An insert into Dr. Sparano's Rhinoplasty NJ series:
When it comes to fixing the crooked nose, there are various tricks a facial plastic surgeon can employ. The nature of this discussion can indeed be detailed and extensive, but I'll try to keep things simple. There is no doubt that crooked nose "deformity" is one of the more difficult aspects of rhinoplasty. Patients seeking repair of this issue, should definitely research their surgeon and ideally work with someone very steeped in rhinoplasty experience, especially with challenging and revision (secondary) noses. I am a facial plastic surgeon with a dedicated niche subspecialty interest in rhinoplasty. It is a true clinical passion of mine!
Mildly crooked noses can often be fixed by commonplace rhinoplasty techniques, including that of a skillful septoplasty (i.e., straightening the midline internal structure of the nose known as the septum). These techniques include careful tip reshaping with PERFECT symmetry and balance of forces; careful midvault restabilization; and CONTROLLED osteotomies (repositioning) of the bones.
Moderately crooked noses often require additional, specialized grafting at the middle segment of the nose, with use of autologous grafts called "spreader grafts." These can be carefully designed to manipulate the middle and lower segments of the nose to create a midline appearance. They are sometimes purposefully asymmetrically placed to create a symmetric appearance. Designing and securing these is an intricate skill which requires experience, or else the nose will take on a wider appearance. At times the full grafts aren't necessary and I use a technique called "spreader flaps." At other times I use spreader grafts with an overlay of upper lateral cartilages to accomplish the desired effect without a "ridgy" appearance.
Severely crooked noses require an array of techniques, each carefully performed with accuracy and intricacy, so that no tensile forces are left unto the nose potentially creating postoperative drift. I am a big believer in getting the front-most aspect of the septum fixed to the midline nasal spine, but in a way where it's attached to bone (and thus stable), and not fibrous tissue (and potentially unstable). With the most severe of circumstances, I utilize a technique known as extracorporeal septoplasty. This is a very complex procedure in rhinoplasty of the crooked nose, but a very powerful one. During it, I remove the entire septum as a single unit of cartilage attached to bone. This allows me to study the complex, 3-D defortmity of the structure and to manipulate it with control. I will often drill down and/or remove certain culprit segments, always preserving as much as I can. I can attach my desired spreader grafts directly to the newly designed STRAIGHT septum with perfect control. Then I replace the entire structure to refortify the nose. The nose becomes rebuilt around this strong midline structure. This is a longer and more complicated operation, but indeed a helpful one for the correct indications.

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