Asymmetric Puzzle Spreader Graft: A Systematic Approach for Correction of Crooked Nose Deformity

Correction of crooked nose deformity remains one of the most challenging aspects of rhinoplasty. C-shaped and reverse C-shaped nasal deviations require asymmetric surgical approaches to achieve optimal aesthetic and functional outcomes. Traditional symmetric spreader graft techniques often fail to address the underlying asymmetric deformity adequately.

This study aimed to evaluate the efficacy of a novel asymmetric puzzle spreader graft technique combined with asymmetric osteotomy and osteoplasty in correcting C-shaped and reverse C-shaped nasal deviations.

Between 2021 and 2023, 50 patients (27 males, 23 females; mean age 35.4 years; range 18-50 years) with axial deviation (28 C-shaped, 22 reverse C-shaped) underwent rhinoplasty using asymmetric osteotomy, osteoplasty, and asymmetric puzzle spreader grafts performed by a single surgeon. On the wider convex side, an extended asymmetric spreader graft reaching the radix was placed, while on the narrower concave side, a smaller spreader graft starting from the K-point was inserted. Rhinion deviation angle (RDA) and nasal tip deviation angle (NDA) were measured using GNU Image Manipulation Program (GIMP, version 2.8.22) on frontal photographs. Mean follow-up was 2 years (range: 1-3 years).

Preoperative mean RDA was 7.28° (range: 3.5-17.46°), which significantly decreased to 3.15° (range: 1.1-4.2°) postoperatively (P < 0.05). Preoperative mean NDA was 4.67° (range: 2.5-13.01°), which significantly decreased to 1.23° (range: 0.45-3.21°) postoperatively (P < 0.05). The mean preoperative Nasal Obstruction Symptom Evaluation (NOSE) score was 62.57 (SD: 19.44; median: 71), which significantly improved to 21.84 (SD: 16.81; median: 16) at 1-year postoperative follow-up (P < 0.001). Statistical analysis using Wilcoxon signed-rank test revealed significant improvement in both RDA (56.7% reduction), NDA (73.7% reduction), and NOSE scores (65.1% reduction). Complications included one wound infection (2%), two minor nasal bleeding episodes (4%), and one patient requiring revision (2%).

The asymmetric puzzle spreader graft technique combined with asymmetric osteotomy provides effective correction of crooked nose deformity with significant improvement in objective nasal deviation measurements and low complication rates. This technique addresses the asymmetric nature of the deformity by tailoring graft size and placement to each side's specific anatomical requirements.

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