On careful examination, no nose is truly straight because however facial features have a multitude of asymmetries and the face does not have a genuine midline. In some instances, either because of the development of a nose or because of injury or previous surgery the shape of the nose shows more deviation that can be improved. This can bring enhanced balance to the facial features.
Nasal deviation can be either limited to the nasal tip or nasal bridge or can involve the whole of the nose. It requires careful assessment, but it is the most likely area of rhinoplasty surgery where the decision prior to surgery needs to be revisited during the surgery since the external appearance may mask many structural asymmetries that need to be addressed.
The approach for surgery can be to relocate the bridge of the nose or to build on one side to produce the perception of straighter. A significant contribution to this decision comes from the desired width of the bridge of the nose:
When targeting a narrower bridge shape, displacement and relocation are typically needed.
When targeting a wider bridge shape, adding to the width can be that preferred technique.
The nasal septum is frequently a significant contribution to the deviation of the nasal tip or nasal bridge. The operation frequently involves removing some of the central part of the septal deviation and repositioning of the attachments of the cartilage of the septum over the anterior nasal spine.
When the septal deviation starts from the very top it is referred to as high deviation. It is a more challenging part of surgery, because displacing both the side walls and the septum can produce instability. There are a number of techniques available to address this type of problem and it represents an important part of the discussion before surgery.
Deviation of the nasal tip can be either due to the septum or to significant asymmetry of the cartilage is that support the tip. Both aspects require attention and adjustment, and in surgery there are many shape elements of the tip that are discovered and were not clearly visible through the skin during the examination.
Some surgeons preferred to use computer imaging for planning the surgery with patients, some prefer to discuss the project in detail but without imaging. Either way, the surgery requires experience and ability to adapt to the findings in order to produce the best result possible.