There are many ways to correct crooked noses, and some of the published results are very dramatic. But like stock market investments, the bigger the potential gains, the bigger the risks.
For example, some surgeons completely remove the deviated septum, taking out all the support for the lower two thirds of the nose, straighten the septum, and then put it back. When that works, the nose becomes beautifully straight. When it doesn’t, the nose collapses. That’s not often discussed.
There are safer ways. First, identify which third of the nose has the asymmetry. If it is the bony upper third, moving one nasal bone in will make the nose more symmetrical.
If the asymmetry is in the middle third and the nose has a hump, taking the hump off often removes the most crooked part of the nose. The remainder can then be straightened by spreader grafts, which split the septum in the midline. If there is still an asymmetry, I take a very thin piece of crushed cartilage and layer it over the nasal dorsum, which hides any remaining crookedness.
If the asymmetry is in the middle third and the nose does not have a bump, I place spreader grafts if they are needed and then cover the remaining crookedness with a dorsal graft.
If the asymmetry is at the lower nose, so that the end of the septum protrudes into one nostril, that section can be removed and replaced as a free graft, which means it won’t go back to its previous location.
None of these techniques require sutures (which don’t hold) or scoring or weakening the septal cartilage (which can compromise stability).
In all these techniques, I preserve at least 15 mm along the bridge and in the lower nose for support. That way collapse is extremely rare.
Getting a crooked nose absolutely straight is very difficult, sometimes impossible, but most patients understand and recognize that predictability, function, and safety are more important.
My priorities in nasal surgery are always safety first, then function, then aesthetics. It doesn’t make sense to put symmetry (aesthetics) first and safety last, increasing the risk of a collapse that will either leave a deformity or require a secondary rib graft.
Risks always have to be balanced against rewards, because it is the patient who ultimately suffers or benefits.