Crooked Nose

Start here. Faces are not symmetrical. Take any photograph, split it down the middle, mirror each half against itself, and you get two people who barely resemble the original. One eye sits fractionally higher. One cheek is fuller. The jaw points a few degrees off centre. Nobody notices, because the eye reads a face as a whole rather than as a set of measurements.

The nose is different only because of where it sits. It runs straight down the midline, so it is the one feature the brain can check against everything else on the face. Two millimetres of asymmetry is invisible on a cheekbone and conspicuous on a nasal tip.

Cameras make it worse. A mirror shows you a reversed face that you have looked at every day of your life, so its asymmetries have stopped registering. A photograph shows the unflipped version, and a front camera held at arm's length adds barrel distortion that widens and skews the centre of the face. Plenty of people arrive in my clinic having found a crooked nose in a group photo rather than in the bathroom mirror.

So most slightly crooked noses need nothing done to them at all. If you breathe evenly through both sides and the bend does not trouble you, that is a complete and sensible answer. Choosing not to have surgery is a legitimate choice, and for many of the people who ask me about an off-centre nose it is the better one. This is an operation on the middle of your face under general anaesthetic, with swelling that takes a year to fully settle and a real, if small, risk of needing further surgery. It is worth doing for breathing you cannot live with, or for a bend that genuinely bothers you. It is not worth doing to satisfy anybody else.

The septum is the partition that divides the nose into two passages. At the front it is a single sheet of cartilage roughly the size of a credit card. Behind and above it becomes the perpendicular plate of the ethmoid bone, and below and behind it becomes the vomer. Its lower edge sits in a shallow groove along the maxillary crest, and its upper edge holds up the bridge. Fixed top, bottom and back. Only the front edge is free.

That anatomy explains most crooked noses. Septal cartilage keeps growing after the bony frame around it has largely stopped, and cartilage trapped between fixed attachments has nowhere to go but sideways. It buckles. Because the septum is also the central support of the bridge and the tip, whatever the septum does, the outside of the nose does too. A bent septum is not a separate hidden problem. It is the reason the visible nose leans.

Deviations fall into recognisable patterns, and the pattern predicts what you see in the mirror.¹

• C-shaped. The septum bows one way along its whole length. The nose leans as a unit: the bridge arcs to one side and the tip follows it. This is the nose that looks tilted rather than kinked, and people often describe the whole face as looking crooked in photographs.
• S-shaped. The septum bends one way at the front and the other way further back. From across a room the nose can look almost straight. Close up there is a definite kink, usually at the junction between the nasal bones and the cartilage. Breathing is often the giveaway: one side blocks high, the other blocks low, and neither side is ever completely clear.
• Caudal deviation. The free front edge has slipped off the maxillary crest and sits inside one nostril. You can see this without any instruments. The columella, the strip of skin between the nostrils, leans to one side, one nostril looks like a slit and the other looks round.
• Localised spurs and ridges. A sharp shelf of bone projecting into one passage. These block well and show little, which is why some people have severe one-sided obstruction and a nose that looks perfectly straight.

When I examine a crooked nose I am working out which of these I am dealing with, because the answer changes the operation completely. A spur takes minutes. A buckled C-shaped septum supporting a leaning bridge is a different undertaking altogether.

Ask anyone with a bent nose whether they have broken it and the first answer is almost always no. Then, a minute later: well, there was a football to the face when I was eleven. A bunk bed. A brother's elbow. A hockey stick, a car door, a fall down the stairs at an age nobody remembers.

A child's nose is mostly cartilage, and cartilage bends rather than snaps. It bleeds for ten minutes, swells for a fortnight, then looks normal again, so it never reaches a hospital and never gets written down. The septum underneath does not always recover as neatly. It keeps the bend, and the nose then grows around a crooked foundation for the next decade. By the time somebody is twenty five, the nose is not the shape of the injury. It is the shape of ten years of growth over the injury, which is why old fractures produce twists rather than simple bends.

This is why most people tell me their nose has always been like this. It has, since an afternoon nobody recorded. Old photographs help more than memory does, and I often ask people to look at pictures of themselves at eight or nine and again at fifteen. The bend usually announces itself somewhere in between. A more recent injury is a different situation with a different clock running, and I have covered that separately on the broken nose page.

A deviation you coped with at twenty five can start blocking at forty five without changing shape at all. The cartilage supporting the side wall of the nose loses stiffness with age, and the internal nasal valve, the narrowest section of the entire airway, begins to draw inwards when you breathe in hard.⁴ The septum has not changed shape. You have lost the margin around it.

Cartilage has memory. Take a septum that has been bent for thirty years, leave the bend where it is, cut the nasal bones and reset the bony pyramid on the midline, and you have built a straight frame around a bent spring. The spring generally wins. Not straight away: the nose looks convincingly straight at six weeks, while everything is still splinted, swollen and stiff. Over the following year the tip drifts back towards the side it came from, a millimetre at a time. Patients describe this as the result not lasting. It only ever looked straight while it was swollen.

This is the single commonest reason I see people for a revision. The first operation addressed the outside and treated the septum as somebody else's department. Published approaches to the deviated nose have made the same point for decades: correcting the external deformity without correcting and stabilising the septal framework invites recurrence.²

There is a separate failure that matters more for breathing than for appearance. Reducing a hump and narrowing the bridge opens the roof of the middle third of the nose. If the upper lateral cartilages are not reattached or supported when that happens, the internal nasal valve narrows further,⁴ and the bridge can develop the shallow shadow surgeons call an inverted V. A nose that ends up straighter and harder to breathe through is a bad trade, and it is avoidable.

So I do the septum first, the framework next, the outside last.

Straightening a crooked nose properly means operating on the septum and the external nose in the same procedure: septorhinoplasty. The septal work comes first and takes longer than people expect.

• Releasing and resecting. The deviated cartilage and bone are freed from the maxillary crest and the bent posterior bone is removed, leaving an L-shaped strut of at least 10 mm along the bridge and the front edge. That strut is the load-bearing part of the nose and it is never removed.
• Straightening the strut itself. If the remaining L is bent, and in a properly crooked nose it usually is, it has to be scored, splinted with a strip of cartilage, or rebuilt. A caudal septal extension graft fixed to the anterior nasal spine is used to pull a leaning front edge back onto the midline and hold the tip there.
• Spreader grafts. Slivers of the patient's own cartilage, roughly 20 to 25 mm long, 2 to 4 mm wide and 1 to 2 mm thick, placed between the septum and the upper lateral cartilages. In a crooked nose they are deliberately asymmetric: thicker on the concave side to shim the dorsal line straight, and they hold the internal valve open at the same time. They do two jobs, which is why they appear in most of these operations.
• Osteotomies. Controlled cuts that mobilise the nasal bones so the bony pyramid can be reset on the midline. Ultrasonic instruments allow finer cuts than a traditional osteotome in some noses, though the principle is unchanged.

What to expect from it. Straighter, not perfect. A nose that has been bent since childhood sits on asymmetric bone, with asymmetric soft tissue and skin of differing thickness on each side, and none of that can be fully equalised. The aim is a nose that reads as straight in normal light and normal conversation, not one that measures straight on a ruler. Some residual asymmetry is usual, and I say so before the operation rather than afterwards. I cannot promise a specific appearance, and anyone who does is telling you something the anatomy cannot support.

Breathing is the part with the firmest evidence behind it. A randomised trial published in the Lancet compared septal surgery against non-surgical management for adults with nasal obstruction and a deviated septum, and found meaningfully better symptom scores in the surgical group at follow up.³ That is a stronger evidence base than most cosmetic claims about the nose can offer, and it is one reason I ask about breathing before I ask about appearance.

Timing. After a recent injury I wait three to six months, so the scar tissue settles and the shape I operate on is the shape that will stay. A nose that is still growing is different again: reshaping surgery is deferred until growth finishes, usually around 16 to 17, because operating on a growing nose can affect how it develops. I do not perform cosmetic nasal surgery on under-18s. Blocked breathing in a younger patient is assessed on its own merits, and that is a separate conversation from how the nose looks.

My background is dual: consultant ENT surgery and facial plastics, a rhinology fellowship in Manchester and an EAFPS facial plastic surgery fellowship in Istanbul, with Intercollegiate Board Certification in cosmetic surgery from the Royal College of Surgeons. I operate at Weymouth Street Hospital, which reports one of the highest rhinoplasty volumes in the UK to PHIN, the body private hospitals are required to publish their activity data to. The reason I lead with the septum on this page is that the airway is where I trained first.