Twisted Nose: Preservation Rhinoplasty with Modified Push-Down/Let-Down Technique

Jasso-Ramírez E, Burgos-Páez A, Sánchez Y Béjar F, Friedman O, Kern E, López-Ulloa F.

What this paper says

Measuring photographs of patients with crooked noses treated by removing a wedge of bone from one side only, the authors report about 80 percent improvement in the angle of deviation while keeping the bridge intact.

Overview

A twisted or crooked nose leans off the facial midline. Preservation rhinoplasty lowers or shifts the bony bridge as a unit rather than cutting the hump off. The authors tested whether removing bone unevenly, more on one side, straightens a twisted nose within the push-down and let-down methods. Deviation angles were measured on front view photographs before and after surgery using Scion Image software, with statistics done in Excel.

Sections of note

Design: retrospective comparative cohort study. Level of evidence therapeutic IV.
The abstract states 78 patients with twisted noses classified as type C and type I, then reports 42 type C and 28 type I, which sums to 70 rather than 78. The paper's own numbers are inconsistent.
Mean age was 19 years.
Improvement ratio in deviation angle: 81 percent for type C and 79 percent for type I.
Angle correction was statistically significant for both types, p less than 0.01.
Most results were graded excellent to good; four cases were classed as bad outcomes, two type C and two type I.
The technique worked with or without a preexisting hump, and the authors state it is better suited to type C deviations.

What it means for a patient

Asymmetric bone removal is presented as a way to straighten a leaning nose without dismantling the bridge.
Improvement was measured as change in angle on photographs, not by breathing tests or questionnaires.
Bad outcomes occurred in four patients, so the technique does not straighten every crooked nose.
Limits: retrospective, no alternative technique compared, no stated follow up, and a discrepancy in the reported patient count.

Why this paper matters

The crooked nose is among the hardest deformities to correct and a frequent cause of revision surgery. Preservation techniques were designed for smooth bridges, and applying them to asymmetric noses required a modification like this one. Whether the correction holds over years is unanswered.

Terms

Twisted or crooked nose: a nose whose axis deviates from the facial midline.
Preservation rhinoplasty: reshaping that keeps the natural bridge surface intact.
Push-down: lowering the bony bridge into the face after cutting its supports.
Let-down: removing a wedge of bone from the side walls so the bridge settles lower.
C-shaped and I-shaped deviation: whether the nose curves or leans in a straight axis.

Summary written by rhinoplasty.cc from the abstract, 2026-09-09; not medical advice. The authors' own abstract follows.

From the abstract

“The authors present a retrospective, comparative, and analytical cohort study, that aimed to prove the utility of unilateral or asymmetrical bony wedge resection to straighten the twisted nose as applied in let-down and push-down methods. The study involved objective angle measurements preoperatively and…”

Excerpt; the full abstract is on PubMed.