The nose is made up of a fixed and rigid part that is called nasal pyramid, although it rather has the shape of a tent or roof, and a pliable mobile part which is the nasal tip, the alae and its annexes. The nasal tip and the alae are structured by the so called alar or lower lateral horseshoe shaped cartilages with their lateral and medial crura or crus and accessory cartilages, the domes between lateral and medial cruras, the interdomal fibrofatty pad, the caudal or lower septum and the skin of the alae.
Both halves of the nasal tip join with each other in the center of the tip to form a tripod in which the lateral legs are the lateral cruras of the alar or lower lateral cartilages and the central leg the union of both medial cruras of the alar or lower lateral cartilages.
In many occasions the patient is unable to detect the nasal asymmetry, attributing their dissatisfaction to the lopsidedness of their nasal tip for being crooked. The osseous and cartilaginous walls forming the nasal pyramid, as well as the alar or lower lateral cartilages building the nasal tip and alae, might be of different size and shape from one side to the other, leading to a high grade of nasal deviation; nasal asymmetries have very difficult or partial, if any, correction, or they might need very complex and rebuilding surgical strategies, having no connection with really crooked noses.
Some patients call crooked nose what is really nasal asymmetry, or both problems coexist so we would be before a case of nose deviation aggravated by the asymmetry of the nasal structures. It must be borne in mind that when the nose is crooked this causes a severe aggravation of the nasal asymmetries, and vice versa, which may confuse patients and surgeons who are not experienced in rhinoplasty surgery. In other words, the greater the asymmetry of the nose, the more it seems that there is nasal crookedness, but it is not the real grade of deviation; the actual grade of deviation is seen once the nose is in its correct position.
It is very important that the patient receives an exact diagnosis, because under no circumstances should nasal asymmetry be treated by deviation correction techniques for misinterpreting that such lopsidedness is due to crookedness, as it would entail a grotesque and artificial appearance.
In most cases, the patients suffer at the same time from nose deviation along with a greater or lesser degree of nasal asymmetry, so it is a discretional decision treating either or both of the problems.
The structures involved causing nasal tip asymmetry are the alar or lower lateral cartilages, the triangular or quadrangular or upper lateral cartilages, the caudal or soft or cartilaginous nasal septum, alae skin, the nostrils, etc. Therefore treatment may require varied techniques addressing each problem, like asymmetric cartilage reduction, asymmetric plications (shaping sutures through the cartilages), asymmetric batten grafts, custom tip grafts, asymmetric or unilateral spacer or spreader grafts, replacement of some of the cartilages by handmade brand new pieces grafted from elsewhere, septoplasty, septal strut, asymmetric wedge skin resections, etc.