A crooked nose can be defined simply as any nose that is “off center” from the centerline of the face. But from this simple definition, there are endless variations of how a crooked nose may look, and different treatment options depending on a patient’s end goal. Rhinoplasty to repair a crooked nose needs to take into account how the asymmetry formed, which existing anatomy is contributing to the asymmetry, and whether other aspects of the face are contributing to an asymmetric look.
Reasons for a Crooked Nose
Here are the 3 main reasons why a person will have a crooked nose:
- Blunt Trauma – A broken nose from an automobile accident, sports injury or other trauma will in many cases look crooked when healed unless it is properly set soon after the injury. Some refinement of the nose may need to occur after this initial healing to fine-tune and correct alignment issues.
- Imperfect Growth during Puberty – Many people find that as their nose develops during puberty, it slants toward one side of the face or the other. The off-center orientation of the nose may become more noticeable with other facial changes during puberty, such as the development or lack thereof of the chin, development of the brow, and loss of “baby fat” in the cheek area.
- Congenital Deformity – A person may have nasal asymmetry from birth due to genetic reasons or in some cases as a result of certain methods used during delivery. Forceps-assisted or breech deliveries have been referenced in causing nasal asymmetry in a small number of instances.
Analyzing a Crooked Nose
When discussing nose asymmetry, it can be helpful to divide the nose into 3 sections – the top third, where the nasal bone is located, the middle third, and the bottom third including the nose tip.
Nasal bone fractures are the most common reason for asymmetry in the top third of the nose. These are generally repaired by cutting, shaving, or re-fracturing the bone so that it can achieve a more symmetrical shape. In most cases, an “open” technique is preferred so that the surgeon has full access to the nasal bone. A “closed” technique (incisions and reshaping are done through the nostrils only) generally will be effective only in cases of a very fresh nasal fracture.
In some cases, adjustment of the nasal bone will also improve symmetry of the lower two thirds of the nose, due to the way the tissue attaches. More likely, further refinements of the lower sections of the nose are also needed to ensure proper breathing and alignment.
If no significant asymmetry is present in the nasal bone, the focus turns to the middle third or dorsal section of the nose. This section of the nose is made up of cartilage that both affects the exterior shape of the nose and shapes the internal functional structures, such as the septum. The technique used to repair asymmetry in the dorsal section of the nose depends on the existing anatomy. Tissue may be grafted in to correct depressions, the septum itself may be reshaped, and spreader grafts may be used to strengthen the nose, better anchor it in an aligned position, and improve breathing function.
If the lowest third or tip of the nose is asymmetrical either on its own or as part of asymmetry in one of the upper thirds, it can also be corrected and in most cases is simpler to repair. When the tip alone is off-center, a closed rhinoplasty approach may suffice to reposition the tip. This is the easiest repair of a crooked nose, but not a very common situation for people with nasal asymmetry.
Rhinoplasty in Relation to Other Facial Asymmetry
For some people, repairing a crooked nose will go a long way toward improving their facial symmetry, but they may still have other imbalances impacting facial alignment. Chin augmentation/enhancement is one of the more common facial plastic surgeries performed along with rhinoplasty. While this is often focused on addressing a “weak” chin that appears receded in profile, it can also help to balance out a chin that looks tilted or projects further on one side or the other.
Improving the symmetry of the eyes can also help to balance the proportions of the face. Upper and/or lower eyelid surgery, in addition to focusing on skin tightening, can also correct a situation where one eye appears more “droopy” or hooded than the other, or where more prominent bagging appears below one of the eyes.
A crooked or off-center nose can be one of the most challenging aesthetic concerns to correct through rhinoplasty. Thankfully, modern techniques allow for significant correction without the downsides of surgery in the past, such as structural weakening of the nose or relapse/return of some degree of prior asymmetry.
The key outcomes of rhinoplasty to correct a crooked nose are improved symmetry and maintained or improved breathing functionality. A skilled rhinoplasty surgeon will have many techniques and tools to use to achieve this result. Nasal deformities, and the nature of a crooked nose, will vary from patient to patient, requiring a unique surgical plan to achieve an improved look. Proper correction requires the surgeon to have a deep understanding of nasal anatomy, experience in modern treatment techniques, and an ability to understand how the nose will respond to surgical intervention as healing occurs.
Dr. Raghu Athré is one of the few cosmetic and reconstructive surgeons in Houston who is a double board certified Facial Plastic surgeon, certified in Otolaryngology and Head/Neck Surgery.