An algorithm for correcting the asymmetrical nose

Correction of the twisted nose forms the watershed of aesthetic and reconstructive rhinoplasty, combining and requiring elements of each. Faced with this formidable task, surgeons have fashioned a great number of techniques, many of which rely for their cardinal step on cutting, fracturing, or scoring the dorsal septal strut. While highly satisfactory results have been achieved with these methods, the constant problem of loss of dorsal support remains. It is possible in many cases to align the crooked nose while leaving intact osteocartilaginous dorsal support. The key determination to be made is the preoperative aesthetic balance, itself a product of bridge height and nasal base size. Once nasal aesthetics have been established, the algorithm proceeds as follows: First, resect the dorsum in the area of the deviation until the dorsal septal edge is sufficiently close to the midline to allow camouflage of the remaining asymmetry. Second, perform the septal resection necessary for the airway, preserving a continuous dorsal strut. Third, augment according to (a) the support needed for the dorsum, middle vault, columella, and tip and (b) the aesthetic balance that must be restored.