In sailing terms the septum is the rudder of the nose!

Often a crooked nose is secondary to deviation of the septum. These deviations of the septum occur after trauma or nasal surgery or during the growth phase of the nose. Childhood injuries can lead to the occurrence of septal deviation in adolescence. It may also be caused by asymmetric development of the facial bones and by unilateral partial or complete facial paralysis. Cleft lip and cleft palate will also cause deviation and deformity of the nasal septum.

Whilst one of the aims of rhinoplasty is to straighten the nose… the recurrence of septal deviation is reported as high as 30% following rhinoplasty (nose job). I believe this is the result of techniques that rely on septal cartilage scoring as a sole means of straightening the deviation. While scoring appears to correct the deviation at the time of surgery, the weakened (scored) cartilage is prone to relapse.

I believe the deforming forces must be fully released and the deviated septum strengthened by adding septal cartilage grafts. With this technique the recurrence with these techniques is less than 5%.

Alternative procedures camouflage a deviation by using ear or septal cartilage grafts to hide the deviation, this is a compromised approach but suitable when deviations are minor and breathing satisfactory.

(Byrd HS, Salomon J, Flood J: Correction of the crooked nose. Plast Reconstr Surg 1998 102(6):2148)

Over projection of the nasal tip occurs when nasal tip projection exceeds the ideal tip defining point. Nasal analysis defiones this position as 0.67 X ideal nasal length.

Read more on the ultra projecting tip

A nose with an inadequate projection often looks tip heavy and unbalanced.
Remembering that the underprojecting nasal tip occurs when the measured tip projection is less than 0.67 X ideal nasal length.

Frequent findings in patients with inadequate tip projection are a dorsal hump and weakness of the nasal tip cartilages. This apparent high bridge is misleading as a “Reduction” of the hump removes support from the tip. With loss of this support the tip drops and often in these instances the nasal change is a wider, and elongated appearing nose, with a flattened profile.

The nasal tip may loose additional projection with the reduction of the dorsum further compromising the outcome. These undesirable events are prevented if and I consider it is essential step to add structural support to this cartilage complex.

My preference is to use shaped and elongated cartilage grafts taken from the nasal septum. I fix these grafts using sutures in a manner that allows the lower lateral cartilages to be both stabilized and shaped. When tip projection is maintained or restored in this manner, minimal lowering of the apparent hump is all that is required.

This step to position and support the tip is significant another component in a plan to achieve controlled results in nasal surgery.

These changes are planned by detailed analysis and shown prior to the procedure with computer imaging.

When considering rhinoplasty the tip is a most important visual structure.
There are 3 main “philosophies” top establishing the new tip and these are as follows:

1. No grafts and suture sculpting: The natural tissue remodelling and not grafts is used to support the nasal tip in a more aesthetic way.

2.Invisible grafts: “These grafts are placed in the substructure of the tip beneath the natural cartilages to add support and shape. These grafts stabilize the natural tip structures but still do not interfere with the skin.”

3.Visible grafts: “These grafts are placed between the skin and the existing alar cartilages. Grafts of this nature create the new, visible shape of the nasal tip while the ‘normal’ anatomy is concealed.”
This technique was popularised by the work Of Dr Jack Sheen Master Rhinoplasty Surgeon.

The clinic utilises all 3 techniques depending on the clinical picture. Where possible I try and maintain a good tip character but where necessary supplement and support tip structure. (PLD)