Aesthetic Outcomes of Rhinoplasty Performed in the Early Posttrauma Period after Nasal Bone Fracture

Abstract

The optimal timing of rhinoplasty for patients with nasal bone fractures remains controversial. We investigated whether the timing of rhinoplasty after nasal trauma affects the aesthetic outcome of the procedure. A total of 41 adult patients with nasal bone fractures who underwent rhinoplasty between 2006 and 2021 were enrolled in this study. A visual analog scale (VAS) was used to indicate the assessor's satisfaction with the surgical outcome after a comparison of the pre- and postoperative facial photographs of each patient. Of the 41 patients, 28 underwent rhinoplasty within 14 days after nasal trauma (early rhinoplasty group), whereas 13 underwent rhinoplasty more than 14 days after nasal trauma (late rhinoplasty group). The rate of receiving spreader and shield graft was higher in the late rhinoplasty group (p = 0.043 and 0.018, respectively). Patients with type IV or V nasal bone fracture and patients with preoperative saddle noses had higher VAS scores than those with types I to III fractures and those without preoperative saddle nose (p = 0.003 and 0.020, respectively). There was no significant difference in overall aesthetic outcome between the early and late rhinoplasty groups. Both groups achieved significantly better radix height, dorsal height, and tip projection after rhinoplasty. The aesthetic outcome of rhinoplasty performed in the early posttrauma period is comparable with that of rhinoplasty performed more than 2 weeks after nasal bone fracture. Rhinoplasty can be considered a safe surgical treatment option for nasal bone fracture, even in the early posttrauma period.

Level of Evidence: 4.

Keywords

rhinoplasty - nasal fracture - posttrauma period - aesthetic outcome

Nasal bone fractures are the most common type of facial bone fractures.[1] [2] [3] Options for acute management of traumatic nasal fractures vary; however, closed reduction is the most frequently used treatment method.[1] [4] Unfortunately, the treatment outcomes of closed reduction are often disappointing and a sizeable subset of patients require secondary surgical corrections.[2] The incidence of postreduction nasal deformities that require rhinoplasty or septorhinoplasty ranges from 9 to 75%.[1] [4] [5] [6] [7]

There are conflicting opinions regarding the timing of rhinoplasty for patients who have nasal bone fractures and desire to improve the appearance of their noses. Conventionally, open treatment of traumatic nasal deformities is reserved for treatment failure after closed reduction, and surgery is typically delayed by at least 6 months after injury or after complete healing of the fracture.[8] [9] The reason why some surgeons are against performing rhinoplasty in the acute stage of nasal trauma is that the unstable bony foundation may adversely affect surgical outcomes and lead to unpredictable results, particularly exacerbation of nasal deviation.[10] Some surgeons suggest a delay of 6 weeks or more when planning first-line open septorhinoplasty to ensure complete resolution of acute inflammation and obtain better results.[2] On the other hand, some studies have revealed that rhinoplasty performed at the same time as nasal bone reduction for nasal trauma yields good surgical outcomes.[10] [11] Better understanding of the impact of the timing for rhinoplasty will facilitate the establishment of more effective surgical approaches and potentially improve patient outcomes. Thus, the purpose of this study was to analyze the factors associated with the surgical outcomes of rhinoplasty in Asian patients with nasal fractures. In particular, we explored whether the timing of rhinoplasty affects the aesthetic outcomes of the procedure.

Materials and Methods

Patients

We retrospectively reviewed the medical records of 41 patients with nasal bone fractures who underwent rhinoplasty performed by a single surgeon between February 2006 and November 2021. The patients decided whether they would undergo rhinoplasty or not. If a patient wanted to undergo both fracture reduction and rhinoplasty, nasal bone reduction and rhinoplasty were performed simultaneously. In addition, we chose to perform rhinoplasty if the fracture was severe enough to require open reduction. Patients with complete medical records and postoperative follow-up clinical photos were included in this study. Patients with a history of rhinoplasty, nasal septoplasty, or nasal bone fracture prior to the most recent injury were excluded from the study. Clinical data, such as age, sex, observation time, number of days between trauma and surgery, graft type, surgical techniques, and type of nasal fracture, were collected. Observation time was defined as the period from the date of rhinoplasty to the date of the last follow-up. Nasal fractures were categorized according to the classification proposed by Yi et al: type I, simple nasal fracture without bony septal fracture; type II, nasal bone displacement with bony septal fracture; type III, nasal bone and cartilaginous septal fracture without dorsal depression; type IV, nasal bone fracture, cartilaginous septal fracture, and dorsal depression; type V, comminuted nasal bone fracture with displaced bony segment and severe caudal septal injury or an open wound.[12] The primary outcome of this study was the association between aesthetic outcomes and the timing of rhinoplasty. Thus, the enrolled patients were divided into two groups: those who underwent rhinoplasty within 14 days after nasal trauma (early rhinoplasty group) and those who underwent rhinoplasty more than 14 days after trauma (late rhinoplasty group). The method used for the assessment of surgical outcomes was based on the methodology used by Kim et al.[13] The surgical outcomes were assessed by two otorhinolaryngologists who were not involved in any of the patients' surgeries. They used a visual analog scale (VAS) to rate their satisfaction with the aesthetic outcomes after comparing the pre- and postoperative facial photographs of the patients. Satisfaction categories ranged from 0, which meant “very dissatisfied,” to 10, which indicated “very satisfied.” Radix height, dorsal height, and nasal tip projection were evaluated using the system developed by Wang et al.[14] Nasal length was defined as the distance from the nasion along the dorsum to where it crossed a line from the nasolabial angle. Nasal tip projection was measured from the nasolabial angle to where it met a line from the nasion along the dorsum. Dorsal height was measured from the rhinion to the point of intersection with a line from the medial canthus to the alar crease (the two lines were perpendicular to each other). Radix height was defined as the distance from the nasion to the medial canthus. The nasal length was fixed at 2 for ratio calculations.

Statistical Analysis

Independent t and Pearson's chi-squared tests were used for the analysis of the basic characteristics of the enrolled patients, the surgical techniques used, revision rates, and complication rates. The independent t-test was used to determine the correlations between surgical techniques and VAS scores. A paired t-test was used to compare the pre- and postoperative radix heights, dorsal heights, and nasal tip projections of the patients. IBM SPSS Statistics version 22 was used for all statistical analyses.

Results

The demographic and clinical data of the study population are outlined in [Table 1]. A total of 41 patients were included in this study. Of these, 28 patients underwent rhinoplasty within 14 days after nasal trauma (early rhinoplasty group), whereas 13 patients underwent rhinoplasty later than 14 days after nasal trauma (late rhinoplasty group). The mean age of the patients in the early and late rhinoplasty groups was 33.75 and 36.46 years, respectively. Thirty-one (75.6%) of the patients were male. The mean observation time for early and late rhinoplasty groups was 325.64 and 348.15 days, respectively (p = 0.925). The mean number of days from trauma to surgery was 8.68 and 80.69 days (p = 0.001). Preoperative clinical features, such as type of fracture and preoperative saddle nose or deviated nose, did not differ significantly between the two groups ([Table 1]). The surgical techniques used are outlined in [Table 2]. The rate of patients in the late rhinoplasty group who received spreader and shield grafts was higher than that in the early rhinoplasty group (p < 0.05). There were no significant differences in the use of septal extension graft, tip onlay graft, columella strut, dorsal implant, surgical approach, and osteotomy between the two groups. Septal, ear, and rib cartilages were the most commonly used materials for dorsal implant during rhinoplasty ([Table 3]). The revision rate and complication rate in both groups did not have significant difference ([Table 4]). The factors associated with VAS scores are listed in [Table 5]. Patients with preoperative saddle nose and those with more severe types of preoperative fracture had higher postoperative VAS scores than those without preoperative saddle nose and those with less severe types of fracture (p = 0.003 and 0.020, respectively). However, the VAS scores of the early and late rhinoplasty groups were not significantly different (p = 0.737). The changes in radix height, dorsal height, and nasal tip projection after rhinoplasty are shown in [Table 6]. Significant improvements in nasal tip projection, dorsal height, and radix height were achieved after rhinoplasty regardless of the timing of the surgery. The clinical outcomes are shown in [Figs. 1] and [2].

Table 1 Demographic and clinical characteristics of the patients

Variable	Within 14 d n = 28	After 14 d n = 13	p-Value
Age (mean, range)	33.75 (14–66)	36.46 (15–59)	0.600
Sex
Male	23 (82.1%)	8 (61.5%)	0.241
Female	5 (17.9%)	5 (38.5%)
Follow-up time (d, mean)	325.64	348.15	0.925
Number of days between trauma and surgery (mean)	8.68	80.69	0.001
Type of fracture			0.181
Type I/II/III	12 (42.9%)	9 (69.2%)
Type IV/V	16 (57.1%)	4 (30.8%)
Preop saddle nose			0.179
Yes	18 (64.3%)	5 (38.5%)
No	10 (35.7%)	8 (61.5%)
Preop deviated nose			0.737
Yes	12 (42.9%)	7 (53.8%)
No	16 (57.1%)	6 (46.2%)

Abbreviation: Preop, preoperative.

Table 2 Surgical techniques used

Variable	Within 14 d n = 28	After 14 d n = 13	p-Value
Spreader			0.043
Yes	9 (32.1%)	9 (69.2%)
No	19 (67.9%)	4 (30.8%)
Septal extension graft			0.237
Yes	4 (14.3%)	4 (30.8%)
No	24 (85.7%)	9 (69.2%)
Shield graft			0.018
Yes	3 (10.7%)	6 (46.2%)
No	25 (89.3%)	7 (53.8%)
Tip onlay graft			0.493
Yes	10 (35.7%)	3 (23.1%)
No	18 (64.3%)	10 (76.9%)
Columellar strut			0.645
Yes	3 (10.7%)	2 (14.3%)
No	25 (89.3%)	11 (84.6%)
Dorsal implant			1.000
Yes	26 (92.9%)	12 (92.3%)
No	2 (7.1%)	1 (7.7%)
Osteotomy			0.492
Yes	9 (32.1%)	6 (46.2%)
No	19 (67.9%)	7 (53.8%)
Approach			0.481
Endonasal	11 (39.3%)	3 (23.1%)
Open	17 (60.7%)	10 (76.9%)

Table 3 Dorsal implant materials

Graft type	Within 14 d n = 28	After 14 d n = 13	p-Value
Ear cartilage	3 (10.7%)	1 (7.7%)	0.995
Septal cartilage	12 (42.9%)	5 (38.5%)
Rib cartilage	3 (10.7%)	2 (15.4%)
Fascia	3 (10.7%)	1 (7.7%)
Surgiform	1 (3.6%)	1 (7.7%)
Combined	4 (14.3%)	2 (15.4%)
No graft	2 (7.1%)	1 (7.7%)

Table 4 Revision or complication rates

Variable	Within 14 d n = 28	After 14 d n = 13	p-Value
Revision			0.095
Yes	0 (0.0%)	2 (15.4%)
No	28 (100.0%)	11 (84.6%)
Septal abscess or hematoma			1.000
Yes	1 (2.9%)	0 (0.0%)
No	27 (97.1%)	13 (100.0%)

Table 5 Analysis of surgical outcomes according to visual analog scale scores

Variable	Postop VAS score	p-Value
Timing of rhinoplasty		0.737
Within 14 d	7.82 ± 0.82
After 14 d	7.73 ± 0.75
Type of fracture		0.003
Type I/II/III	7.45 ± 0.69
Type IV/V	8.15 ± 0.75
Approach		0.285
Endonasal	7.60 ± 0.74
Open	7.88 ± 0.81
Preop saddle nose		0.020
Yes	8.04 ± 0.70
No	7.47 ± 0.79
Preop deviated nose		0.078
Yes	8.02 ± 0.75
No	7.59 ± 0.78
Spreader
Yes	7.81 ± 0.69	0.928
No	7.78 ± 0.87
Septal extension graft		0.747
Yes	7.80 ± 0.77
No	7.78 ± 0.90
Shield graft		0.950
Yes	7.75 ± 0.86
No	7.79 ± 0.74
Tip onlay graft		0.772
Yes	7.85 ± 0.89
No	7.77 ± 0.75
Columella strut		0.983
Yes	7.79 ± 0.79
No	7.80 ± 0.91
Osteotomy		0.290
Yes	7.97 ± 0.93
No	7.69 ± 0.69

Abbreviations: Postop, postoperative; preop, preoperative; VAS, visual analog scale.

Table 6 Analysis of radix height, dorsal height, tip projection

Variable	W/in 14 d	p-Value	After 14 d	p-Value
Radix height		0.001		0.001
Preop	0.367		0.323
Postop	0.424		0.391
Dorsal height		<0.001		0.001
Preop	0.627		0.609
Postop	0.720		0.675
Tip projection		0.003		0.013
Preop	0.824		0.799
Postop	0.867		0.857

Abbreviations: Postop, postoperative; preop, preoperative.

Fig. 1 A 63-year-old man with type IV nasal bone fracture, cartilaginous septal fracture, and saddle nose. Open septorhinoplasty was performed 6 days after trauma. Septal reconstruction with costal cartilage was performed. Spreader graft, septal extension graft, and dorsal graft (diced cartilage) were used. The postoperative photo shows a straight nose and well-projected tip. Postop, postoperative; preop, preoperative.

Fig. 2 A 32-year-old man with type IV nasal trauma, cartilaginous septal fracture, and dorsal depression. Open septorhinoplasty was performed on the 18^th day after trauma. Spreader graft, tip onlay graft, and dorsal graft obtained from the ear cartilage were used. After the surgery, the dorsal line was straight on the lateral view, and the tip projection was better. Postop, postoperative; preop, preoperative.

Discussion

There is still no consensus on the optimal timing of rhinoplasty for patients with nasal fractures. Many surgeons consider open reduction or rhinoplasty at least 3 to 6 months after a traumatic nasal bone fracture, only if the outcome of an initial closed reduction is unsatisfactory.[4] [8] [9] The reason why some surgeons are against immediate rhinoplasty is that the fractured nasal bone or septum provides an unstable framework for rhinoplasty and may lead to unpredictable results. On the other hand, the results of recent studies suggest that immediate rhinoplasty with nasal bone reduction yields good surgical outcomes.[10] [11] In the present study, we observed that the timing of rhinoplasty was not a determining factor of aesthetic outcomes evaluated using the VAS score, objective measurement of radix height, dorsal height, or tip projection. This result may be explained by the routine surgical technique used by the senior author. During each rhinoplasty, the senior author always built a strong and stable L strut by rigid fixation of the caudal septum to the anterior nasal spine, placing batten grafts for strengthening the caudal strut, and/or using spreader grafts to provide reliable stabilization. This result is consistent with the concept proposed by Davis and Chu, which states that skeletal stabilization is the key factor for successful and predictable rhinoplasty results in patients with nasal fractures.[2] Without skeletal stabilization, wound healing aberrations may occur.[2]

We observed that although the aesthetic outcomes of the two patient groups did not differ significantly, the number of patients in the late rhinoplasty group who received grafts, such as spreader and shield grafts, was higher than that in the early rhinoplasty group. This result suggests that patients who do not undergo early intervention may be more likely to develop tissue contracture, wound healing aberration, and progressive distortion of nasal structures, which increases the need for structural grafts and more aggressive procedures.

Camouflage grafts or rasping is useful for correction of nasal bone deformity. In the late group, 7 (53.8%) patients did not receive osteotomy and 12 (92.3%) patients needed dorsal implants. The material used for dosrum included homologous fascia with or without crushed cartilage, which provided good camouflage effects. Rasping is a frequently used technique for correcting deviated nose, especially for patients with short nasal bones who are not good candidates for osteotomy.

All the patients enrolled in the present study underwent nasal bone reduction and rhinoplasty simultaneously. We did not perform rhinoplasty as a second-stage surgery. Previous studies have shown that the treatment outcomes of closed reduction for nasal fracture are not optimal. Of patients with nasal fracture treated using closed reduction, 42 to 75% have significant functional or aesthetic concerns that require subsequent septoplasty or septorhinoplasty.[7] [15] [16] However, most patients would not choose to undergo a second surgery.[16] Thus, for patients with severe nasal fractures that require open management of the septum and dorsum, and patients who want to undergo rhinoplasty simultaneously because they have a preexisting desire for rhinoplasty, the full septorhinoplasty approach in the initial treatment of nasal fractures, rather than closed reduction followed by second-stage rhinoplasty, may be necessary.

We observed that patients with more severe nasal fractures or a preoperative saddle nose had better VAS scores than those with less severe nasal fractures and those without a preoperative saddle nose. This finding may be explained by the fact that as these patients had more obviously deformed noses, they underwent more comprehensive structural procedures and grafting.

This study had a few limitations. First, the sample size of the late rhinoplasty group was much smaller than that of the early rhinoplasty group; thus, statistical bias may be inevitable. Second, nasal function evaluation is important for rhinoplasty cases, but we did not have complete data on preoperative and postoperative function assessment for these patients. Further studies are needed to gain a better understanding of whether the timing of rhinoplasty affects the postoperative nasal function in patients with nasal trauma.

Conclusion

The aesthetic outcome of rhinoplasty performed within 14 days after nasal fracture is not significantly different from that of rhinoplasty performed later than 14 days after nasal fracture. The results suggest that the timing of rhinoplasty for patients with nasal fractures, even in the early posttrauma period, does not affect the aesthetic outcome of the procedure.

Conflict of Interest

None declared.

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Publication History

Accepted Manuscript online:
27 December 2023

Article published online:
29 January 2024