CRANIOFACIAL

Nasal Trauma and the Deviated Nose

Stephen Higuera, M.D.
Edward I. Lee, M.D.
Patrick Cole, M.D.
Larry H. Hollier, Jr., M.D.
Samuel Stal, M.D.
Houston, Texas
Summary: As the most prominent facial feature, the nose carries an increased
risk of traumatic injury. Nasal fracture is the most common bone injury of the
adult face and frequently results from motor vehicle accidents, sports-related
injuries, and altercations. Although often initially considered minor, nasal frac-
ture may eventually result in significant cosmetic or functional defects. Optimal
management of nasal trauma in the acute setting is critical in minimizing
secondary nasal deformities. In recent years, numerous guidelines have been
described to refine and optimize acute nasal trauma management. However,
restoration of pretraumatic form and function remains a challenge. Commonly
the product of a poorly addressed underlying structural injury, posttraumatic
nasal deformity requiring subsequent rhinoplasty or septorhinoplasty remains
in as many as 50 percent of cases. In this article, the authors review the anatomic,
diagnostic, and management considerations as well as discuss their own expe-
rience in approaching nasal trauma and the deviated nose. (Plast. Reconstr.
Surg. 120 (Suppl. 2): 64S, 2007.)
T
he nose is perhaps the single most prominent
aesthetic featureof theface. However, withthis
prominent position comes an increased risk of
blunt trauma. Frequently the result of even minimal
force, fracture of the thin nasal bones is the most
common bone injury of the adult face.
1
The most
common mechanism is blunt trauma from either
motor vehicle accidents, sports-related injuries, or
altercations.
1,2
Although often considered minor,
nasal fracture may eventually result in significant
cosmetic or functional defect.
3
Optimal manage-
ment of nasal trauma in the acute setting is critical
in minimizing secondary nasal deformities.
Over the years, numerous methods and guide-
lines have been described to refine and optimize
the management of acute nasal trauma; however,
restoration of pretraumatic form and function re-
mains a challenge. Posttraumatic nasal deformity
requiring subsequent rhinoplasty or septorhino-
plasty remain in as many as 50 percent if cases.
47
This is partly attributable to the simple failure to
recognize that a more extensive underlying injury
has occurred, particularly to the septum. Aggressive
management of nasal septal injuries has been rec-
ognized as a major key to successful management.
8
Subsequent revision rhinoplasty in such cases is fre-
quently difficult.
ANATOMIC CONSIDERATIONS
The skeletal component of the nose includes
the frontal process of the maxilla, the nasal pro-
cess of the frontal bone, the ethmoid, the vomer,
and the nasal bones. Fractures of the nasal bones
occur more commonly distally, where they are
broader and thinner.
9
Significant force is required
to fracture the more proximal nasal bones, in
which case injury extension into the frontal pro-
cess of the maxilla and frontal bone may be
present.
The cartilaginous structures include the two
lower lateral cartilages, two upper lateral carti-
lages, and the central septal cartilage. Paired up-
per lateral cartilages have solid attachments to the
caudal aspect of the nasal bones and help maintain
the midline locationof the quadrangular cartilage.
10
The lower lateral cartilages provide little midline
structural support but are responsible for much of
the aesthetics and contour of the nasal tip.
The fact that cartilage surrounds the bony ma-
trix bothdorsally andlaterally to provide a soft and
malleable framework allows some dissipation of
force without incurring a permanent deformity.
11
In general, significant force is required for a car-
tilaginous injury.
The blood supply to the nose is frombranches
of both internal and external carotid arteries. The
From Baylor College of Medicine and Department of Plastic
Surgery.
Received for publication May 5, 2006; accepted December 12,
2006.
Copyright 2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000260722.91183.50
Disclosure: Educational/research grants were re-
ceived from Stryker, Synthes, and KLS-Martin.
www.PRSJournal.com 64S
main blood supply is from the external carotid
artery by means of the maxillary artery through its
sphenopalatine, greater palatine, and infraorbital
branches. The facial artery, another branch of the
external carotid artery, also supplies the anterior
portion by means of the superior labial branch.
The external carotid artery supplies the nose in-
ferior to the middle turbinate. The internal ca-
rotid artery contributes by means of anterior and
posterior ethmoidal branches and ophthalmic
branches, supplying the area superior to the mid-
dle turbinate.
The rich blood supply to the nasal region pre-
disposes individuals to epistaxis in nasal trauma.
Epistaxis can be categorized as anterior or poste-
rior, depending on the source of bleeding. The
most common location is anterior epistaxis, orig-
inating from Kiesselbachs plexus in the antero-
inferior septum, which receives its blood supply
from both internal and external carotid arteries.
Posterior epistaxis typically arises from branches
of both the sphenopalatine and anterior eth-
moidal arteries. It is less common than anterior
bleeding but a more frequent cause of severe hem-
orrhage. Nasal hemorrhage can usually be con-
trolled by direct manual pressure in anterior
bleeds. Hemorrhage from posterior sources usu-
ally resolves spontaneously, particularly if the pa-
tients blood pressure is controlled. However, in
persistent cases, posterior packing or Foley bal-
loon catheterization of the nasal passage may be
necessary. In the most severe cases, usually sec-
ondary to maxillary arterial sources, interven-
tional embolization may be required.
12
Both the ophthalmic and maxillary divisions of
the trigeminal nerve supply sensation to the nose.
The infratrochlear nerve provides sensation to the
skin of the upper nasal dorsum and sidewalls, and
the anterior ethmoidal supplies the lower dorsum
and tip.
Finally, understanding the anatomy of the na-
sal septum is crucial in appropriately managing
nasal fractures. The septumis composed mostly of
the quadrangular cartilage, with contributions
from the vomer inferiorly and the perpendicular
plate of the ethmoid posteriorly and superiorly.
The quadrangular cartilage is supported laterally
by the medial crus of the lateral cartilages and
inferiorly by means of its location within the
vomerine groove. The central caudal portion of
the septum is relatively thin.
3
It is the thicker pos-
terior septal cartilage that provides the primary
support for the dorsum. It is also important to
recognize that the septumis a major growthcenter
for the face. In most individuals, there is growth
here until approximately 12 to 13 years of age.
Significant septal trauma can adversely affect mid-
facial development.
DIAGNOSIS OF NASAL TRAUMA
Clinical History
The history of the patient with a nasal injury is
important in management. Essential factors in-
clude the mechanism of injury, time since injury,
patient age, differentiation between acute versus
chronic/preexisting deformity.
With respect to the mechanism of injury, the
vector and magnitude of the force are critical. The
commonly seen aggravated assault usually results
in a relatively low-energy lateral blow, resulting in an
infracture of the ipsilateral nasal bone and an out-
fracture on the contralateral side (Fig. 1). This type
of injury is almost always associated with some shift
of the nasal septum. Frontal impact injuries are
commonly seen from projectiles and motor vehi-
cle collisions and are typically higher energy in-
juries that result in a greater degree of comminu-
tion and septal injury. Frontal impact may also
result in crush injury to the nasal bone and sep-
tum.
Whether the patient presents within hours,
days, or weeks after injury is also an important
factor to consider. Within the first few hours after
injury, before substantial swelling, there is an op-
portunity to fully visualize the deformity. This al-
lows the surgeon to perform a closed reduction.
After this period, swelling obscures the shape of
the nose, and intervention should be deferred
until this has resolved.
The pediatric population poses a diagnostic
and management dilemma because of the relative
plasticity and smaller size of the nasal bones as
compared with adults. Children are less likely to
fracture their noses with trauma; however, septal
injuries are more frequently missed in this
population.
13,14
With subacute or mild trauma, the
septum may deviate, creating a space for forma-
tion of a hematoma. If untreated, the septal injury
may progress to localized septal necrosis and/or
disruption of growth centers, which may eventu-
ally lead to a more substantial deformity.
15
Such a
sequence of events may explain much of the nasal
deformities seen in adults.
In addition, it is important to obtain a medical
history to rule out previous nasal trauma and de-
formities. It is possible that the patients nasal
deformity is secondary to a previous nasal injury.
Ahistory of previous nasal surgery and its outcome
is also obviously significant. Management of an
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Fig. 1. Prereduction (above), postreduction (center), and worms eye (below) views of a patient with a type IIb injury. The 15-year-old
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acute nasal fracture in the presence of an un-
treated or undertreated prior nasal injury is dif-
ficult because the nose has an incredible mecha-
nism for returning to the previously deformed
state. To achieve a better understanding of how
the patients nose appeared before the acute in-
jury, a review of old photographs may be helpful.
The patient should be questioned regarding a his-
tory of difficulty breathing, nasal congestion, snor-
ing, sleep apnea, and nasal drainage. Use of in-
halers or allergy medications is also significant.
The patients expectations regarding surgery for
the current injury must be in keeping with these
previous problems.
Physical Examination
The physical examination can be divided into
an external examination and an internal exami-
nation. The goal of the external examination is to
evaluate nasal deformities (Table 1). The nose
should be palpated gently to detect step-offs and
areas of tenderness. The most certain sign of frac-
ture is a tender palpable or visible deformity. Ra-
diographs are of no real use in this evaluation. Any
significant drainage from the nose should lead to
concern for cerebrospinal fluid rhinorrhea. Frac-
tures within the cribriform plate secondary to sep-
tal injury may cause this. This can be confirmed by
testing the fluid for glucose or -transferrin. Al-
though the vast majority of such leaks resolve
spontaneously, the patient should be counseled to
avoid the supine position to minimize cerebrospi-
nal fluid pressure at the site of the dural tear.
Often, the only complaint associated with persis-
tent cerebrospinal fluid rhinorrhea is postnasal
drip, as the fluid preferentially drains down the
throat. Leaks that fail to resolve by 10 to 14 days
may warrant lumbar drainage.
A proper internal examination of the nose is
facilitated by the appropriate instruments: a head-
light, nasal specula, decongestant spray, cotton-
tipped applicators, Frazier-tipped suction, and na-
sal packing material.
16
Arigid or flexed endoscope
can facilitate the internal examination but is not
a necessity.
Internal examination begins with suctioning
out any blood. A topical anesthetic with vasocon-
strictive effects, suchas 4%lidocaine and oxymeta-
zoline (Afrin; Schering-Plough HealthCare Prod-
ucts, Inc., Kenilworth, N.J.) or phenylephrine
hydrochloride (Neo-Synephrine; Bayer Consumer
Care, Morristown, N.J.) should be used to control
the bleeding and facilitate the examination. Par-
ticular attention should be paid to the status of the
septum. One should note any mucosal disruptions
indicative of the trauma. Septal deviations, chronic
or acute, should be easily seen on the internal
examination. If a rigid or flexible endoscope is
being used, the scope should be placed in the
nasal vestibule and advanced posteriorly under
direct vision. Once the endoscope is advanced
along the floor of the nose, beneath the inferior
turbinate, the inferior meatus, turbinates, sep-
tum, and the posteroinferior septal junction with
the perpendicular plate of the ethmoid should be
examined.
17
Septal hematomas, if present, should be evacu-
ated promptly to prevent cartilage resorption. The
importance of recognizing and optimally treating
septal deformity cannot be overemphasized. An un-
recognized septal deformity is one of the major rea-
sons for unfavorable outcomes. Correcting a nasal
fracture while neglecting septal injury is futile; the
unrepairedseptumwill only serve as a pivot point for
future nasal bone deviation.
18,19
MANAGEMENT OF NASAL TRAUMA
As described above, a thorough clinical anal-
ysis of the nose must be performed before pro-
ceeding with a definitive rhinoplasty after nasal
trauma. The preoperative assessment involves a
systematic approach integrating the clinical his-
tory and physical exam. And once a diagnosis has
been made, we believe that proper management
of nasal trauma requires consideration of four
important points: (1) severity of injury; (2) timing
of injury; (3) use of local versus general anesthesia;
and (4) once the decision is made to reduce the
nasal fracture, whether to perform a closed versus
an open reduction. As such, we have developed a
classification system for nasal injuries and an al-
boy presented two hours after sustaining a blow to the left side
of the nose. There was an infracture of the left nasal bones, an
outfracture of the right nasal bones, anda right septal deviation.
The patient was subsequently treatedwithanimmediate closed
reductionof thenasal fracture. Hispostoperativecourseandsub-
sequent follow-up were unremarkable.
Table 1. Signs and Symptoms of Nasal Fractures
Cerebrospinal fluid rhinorrhea
Epistaxis
Hypoesthesia (orbital floor blowout)
Obvious malposition
Periorbital ecchymoses/hematoma
Tenderness on palpation
Palpable deformity
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gorithm for managing acute nasal trauma that
integrates these four components (Fig. 2).
SEVERITY OF INJURY
Management of nasal trauma is dictated by the
degree and severity of injury. Several different ap-
proaches to classifying nasal fractures have been
proposed. Murray et al.
19
provide perhaps the
most thorough approach to nasal fracture man-
agement. Their study demonstrates that fracture
pattern is not consistently predicted by the
amount and vector of the applied force. In addi-
tion, septal fractures occur more frequently within
the perpendicular plate of the ethmoid rather
than the quadrangular cartilage.
19
Murray et al.
19
also suggest that if the nose is acutely deviated
more than half of its width from the midline, the
septum is likely involved.
However, we prefer to classify the injury clin-
ically rather than by the pathologic pattern of
injury. Type I injury can be defined as soft tissue
injury without any concomitant injury to the un-
derlying structures of the nose. Type IIa injury
Fig. 2. Nasal trauma management algorithm.
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68S
defines a simple unilateral nondisplaced frac-
ture whereas type IIb involves simple bilateral
nondisplaced fracture. Type III describes simple
displaced fracture whereas type IV injury is de-
fined as closed comminuted fracture. An open
comminuted fracture or any of the above types
with concomitant cerebrospinal fluid rhinor-
rhea, airway obstruction, septal hematoma, crush
injury, severe displacement, or associated naso-
orbito-ethmoid midface fractures are defined as
type V injuries.
TIMING
The best opportunity for successful closed re-
duction of a nasal fracture is within the first few
hours following the injury. Within this time pe-
riod, immediate reduction of the fracture is an
accepted practice and is usually successful. How-
ever, the majority of patients present subsequent
to this window of opportunity and edema pre-
cludes immediate treatment. In such cases, the
accepted practice is to provide pain medications,
antibiotics for any open wounds, and instructions
for ice use, advise head elevation, and follow up in
5 to 7 days.
11
Whenthe edema has begunto resolve
at this point, the resultant deformity can be better
appreciated and a reasonable treatment plan for-
mulated.
LOCAL VERSUS GENERAL ANESTHESIA
When deciding between local versus general
anesthesia for closed reduction, one must con-
sider cooperativeness of the patient, patient ex-
pectations, the patients overall health, and the
cost differential. Most, if not all, cases involving the
pediatric population should be managed under
general anesthesia because of the difficulty in se-
curing cooperation of children using local anes-
thesia.
Local anesthesia can be divided into topical
and infiltrative. Topical anesthesia can be admin-
istered through the use of pledgets. A topical an-
esthesia with 4% lidocaine and oxymetazoline
(Afrin) or phenylephrine hydrochloride (Neo-
Synephrine), which can be administered through
the use of pledgets. A total of three pledgets
should be used in each nostril and these pledgets
should be left in place for around 8 to 10 minutes
for adequate effect. They should be placed
along the dorsal aspect of the septum close to
the anterior ethmoid nerve and artery, around
the middle turbinate near the pterygopalatine
ganglion, and along the nasal floor adjacent to the
nasopalatine nerve and sphenopalatine artery.
Infiltrative anesthetics should contain epi-
nephrine. Intranasally, the septum should be in-
jected submucosally on each side. The underside
of the nasal bones should also be injected, as el-
evators are typically placed here. Because of the
difficulty in accessing this area with a needle, it
may be helpful to direct the needle transseptally
to inject this mucosal surface of the contralat-
eral side. Depending on the degree of manip-
ulation and the patients comfort level, dorsal
nasal and infraorbital nerve blocks may be help-
ful. However, the volume of anesthetic used
should be minimal to prevent obscuring nasal
shape and complicating the assessment of the
results of the reduction.
CLOSED REDUCTION
The basic strategy of closed reduction of a
nasal fracture is to reverse the vector of force that
resulted in the injury. The typical approach is to
first reduce the bony nasal pyramid followed by
reduction and stabilization of the septum. After
achieving an adequate level of anesthesia, using a
headlight and a nasal speculum, the internal nose
should be examined carefully. At this point, a
Goldman bar should be inserted into the nose up
underneath the nasal bones and upward outward
pressure exerted (Fig. 3). The combination of ex-
ternal digital pressure and intranasal instrument
pressure should be adequate to reduce fracture of
the bony pyramid. Once these bones have been
immobilized and reduced, attention should be
turned to straightening the septum with blunt
pressure from the Goldman bar. The nasal pyra-
mid is elevated and direct pressure is applied to
the displaced septal portion.
2,7,16
It is critical to
reduce concomitant injury to the septum because
the nasal bones will typically relapse to their in-
jured position if septal injury is not addressed.
Next, the airway should be assessed. The Goldman
bar should pass easily along each nasal floor to the
nasopharynx. The external contour of the nose
should be elevated carefully, both visually and
manually with a moistened finger to detect any
subtle irregularities. Should such a problem per-
sist despite the manipulation, a rasp can be used
through an intercartilaginous incision or thought
should be given to onlay cartilage grafting.
Several points must be considered when using
the closed reduction technique. First, when using
the Goldman bar, the surgeon should be cautious
not to advance the bar too far into the nasal vault
in case there is injury to the cribriformplate. Next,
incomplete fractures may require osteotome mo-
bilization for appropriate reduction.
2,13,16
If reduc-
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69S
tion of the septum is required, it should be ap-
proached by elevating the nasal pyramid and
applying direct pressure to the displaced septal por-
tion. Lastly, all reduced nasal fractures, whether the
closed or open reduction technique is used, should
be splinted at the conclusion of the procedures.
The importance of patient expectations can-
not be overemphasized at this point. It is highly
unlikely that the nasal deformity will be totally
corrected with a closed reduction. The primary
goal is to minimize the deformity. All patients
must understand that it is entirely possible that
they will decide to undergo open reduction and
rhinoplasty in the future.
OPEN REDUCTION
There can be no question that open reduction
has historically been underused in the treatment
of nasal trauma. Some nasal injuries simply cannot
be adequately managed by closed reduction. This
includes comminuted fractures with such a loss of
support that nasal shape cannot be maintained,
severe septal injuries resistant to closed reduction,
and nasal fractures with substantial soft-tissue
trauma. Open reduction should be undertaken in
these cases once the early edema has resolved.
There is no rationale for delaying definitive man-
agement in these cases for the oft-quoted 4 to 6
months. During this period, the remodeling and
secondary changes that occur in the nasal shape
may make restoration of the preinjury appearance
more difficult.
In short, any basic rhinoplasty sequence may
be used, but because the septum is the keystone of
the correction, it should be addressed early in the
procedure. We prefer to use the following steps:
(1) exposure; (2) septal reconstruction; (3) hump
removal; (4) osteotomies; (5) adjunctive proce-
dures; and (6) appropriate splinting, both inter-
nally and externally.
Exposure
The open rhinoplasty technique, which allows
excellent exposure with direct visualization of
the anatomy, may be useful when correcting the
twisted nose.
8,2022
The open access allows easier
anatomical reapproximation and direct suture fix-
ation and support, especially when nasal tip dis-
tortion is also a problem. In addition, the classic
transfixion or hemitransfixion incision in the
membranous septum will allow adequate expo-
sure of the caudal, inferior, and posterior septum,
and the tip and the dorsum.
23,24
It is important to
preserve as much of the septal mucoperichon-
drium as possible because it maintains blood sup-
ply to cartilage and, more importantly, helps main-
tain mobilized cartilage segments and aids in their
support (Fig. 4).
8
Fig. 3. Examples of how to use the Boise elevator for outfractures of nasal bones.
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Septal Reconstruction
Elevating the mucoperichondrium and the
periosteum at the junction of the anterior max-
illary crest with the septum is difficult and can
frequently lead to perforation. The flap may be
elevated safely, with excellent exposure of the
vomerian crest and the floor of the cartilaginous
septum by using the mucoperichondrial and mu-
coperiosteal tunnels. A single superior mucoperi-
chondrial tunnel carefully brought inferiorly from
back to front can also achieve excellent perfora-
tion-free exposure.
24
Meticulous extramucosal dis-
section of the dorsal septum from the upper lateral
cartilages andthe nasal bones preserves support and
separates the internal fromthe external nose. Initial
care inthe elevationof these flaps leads todecreased
bleeding and preservation of normal anatomy and
minimizes postoperative valvular scarring. If a large
perforation results, an attempt at mobilization and
closure should be made.
Quadrangular Cartilage
Removal of the complete inferior horizontal
segment allows the septum to be positioned in the
midline. The septum has a tendency to become
distorted if it is not permanently modified, and
splints, tractions, sutures, or pin fixation cannot
be depended on to maintain a septum that is in-
appropriately repositioned and fixed. Therefore,
it is essential to maintain a dorsal and a caudal
strut of cartilage approximately 10 to 15 mm in
width. Because septal procedures performed pos-
terior to a line joining the bases of the frontal and
nasal spine will not influence the result of any
simultaneously performed rhinoplasty, provide
that the continuity of the dorsal segment is intact,
it is possible to safely fracture or remove certain
portions of the perpendicular plate or the eth-
moid bone. It is preferable to break the spring
of the cartilage and to maintain some attachment
of the underlying mucoperichondrium than to
completely remove and replace it.
Bony Septum
If the bony septum is malpositioned, aggres-
sive greenstick fracture or resection is indicated
because it is not critical to support the nose and
can frequently contribute to airway obstruction
and interfere with mechanical midline position-
ing of the septal cartilage. In deviated noses, the
vomer and the premaxillary crest are often devi-
ated and compromise inferior airflow. After care-
ful dissection of the lining, a 2-mmosteotome may
be used to resect or greenstick the deviated bone
to the midline. Removing spurs or malformed
bone greatly relieves the problem of mechanical
obstruction.
Aggressive resection of the bony septum and
repositioning of the quadrangular septum are in-
dicated if the premaxillary crest or the nasal spine
bone is malpositioned, and if the septum is buck-
led or crowded. Removing a 3- to 4-mmstrip of the
entire septal cartilage inferiorly will often allow
midline positioning. A permanent suture of 4-0
clear nylon may be used to fix the caudal septum
to the premaxillary periosteum or through a small
hole created by a hand drill.
The entire complex of septum, nasal spine,
and premaxillary periosteum moves best as one
unit. Therefore, if the nasal spine itself is deviated
and the septum is relatively straight, the nasal
spine may be straightened by cutting it on the bias
or by greensticking it and placing it in an appro-
priate plane. This may be augmented with a small
piece of excised perpendicular plate or cartilage.
Caudal Septum
Twisted caudal septum is an extremely diffi-
cult challenge, and weakening this support struc-
ture with incisions or morselization may destroy
or weaken tip support. The caudal strut may be
splinted with autogenous cartilage for support, but
this is difficult and a bit bulky. If necessary, shaved
cartilage should be used for support and carefully
sutured. Replacement of the severely damaged can
be accomplished with a sturdy piece of cartilage.
Careful fixation with a permanent suture (4-0 clear
Fig. 4. Cross-sectionnasal viewshowingmaintenanceof at least
some segments of the mucoperichondrium for support and
blood supply.
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nylon or Mersiline; Ethicon, Inc., Somerville, N.J.)
reconstitutes and maintains support.
Dorsal Septum
If the cartilaginous dorsum is still crooked de-
spite conservative attempts at straightening the
inferior, posterior, and caudal cartilage, it may be
possible to achieve straightening by making ver-
tical incisions in the intact dorsal strip of cartilage,
which terminates within 2 to 3 mm of complete
transection. Often, no method short of interrupt-
ing dorsal continuity will suffice. If the continuity
must be interrupted to straighten a deviated nose,
the surgeon must guard against displacement of
mobilized septal elements posteriorly into the
nose, and the procedure must be performed only
after the following steps have been accomplished:
(1) transeptal mattress sutures should be intro-
duced beneath the dorsum buttress of cartilage or
bone to prevent them from falling into the nose;
(2) the caudal cartilage strut and remaining sep-
tum should be stabilized by splinting with semi-
rigid splints [Doyle (Xomed, Jacksonville, Fla.)
exposed x-ray film, or Teflon (DuPont, Wilming-
ton, Del.)]; and (3) lateral osteotomies should
have already been mobilized with the new skeletal
position. In addition, direct suture suspension of
the septal cartilage to the upper lateral cartilage
via an open rhinoplasty technique may further aid
in nasal reconstitution. If hump removal is not
performed, the upper lateral cartilages must be
released from the septum through submucosal
tunnels which, combined with septoplasty, allow
exposure and access.
HUMP REMOVAL
Hump removal can be performed after septal
repair. Using the previously created submucosal
tunnels, hump removal remains extramucosal and
can be performed with a chisel or a rasp, depend-
ing on the quantity of bone to be removed. Hump
removal should be very conservative in deviated
noses because of the skeletal asymmetry com-
monly seen. Incremental cartilaginous excision
and minimal rasping is preferred. Onlay cartilage
grafts are indicated when the bridge is wide, with
convexity or saddling. Cartilaginous asymmetry
should also be addressed at this time under direct
visualization.
OSTEOTOMIES
Precise, planned osteotomies are integral in
correction of deviated noses. Although mobiliza-
tion and reduction by incomplete osteotomies
may correct deviation initially, subsequent con-
traction of fibrous tissue may result in recurrence
of the deformity. The nasal bones are often asym-
metric, and bony size and shape discrepancies are
present, such as bowing of the nasal bone and the
nasal process of the maxilla. After manipulation
with infracturing, this bowing and asymmetry may
persist in the nasal bone itself. In such severe
deviations, paramedianor double osteotomies can
be very helpful for creating comminution and ap-
propriate reapproximation and positioning.
25
This technique will produce narrowing and sym-
metry (Fig. 5). Because nasal bones and upper
lateral cartilage cannot be shifted medially in the
presence of a high septal deflection, efforts to
achieve a straight external nasal vault by osteoto-
mies alone will prove fruitless. The dorsal septum
will remainshiftedsignificantly to one side andthe
bone and the upper lateral cartilages will be
splinted laterally by the septal deviation.
22
ADJUNCTIVE PROCEDURES
Defects in the dorsum and the middle vault
can be filled in, when indicated, with septal frag-
ments of cartilage or bone. If needed, larger septal
spreader grafts can be used to support the middle
and lower nose. These supporting grafts are fitted
in the most effective position behind or between
the nasal bones for as much as 1 cm (the keystone
area). After bony mobilization, other adjunctive
procedures may be performed as indicated, which
may include greensticking or subtotal resection of
the turbinate. Nostril asymmetry is commonly
present because of soft-tissue growth disturbance,
and alar base narrowing is often necessary.
Several caveats are important to remember in
the open reduction. First, the incisors can serve as
a midline reference when the nasal bones are
mobilized.
16
Second, in severely comminuted
open fractures, the base of the frontal bone or
maxilla can serve as an anchor if plating is neces-
sary. Thin small plates should be used with caution
in patients who wear glasses because of problems
with skin erosion. If wires are used, 26- to 30-gauge
wires should be used because larger wires can pro-
duce palpable sharp edges. Alternatively, thick ab-
sorbable sutures in figure-of-eight patterns can be
used in lieu of wire to lock the bone into position.
2
Fourth, rasping should not be attempted near the
fracture fragments because the bony segments
may be devascularized. Fifth, soft-tissue lacera-
tions should be repaired after the fracture is re-
duced. Lastly, the goal is to repair the injury and
not necessarily alter the preinjury appearance.
For a detailed discussion on the operative
strategy, the operative algorithms presented by
Rohrich et al.
26
on the management of deviated
Plastic and Reconstructive Surgery December Supplement 2, 2007
72S
Fig. 5. Preoperative (above), postoperative (center), andworms eye (below) views of a patient withsignicant asymmetry. Lateral and
obliqueviews demonstratingnotableposttraumaticdorsal humpassociateddorsal asymmetry. Worms eyeviews showmarkednasal
deviation associated with dorsal asymmetry.
Volume 120, Number 7 Suppl. 2 Nasal Trauma and Deviated Nose
73S
cartilaginous and bony vaults nicely summarize
the operative technique we use and are recom-
mended. Again, the importance of addressing sep-
tal injuries cannot be overemphasized. The oper-
ative technique to be chosen in open rhinoplasty
for nasal fractures depends on the presence and
degree of septal injury and whether it is a caudal
or a dorsal deformity.
EXTERNAL SPLINTS
The external splint protects and supports the
nasal bones and cartilages in their reduced posi-
tions. It helps with the adherence of the skin to the
underlying framework, particularly in open reduc-
tions. Intranasal Silastic splints should be used to
maintain the corrected septal position and pre-
vent synechiae after extensive intranasal manipu-
lation. Generally speaking, these splints are left in
position for 2 to 3 weeks. Nasal packing is not used
as frequently now as it was in the past because of
concerns over the possibility of toxic shock syn-
drome. It may be used in some cases where there
is such comminution of the nasal bones that
packing directly underneath them is required to
maintain their position. In such cases, the pack-
ing should be kept in position no longer than 72
hours.
MANAGEMENT OF DEVIATED SEPTUM
Optimal septal management should serve as the
cornerstone in nasal fracture treatment. Once
the cartilage is deviated, it is not possible to cor-
rect the deviation in that segment of cartilage.
27
The only way to correct deviation of the nose is to
reshape the segment to create apparent straight-
ening of the cartilage or to camouflage the crook-
edness of the cartilage.
15
The shape of the septum
and the septocartilage is determined at least in
part by the deforming forces applied by the sur-
rounding structures, including bone, cartilage,
and skin. If the deforming forces are not removed
and cartilage is not dealt with appropriately, a
crooked nose can result after attempted correc-
tion. It may be possible to splint crooked cartilage
into a newposition and maintain this newposition
postoperatively; however, it must be kept in this
position until the fibrous tissue has a chance to
become firmly entrenched. Splinting, however,
will probably have to remain for a long time and
is unlikely to be maintained by either internasal or
external splints. Only splinting with autogenous
materials (i.e., cartilage) can maintain the carti-
lage in its newly deformed shape.
The incidence of posttraumatic nasal defor-
mities remains high. As such, it is hoped that our
discussion and algorithm for management of na-
sal trauma in the acute setting will be helpful in
minimizing secondary nasal deformities that are
difficult to treat. However, such posttraumatic de-
formities are often inevitable, especially with high-
impact, crush injuries. Therefore, proper and reg-
ular follow-up examinations are integral to the
management of nasal trauma and the deviated
nose and should not be overlooked.
Samuel Stal, M.D.
6621 Fannin, Suite 620.10
Houston, Texas 77030
sxstal@texaschildrenshospital.org
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