External Nasal Deformities

Introduction

External nasal deformities encompass a spectrum of structural abnormalities affecting the bony and cartilaginous framework of the nose that produce visible cosmetic and/or functional impairment. They may arise from trauma, congenital anomalies, systemic disease, or iatrogenic causes following prior rhinoplasty. Correction requires a thorough preoperative analysis integrating observation, palpation, photography, and radiological assessment before planning septorhinoplasty.

Surgical Anatomy of the External Nose

The external nose is supported by a three-part skeleton:

Region	Structures
Upper third (bony vault)	Paired nasal bones + frontal process of maxilla
Middle third (middle vault)	Upper lateral cartilages (ULC) + dorsal septum
Lower third (tip & alar lobule)	Lower lateral cartilages (LLC) — medial & lateral crura

Nasal skeleton diagram showing nasal bone, upper lateral cartilage, lower lateral cartilage, fibroareolar tissue, frontal process of maxilla

Fig. 1 — The nasal skeleton (Bailey & Love's Surgery, p. 785)

Alar cartilage anatomy from lateral, anterior and basal views

Fig. 2 — Greater alar (lower lateral) cartilages: lateral, anterior, and basal views showing medial and lateral crura

Classification of External Nasal Deformities

1. Traumatic Nasal Deformity

The most common cause. Nasal trauma displaces nasal bones, the external nasal cartilages, or the septum. Isolated nasal deformity results from displacement of the nasal bones, external nasal cartilages, or the septum. Nasal bones can often be repositioned with closed reduction if performed within 2 weeks of injury. Delayed or comminuted fractures require open septorhinoplasty.

2. The Twisted (Crooked) Nose

The twisted nose involves deviation at the bony vault, middle vault, or tip — or all three levels simultaneously. The septum must be straightened to correct a severely twisted nasal deformity; the external approach (open rhinoplasty) is almost universally employed for the twisted nose.

Key surgical manoeuvres:

Septoplasty — straightening the dorsal and caudal struts
Spreader grafts — to stabilise the middle vault and widen the internal nasal valve
Batten grafts — correct internal and external nasal valve collapse
Osteotomies — to reposition a deviated bony pyramid
Caudal septal repositioning with draw sutures and anterior spine fixation

3. Saddle Nose Deformity

Characterised by depression of the nasal dorsum (loss of the normal convex profile) due to collapse of the cartilaginous or bony nasal framework.

Clinical photograph showing saddle nose deformity with collapsed nasal dorsum and upturned tip

Fig. 3 — Classic saddle nose deformity: collapsed nasal bridge, upturned tip, columellar retraction

Causes:

Trauma (septal haematoma → avascular necrosis)
Iatrogenic (over-resection of dorsal septum)
Infections — syphilis, leprosy, tuberculosis
Granulomatous disease — Granulomatosis with Polyangiitis (GPA/Wegener's)
Congenital (e.g., failed septal support)

Surgical correction: Augmentation is the mainstay. Preferred autogenous materials in order of preference:

Septal cartilage — first choice
Auricular cartilage
Costal (rib) cartilage — for large defects
Bone grafts (iliac crest, calvarial) — for bony defects
Alloplastic implants (Gore-Tex, Silastic) — if autologous unavailable

4. Cleft Lip Nasal Deformity

A congenital deformity with distinct features:

Type	Features
Unilateral	Tip and columella deviated to noncleft side; cleft nostril wider; nasal floor widened
Bilateral	Short columella deviated to less involved side; bifid, poorly defined tip; alar base displaced laterally, posteriorly, and inferiorly

Surgical goal: improve symmetry of nasal tip and base, and restore nasal airway. The LLC is freed of both surface and vestibular skin and rotated medially to project the tip (Millard technique).

5. Non-Caucasian Nose

A recognised anatomical variant requiring specialised surgical approach. Characteristics: thick skin, weak cartilage, flat/broad dorsum, underprojected and poorly defined tip, wide alar base. Augmentation rhinoplasty with structural grafting is usually required rather than reduction techniques.

6. Hump Nose (Dorsal Hump Deformity)

An excess convexity of the nasal dorsum, predominantly at the osseocartilaginous junction. The nasofrontal angle can be modified to shorten or lengthen the apparent nasal dorsum. Correction involves dorsal hump reduction followed by osteotomies to close the open roof deformity.

Surgical Approach

Approach	Indication
Closed (endonasal)	Mild deformities, limited tip work
Open (external/decorticate)	Twisted nose, revision rhinoplasty, cleft nose, implant placement, severe asymmetries

The external approach is preferred when severe asymmetries, deviations, and tissue deficiencies are evident, as it provides superior exposure and opportunity for precise graft placement. — Cummings Otolaryngology, Chapter 32

Summary

External nasal deformities are classified by aetiology and anatomical level of involvement. A combined septorhinoplasty that corrects both internal and external nasal deformities in one stage is the ideal strategy. The surgeon must master a variety of grafting, osteotomy, and suturing techniques to address each unique nasal deformity. Autogenous materials — primarily septal, auricular, and costal cartilage — remain the gold standard for augmentation and reconstruction.

Sources: Cummings Otolaryngology Head and Neck Surgery (Ch. 32); Bailey & Love's Short Practice of Surgery (28th ed., p. 785); Textbook of Family Medicine 9e

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