Abstract
Objective
Traditionally, rhinoseptoplasty for nasal bone fracture is only considered after an unsatisfactory outcome from initial closed reduction. However, better surgical outcomes may be achieved if rhinoseptoplasty is performed at the same time as the nasal bone fracture reduction. This study investigated the surgical outcomes of patients who underwent rhinoseptoplasty concomitantly with nasal bone fracture reduction according to their computed tomography image-based nasal bone fracture classifications.
Study Design
Case series with chart review.
Setting
Academic tertiary care medical center.
Subjects and Methods
Fifty-six patients who underwent rhinoseptoplasty concomitantly with nasal bone fracture reduction were enrolled in this study. Nasal bone fractures were classified into 6 types by computed tomography scans. Two independent facial plastic surgeons evaluated the outcomes 6 months postoperatively using a visual analog scale. The nasal tip projection and rotation were measured using the pre- and postoperative profile views.
Results
The satisfaction scores of type I, IIo, and IIIo fractures without septal fracture were significantly higher than those of type II, III, and IV fractures with septal fractures. Among the patients, 82.1% underwent lower vault surgery. The nasal tip projection and rotation were increased after surgery in patients without septal fractures, whereas the tip rotation was elevated but the projection was unchanged postoperatively in patients with septal fractures.
Conclusion
Rhinoseptoplasty for acute nasal bone fractures can be performed at the same time as nasal bone fracture reduction. However, nasal bone fracture with septal fracture should be managed carefully.
Nasal bone fracture is the most common type of facial trauma and can lead to complications, such as a prominent external nose deformity and intranasal dysfunction, if it is not treated appropriately. Furthermore, unless it is managed properly, the morbidity of these complications is higher than that of other facial fractures.1,2
Traditionally, most nasal bone fractures are treated with closed reductions. However, some surgeons advocate performing rhinoplasty concomitantly with nasal bone fracture reduction because of the possibility of better cosmetic results and a high possibility that closed reduction will eventually require revision rhinoplasty.3,4
The specific characteristics of the fracture should be considered in the effective management of nasal bone fractures. A classification system for nasal bone fractures would enhance surgical planning and management. Computed tomography (CT) images offer more precise information about the nature of the fracture site and the accompanying facial bone fracture than a simple plain image. These images are especially helpful in patients with severe facial swelling, lacerations, or disturbances of consciousness. 5 We have previously suggested new classifications of nasal bone fractures according to CT scans and reported their practical effectiveness. In type III fractures (bilateral thin and thick bones with septal fractures), the satisfaction scores of open reductions were significantly higher than those of closed reductions. 6
This study evaluated the surgical outcomes of patients who underwent rhinoseptoplasty concomitantly with nasal bone fracture reductions according to the nasal bone fracture classifications based on CT images.
Patients and Methods
Patients
This study was approved by the institutional review board of Chuncheon Sacred Heart Hospital. We retrospectively reviewed the medical records of 56 patients who underwent rhinoseptoplasty concomitantly with nasal bone fracture reduction within 1 to 4 weeks after trauma from January 2001 to April 2012 at the Department of Otolaryngology–Head and Neck Surgery in Chuncheon Sacred Heart Hospital.
Each patient enrolled had medical records and postoperative facial photos available for review. Patients were usually dissatisfied with their noses and wanted to undergo rhinoplasty simultaneously with a reduction of the nasal bone fracture because of concerns of time or cost. Open, naso-orbital/ethmoid, and pediatric fractures were not included in this study. The patients enrolled included 34 men and 22 women who ranged in age from 18 to 52 years (mean, 31.3 years). Their operations took place between 3 and 28 days after injury (mean, 13.2 days), and their mean follow-up period was 13.4 months (range, 6–23 months). Each was diagnosed using 3-mm facial CT and nasal endoscopy, and all pre- and postoperative photographs were taken in the sitting position.
Classification of Nasal Bone Fracture
Nasal bone fractures were classified into 6 types by the CT scans ( Figure 1 ). Type I included unilateral thin bone fractures with displacement; type II, bilateral thin bone fractures with displacement; and type III, bilateral thin and thick bone fractures. Type IV fractures were accompanied by fractures of the neighboring bones, including the orbit wall, ethmoid bone, frontal bone of skull, lacrimal bone or maxilla, and so on. Types II and III were subdivided into “o” and “s,” according to the absence or presence of septal fracture. Consequentially, we classified nasal bone fractures into type I, IIo, IIs, IIIo, IIIs, and IV. 6
Classification of nasal bone fracture.
Surgical Techniques
Septoplasty was performed through hemitransfixion incision and tunneling, followed by the harvest of the septal cartilage, if possible. The fractured nasal septum was replaced in the midline using Asch forceps. Rhinoplasty was performed via an endonasal or open approach. After dissection from the lower lateral cartilage to the nasal dorsum, the displaced bone fragment was reduced into place or contralateral nasal bone was adjusted to the fracture site using medial and/or lateral osteotomy techniques via an endonasal route. Hump reduction was conducted as an en bloc removal and/or incremental rasping corresponding to the newly elevated nasal tip. A deviation of the cartilaginous dorsum was corrected using a spreader graft and/or modified clocking suture technique. To create a new tip, we performed septal extension grafts, columellar struts, shield and/or onlay grafts, suture techniques, cephalic resections, and/or alar base resections as in conventional rhinoplasty.
Postoperative Outcome
All pre- and postoperative photographs were analyzed by 2 independent otorhinolaryngologists using a visual analog scale (VAS) that ranged from 0 (poor) to 10 (excellent).
Anthropometric measurements and nasal tip projections and rotations were also made using pre- and postoperative profile photographs. Nasal tip projection was determined using the ratio of the alar crease-tip to the nasion-tip length. 7 The nasal tip rotation was evaluated by measuring the nasolabial angle.
The Student t test was used to compare VAS scores according to the type of fracture, and a paired t test was used to compare the pre- and postoperative nasal tip projections and rotations. A P value less than .05 was considered significant. Data analyses were performed using SPSS for Windows, version 12.0 (SPSS, Inc, an IBM Company, Chicago, Illinois).
Results
Type IIo was the most common type of nasal bone fracture, occurring in 22 (39.3%) patients. The second most common type was type IIIs, identified in 16 (28.6%) patients, whereas type IIIo was found in only 4 (7.1%) patients ( Table 1 ).
Classification of nasal bone fractures by computed tomography images.
Thirty-eight (67.9%) patients underwent procedures via an endonasal approach and 18 (32.2%) via an open approach. Dorsal augmentation was performed on 36 (64.3%) patients; osteotomy, on 21 (37.5%) patients; and hump removal, as en bloc removal and/or rasping on 11 (19.6%) patients. The graft materials for dorsal augmentation were Gore-Tex in 27 (75.0%) patients, septal cartilage in 4 (11.1%) patients, silicone in 3 (8.3%) patients, costal cartilage in 1 (2.8%) patient, and dermofat in 1 (2.8%) patient. A spreader graft for the correction of middle vault deviation was used in 5 (8.9%) patients. Forty-six (82.1%) patients underwent lower vault surgeries using septal cartilage, such as a septal extension graft, columellar strut, shield and/or onlay graft, suture technique, cephalic resection, or alar base resection ( Table 2 ).
Techniques used on the patients who underwent nasal tip surgery (n = 46).
The mean ± SD VAS score of the overall patients was 7.14 ± 1.07 ( Table 1 ). The VAS scores of type IIo and IIIo were higher than those of IIs and IIIs, respectively. Consequently, the VAS scores of patients without septal fractures (types I, IIo, and IIIo) were significantly greater than those of patients with septal fractures (types IIs, IIIs, and IV) (P = .006) ( Table 3 , Figures 2 and 3 ).
Comparison of satisfaction scores according to the presence of septal fracture.
Preoperative (above) and postoperative (below) photographs of a 21-year-old man with type I right nasal bone fracture showing excellent surgical outcome.
Preoperative (above) and postoperative (below) photographs of a 22-year-old woman with type IIs left nasal bone fracture with septal fracture resulting in unsuccessful outcome.
In patients who underwent the low vault technique, the VAS scores of patients without septal fractures were significantly higher than those of patients with septal fractures (P = .010). Among them, the nasal tip projections and nasolabial angles of the patients without septal fractures increased postoperatively (P < .05). On the other hand, in patients with septal fractures, nasal tip projections were unchanged after surgery (P = .672), but the mean nasolabial angles increased (P = .011) ( Table 4 ).
Comparison of tip projections and nasolabial angles in patients who underwent the lower vault technique.
There were no complications, such as infections, inflammation, or graft extrusions. Two patients underwent revision surgery, one because of recurrent nasal trauma and the other because of the undercorrection of saddling and deviation.
Discussion
The nasal bone is prominently located in the central portion of the face and is therefore extremely vulnerable to injury. Most surgeons consider open reduction or rhinoplasty of nasal bone fracture at least 6 months after trauma, only if the outcome of an initial closed reduction is unsatisfactory.8,9 Many surgeons hesitate to perform rhinoplasty of the acute nasal bone fracture because of the uncontrolled fracture site and unpredictable nasal bone resorption at the fracture site. 2 However, some authors have recommended early rhinoplasty for an acutely fractured nose. Clark and Stiernberg 3 suggested that early open reduction, septoplasty, and rhinoplasty gave a better result than closed reduction alone for nasal bone fractures. Staffel 10 concluded that acutely fractured noses may be safely repaired by certain rhinoplastic procedures, as well as by closed reductions alone. Miniscrew fixations of cantilever nasal bone grafts were suggested to achieve stable, predictable nasal contours and tip projections without significant bone graft resorption. 11
A simple x-ray is commonly used in patients with simple nasal traumas, but in this case, x-rays are of limited diagnostic value. 12 Recently, a CT image has been shown to be a more accurate tool to visualize the nature of the fractured nasal bone and its associated injuries. A CT analysis contributes to decision making and the subsequent prognosis. 13 Manson et al 5 classified nasal bone fractures using CT images into low-, middle-, and high-energy fractures based on the degree of exodeviation and posterior deviation of the fractured nasal bones and suggested guidelines for the management of nasal bone fractures. However, it is difficult to define the characteristics of nasal bone fractures based only on impact direction while fully identifying other concurrent fractures and making a prognosis based on the classification. Hwang et al 13 also classified nasal bone fractures by CT analysis; however, they reported the necessity of CT for the diagnosis of nasal bone fracture, not its prognoses according to a CT-based classification system.
We previously demonstrated the practical effectiveness of the new classification system for nasal bone fractures according to CT analysis, considering both the anatomic structures of nasal bones and the impact on the nasal bones. 6 In the present study, we performed rhinoplasty on 56 patients with acute nasal bone fracture and analyzed the surgical outcomes according to our new classifications. Gore-Tex implants for dorsal augmentation were used in 64.3% of patients, but no infections occurred in these patients. Therefore, it is possible to use Gore-Tex for dorsal augmentation unless communication with the nasal cavity or open wound is present. Forty-one percent of the nasal bone fractures presented in combination with septal fractures. The satisfaction scores of type IIs, IIIs, and IV fractures with septal fractures were significantly lower than those of type I, II, and III fractures without septal fractures. In the 82.1% of patients who underwent low vault surgery, the satisfaction scores of patients with septal fractures were significantly higher than those of patients without septal fractures. Furthermore, although both nasal tip projection and rotation were improved postoperatively in patients without septal fractures, the nasal tip rotation was elevated while the projection was unchanged in patients with septal fractures. These results indicate that although the low vault of a patient with a septal fracture was modified, the fractured septum would decrease its support to the distal nose progressively, leading to a progressive decrease in tip projection and a poor surgical outcome. However, an overall impression was acceptable in the majority of cases unless the septal fracture was severe. Therefore, although the lower vault technique, including tip and alar base surgery, could be an option for patients with nasal bones with or without septal fractures, rhinoplasty surgeons should pay attention to nasal bone fractures accompanied by septal fractures. Further analysis of the surgical outcomes of rhinoplasty in acute nasal bone fractures according to the patterns of septal fractures is required.
Rhinoplasty for acute nasal bone fracture has some advantages. Because the fractured bone segments are identified through the rhinoplasty approach, the nasal bone can be reduced more accurately. In addition, rhinoplasty satisfies the aesthetic demands of patients at the same time. As most patients request a dorsal augmentation, the dorsum can be camouflaged with implants. In our experience, their satisfaction is not significantly different from that of rhinoplasty patients without nasal bone fractures. However, surgeons should not ignore the CT scan, and this approach is not practical in most cases of rhinoplasty only for cosmetic purposes. Closed reduction still plays a role in the management of nasal bone fracture. In addition, CT scan and rhinoplasty should be performed considering the differences in the socioeconomic situation of each country.
Several difficulties exist in rhinoplasty for acute nasal bone fractures. In comminuted fractures of the nasal bone, the dissection of fractured bone segments is complicated by their advanced fibrosis; thus, their reduction may not be accurate, and the selection of the appropriate osteotomy site is relatively difficult. When the nasal bone fracture is accompanied with septal fracture, it can be hard to harvest the septal cartilage. In our study, 1 patient with a comminuted nasal bone fracture and a septal fracture had a deviated remnant and saddle nose after the first operation, both of which were resolved by revision surgery.
Conclusion
Previously existing deformities in nasal bone fractures can be corrected at the same time as nasal bone fracture reduction. The lower vault technique is an option for patients with nasal bone fractures with or without septal fractures; however, nasal bone fractures accompanied by septal fractures should be handled carefully.
Author Contributions
Disclosures
Footnotes
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.