This patient previously underwent a closed rhinoseptoplasty, which resulted in a large septal perforation (“fistula”), as well as an unsatisfactory aesthetic outcome and persistent breathing impairment. CT imaging demonstrates the septal perforation, a residual posterior septal deviation, and a significant bony deviation. On the frontal view, disruption of the aesthetic lines of the dorsum is clearly evident, while the base view and the two three-quarter views reveal an obvious asymmetry and torsion of the tip. On profile view, the nose appears excessively short (over-rotated upward) due to an incorrect and overly extensive resection of the distal (lower) portion of the septum.

The procedure requires selective osteotomies of the deviated nasal bones in addition to osteoplasty. These adjustments of the position and shape of the nasal bones are now facilitated by the use of micro–electric and piezoelectric (ultrasonic) power tools, which represent a major advancement in precision compared with traditional manual osteotomes and rasps. Multiple rib grafts will be necessary both to re-establish the central “plateau” of the nasal pyramid (along its vertical axis) and to restore symmetry and support of the tip and nasal alae. Because of its size, the fistula will not be closed; instead, the reconstruction of the septum and dorsum will be performed “around” the fistula itself. Attempts at closure in cases of this magnitude are often unsuccessful.