Pisa Tower Concept and swinging door septoplasty: a winning combination in the most complex dorso-septal deviation

The crooked nose – that is, the deviation of the nasal pyramid from the median line of the frontal plane – is a constant challenge for rhinosurgeons. The types of dorsal deviation can be many and often also involve the nasal tip. There are multiple causes of the deviation of the nasal pyramid and include, in the first instance, traumas, followed by iatrogenic or congenital factors. All faces present an asymmetry but most people do not notice this if it is less than 3-4 mm. However, it is very important to show the patient their facial asymmetry before performing the operation since the level of attention to each little detail will in- crease the post-operative period. A careful analysis becomes essential for planning the operation. Each of the ana- tomical components (upper lateral cartilages and alars, the septum, the osseous vault, the nasal spine, the soft tissues and the ligament must be assessed since each can contribute to creating this deformity. Even though, in structured rhinoplasty, various nasal osteotomy techniques have been described for the correction of osseous nasal deformities, so far surgical strategies have not been described that would be compatible with the dorsal pres- ervation philosophy. The three main pillars of the dorsum are made up of the nasal bones (in conjunc- tion with the upright branch of the maxillary bone) and the nasal septum. There- fore, the correction of a crooked pyramid must involve the evaluation and, where necessary, management of one or more pillars.