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\begin{document}

\title{MOBILE BONY CAP (MEYSEM YORGUN TECHNIQUE): AN INNOVATIVE TECHNIQUE IN
PRESERVATION RHINOPLASTY FOR CROOKED NOSE DEFORMITY}



\author[1]{Meysem Yorgun}%
\author[2]{Erdinç Çekiç}%
\author[3]{Ali Evlice}%
\affil[1]{Private clinic}%
\affil[2]{Haseki Education Research Hospital}%
\affil[3]{Private Clinic}%


\vspace{-1em}



  
  \date{May 23, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Abstract Introduction Crooked nose deformity is a vertical axis
deviation of the nasal pyramid; despite all advancements, it remains a
significant problem to resolve. In this study, we present our I- and
C-shaped crooked nose rhinoplasty results with this new osteotomy
technique. Method This study included 25 patients with I- or C-shaped
crooked nose deformities who underwent correction with a closed-approach
let-down procedure. In this technique, the middle vault is preserved,
the bony cap is mobilized and preserved, and the lateral nasal bones are
equalized by a piezo device or classical osteotomes. By the mobilization
of the bony cap, tension on the dorsal septum is released, and slight
asymmetries are hidden behind this mobile bony cap. Results The
postoperative angles for both type I and C deformities were closer to
the ideal angle, and the difference was statistically significant. All
patients were satisfied with their aesthetic and functional results.
Conclusion In this procedure, we correct asymmetries at the lower
maxillary nasal junction, such as in the Let-down approach, as well as
asymmetries at the K-point, such as in the structural approach. Thus, we
combine the advantages of both techniques. Additionally, the mobile-bony
cap left on the patient is very useful for releasing the tension of the
septal dorsum and hiding slight asymmetries that remain below in the
patients.%
\end{abstract}%



\sloppy


\textbf{MOBILE BONY CAP (MEYSEM YORGUN TECHNIQUE): AN INNOVATIVE
TECHNIQUE IN PRESERVATION RHINOPLASTY FOR CROOKED NOSE DEFORMITY}

\textbf{Abstract}

\emph{Introduction} Crooked nose deformity is a vertical axis deviation
of the nasal pyramid; despite all advancements, it remains a significant
problem to resolve. In this study, we present our I- and C-shaped
crooked nose rhinoplasty results with this new osteotomy technique.

\emph{Method} This study included 25 patients with I- or C-shaped
crooked nose deformities who underwent correction with a closed-approach
let-down procedure. In this technique, the middle vault is preserved,
the bony cap is mobilized and preserved, and the lateral nasal bones are
equalized by a piezo device or classical osteotomes. By the mobilization
of the bony cap, tension on the dorsal septum is released, and slight
asymmetries are hidden behind this mobile bony cap.

\emph{Results} The postoperative angles for both type I and C
deformities were closer to the ideal angle, and the difference was
statistically significant. All patients were satisfied with their
aesthetic and functional results.

\emph{Conclusion} In this procedure, we correct asymmetries at the lower
maxillary nasal junction, such as in the Let-down approach, as well as
asymmetries at the K-point, such as in the structural approach. Thus, we
combine the advantages of both techniques. Additionally, the mobile-bony
cap left on the patient is very useful for releasing the tension of the
septal dorsum and hiding slight asymmetries that remain below in the
patients.

\emph{Level of evidence: IV}

\textbf{Keywords: Crooked nose, Osteotomy, Preservation, Rhinoplasty}

\textbf{Key points}

*There are 4 different types of crooked nose deformities (I-type,
C-type, S-type, cartilaginous) described in the literature.

*Despite all technological, anatomical and surgical advancements,
correcting a crooked nose may not be possible in a significant group of
patients.

*There are both functional and esthetic problems in crooked nose
deformities, and achieving a successful result is possible with
appropriate preoperative analysis.

* In this technique, the middle vault is preserved, the bony cap is
mobilized and preserved, and the lateral nasal bones are equalized by a
piezo device or classical osteotomes.

*Mobilization of the bony cap allows the dorsal septal cartilage to move
freely, and this maneuver helps the correction of the middle third
deviations.

*In our technique, we correct asymmetries at the lower maxillary nasal
junction, such as in the Let-down approach, as well as asymmetries at
the K-point, such as in the structural approach. Thus, we combine the
advantages of both techniques.

\textbf{Introduction}

Crooked nose deformity is a vertical axis deviation of the nasal pyramid
on basal and/or frontal views and is still a challenging problem for
rhinoplasty surgeons. Despite all technological, anatomical and surgical
advancements, achieving a straight nose may not be possible in a
significant group of patients. Several techniques, such as double or
asymmetric osteotomies, spreader grafts, cartilage scoring, and several
onlay graft techniques, have been described in the literature(1-4).
Since a significant number of patients still undergo revision surgeries
for crooked nose, we believe that this problem has not yet been fully
resolved.

The nasal pyramid has 3 sections: the upper, middle and lower thirds.
Deviations may be seen in all three sections. Upper-third deviations are
generally caused by bony pyramid deviations, and lower two-third
deviations are caused by cartilaginous and soft tissue structures (5).
Preoperative analysis of deviation on nasal bones and cartilaginous
structures is very important and essential to resolve this problem.

There are 4 different types of crooked nose deformities described in the
literature. (2,6,7,8)

Cartilaginous type: The deviation only involves less than 2/3 of the
cartilaginous structures of the nose. There is no deviation on the bony
part.

Linear type (I-shaped): The nasal axis is deviated to one side with a
linear shape.

C-shaped: The major etiological reason for this most frequent type of
deviation is septal cartilage fracture. The vertical axis of the nose is
C-shaped, and the concavity may face the right or left side.

S-shaped: This most complicated type has different angulations and
deviations on 1/3 of the nasal pyramid.

Compared with classical structural rhinoplasty techniques, preservation
rhinoplasty is a very popular technique and has many advantages, such as
achieving a more natural middle vault (9,10). In our technique, the
middle vault is preserved, the bony cap is mobilized and preserved, and
the lateral nasal bones are equalized by a piezo device or classical
osteotomes. By the mobilization of the bony cap, tension on the dorsal
septum is released, and slight asymmetries are hidden behind this mobile
bony cap. Here, we present our I- and C-shaped crooked nose rhinoplasty
results with this new osteotomy technique.

\textbf{Materials and Methods}

This retrospective study included 25 patients who underwent correction
with I- or C-shaped crooked nose deformities between February 2020 and
April 2021 with a single experienced surgeon (M.Y.). Patients with a
previous nasal surgical history (septoplasty, rhinoplasty or endoscopic
sinus surgery) were excluded from this study. This retrospective study
was approved by the Haseki Research and Education Hospital Ethical
Committee, and all patients were informed both verbally and via written
comprehensive consent forms. All procedures performed in this study were
in accordance with the ethical standards of institutional and national
ethics committees and with the 1964 Helsinki Declaration and its later
amendments or comparable ethical standards. The AGREE reporting
checklist was used for standardization for methodological quality(11).
Preoperative and postoperative photographs with 7 different angles
(frontal, lateral, oblique, helicopter and basal views), as well as
videos, were taken and recorded. Patients were followed for 12 months to
24 months, and a postoperative evaluation was performed at least 12
months after the surgery. Image analysis was performed with the GeoGebra
License program (version 6.0.677-wgeometry), and the deviation angles
were measured using the (anterior) views, provided the Frankfort
horizontal line was parallel to the ground. The deviation angles of the
C-type and I-type crooked nose were measured as previously described in
the literature (12). The ideal angular value is 180 for C-type
deformities and 0 for I-type deformities. Surgical results were
classified according to the rate of correction of deviation angles. With
surgical correction, 90-100\% closeness to the ideal angle was evaluated
as excellent, 70-89\% closeness as good, 50-69\% acceptable,
\textless{}50\% unsuccessful. A postoperative angle closer to the ideal
angle was considered more successful.

\textbf{Surgical Technique}

After preparing the surgical field, patients were covered with sterile
surgical cloths. After local anesthetic administration, the closed
approach let-down technique is preferred. Infracartilaginous and
marginal incisions were applied. Supraperichondrial and subperiosteal
dissection was performed carefully. Wide subperiosteal dissection is
essential for better visualization and control of lateral osteotomies
and ostectomies. First, the lateral nasal walls were measured and
recorded. Planned lateral nasal walls were calculated according to the
hump and equalized on both sides. First, osteotomies were localized 2-3
mm below the bony cap and with an average of 8 to 10 mm in size, and
their connection with the upper lateral cartilages was preserved on both
sides. Mobilization of the bony cap allows the cartilage to move freely,
and this maneuver helps the correction of the middle third deviation.
Subsequently, we left 15 to 18 mm of lateral nasal bone on both sides
with an equal size and shape just below the mobile bony cap and took the
excessive bones between the lateral osteotomy lines and maxillary bone
to prevent step deformities and the recurrence of deviations. Bony
pyramid deviation is corrected with this asymmetric reduction of the
bone on both sides. The important point is that the residual lateral
nasal bone sizes left in the patient should be equal for symmetry. Lower
strip resection of the septum and a lower strip cut in the perpendicular
plate of the ethmoid bone were performed, and the let-down procedure was
completed. In our technique, to correct the 3-dimensional asymmetry in
the lateral nasal bones, the dimensions of the lateral nasal bones are
measured and equalized. The bony cap is mobilized and preserved to hide
the slight asymmetries below and release the tension on the dorsal
septum. A schematic diagram of the surgery is provided in Figure 1.

The SPSS statistical package (version 15.0; Chicago, IL) was used for
all data analyses. Preoperative and postoperative angles were compared
by a dependent t test for both I- and C-type deformities separately, and
a statistically significant p value was accepted as \textless{}0.05.

\textbf{Results}

In total, 25 patients (16 male and 9 female) with I-type (11 patients)
and C-type (14 patients) deformities were included in the study. All
patients were operated on with a closed-approach let-down procedure, and
none of the patients required costal cartilage harvesting. All patients
were followed at 1, 3, 6, and 12 months postoperatively, and
postoperative image analysis was performed at least 12 months after the
surgery.

The preoperative mean deviation angle for C-type deformities was 146.15
\selectlanguage{ngerman}± 3.59\selectlanguage{greek}\textsuperscript{ο} \selectlanguage{english}(142-154.6), and the postoperative mean
deviation angle was 178.71 \selectlanguage{ngerman}± 2.12\selectlanguage{greek}\textsuperscript{ο} \selectlanguage{english}(175-180). The
preoperative mean deviation angle for type I deformities was 12,49 \selectlanguage{ngerman}±
1.73\selectlanguage{greek}\textsuperscript{ο} \selectlanguage{english}(10.6-15.9), and the postoperative mean angle
was 1.03 \selectlanguage{ngerman}± 1.43\selectlanguage{greek}\textsuperscript{ο} \selectlanguage{english}(0-2.9). The postoperative angles for
C-type deformities were higher and closer to the ideal angle
(180\selectlanguage{greek}\textsuperscript{ο}\selectlanguage{english}), and this difference was statistically
significant (p\textless{}0.001). The ideal angle
(180\selectlanguage{greek}\textsuperscript{ο}\selectlanguage{english}) was achieved in 10 patients (10/14). The
postoperative angles for I-type deformities were smaller and closer to
the ideal angle (0\selectlanguage{greek}\textsuperscript{ο}\selectlanguage{english}), and this difference was also
statistically significant (p\textless{}0.001). The means of preoperative
and postoperative angles are given in Table 1.

According to the postoperative surgical success rate, the outcomes for
17 patients (10with C-type deformities and 7 with I-type deformities)
were accepted as excellent, and those for 8 patients (4 with C-type
deformities and 4 with I-type deformities) were accepted as good. The
results are listed in Table 2.

All patients were satisfied with their aesthetic and functional results
and did not encounter any complications in the postoperative period.
Preoperative and postoperative digital images of 2 patients are
presented in Figures 2,3 and 4.

\textbf{Discussion}

Crooked nose deformity is the vertical axis deviation of the nasal
pyramid to the left or right on the basal or frontal view. Generally, it
occurs due to trauma during the early childhood or adolescence period
and is accepted as a challenging problem to solve. Many authors have
claimed that the etiologic reasons for the crooked nose are unnoticed
trauma during birth or early childhood and insufficient correction of
nasoseptal fractures (13,14).

There are both functional and esthetic problems in crooked nose
deformities, and achieving a successful result is possible with
appropriate preoperative analysis. Detailed examination of frontal,
basal and helicopter views and analysis of the reason for deviation are
crucial for a correct preoperative plan and for ultimately successful
postoperative results.

The use of spreader grafts is a classical and useful method for the
correction of septal deformities in classical structural rhinoplasty
approaches but may not be sufficient to solve the problem in some
patients (15,16). The location, number and thickness of spreader grafts
may be different from patient to patient. Generally, spreader grafts are
placed on the concave side of the deformity, but asymmetric locations
and different numbers of spreader grafts on both sides may be used in
patients with crooked nose deformity (17). However, the use and benefits
of spreader grafts are limited in the case of bony pyramid deviations.
Asymmetries in the lower parts of the lateral nasal bones in maxillary
regions cannot be solved with classical single osteotomies; in contrast,
using spreader grafts can make the asymmetries more pronounced during
the classical structural rhinoplasty approach.

Extracorporeal septal reconstruction (ECSR) is another and generally
accepted final reconstruction method for severe crooked nose
deformities. In the ECSR technique, the septum is totally mobilized and
removed from the nose, reconstructed as an L-shaped strut and
repositioned into the midline of the nose (18). The main challenge is
achieving a straight L-shape and stabilization of the new septum.
Because of the highly deformed septal cartilages, achieving a straight
septum is an important problem that can be solved only with costal
cartilage harvesting in a significant number of patients. Many authors
have hesitated to use this technique because of the risk of
destabilization and technical difficulty. Additionally, combinations of
different techniques, such as asymmetric osteotomies, ostectomies and
spreader grafts, have been described in the literature, and the
deformities have been solved (19-21).

When the nasal pyramid is considered in three dimensions, it can be
easily seen that the lateral nasal bones do not lie in a straight plane.
For example, the lateral nasal bone is generally convex in its upper
parts close to the eye and concave in the lower parts in the maxillary
region. This situation becomes much more pronounced in patients with
crooked nose deformities. In our technique, to correct this
3-dimensional asymmetry in the lateral nasal bone, the dimensions of the
lateral bone were measured and equalized, and a mobile bony cap was left
to hide the slight asymmetries below. First, osteotomies were localized
2-3 mm below the bony cap and were an average of 8 to 10 mm in size, and
their connection with the upper lateral cartilages was preserved on both
sides. Mobilization of the bony cap allows the dorsal septal cartilage
to move freely, and this maneuver helps the correction of the middle
third deviation. Lateral nasal bones were left 15 to 18 mm in length,
and the excessive bone just below the lateral nasal bone from the lower
maxillary nasal bone junction was removed. Thus, we obtained a straight
and more symmetric nasal bony structure assessed by 3-dimensional
examination on both sides. Bony pyramid deviation is corrected with this
asymmetric reduction of the bone on both sides, and the important point
is that the residual bone size and shape left in the patient should be
equal for symmetry.

Nasal bones become fully mobile as in the structural rhinoplasty
approach. In addition to the advantages of the structural approach, more
bone must be removed from the hump, but asymmetry in the base remains.
In the structural rhinoplasty approach, the nasal bones are brought
closer together and lowered. Since there is remaining asymmetry at the
base, the preoperative asymmetry can be felt again while the bone is
rebonded in postoperative follow-ups. In the let-down procedure,
asymmetries in the nasal maxillary junction at the base can be resolved,
but since the dorsum remains as one piece, asymmetries are eliminated
only by removing the asymmetrical bone at the base, and deviation to one
side at the K-point can still be felt. In our technique, we correct
asymmetries at the lower maxillary nasal junction, such as in the
Let-down approach, as well as asymmetries at the K-point, such as in the
structural approach. Thus, we combine the advantages of both techniques.

We believe that complete mobilization rather than green-stick fractures
and measurement and equalization of all bony fragments on each side is
essential for successful postoperative results. In addition, the
mobile-bony cap left on the patient is very useful for releasing the
tension of the septal dorsum and hiding slight asymmetries remaining
below in the patients. This presented technique may be an alternative
technique for crooked nasal deformities.

\textbf{Compliance of ethical standards}

\textbf{Conflict of interest} The authors declare that they have no
conflicts of interest to disclose.

\textbf{Ethical approval} All procedures performed in this study were in
accordance with the ethical standards of institutional and national
ethics committees and with the 1964 Helsinki Declaration and its later
amendments or comparable ethical standards.

\textbf{Informed consent} All patients were informed both verbally and
via written comprehensive consent forms.

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\end{enumerate}

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