Comparative study between different types of intermediate osteotomies in twisted nose deformity management: a randomized controlled trial

Background The nasal dorsum plays an important role in defining the facial harmony. Osteotomy techniques in rhinoplasty surgery are challenging, as in many cases they require visionless tissue manipulation to achieve an aesthetic facial symmetry. This research elucidates the aesthetic outcome of the different types of intermediate osteotomies for correction of twisted nose deformity. Patients and methods This study was randomized controlled trial on 20 selected patients, divided randomly into 2 groups: group A included 10 patients who underwent routine vertical intermediate nasal osteotomies, while group B involved 10 patients subjected to transverse intermediate nasal osteotomies. Patients were assessed aesthetically both by the surgeon and a layperson based on pre and postoperative VAS scale and frontal view photography. Results Comparing pre and postoperative VAS showed statistically significant improvement with median score improvement from 8 pre to 1–2 post which is 80% improvement with P value of 0.004 for surgeon and 0.004 for lay-person. Comparing the postoperative VAS for both groups showed statistically insignificant difference with P value of 0.106 for surgeon and 0.218 for lay person. Conclusion Twisted nose deformity is one of the challenging cases in rhinoplasty. Both types of intermediate osteotomies have shown significant improvement in postoperative dorsal aesthetic view. There was no statistically significant difference between either group; yet, more improvement was noted in the transverse type.


Background
One of the main components of rhinoplasty surgery is to achieve a pleasing dorsal aesthetic line.It is important to straighten the osseocartilaginous vault anatomy in order to obtain both aesthetic and functional outcomes in rhinoplasty surgery [1].
Twisted nasal deformity is defined as deviation of the axis of the nose from the midline and considered one of the most common deformities encountered in rhinoplasty.Twisted nasal deformity is a complex pathology to treat and requires different types of osteotomies for correction [2].The corrective surgical approach must be tailored to maximize both functional and aesthetic outcomes [3].Osteotomy techniques are one of the challenging techniques in rhinoplasty surgery, as many cases require visionless surgical manipulation to achieve the desired nasal and facial harmony.Osteotomies can be used to narrow a wide bony nasal vault, to  [4].Different approaches were described; the most popular are the external percutaneous perforating osteotomy and the internal endonasal continuous osteotomy.The intraoral and trans-palpebral approaches have also been described.
External osteotomies are widely used despite the possibility of visible scar formation in the percutaneous tissues.The internal osteotomies also have a high rate of mucosal tear.To avoid these possible disadvantages of conventional osteotomy approaches, complete subperichondral dissection is better performed before performing different techniques of osteotomies [5].
There are controversies regarding choice of different osteotomy sites such as medial oblique, low-to-high lateral osteotomy, high-to-low lateral osteotomy, and medial osteotomy that is perpendicular to the long axis of the bone.It has been recognized that an excessively wide osteotomy site can damage the periosteum and can cause excessive bleeding.There is also a region of dense bone which is a zone of 30° off the midline that one should avoid, to decrease the incidence of bleeding and spicule formation [6].
Traditional intermediate osteotomies are done vertically between the medial and lateral osteotomies prior to the lateral osteotomies.They are indicated in upper third dorsal deviations, excessive convexity, or concavity of nasal bone contour or when there is evident asymmetry in the dorsal nasal width [7].They can be used to narrow the excessively wide nose with a good height and to correct the deviated nose with one sidewall much longer than the other and to straighten a markedly convex nasal bone.Intermediate osteotomy is done parallel to the lateral osteotomy somewhere along the middle portion of the nasal sidewall.The exact medial or lateral placement of the osteotomy along the lateral nasal wall may vary depending on the goal of surgery.In a closed rhinoplasty, it is usually performed via an inter-cartilaginous incision with a small osteotome and carried superiorly to the cephalic fracture site.It can be done more precisely through the open rhinoplasty approach [8].
Transverse osteotomies are classically done at the radix level; however, in this study, transverse intermediate osteotomies were compared to the traditional vertical intermediate osteotomies regarding the aesthetic outcome (Fig. 1).

Methods
This study is a randomized controlled trial performed on 20 selected patients presenting with a crooked nasal deformity without any other medical conditions.Patients were randomly divided into two groups.Group A included patients who underwent vertical type of intermediate osteotomy during surgery, while group B included patients who underwent transverse type of intermediate nasal osteotomies.
The study was conducted in the otolaryngology department in a tertiary care hospital.All patients were consented, and the study was approved by the scientific and ethical committee of our institution.Our primary outcome will be the effect of surgical techniques on aesthetic nasal view.
The inclusion criteria included patients aging more than 18 years with a C-shaped crooked deformity Patients less than 18 years old, with history of previous rhinoplasty, with contraindications to general anesthesia, and patients with recent nasal trauma (less than 3 months) or I-shaped crooked deformity were excluded.

Preoperative assessment
Aesthetic evaluation and full otorhinolaryngologic examination including both anterior rhinoscopy and nasal endoscopy were done.Preoperative photography included a set of seven photos taken from different angles (full face frontal view, full face basal view, facedown view, bilateral profile views, and bilateral oblique views).Preoperative and 3 months postoperative visual analogue scale (VAS) were noted by another rhinoplasty surgeon and a layperson to avoid self-bias.The visual analogue scale has a score from 0 to 10 with 0 is the best and 10 is the worst outcome.

Surgical procedure
All candidates underwent primary rhinoplasty by the same surgeon through open approach and external osteotomies.Group A patients underwent correction of twisted nasal deformity by vertical intermediate osteotomies at first, followed by paramedian and lateral osteotomies.Vertical intermediate osteotomies were placed in a parallel direction to the lateral osteotomies line, at the most convex or concave part, until they met the transverse osteotomies at the radix level (Fig. 2).Intermediate osteotomies were done either endonasally or externally.An in-fracture was then made upon completion of the osteotomies of both sides.At this point, the nasal dorsum was molded to achieve the desired result.Reconstruction of the nasal dorsum was completed by unilateral or bilateral spreader grafts or flaps as needed based on the surgeon preferences.
Group B patients underwent correction of the twisted nasal deformity by horizontal transverse osteotomies.The intermediate osteotomy was performed externally before the lateral osteotomy, as it would be difficult to perform after the bone was mobilized laterally.The intermediate osteotomies were done perpendicular to the lateral osteotomies from the nasal dorsum until it met the lateral osteotomies level ventrally (Fig. 3).Then, paramedian, lateral osteotomies, and in-fracture were done similar to the previous group.

Sample size calculation
In a similar study [4] (Intermediate osteotomies in rhinoplasty: a new perspective), the results were used for calculation of the sample size with a study power of 80% and alpha error of 0.05.The minimum number calculated was 18 (9 patients per group) using Medcalc software.The number will be increased by 10% to be 20 patients (10 patients per group) to compensate for possible dropouts.

Statistical methods
Data were coded and entered using the statistical package SPSS (Statistical Package for the Social Science; SPSS Inc., Chicago, IL, USA) version 20.Data was summarized using mean, standard deviation, median, minimum, and maximum in quantitative data and using frequency (count) and relative frequency (percentage) for categorical data.Comparison between normally distributed quantitative variables was done using the independent t-test while the non-parametric Mann-Whitney test or Wilcoxon signed-rank test was used for the non-normally distributed variables.P values less than 0.05 were considered statistically significant.

Results
Age of the patients ranged from 20 to 44 years.Twelve patients were males (60%) while eight patients were females (40%).Comparing both groups showed mean age of 29 for group A and 27 years for group B with SD of 8 and 4, respectively.
Preoperative VAS for group A patients showed scores ranged from 6 to 10 and median of 8, IQR (interquartile range) of 2 for surgeon and scores ranged from 7 to 9 and median of 8, IQR of 2 for layperson.Postoperative VAS showed improvement of scores which ranged from 1 to 4 and median of 3, IQR of 1 for surgeon and from 0 to 4 with and median of 2, IQR of 2 for layperson.Comparing pre and postoperative VAS showed statistically significant improvement with median score improvement from 8 pre to 2-3 post which is 70% improvement with P value of 0.004 for surgeon and 0.005 for layperson.
For group B patients, preoperative VAS showed scores ranged from 6 to 9 and median of 8, IQR of 2 for surgeon and scores ranged from 6 to 9 and median of 8, IQR of 2 for layperson.Postoperative VAS showed improvement of scores which ranged from 1 to 4 and median of 1.5, IQR of 2 for surgeon and from 0 to 3 with median of 1, IQR of 1 for layperson.Comparing pre and postoperative VAS showed statistically significant improvement with median score improvement from 8 pre to 1-2 post which is 80% improvement with P value of 0.004 for surgeon and 0.004 for layperson.Comparing the postoperative VAS for both groups showed statistically insignificant difference with P value of 0.106 for surgeon and 0.218 for lay person.

Discussion
Intermediate osteotomies have only been sparsely described in publications and are mainly indicated for upper third deviations, severely convex or concave nasal bony contour or evident discrepancy in nasal bony width [4].To date there have been no reports of the use of this technique instead of the vertical type.
Correction of the twisted nose often presents a challenge with various functional and aesthetic difficulties.Although many surgical techniques have been described, A little attention has been given to the central area of the nose, which may or may not come to the midline despite well-performed medial and lateral osteotomies as both being unable to create a desired fracture line in the central area.Therefore, any deviation involving the central area needs to be specifically addressed [2].
The double lateral osteotomy addressed the problem of lateral nasal wall which is convex in the anteroposterior plane.The intermediate osteotomy technique was found to approximate the suture line between the maxilla and nasal bone.Sequencing the osteotomies plays a crucial role for preservation of the stability of the bony segments during performing combined osteotomies [1].
This study matches the improvement gained by performing the conventional vertical intermediate osteotomies where their results for the postoperative subjective assessment of cosmetic outcome yielded a score of 4.4 (average score, from a maximum of 5) which is 80% improvement similar to our study which showed statistically significant improvement with median score improvement from 8 pre to 2-3 post which is 70% improvement with P value of 0.004 for surgeon and 0.005 for layperson [4].
The deformity is usually multiplanar where the bowing is not only cranio-caudally in all cases but also dorso-ventrally in many cases.Classically, the intermediate osteotomies were done to correct the dorsoventral bowing.Nevertheless, in this study, the authors compared the conventional technique to the other one which was proposed to correct the cranio-caudal deformity.In the studied group B, where transverse  pre to 1-2 post which is 80% improvement with P value of 0.004 for surgeon and 0.004 for layperson.Comparing both groups, however, did not show any statistical significance, which means that any type of both would be sufficient to induce improvement.Although both groups' comparison was statistically insignificant, group B had greater percentage improvement (80%) compared to A (70%).
Complications included prolonged subcutaneous peri-orbital edema noted in two patients of the transverse group.Mild nasal obstruction was observed in one patient of the vertical group and residual dorsal irregularities noted in three patients of the vertical group and one patient of the transverse group.
This study is a preliminary one and the authors recommend functional evaluation of the technique and its effect on quality of life in future studies also increasing the sample size and follow-up period will be beneficial to better monitor the long-term aesthetic changes.

Conclusion
Twisted nose deformity is one of the challenging cases in rhinoplasty.Both types of intermediate osteotomies have shown significant improvement in postoperative dorsal aesthetic view.There was no statistically significant difference between either group; yet, more improvement was noted in the transverse type.

Fig. 8
Fig. 8 Pre and postoperative vertical group

Fig. 9
Fig. 9 Pre and postoperative transverse group Page 2 of 7 Sabaa et al.The Egyptian Journal of Otolaryngology (2024) 40:57 widen a narrow bony vault, to correct a twisted nose, or to close an open-roof deformity.The different types of osteotomies (medial, lateral, intermediate, and transverse) can be performed and combined to avoid airway dysfunction.Recently, intermediate osteotomies have been routinely performed in patients with a change in eyebrow-tip line harmony