Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Caudal Septal Stabilization Suturing Technique to Treat Crooked Noses Bahadir Baykal, MD,  Ibrahim Erdim, MD, y Ali Guvey, MD, z Fatih Oghan, MD, z and Fatma Tulin Kayhan, MD  Aim: To rotate the nasal axis and septum to the midline using an L- strut graft and a novel caudal septal stabilization suturing technique to treat crooked noses. Patients and Methods: Thirty-six patients were included in the study. First, an L-strut graft was prepared by excising the deviated cartilage site in all patients. Second, multiple stabilization suturing, which we describe as a caudal septal stabilization suturing technique with a ‘‘fishing net’’-like appearance, was applied between the anterior nasal spine and caudal septum in all patients. This new surgical technique, used to rotate the caudal septum, was applied to 22 I-type and 14 C-type crooked noses. Correction rates for the crooked noses were compared between the 2 inclination types with angular estimations. Results: Deviation angles were measured using the AutoCAD 2012 software package and frontal (anterior) views, with the Frankfurt horizontal line parallel to the ground. Nasal axis angles showing angle improvement graded 4 categories as excellent, good, acceptable, and unsuccessful for evaluations at 6 months after surgery in the study. The success rate in the C-type nasal inclination was 86.7% (21.9) and 88% (16.7) in the I-type. The overall success rate of L-strut grafting and caudal septal stabilization suturing in crooked nose surgeries was 87.5% (18.6). ‘‘Unsuccessful’’ results were not reported in any of the patients. Conclusions: L-strut grafting and caudal septal stabilization suturing techniques are efficacious in crooked noses according to objective measurement analysis results. However, a longer follow- up duration in a larger patient population is needed. Key Words: Crooked nose, L-strut, suturing (J Craniofac Surg 2016;27: 1830–1833) A crooked nose is a term used to describe deviation of the nasal axis from the midline. There are 3 crooked nose types: ‘‘C shaped,’’ ‘‘S shaped,’’ and ‘‘I shaped.’’ In the C-type crooked nose, there is convexity on one side of the nasal axis and concavity on the other side. In the I-type crooked nose, the nasal axis is deviated thoroughly to one side linearly. In the S-type crooked nose, there is >1 convexity, and >1 concavity, on the nasal axis. 1 Correction of a crooked nose is a complex operation, and careful detailed preoperative analysis is required for surgical treatment; however, despite all efforts, satisfactory surgical results have not been obtained. During the intraoperative and early postoperative periods, satisfactory results are obtained but, because of ‘‘cartilage memory,’’ there could be deviation of the nasal axis. Given this fact, the patient should be informed that the nasal axis cannot be perfectly positioned on the midline. The patient should also be informed about the requirement of repeated operations. 2–4 Although several surgical techniques have been used, similar to other nasal operations, forming a strong ‘‘L-strut’’ released from internal and external forces is among the key factors in surgical success. Engaging the formed L-strut with the nasal base is essential for preventing the recurrence of inclination. Although there are many studies in the literature concerning crooked noses, a limited number have evaluated the success of surgery. 5–8 In this study, we aimed to obtain successful surgical results with respect to forming an L-strut using the ‘‘L-strut graft,’’ and to strongly fix this corrected type to the nasal base using a ‘‘caudal septal stabilization suturing technique.’’ We also aimed to measure the effectiveness of this technique objectively. PATIENTS AND METHODS This study was approved by the Ethics Committee of our institution numbered as 2015/10/12. Informed consent was obtained from all patients. The study included 36 patients who underwent primary rhinoplasty for correction of a crooked nose from January 1, 2011 to January 1, 2013. Their surgeries were performed at a tertiary-care hospital. The procedures involved an open approach. Photographs of patients between the preoperative week 1 and postoperative week 6, who underwent open septorhinoplasty operations using ‘‘L-strut grafting’’ and‘‘caudal septal stabilization suturing,’’were analyzed angularly and compared. Because the angular analysis of the S-type crooked nose is difficult and unreliable, patients with this type of deformity were excluded. Crooked noses were classified into 2 groups: C type (14 patients) and I type (22 patients). Deviation angles were measured using the AutoCAD 2012 software package (version 18.2; Autodesk, San Rafael, CA) and frontal (anterior) views, with the Frankfort horizontal line parallel to the ground. Nasal axis angles showing angle improvement were classified into 4 categories, per Okurs’ study 8 : excellent, good, acceptable, and unsuccessful (for evaluations 6 months after surgery; Table 1). Surgical Procedure Operations were performed using a transverse midcolumellar inverted-V incision and an open septorhinoplasty method. Inverted- V incisions were continued to a bilateral marginal incision. The osteocartilaginous skeleton was uncovered. Septal mucoperichon- drial flaps were elevated. The septum was released from the outer From the  Department of ORL, Bakirkoy Sadi Konuk Education and Research Hospital, Istanbul; y Department of ORL, Erbaa Government Hospital, Tokat; and z Faculty of Medicine, Department of ORL, Dum- lupinar University, Kutahya, Turkey. Received March 3, 2016; final revision received April 29, 2016. Accepted for publication May 10, 2016. Address correspondence and reprint requests to Fatih Oghan, Department of ORL&HNS, Education and Research Hospital, Dumlupinar University, Kutahya, Turkey; E-mail: foghan2001@yahoo.co.uk The authors report no conflicts of interest. Copyright # 2016 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000002941 TECHNICAL STRATEGY 1830 The Journal of Craniofacial Surgery  Volume 27, Number 7, October 2016