Aesth. Plast. Surg.

22:245252, 1998

1998 Springer-Verlag New York Inc.

Nose Surgery (Rhinoplasty) Without External Immobilization and Without

Internal Packing: A Review of 812 Cases

Andre Camirand, M.D., Jocelyne Doucet, R.N., and June Harris, M.D.
Montreal, Quebec, Canada

Abstract. In a review of 812 cases of rhinoplasty, none of our
patients had early bone or septal displacement; swelling, bruis-
ing, and pain were almost nonexistent. This confirms that an
external split would not have been of any benefit in these cases.
Packing should help prevent epistaxis, synechiae, and early
bone and septal displacement. Not using any packing, we have
not encountered these complications. Besides, we have not seen
a single submucosal hematoma or a septal necrosis. Therefore,
we doubt the value of packing in our patients. The inconve-
niences and complications of external splits and internal pack-
ing are described. Early postoperative photographs show the
reduced swelling and bruising, and late photographs show the
final results. Difficult primary and secondary rhinoplasty cases
are demonstrated.
Key words: RhinoplastyNasal castNasal splintNasal
packingBruising (reduced)Edema (reduced)
black eyes. In addition, packing is aversive because
of the resulting pain, headaches, and nauseating odors.
When the packing is removed, relief is immediate, but
the removal is often painful and frequently causes bleed-
ing.
By using small instruments and reducing trauma to
nasal tissues when performing rhinoplasty, we have been
able to eliminate nasal packing and external immobili-
zation. General edema and ecchymosis of the eyelids are
decreased significantly. Some of our patients can breathe
through the nose with little difficulty within minutes af-
ter surgery, and there is virtually no pain. Since 1979 we
have surgically manipulated well over 1,0001 noses, with
very few complications. The technique we use results in
minimal swelling and bruising (Table 1).
Table 1. Outcomes of rhinoplasties performed without splints.

Of our 812 rhinoplasties

Role of a splint without a splint
During residency training, plastic surgeons are taught to
immobilize the bones of the nose after performing an 1. Immobilize bone 1. Early bone displacement 0
osteotomy. A pliable metal splint or a paper-thin, weak 2. Immobilize septum 2. Early septal displacement 0
cast is fixed to mobile skin and then attached with 3. Decrease swelling 3. Excessive swelling 0
stretchable Elastoplast; logically, nothing could be more 4. Decrease pain 4. Excessive pain 0
unstable. Packing is inserted into the nostrils to maintain
immobilization, to prevent bleeding and septal hemato-
mas, and to avert synechiae; however, this conventional Technique
approach may actually cause edema and hematomas.
When both internal packing and an external splint are If rhinoplasty is done under local anesthesia, we use
applied, the venous capillaries are compressed, interfer- narcolepsy. When the patient arrives, we administer 15
ing with venous return and the healing process. Thus, mg of diazepam orally. Once the patient is on the oper-
blood is evacuated upward toward the eyelids and creates ating table and the markings on the nose are made, we

1
Correspondence to Andre Camirand, M.D., 12245 Rue Grenet, We reviewed only 812 charts but we have performed the
Suite 112B, Montreal, Quebec H4J 2J6, Canada technique in well over 1,000 cases.
246
generally inject 2 ml of fentanyl intravenously (more
fentanyl can be given to heavier patients) over a period of
3 min. Not only does this sedate the patient, but its strong
analgesic effect facilitates infiltration of the nose, which
must be undertaken within 10 min. Occasionally, at the
time of osteotomy, we administer a further 1 ml of fen-
tanyl. The patient is monitored with an oximeter and the
attending staff are trained in cardiopulmonary resuscita-
tion; however, we have used narcoleptics extensively,
without any incidents.
Undermining of the dorsum of the nose is kept to a
minimum, allowing a rasp to be inserted. The bony dor-
sal hump is rasped down and the cartilaginous hump is
resected with the blade of a scalpel. The nose is short-
ened by resecting the membranous septum and, if nec-
Rhinoplasty Without Immobilization or Packing
Fig. 1. (A) Preoperative. (B) Four days
following a rhinoplasty, the patient
presents minimal swelling and
ecchymosis.
Fig. 2. (A) Preoperative. (B) Six days
following an extensive
septorhinoplasty. There is swelling
and eyelid ecchymosis, but we feel
that a splint and external
immobilization could have made them
worse.
essary, some cartilaginous septum. A narrow osteotome
is used, with a narrow guard. Undermining of the skin or
mucosa is avoided. We do not use a midline fracture
because we want to maintain the nasoorbital line and
keep the fractured bones stable. We rarely, if ever, see
indications for this maneuver. A greenstick fracture is
performed by inserting the osteotome past the midpoint
of the bone. We then raise the osteotome and rotate it
internally, creating a greenstick fracture with a very solid
cephalic attachment (Figs. 18).
With this technique, the cephalic part of the bone is
not separated from the forehead bone. It will not narrow
the radix, which, in our experience, rarely requires nar-
rowing. In addition to maintaining nasoorbital continui-
ty, this technique ensures that there is strong stability
A. Camirand et al.
without creating either the floating fragments of a con-
ventional lateral bone fracture or the midline separation
of a medial osteotomy. There is little chance that bone
fragments can be displaced. In fact, once done, we often
ask our visiting surgeons to mobilize the head by moving
the reduced bones with their fingers. The fact that this
can be done proves that the bones are very stable and do
not require splinting or any other form of immobiliza-
tion. Another advantage of this technique is that the os-
teotome will not transect the angular artery, the most
common cause of excessive ecchymosis of the eyelids.
A deviated septum is relocated by hatching its con-
cavity. The septum may have to be detached from the
vomer, and occasionally we fracture the nasal spine. In-
stead of resecting the cartilage or the bone, we relocate it.
In cases with hypertrophied lower turbinates, we use
bipolar cautery with good success. Unlike conventional
turbinectomy, there is no need for packing. The coagu-
lation prevents bleeding and risks of synechiae.
We suture all the vestibular skin and mucosa, elimi-
nating the risk of synechiae and septal hematomas.2 If we
undermine the mucosa of the septum, we use U-type
stitches to reapproximate the mucosa onto the septum. A
247
Fig. 3. (A, B) Preoperative views of a
patient. (C, D) Frontal and lateral views of
the patient 5 days following a rhinoplasty.
few Steri-strips are applied to shape the skin and the
underlying bone and cartilage.
The outcomes of our rhinoplasty procedures per-
formed without splints or packing are illustrated in Ta-
ble 1.
The general public is at times afraid of a rhinoplasty
because of the pain, the black eyes, and the dressing, but
their greatest fear is of the removal of the packing.
Results
We have reviewed the operative protocols of the >800
rhinoplasties performed. None of these patients had an
external immobilization (splint or cast) and none had a
nasal packing. We perform osteotomies on all of our
patients.
We were very impressed to note that the swelling was
2
A tight anterior packing can prevent the evacuation of a sub-
mucosal hematoma posterior to this packing.
248
minimal. A large number of our patients had no black
eyes, and if they did, it was minimal (Figs. 18).
We prescribe Arthrotec b.i.d. for 5 days and Tylenol
Extra Strength every 4 h p.r.n. None of our patients com-
plained of excessive pain and none required more medi-
cation.
We had no bone or septal displacements in the early
postoperative period (Table 1). One hundred fifty-two
patients returned for secondary rhinoplasties (Table 2).
We follow our patients very closely for at least 1 year.
We are very demanding and expect our patients not to
Rhinoplasty Without Immobilization or Packing
Fig. 4. (A, B) A patient referred to us
following a previous rhinoplasty. (C, D) Six
days following an open secondary
rhinoplasty. There is very little swelling and
ecchymosis. (E, F) Five months following
the secondary rhinoplasty.
hesitate to ask for further improvement even if it is mini-
mal. We work very hard to maintain a good rapport with
our patients; however, we realize that some patients must
have gone to other surgeons for further opinions and
possibly had secondary rhinoplasties, but we do not have
any statistics on this occurrence.
The majority of patients submitting to secondary rhi-
noplasty require one or more of the following: reduction
of the dorsal projection, shortening of the nose, narrowing
of the tip, or reduction of the lumen of the nostril caliber.
However, 16 patients required secondary osteotomies
A. Camirand et al. 249

Table 2. Occurrence of secondary rhinoplasties

after our 812 rhinoplasties.

A. 152 patients had secondary rhinoplasties

16 patients had secondary osteotomies
16 patients had secondary septoplasties
B. Other reasons for our secondary rhinoplasties
1. To lower the dorsum
2. To shorten the nose
3. To narrow the tip
4. Alar plasty

Table 3. Outcomes of rhinoplasties performed

without packing.

Of our 812 rhinoplasties

Role of packing without packing

1. Prevent epistaxis 1. Epistaxis 0

2. Prevent synechiae 2. Synechiae 0
requiring
treatment
3. Prevent early 3. Early septal 0
septal displace- displacement
ment
4. Prevent early 4. Early bone 0
bone displace- displacement
ment
5. Prevent submu- 5. Submucosal 0
cosal hematoma hematoma
6. Prevent septal 6. Septal necrosis 0
necrosis

Fig. 5. (A, B) Postoperative nasal deformity.

(C, D) Less than a week following the
secondary rhinoplasty, there is minimal
swelling and ecchymosis. (E, F) Final
postoperative result, 3 years, 4 months later.

because of late bony displacement. The cause for these
was either trauma or an underlying septal displacement
redisplacing the bones. The absence of immobilization
was never a cause (Table 2).
Another 16 patients required septal relocation. As we
know, cartilage has a memory, and all of these displace-
ments were late and would not have been prevented by
the presence of a splint or packing left in place for 1
week.
No epistaxis required treatment. We had very few pa-
tients with early adherence in the vestibular area, but all
were freed using a speculum in the examining room. No
one had synechiae as a cause for reoperation (Table 3).
None of our patients had submucosal hematoma neces-
sitating drainage and there were no cases of septal ne-
crosis. No patient suffered from rhinitis, otitis, or sinus-
itis and there were no cases of asphyxia by nocturnal
aspiration or cases of septic shock.
250
Discussion
Presumably, external splints (either a cast or metal splint)
should immobilize bony fragments and possibly the sep-
tum. The splint, which is malleable, and a weak, paper-
thin cast cannot immobilize anything. Both offer no re-
sistance as you can easily bend or break them with your
thumb and index finger.
Even if they were strong, any lateral blow such as
lying on ones nose would displace the structures (bone
or septum) if they were unstable. I am occasionally told
that a splint is applied to remind the patient that he had
a rhinoplasty! It has been our experience that all of our
patients know they have had a rhinoplasty and even with-
out a splint they will do anything to avoid a nasal trauma.
If the splint has a frontal extension, it is fixed to the
forehead which is a very mobile structure. By the same
token, one should not expect much stability from a fixa-
tion on the mobile cheek. Some surgeons fix it with
Rhinoplasty Without Immobilization or Packing
Table 4. Complications of external im-
mobilization (metal splint or cast).a
Pain
Scar
Skin necrosis
Skin infection
a
This occurs particularly when an in-
ternal packing is pressing from the in-
side against the exterior rigid immobi-
lization.
Fig. 6. (AD) Final result close to 2
years following feminization of the
nose in a transsexual.
stretchable Elastoplast. It is not logical to believe that an
immobilization could be accomplished using this
method.
Following a rhinoplasty patients will experience ir-
regular swelling, and an external splint cannot mold to
adjust to this swelling; therefore, there are inevitably
areas of pressure. The inferior sharp edges will compress
the skin and can cause pain; they will also interfere with
venous return (Table 4). This is compounded by the use
of nasal packing. One must remember that the venous
capillaries have a blood pressure of 25 mm Hg. There is
inevitable congestion, which will create more swelling
and pain, with the additional possibilities of necrosis,
infection, and an ensuing scar. Congestion is not physi-
ological and interferes with healing.
A greenstick fracture without a midline fracture will
provide greater stability and no need for an external
splint. It eliminates the inconveniences and complica-
tions of an external splint, which is removed a few days
A. Camirand et al.
or a week later. Remember that if there is displacement
of the bones or septum, this occurs after weeks or
months. Interestingly, we have also noticed that not us-
ing an external splint causes a further reduction in swell-
ing and pain.
The nasal packing is not physiological (Table 5)it
applies pressure on the internal structures, compresses
venous capillaries, and is often a cause of swelling and
pain. Our incisions are loosely sutured and will allow
evacuation of blood. A packing will interfere with this
evacuation and the blood will diffuse into a plane of
lesser resistancethe eyelidsresulting in palpebral ec-
chymosis, which is one of the stigmas of a rhinoplasty.
A packing is unpleasant and painful, and a cause of
headache, bad odor, and airway obstruction. All of these
symptoms improve on removal of the packing, but often
this removal is accompanied by some pain and persistent
bleeding. Not only is a packing not hygienic, but it is
unhealthy and dangerous. It can be a cause of rhinitis,
sinusitis, and otitis, and septic shock or asphyxia by noc-
251
Table 5. Inconveniences arising from na-
sal packing following rhinoplasty.
Pain
Airway obstruction
Bleeding on removal
Unpleasant odor
Headaches
Ecchymosis and swelling of eyelids
Table 6. Complications (theoretical) of
nasal packing.
Sinusitis
Rhinitis
Otitis
Asphyxia by nocturnal aspiration
Septic shock
Fig. 7. (AD) A patient referred to us
following a rhinoplasty. One and a
half years following a secondary
rhinoplasty using our technique.
turnal aspiration has occasionally been reported (Table
6). It has no immobilizing virtues because it is removed
after a few days, and a bony or septal redeviation will
take weeks or months to occur.
We suture our vestibular skin incision and membra-
nous septal incisions and we have not had one case of
synechiae.
As we do our septoplasties, we undermine the mucosa
on the concave side and then hatch the septum to
straighten it. We then use Plain Catgut to bring back the
mucosa on the septum. We have never encountered sub-
mucosal hematomas, septal necrosis, or epistaxis requir-
ing treatment.
Conclusion
Using the technique described for well over a thousand
rhinoplasties without an external splint and nasal pack-
ing, we have not had a single case of epistaxis, syn-
252
echiae, bony or septal displacement, submucosal hema-
toma, or necrosis. Based on objective observation, we
conclude that this rhinoplasty technique reduces discom- 6.
fort, pain, swelling, and ecchymosis.
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1986 11.
3. Camirand A: Rhinoplasty. Reunion Internacional Contro- 12.
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Surgery, Toronto, Ontario, Sept 1986 15.
5. Camirand A: How to reduce to a minimum peri-orbital 16.
Rhinoplasty Without Immobilization or Packing
Fig. 8. (A, B) The final result
in one of our patients.
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