So let's start with the upper third. Now, of course, the upper third is bony; it is comprised of the nasal bones and the contribution of the maxilla to the nasal pyramid. And so, when the upper third of the nose is twisted, the treatment is to perform osteotomies, to cut the nasal bones. I will typically use medial and lateral osteotomies.

Sometimes intermediate osteotomies are necessary too. Essentially, you have to diagnose where the bones are twisted. If the nasal bones are shifted off of the midline, then medial and lateral osteotomies will suffice. However, if there in an inherent deviation of the nasal bones, these locations must be identified, and the bone must be cut in these locations – intermediate osteotomies – to allow you to straighten the nasal bone. Here is a patient whose primary request was simply to straighten his nose, and the only thing we did in his surgery was to do medial, intermediate and lateral osteotomies. The only reason his nose was twisted was due to his twisted nasal bones. In this patient, medial, intermediate and lateral osteotomies were required to straighten his nose. No other changes were made to this patient’s nose.

When you are fixing a twist of the nose that is caused by the upper or bony portion of the nose, you need to be sure that the deviated bony septum is also straightened. The septum, of course, is on the inside, and if it is twisted you can straighten the outside part of the nose all you want, but if you don't fix and straighten the underlying support structure, then after surgery the nasal bones will just shift back to where they were and the correction will be temporary. There is an instrument that I like to use called a Sayer elevator, and in the situation that I have just described, I will place the Sayer elevator intranasally and I will fracture the deviated nasal septum in the appropriate location, in that bony portion. That completes my thoughts on the upper or bony third of the nose. I do want to reiterate a take-home point, that you need to carefully analyze the nose to assess if you will need to do more than a medial and lateral osteotomy. Sometimes you need what intermediate osteotomies as well.