 (46.3%) patients had a suboptimal correction, 11 (26.8%) had dorsum saddling, and eight (19.5%)
had an asymmetric tip. Three (7.4%) patients complained of stiffness or pain in the dorsum and tip area
(Table II). We analyzed the revision cases based on the
type of original deformity. Of the 41 revision cases, 12
TABLE I.
Outcome According to Type of Deviated Nose.
Type of Deviated Nose
I
Excellent
83 (49.1)
Fair
No change
31 (18.3)
3 (1.8)
II
139 (100)
Excellent
Good
42 (30.2)
58 (41.7)
Fair
35 (25.2)
No change
4 (2.9)
150 (100)
Excellent
105 (70.0)
Good
Fair
No change
IV
Excellent
1140
34 (22.7)
10 (6.7)
1 (0.6)
101 (100)
73 (72.3)
Good
17 (16.8)
Fair
No change
11 (10.9)
0 (0)
V
Laryngoscope 123: May 2013
169 (100)
52 (30.8)
Good
III
Fig. 7. Treatment outcomes of the deviated noses (N ¼ 631). Surgical outcomes for the 631 patients were excellent in 289 (45.8%),
good in 217 (34.4%), fair in 111 (17.6%), and no change in 14
(2.2%).
No. of Cases (%)
72 (100)
Excellent
Good
17 (23.6)
25 (34.7)
Fair
24 (33.3)
No change
6 (8.4)
Cho and Jang: Treatment Outcome of the Deviated Nose
Fig. 8. Unsuccessful outcomes according to type of nose deviation. The occurrence of unsuccessful outcome was significantly
different according to the different types of deviated nose (P <
.001).
(29.2%) had type V deformities, 10 (24.4%) had type I
deformities, eight (19.5%) had type II deformities, seven
(17.1%) had type III deformities, and four (9.8%) had
type IV deformities (Table II).
DISCUSSION
Numerous surgical techniques have been proposed
for deviated nose correction.5–13 In general, a deviated
bony pyramid can be corrected using a number of osteotomy methods.5 Deviation of the dorsal septum can be
corrected using several grafting techniques such as
spreader, batten, or septal bone grafts.6 In severe deviations of the septal cartilage involving both dorsal and
caudal portions of the L-strut, the extracorporeal septoplasty technique may be effective.8 Despite the extensive
literature regarding deviated nose correction, most studies were limited to specific surgical techniques and their
effectiveness. Although the deviated nose correction
remaining a significant rhinoplasty challenge, few studies have examined the overall success rate in an
extensive case series.
The present study evaluated treatment outcomes
following deviated nose correction in 631 patients with a
mean follow-up of 34.7 months. We found that 80.2% of
patients showed improvement in terms of deviation after
corrective rhinoplasty (i.e., excellent or good outcomes),
and approximately one-fifth (19.8%) of patients had
unsuccessful outcomes (i.e., fair or no change outcomes).
Similar outcome rates have been reported by others. In
a review of 27 deviated noses, Okur et al. reported that
only 66.7% patients had successful results.10 In a review
of 120 deviated noses, Erdem and Ozturan found that 70
patients (58.3%) had excellent or good results, and 50
patients (41.7%) had moderate or bad results.11
Deviations can be diverse and complex, and therefore individualized surgical strategies are required for
each patient. Before surgical correction of a deviated
nose, thorough preoperative evaluation for each patient
is mandatory. Preoperative planning is facilitated and
rendered more accurate through an awareness of underLaryngoscope 123: May 2013
lying pathologic features. In addition, a simple and
descriptive classification of deviated noses would be of
great help in the analysis and characterization of pathologic abnormalities. Others have proffered such
classifications,2,3 as did we in 2008.4
We classified the current cases using our five-type
classification system.4 We found that type I (26.8%) was
the most common deformity. In addition, we found that
the type V deformity was associated with the highest
proportion of unsuccessful outcomes (41.7%).
The type V deviation in our classification system
indicates that both the bony pyramid and the cartilaginous dorsum are tilted in the same direction. Other
researchers have classified that type of deviation as an
I-shaped deformity.3 In general, it has been recognized
that C- or S-shaped deviations are more difficult to treat
than I-shaped deviations because the strong cartilage
memory resists the use of conservative corrective measures.3,12,14 In contrast to the present findings, Cheng
et al. documented that success rates in deviated nose
correction did not significantly differ according to the
type of deviation.15 They classified deviated noses into
three types; deviation of the lower two-thirds of the nose
(type I), deviation of the whole nose in the same direction (type II, I-shaped), and deviation of the whole nose
with a curved rhinion (type III, C-shaped). In that
report, of the 384 deviated noses, the percentages of
‘‘satisfied’’ or ‘‘very satisfied’’ aesthetic outcomes were
89.1%, 88.5%, and 87.7% for the type I, type II, and type
III groups, respectively. We believe several reasons may
explain the difficultly in achieving a satisfactory surgical
outcome in type V deformities (I-shaped deformity).
First, it is difficult to correct linear bony deviations commencing high up at the nasal root. Second, a type V
deformity is commonly associated with facial asymmetry.
Third, a type V deformity may merely be converted to a
type I deformity by surgery. To overcome aforementioned
difficulties in correction of type V deviation, we would
emphasize the importance of a few surgical tips. First,
the septum should be completely freed from its original
position and suture-fixated to the contralateral side of
the anterior nasal spine. Second, the midline bony dorsum should be completely fractured by digital
TABLE II.
Analysis of Revision Cases (N 5 41).
No. of Cases (%)
Cause of revision rhinoplasty
Suboptimal correction
Saddling of dorsum
Asymmetric tip
Nasal stiffness or pain
Type of deformity
19 (46.3)
11 (26.8)
8 (19.5)
3 (7.4)
I
10 (24.4)
II
III
8 (19.5)
7 (17.1)
IV
4 (9.8)
V
12 (29.2)
Cho and Jang: Treatment Outcome of the Deviated Nose
1141
compression or percutaneous root osteotomy after performing medial and lateral osteotomy. Third, the
residual dorsal deviation should be camouflaged by
asymmetrically placed spreader grafts or dorsal onlay
graft.
Forty-one (6.5%) patients in our study required revision rhinoplasty because of dissatisfaction. Similarly,
Gubisch reported a revision rate of 7% in the evaluation
of 1,885 deviated nose patients who received extracorporeal septoplasty.14 In contrast, another study reported
only two of 384 patients had residual dorsum deviation
that underwent revision rhinoplasty, equating to a revision rate of 0.5%.15
The present study had certain limitations. Any
postoperative ratings carry a risk of lack of reliability
and validity. The objective anthropometric measurement
has been used to determine surgical outcomes of the
deviated nose in the other studies.8,10,11 However,
patients with S-shaped deviations (type II and IV
patients in this study) could not be evaluated using this
method like other studies. Therefore, to assess the surgical outcomes of all patients included in this study, we
did not use that method and used only a subjective
scale. To mitigate against such risks, all preoperative
and postoperative photographs in the current study
were analyzed by two rhinoplasty surgeons who were
not involved in any of the surgeries. Based on their consensus, the postoperative outcomes were classified as
excellent, good, fair, or no change.
The present study found that surgical correction of
a deviated nose entails a significant risk of an unsatisfactory surgical outcome. In addition, we found that
surgical outcome differed depending on the deviation
type. Therefore, achieving good results in corrective rhinoplasty of a deviated nose requires a thorough
preoperative evaluation and correct surgical techniques
according to the underlying pathologies.
Laryngoscope 123: May 2013
1142
CONCLUSION
The present study of 631 deviated nose cases found
that 80.2% of cases had satisfactory outcomes, and
19.2% had unsatisfactory outcomes. In addition, we
found that the likelihood of a satisfactory outcome was
dependent on the type of deviation. Finally, the rate of
revision was 6.5%. Therefore, surgical correction of a
deviated nose is associated with a significant risk of an
unsatisfactory surgical outcome, and surgical planning
must take into account the underlying pathology.
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Cho and Jang: Treatment Outcome of the Deviated Nose