Management
The primary goals in the treatment of isolated nasal bone fractures are premorbid
function restoration and cosmesis. Given the variably high rates of revision septorhinoplasty
in the literature, a secondary goal of treatment would be to minimize posttreatment
deformity. A thorough nasal analysis including intranasal evaluation must be completed
at the time of evaluation. Septal hematoma can present as boggy-appearing mucosa that
is fluctuant upon palpation with a Q-tip or suction. Patients may have nasal obstruction
from septal mucosal swelling out laterally and contacting the inferior turbinates.
Any septal hematoma should be drained immediately to avoid septal cartilage necrosis,
infection or saddle-nose deformity ([Fig. 3]).
Fig. 3 Septal hematoma/abscess drainage. Anterior rhinoscopy is performed and a no. 11 blade
is used to incise the mucoperichondrium and allow drainage of contents to prevent
septal cartilage necrosis. Once the hematoma is drained, a small drain can be sutured
to keep the incision open for approximately 3 to 5 days or longer for ongoing irrigation
if infected.
In the literature, there is no clear consensus on the best treatment algorithm in
an acute trauma setting. There have been many attempts at streamlining the approach
to the management of nasal bone fractures. The options for primary management in an
acute setting include the following:
-
Observation.
-
Closed nasal reduction.
-
Closed nasal reduction with limited septoplasty.
-
Open septorhinoplasty with ear cartilage or rib cartilage.
-
Open reduction internal fixation of nasal bones/NOE fractures ± septorhinoplasty
In the acute setting, aside from closed nasal reduction and laceration repair, most
practitioners tend to avoid performing definitive open septorhinoplasty (option 4)
that requires extensive dissection and cartilage grafting. The trend is to perform
conservative procedures acutely and wait for 3 to 6 months prior to considering a
definitive open septorhinoplasty once all of the soft tissue trauma and cartilage
contracture forces have stabilized to more accurately reflect long-term appearance
and nasal airflow.
The reasoning for initial conservative, less invasive treatment in the acute setting
is that there are several variables that can influence the final, long-term outcomes
both cosmetically and functionally. First, if there is a laceration involving the
nasal skin, the traditional open rhinoplasty approach can severely compromise the
skin envelope vascularity and may result in exposed nasal cartilages if the skin flap
dies. Furthermore, the scar can thin out greatly over time and can give the illusion
of saddle-nose deformity even if the underlying cartilage is intact, which may require
subcutaneous grafting under the thin scar to provide desirable skin contour. A scar
can also become hypertrophic and provide excess volume to the nasal dorsum or highlight
asymmetry. All scars take time to mature and may improve in appearance naturally with
time. Long-term appearance of facial scars cannot be reliably assessed until approximately
6 to 12 months after the accident. Second, if the nasal cartilages have been transected,
it is best to avoid performing any significant dissection as lifting the skin or underlying
nasal mucosa away from the cartilage, which is typically required in cartilage grafting,
as this can devascularize the nasal cartilage. In the acute setting, it is best to
reapproximate the transected nasal cartilages with sutures and close the overlying
and skin and the nasal mucosa in a layered fashion. Transected cartilages will likely
undergo a varying degree of scarring and weakening, and this area may require cartilage
grafting to provide adequate support at the time of definitive nasal surgery. Third,
similarly, if the nasal bones are severely disrupted with an open laceration, it is
imperative that the nasal bones are not exposed and the overlying skin envelope must
be repaired. If the nasal bones are present in combination with concurrent upper or
midface fractures, it may require open reduction and internal fixation with hardware
using the existing laceration for approach. Modified lynch incisions can be used to
access the NOE fracture site along the upper one-third, whereas bicoronal incision
can be used if there is a concurrent frontal sinus fracture that will require repair.
Fourth, in the setting of a dirty, infected wound, it is best to avoid performing
any cartilage grafting as any cartilage graft will likely necrose and make the infection
worse. Cartilage grafts rely on surrounding skin and mucosal envelope for blood supply.
As such, definitive rhinoplasty requiring cartilage grafting cannot occur in a reliable
fashion when an infection is present. In such a scenario, any abscess present should
be drained and the patient should be treated conservatively with antibiotics. It is
generally advisable to defer definitive correction septorhinoplasty for several months
until all the infection has been resolved.
In the literature, most authors recommend initial conservative approach with closed
nasal reduction and limited septoplasty in the acute setting with a plan for delayed
definitive correction septorhinoplasty depending on the outcome. Basheeth et al reported
in their prospective study that 191 out of 400 patients required closed nasal reduction,
while others were treated with initial observation alone.[14] Rohrich and Adams proposed an algorithm in which patients with noncomminuted, unilateral
or bilateral, and comminuted nasal bones underwent fracture reduction after overlying
skin edema subsides. In cases in which septal fracture was present, reduction of septal
fractures and conservative septoplasty were considered. Contrastingly, patients with
nasal bones fractures with concurrent NOE, frontal sinus, or LeFort fractures underwent
early open reduction internal fixation. They reported a revision rate of 9% in 110
patients, which is one of the lowest reported in the literature.[10]
Hoffmann described a more simplified algorithm. He recommends that closed reduction
should be performed in unilaterally/bilaterally displaced or mildly comminuted nasal
bone fractures with mild septal deviation. Bilateral comminuted nasal fractures with
moderate septal deviation should be treated with closed nasal reduction, with closed
septal reduction or limited septoplasty. Severe comminution and impacted nasal bone
fractures, with severe septal disruption and saddle deformities, should be treated
with closed nasal reduction, limited osteotomies, limited septoplasty, and bone grafting.
Formal septorhinoplasty is reserved in all cases as needed for 3 to 6 months postoperatively.[15] Ondik et al proposed a similar simplified algorithm with a revision rate of 9%.[16]
Based on existing algorithms, we describe our treatment approach to also include revision
options following the initial repair ([Fig. 4]).
Fig. 4 Treatment algorithm of nasal bone and septal fractures after acute trauma.
Timing of Intervention
Most argue for early reduction in the pediatric population given faster healing, generally
within 7 days, and 10 days of injury for adults.[10] Time to surgery has not shown to be a relevant factor in predicting long-term surgical
outcomes in pediatric patients in multiple studies. Lee and Jang showed similar cosmetic
outcomes in the pediatric age group who underwent treatment less than or greater than
7 days after injury.[17] Yoon and Han reviewed 10 patients, with a mean trauma-to-reduction time of 22 days
with good or excellent outcomes postoperatively. They suggest that a window of up
to 2 to 4 weeks is adequate for closed reduction.[18] Basheeth et al report having success with primary closed manipulation of the nasal
bones up to 5 weeks postinjury, with a postreduction deformity rate of 22.5%.[14] Li et al similarly did not find delay to fracture repair to be an associated risk
factor for secondary rhinoplasty in their population study.[5]
In summary, closed nasal reduction can be safely performed in the acute setting. If
there is a troubling skin swelling present that makes intraoperative evaluation of
underlying nasal bones difficult, it is acceptable to defer closed nasal reduction
for 7 to 10 days or longer to allow the skin swelling to resolve, but ideally before
the bony fusion occurs. If the bony fusion has already occurred, closed nasal reduction
may also require concurrent nasal osteotomy to mobilize the displaced bone segment.
Closed Nasal Reduction in the Acute Setting
Closed nasal reduction is a simple outpatient procedure that can be performed under
local anesthesia or brief general anesthesia and thus is a cost-effective approach
to nasal bone fractures. Performing open septorhinoplasty as the initial procedure
is complicated by the acute swelling from trauma, as well as the potential lack of
viable septal cartilage use given variable septal fracture patterns, making rhinoplasty
results less precise. While studies have shown the closed nasal reduction can be performed
under local anesthesia, brief general anesthesia may be preferable in patients who
are poorly cooperative or tolerant of the procedure, as some studies have shown improved
functional and cosmetic outcomes, as well as patient satisfaction.[19] Additionally, general anesthesia shortens the duration of the procedure considerably
in most cases.
Closed nasal reduction is performed in the following fashion. Topical anesthetic and
vasoconstrictor is applied through cotton pledgets in the nose. If performing under
local anesthesia, cranial nerve V1 and V2 nerve blocks can be performed to improve
patient tolerance of the procedure. Digital pressure along the upper third of the
nose may be an effective maneuver in a mild, outfractured nasal bone deviation ([Fig. 5]). However, a Boies elevator can be resourceful in addressing more significantly
depressed nasal bone fracture. The length of the elevator being inserted intranasally
is measured from the alar rim margin to the medial canthus to avoid overinsertion
of the elevator into the skull base. The elevator is placed in the depressed nasal
bone side and is placed between the nasal bones and the nasal septum intranasally
([Fig. 6A], [B]). The elevator is then used to lift the depressed bone out toward the surgeon and
is pushed laterally to outfracture the depressed nasal bone, and at the same time,
the opposite nasal bone (that is lateralized) is pushed toward the midline. It is
important to mobilize the depressed nasal bone side first to create room for the contralateral,
outfractured nasal bone side to medialize. Beekhuis as well as Staffel described the
use of limited osteotomies if continued drift of the nose is noted after closed reduction
and septoplasty.[20]
[21] Adhesive strips and external splint are applied to the nasal skin after reduction.
Fig. 5 Manual closed reduction can be performed with digital pressure against the nasal
bones.
Fig. 6 (A) A Boies elevator is inserted into the naris to elevate depressed nasal bone fragments.
Prior to inserting the elevator the depth of insertion should be measured along the
nasal bone length from the nostril opening to avoid inserting the instrument too deeply
and causing potential cerebrospinal fluid leak. (B) The elevator is placed into the concave side (depressed side) and is lifted toward
the surgeon to lift the nasal bone out of the nasal cavity and also pushed laterally
to outfracture the depressed segment. At the same time, once the depressed segment
is lifted to create a space for the outfractured nasal bone side to move inward, a
thumb placed along the convex side (outfractured side) and the outfractured nasal
bone is pushed medially to bring the nasal bones into the midline. Arrows mark the direction of forces being applied.
After closed nasal reduction, the literature reports persistent deformity rates ranging
from 14 to 50%. Basheeth et al reported a persistent deformity rate of 22.5% following
initial management. In their prospective series of 400 patients, only 191 patients
were managed with closed nasal reduction with or without septoplasty, whereas more
than 50% of patients were observed without intervention.[14] In the largest prospective study of 756 patients, Murray and Maran reported a postreduction
deformity rate of 41%.[4]
Conservative Septoplasty in the Acute Setting
To avoid persistent nasal bone deviation despite closed nasal reduction, the importance
of septal correction has been widely discussed in the literature. As stated earlier,
septum, nasal bones, and the upper lateral cartilages all meet together at the rhinion
and form a critical structural support called the keystone area ([Fig. 2]). Fry and Verwoerd's studies have demonstrated that septal fractures can cause progressive
nasal deformity due to the release of locked internal stresses.[22]
[23]
[24] Wexler showed that the nasal bones conform to the direction of the deviated septum
after manipulation.[25] Rohrich and Adams mention that the septum is the key structure that needs to be
aligned in correcting nasal fractures to avoid secondary deformity and suggests that
high reported rates of failure previously can be from unrecognized septal deformities.
Ondik et al and Rohrich and Adams' postreduction deformity rate of 9% is among the
lowest reported in the literature.[10]
[16]
It is important to understand that normal nasal airflow occurs primarily along the
inferior nasal airway between the inferior septum and the inferior turbinates. In
addition, internal and external nasal valves also have a profound impact on normal
airflow, but correction of these structures are typically reserved for definitive
correction surgery in a delayed fashion as extensive cartilage grafting may be required.
In the acute trauma setting, both septum and the inferior turbinates can be targeted
primarily as these two structures have a direct impact on normal nasal airflow. Computational
fluid dynamics study has shown that anteroinferiorly located septal deviation can
cause the greatest nasal obstruction, whereas medially and superiorly located septal
deviation (near the skull base) has relatively limited impact on nasal airflow, highlighting
the importance of correcting the caudal septal deviation and septal spurs located
along the nasal floor.[26] The inferior turbinates play a major role in normal flow as well. The full length
of the inferior turbinates should be assessed for inferior turbinate hypertrophy,
especially at the posterior end (near nasopharynx), as the posterior inferior turbinate
hypertrophy can lead to nasal obstruction.[27] Since unilateral nasal cavity can be considered as a cylinder that runs from the
nostril opening to the nasopharynx, any obstruction that occurs due to the inferior
turbinate hypertrophy, whether it occurs along the anterior, middle, or posterior
segments of the inferior turbinates, may still negatively influence the nasal airflow.
As such, bilateral inferior turbinates along its full length can be reduced safely
at the same time in the acute trauma setting. If the septum appears tenuous in appearance
with severe mucosal disruptions from trauma, it is best to minimize extensive septal
mucosal dissection, as this may lead to a large septal perforation, and instead focus
on removing gross septal spur that may obstruct the nasal airway and close the septal
mucosal laceration, especially if there are opposing septal mucosal tears. In a situation
in which the septum is severely injured with extensive septal mucosal injury, performing
inferior turbinate outfracture to mobilize the lateral nasal wall away from the septum
will help restore normal nasal airflow. Due to the possibility of septal perforation
formation in a delayed fashion, aggressive inferior turbinate submucosal reduction
is not performed as the inferior turbinates and adjacent lateral nasal wall mucosal
flaps can be used as local tissue advancement flaps to repair septal perforation if
it occurs in a delayed fashion. It is imperative to avoid septal perforation formation
as this may also lead to nasal obstruction, and definitive corrective septoplasty
with more extensive dissection may be performed in a delayed fashion once the nasal
mucosa, and thus the blood supply to the septal cartilage, has fully healed. Ideally,
upon completion, one should be able to easily visualize the nasopharynx in a straight
line without obstruction along the nasal floor, and the maxillary crest/inferior septum
should sit midline without obstructing septal spurs and the inferior turbinates should
be nicely lateralized ([Fig. 7]).
Fig. 7 (A) Endoscopic view of the left nasal airway. Before the surgery, the patient has severe
left-sided inferior turbinate hypertrophy[3] contacting the septum[1] and the nasal floor.[2] (B) After the surgery, inferior nasal airway between the inferior septum, the nasal
floor, and the inferior turbinate has been widened significantly to allow for direct
visualization of the nasopharynx.[4] Left inferior turbinate[3] has been significantly lateralized and reduced along its full length, including
the posterior head.
In the acute setting, a limited septoplasty or septal fracture reduction can be performed
in the following fashion. General anesthesia is typically required. The goal in the
acute setting is to minimize extensive mucoperichondrial flap dissection as this may
devascularize the septal cartilage. Primary goals are to reestablish normal airflow
along the inferior nasal airway and to minimize deviating force being applied to the
overlying nasal bones. With that in mind, inferiorly located obstruction from septal
deviation or septal spurs is identified through anterior rhinoscopy. At the same time,
inferior turbinates are also assessed along its entire length to see if it will require
concurrent inferior turbinate outfracture. Closed reduction of the septum may be possible
using reduction forceps. If there is an isolated septal spur present, a submucoperichondrial
septoplasty can be performed through Killian incision to minimize extensive mucosal
dissection. Isolated septal spur along the inferior nasal airway is removed without
performing the standard L-strut septoplasty to minimize mucosal dissection. If there
is a severe anterior septal deviation that exists with reliable nasal mucosa present,
hemitransfixion incision may be used to perform conservative septoplasty with generous
preservation of L-strut (at least 1.5 cm in width along the dorsal and caudal septa).
If there is concurrent caudal septal deviation, the senior authors (T.L. and Y.D.)
use retrodissection through the hemitransfixion incision to create a soft tissue pocket
between the medial crus, where the caudal septum can be repositioned as a tongue-in-groove
fashion. This maneuver may be better reserved in a delayed corrective septoplasty
as it typically requires extensive bilateral caudal mucosal flaps to be elevated and
the entire caudal septum to be mobilized away from the maxillary crest attachment
and repositioned into the midline position. A traction suture placed along the caudal
septum and then passed through the columella skin can provide midline traction while
the caudal septum is locked into the midline position with multiple transseptal sutures
([Fig. 8]).[28] To prevent synechiae formation from extensive mucosal swelling postoperatively and
to provide additional structural support to keep the septum in midline position, Doyle
or silastic splints are then placed intranasally and sutured in place for 5 to 7 days.
Fig. 8 (A) A soft tissue pocket is first created between the medial crus with a converse scissor
through the hemitransfixion incision placed along the caudal margin of the septum.
A traction suture (4–0 Vicryl) is placed at the caudal septum, then the suture is
passed between the medial crura and exits through the columella. (B) Traction suture holding the septum midline by an assistant. (C) While the caudal septum is held in position at the midline, the medial crura and
the surrounding mucoperichondrial flap are then quilted using multiple transseptal
sutures to secure the septum into the midline position using a straight Keith needle
with an absorbable suture (4–0 Chromic). Excessive medial crural foot flaring that
is causing external valve narrowing can also be corrected at the same time. Transseptal
sutures can also be used to close the hemitransfixion incision at the same time. (D) Left caudal septal deviation is noted preoperatively with columella asymmetry. (E) Severe caudal septal deflection is noted after bilateral mucoperichondrial dissection.
(F) One-year postoperative basal view. The columella shows good symmetry and midline
caudal septum
Recent advances in endoscopic technology have led to endoscopic instrumentation during
septoplasty with good clinical results and provide improved visualization to the posterior
nasal airway as well as the superior septum near the skull base if there is concurrent
cerebrospinal fluid leak that requires surgical repair. Andrades et al describe a
closed nasal reduction approach with endoscopic assist septoplasty in three (3.3%)
patients requiring revision septorhinoplasty.[29]
In summary, nasal bone fractures with concurrent severe septal deviation require conservative
septoplasty or septal fracture reduction at the same time as the closed nasal reduction
to minimize the risk of persistent or delayed nasal bone deviation. It is best to
avoid extensive mucoperichondrium dissection during the septoplasty to preserve vascularity
to the cartilage and focus on removing obstructing septal spur along the inferior
septum. If there is an opposing septal mucosal laceration present, attempt should
be made to reapproximate the septal mucosal linings with placement of the crushed
cartilage grafting in the middle to minimize the risk of septal perforation formation.
To restore normal nasal airflow, aggressive bilateral inferior turbinate outfracture
can be safely performed in the acute setting, whereas conservative submucosal inferior
turbinate reduction is advised in case the inferior turbinate mucosa may need to be
used as a local tissue advancement flap if the patient develops a delayed septal perforation.
Open Approaches in the Acute Setting
In cases in which the nasal bone fracture cannot be properly reduced via closed methods,
such as when the nasal root is involved or when in combination with LeFort, or anterior
table fractures of the frontal bone, open approaches can be used. The ideal open approaches
depend on the presence of laceration and the type of concurrent bony fractures present.
These approaches may include the following:
-
Endonasal or open rhinoplasty incision approaches if there is reliable nasal skin
present without laceration ([Fig. 9]).
-
Using preexisting lacerations for approach if present.
-
Modified Lynch incision with a Z-plasty for isolated NOE fracture.
-
Modified Lynch incision with maxillary gingival sulcus incision for concurrent LeFort
II and III fractures.
-
Bicoronal approach if there is a need for extensive bone grafting at the nasion that
requires hardware fixation or if there is concurrent supraorbital rim or frontal sinus
fractures that also require open repair
Fig. 9 Various incisions to access septum and remainder of the nose. Purple dotted line marks hemi- or full-transfixion incision. Typically, closed septoplasty is performed
through hemitransfixion incision. Blue dotted line marks the marginal incision along the caudal margin of the lower lateral cartilages,
which is commonly used for an open rhinoplasty approach when combined with a transcolumellar
incision. Red dotted line marks the intercartilaginous incision, which can be used in endonasal rhinoplasty
for access to the middle one-third for dorsal onlay as well as the upper one-third
for medial osteotomy.
When possible, use of existing lacerations limits additional incisions and scars in
the patient to optimize cosmesis. If a laceration is present, an open rhinoplasty
incision should not be used as this may fully devascularize the tenuous nasal skin.
Endonasal rhinoplasty incision, such as intercartilaginous incision, can be used for
dorsal onlay graft placement along the upper two-thirds to further augment the nasion
or to correct mild saddle-nose deformity, and it can also be used to perform medial
osteotomy. The dorsal onlay graft derived from either an iliac/calvarial bone graft
or ear/rib cartilage graft can be inserted in a midline subperichondrial/subperiosteal
dissection pocket without the need for hardware plating. If there is a concern for
infection, it is again best to avoid extensive cartilage grafting.
For repair of an NOE fracture without a laceration, the traditional gull-wing incision
should be avoided as it tends to leave an unacceptable appearing scar. The modified
Lynch incision provides a direct open access to the NOE region. The risk of developing
a webbed scar along the medial canthus region can be minimized by using a z-plasty modification described by Esclamado and Cummings.[30] When there is concurrent LeFort II or III fractures, a modified Lynch incision can
be combined with a maxillary gingival sulcus incision.
A bicoronal incision may be useful in cases of severe comminution when a large bone
graft must be secured with hardware to restore the nasal contour along the upper two-thirds.
However, a smaller bone graft or a dorsal onlay cartilage graft can be instead placed
using an endonasal, intercartilaginous incision that is more cosmetically favorable.
Furthermore, bicoronal incision is typically reserved for situations in which supraorbital
rim or frontal sinus fractures must also be repaired. A major limitation of the bicoronal
incision is that the inferior extent of the approach is at the nasion, limiting access
to the middle third of the nose. If needed, the bicoronal approach may need to be
combined with an open rhinoplasty approach if the entire length of the nose needs
to be accessed. Incision alopecia and temporal hollowing (if dissected through the
temporal fat pad) are potential complications of the bicoronal approach. Temporal
hollowing can be minimized if the deep temporalis fascia (fascia on top of the temporalis
muscle) is not violated and instead the dissection is performed immediately on top
of the deep temporalis fascia while remaining deep to the loose areolar tissue and
the temporoparietal fascia.
Open Septorhinoplasty in Acute Trauma
Severe septal fractures, comminuted nasal bone fractures, resulting in significant
destabilization of the nasal framework are indications for open surgical approaches.
Mondin et al's indications for open surgical reduction include extensive fracture
or dislocation of nasal bones and septum, nasal pyramid deviation greater than half
the width of the nasal bridge, open septal fractures, and caudal septal fractures.[31] McCullough described dorsal hump reductions being amenable to treatment with bilateral
osteotomies in the setting of primary nasal fracture repair.[32] However, if there is an extensive nasal skin laceration present, it is best to avoid
using a traditional open rhinoplasty approach (marginal + transcolumellar incision)
and let the skin envelope heal first before considering an open approach. Instead,
an existing laceration should be used for approach with limited skin flap elevation,
just enough to see the fracture and to place the hardware. Additional skin incisions
that can deglove the nasal skin should be avoided. As such, senior authors (T.L and
Y.D.) typically defer open septorhinoplasty for a delayed definitive correction surgery
at 1 to 6 months post trauma depending on the severity of cosmetic and functional
problems and the potential for infection.
Due to the significant skin and soft tissue swelling that can interfere with assessing
outcome during the surgery, the use of primary open septorhinoplasty for nasal bone
fractures is uncommon but reported. With careful patient selection, some authors actually
advocate early open procedures as patient outcomes are better than closed reduction
results.[33] Staffel concluded that certain rhinoplasty procedures can be safely employed in
the setting of acute nasal bone fracture.[21] Kim et al demonstrated in a retrospective series of 56 patients that simultaneous
cosmetic rhinoplasty was relatively safe in open reduction of nasal bone fractures,
with one revision case of saddle nose with significant septal fracture.[34] Another group focused on a retrospective analysis of patients with existing nasal
deformity prior to nasal bone fracture. Of 45 patients who underwent open rhinoplasty
within 4 weeks of fracture, spreader grafts and extracorporeal septoplasty were used
predominantly in different fracture patterns, with a revision rate of 4.4%.[7]
Proponents of acute septorhinoplasty approach stress that direct visualization of
the nasal bones allows for more accurate reduction. In the Asian population, patients
may request dorsal augmentation concurrently, and this can be addressed safely at
the time of nasal fracture reduction per Kim et al.[34] Challenges include fibrosis and difficult dissection of fractured nasal bone segments.
Ondik et al showed revision rates, patient satisfaction, and outcomes to be similar
in closed and open reduction groups. However, this retrospective study focused on
various fracture patterns, and the majority of the open approach group were associated
with higher level fracture patterns.[16] No studies to date have compared closed reduction with open repair for similar fracture
patterns. Overall, there is likely a subset of severe nasal fracture patients who
are candidates for primary open repair, but the majority of them appear to be manageable
with closed reduction. Most can agree that if concurrent extensive nasal laceration
or infection is present, the laceration should be used for open approach, and the
corrective open septorhinoplasty should be performed in a delayed fashion once the
skin envelope or residual infection has fully resolved.
In cases of concurrent NOE, LeFort, and frontal sinus fractures, open approaches to
address reduction and fixation are well established. The details of these fracture
repairs are beyond the scope of this paper, but, nonetheless, this subset of nasal
trauma patients may also require revision septorhinoplasty following initial repair.
Patient Considerations
Studies have found that those who undergo nasal fracture repair have lower postoperative
expectations if they do not have a history of previous cosmetic rhinoplasty. Reilly
et al showed that five of six patients requiring revision following open reduction
had previous cosmetic rhinoplasty.[35] There may be some intrinsic expectations that lead this subgroup of patients to
require revision procedures. Questionnaire data are often confounded by patients'
lack of desire for undergoing secondary revision surgery and may partially explain
the disparity in patient versus surgeon satisfaction following closed reduction (62–91%
vs. 21–65%).[21] Hung et al reported a retrospective study of 62 patients who underwent closed nasal
reduction. Eighteen patients were unsatisfied with their result, but only 11 of these
requested revision surgery. Of those who were satisfied, seven requested further surgery.
This study had an overall secondary surgery rate of 29%.[1] These findings are in line with Li et al's population data reporting that patients
with previous nasal deformity or obstruction are at an increased risk for revision
septorhinoplasty.[5] These patients may inherently be more aware and fixate on the subtler details of
their nose compared with the general population and may be prone to a higher rate
of dissatisfaction. Preoperative deformities are thus important to assess, when possible,
and can be assessed with preinjury photos.
Revisions
Following primary repair of the nasal fracture through whichever approach, patients
require follow-ups at least 1 to 3 months postoperatively for any residual cosmetic
or functional deficits. The secondary treatment that can be offered can be broken
down based on functional or cosmetic complaints. In most cases, functional concerns
should be prioritized before cosmetic concerns, but in many instances, they can be
addressed concurrently. For primarily functional concerns, medical management includes
optimization of nasal mucosa and inferior turbinate hypertrophy with nasal steroid
sprays and routine nasal irrigation rinses.
If the nasal obstruction persists despite 1 to 3 months of conservative medical therapy,
the patient may benefit from corrective nasal airway surgery using either endonasal
or open septorhinoplasty with inferior turbinate reduction as is routinely performed
in nontraumatic nasal airway surgery patients. Once a nasal skin laceration or infection
has fully resolved with time, there is no serious risk of nasal cartilage being devascularized
with extensive skin and mucosal dissection that is commonly seen in definitive septorhinoplasty.
Cartilage grafting can be performed reliably in a delayed corrective surgery.
The components affecting the nasal obstruction must be properly assessed preoperatively,
as is performed for any nontraumatic nasal airway surgery. In particular, septal deviation
along the caudal aspect and along the maxillary crest near the nasal floor should
be corrected to optimize normal airflow that occurs along the inferior airway. Any
deviation along the maxillary crest is removed using hemitransfixion incision. Caudal
septal deviation can also be corrected using the traction suture technique in a tongue-in-groove
fashion.[28] Similarly, inferior turbinate hypertrophy along its full length should be reduced
using submucosal reduction techniques and outfracture to lateralize the inferior turbinates
to widen the inferior nasal airflow. If there is a septal perforation present, closure
of the septal perforation should be of top priority, as it will lead to nasal obstruction
from recirculation. In addition, dynamic internal and external nasal valve collapse
should be evaluated and addressed using various grafting options to strength the valve
region. Asymmetric middle one-third collapse with or without concurrent internal nasal
valve collapse can be addressed using a wide range of techniques including asymmetrically
placed spreader grafts, butterfly suture technique, and a dorsal onlay augmentation.
If there is a severe fracture along the dorsal L-strut, it may require extended spreader
grafts to rebuild the L-strut to avoid a saddle-nose deformity ([Fig. 10]). Lastly, nasal tip deviation with undesirable rotation or projection can be corrected
during the revision surgery using a multitude of rhinoplasty techniques (caudal septal
extension graft, columellar strut graft, caudal septum repositioning [[Fig. 8]], lateral strut grafts, rim grafts, lateral crural steal, medial crural steal, intra-
or interdomal sutures, shield graft, etc.). For upper one-third nasal bone deviation,
medial and lateral osteotomies can be performed, and if additional volume is desired
to optimize contour, bone graft or cartilage graft can be placed. In individuals with
thick skin, it is common for a laceration to cause extreme thinning of the skin, giving
the illusion of saddle-nose deformity even when the L-strut is well maintained. In
such a situation of undesirable thin scar affecting the profile contour, placement
of dorsal onlay grafts at the laceration site, such as finely crushed cartilage, fascia
graft, or acellular dermal matrix (such as Alloderm; Allergan), may be an option to
provide loss of volume in the subcutaneous tissue plane. The multitude of corrective
maneuvers that exists with corrective open septorhinoplasty is outside the scope of
this paper. This corrective procedure is typically delayed at least 3 to 6 months
after the initial injury and repair to allow bone and cartilaginous healing, as well
as minimization of facial edema to allow a more precise surgical result.
Fig. 10 (A) Patient at rest without inspiration, basal view demonstrating symmetric nostrils
without any obvious valve collapse. (B) The basal view on inspiration demonstrating collapse of the left external nasal
valve.
Following the management strategy and resolution of soft tissue edema, as well as
discussion of patient expectations, minor cosmetic deformities without functional
airway obstruction may be corrected with injectable fillers. This may be a suitable
management strategy in patients who are not fully satisfied with their results but
do not want to pursue further surgical treatment.
For demonstration, we present a case of untreated septal hematoma developing a delayed
septal abscess after a motor vehicle accident. The patient went on to develop saddle-nose
deformity and bilateral nasal obstruction. Initially, the septal abscess was drained
and treated with antibiotics. A corrective delayed open septorhinoplasty approach
was performed 3 months after the infection had completely cleared. The patient required
total septal L-strut reconstruction with bilateral extended spreader grafts and large
columellar strut graft derived from a rib cartilage graft. In addition, iliac bone
graft was used to augment the upper two-thirds to provide an optimal nasal profile
([Fig. 11]). A large rib cartilage graft can also be used as a large dorsal onlay as an alternative
option.
Fig. 11 (A) The patient presented with infected septal hematoma at 1 month after trauma. He
underwent immediate septal hematoma drainage with a drain placement and oral antibiotics
treatment. The drain was removed after 1 week and was treated with antibiotics for
a total of 3 weeks. Due to the severe infection, final reconstruction was delayed
for 3 months to allow for complete resolution of septal cartilage infection. The patient
complained of severe bilateral nasal obstruction, and the preoperative frontal view
is shown. (B) The sagittal view shows severe saddle-nose deformity along the middle one-third
due to total septal collapse. (C) An open septorhinoplasty approach was used. The septum showed severe scarring with
total destruction of L-strut with entirely missing caudal septum. (D) For nasal obstruction correction, bilateral inferior turbinate reduction and septoplasty
were performed. The remaining septum at the keystone area was preserved. The entire
septal L-strut was reconstructed using rib cartilage to create bilateral extended
spreader grafts that were secured to the remaining septum at the keystone area and
placed between the bilateral upper lateral cartilages. The extended spreader grafts
were then secured to a large columellar strut graft located between the medial crura.
The nasal tip shows improved projection and rotation along the lower one-third. (E) To improve contour along the upper two-thirds, an iliac crest bone graft was shaped
as a dorsal onlay graft and placed on top of the extended spreader grafts and the
nasal bones to further correct the saddle-nose deformity. (F) At 1 year postoperative, the patient reported good bilateral nasal breathing. The
frontal view is shown. (G) The sagittal view shows an excellent profile with correction of the saddle-nose
deformity.
