Asymmetric Osteotomies in Structural Rhinoplasty: A Pisa Tower-inspired Approach for Crooked Noses

Abstract Background The Pisa Tower Concept, originally described by Finocchi et al., corrects bony vault deviation through asymmetric osteotomies without dorsal reduction. This study evaluates a structural adaptation in which asymmetric osteotomies are integrated into a structural workflow including dorsal hump management and septal reconstruction. Objectives To assess the effectiveness, safety, and satisfaction of Pisa Tower–style osteotomies as an adjunct to structural rhinoplasty for crooked nose. Methods A retrospective analysis was conducted on 37 patients undergoing structural rhinoplasty for crooked nose deformity. Osteotomies were adapted from the Pisa Tower model: low-to-low or high-to-low lateral osteotomy on the concave side, wedge resection on the convex side, and transverse or oblique osteotomy depending on deviation origin. All patients underwent endoscopic L-strut septoplasty, dorsal hump removal, and tip support with a septal extension graft. Outcomes included pre- and postoperative CT-based R–Webster angles, nasal axis deviation, a 5-point Likert satisfaction scale, and complications, after a mean follow-up of 18 months (range, 12–28). Results Mean nasal axis deviation improved from 7.9° ±1.9° to 1.2° ±0.6° (p = 0.0001). R–Webster distance on the convex side decreased from 30.4 ±4.8 mm to 23.1 ±3.9 mm (p = 0.0003); concave side, from 23.7 ±3.5 mm to 22.8 ±3.3 mm (p = 0.18). Overall, 89.2% of patients rated satisfaction as 4 or 5. Minor complications occurred in 13.5%; none were major. Conclusions In this preliminary report, Pisa Tower–style asymmetric osteotomies may represent a promising adjunct to structural rhinoplasty for the correction of bony nasal deviation, extending Finocchi’s concept to a structural framework.