C o r re c t i o n o f N a s a l

F r a c t u res
G. Nina Lu, MDa, Clinton D. Humphrey, MDa, J. David Kriet, MDb,*

KEYWORDS
 Nasal fracture management  Open reduction internal fixation nasal fracture
 Nasomaxillary fracture  Facial trauma  Nasal bone

KEY POINTS
 Nasal fracture is the most common bony injury resulting from blunt facial trauma.
 Optimal management of nasal trauma in the acute setting is critical to restoring pretraumatic form
and function and minimizing secondary nasal deformities.
 Evaluation of nasal fractures should include careful examination of the nasal septum because un-
successful fracture management is often due to inadequate treatment of concurrent septal fracture.
 Complex traumatic nasal deformities, especially with significant septal involvement, may require
more aggressive acute surgical management and an initial open surgical approach.
 The open treatment of isolated nasal fractures is a controversial subject without widely accepted
indications for timing, patient selection, and surgical technique.

INTRODUCTION discussion is focused on the treatment of isolated

nasal fractures.
Nasal fractures most commonly result from blunt
facial trauma in events, such as motor vehicle
ANATOMIC CONSIDERATIONS
accidents, sports-related injuries, assaults, and
falls.1 The nasal bones are the most frequently The structural framework of the nose includes the
fractured facial bone, with a peak incidence during nasal bones, the nasal septum, the nasal process
the second and third decades of life with boys and of the frontal bone, the frontal process of the
men more commonly affected than girls and maxilla, the ethmoid bone, the vomer, and carti-
women.1–4 Isolated nasal fractures are defined as laginous structures. The nasal bones are thicker
fractures involving the nasal bones with or without above the intercanthal line as they meet the naso-
concomitant involvement of the nasal cartilages frontal suture. Inferiorly, the thinner nasal bone
and nasal septum. Nasal septal fractures are asso- serves as a cantilever point for the attached upper
ciated with 39% to 96% of nasal fracture cases, lateral cartilages (ULCs) and corresponds exter-
with increasing severity associated with more nally to the rhinion. The transition between the
frequent septal fractures.5–7 In more severe cases, thicker and thinner nasal bone is a common frac-
they can coincide with fractures of the nasomaxil- ture site.8 Within the nasal cavity, the perpendic-
lary buttress, naso-orbitoethmoid (NOE) complex, ular plate of the ethmoid fuses with the nasal
and frontal sinus. For the purposes of this article, bones along the dorsum. External impact to the
facialplastic.theclinics.com

Disclosure Statement: The authors have nothing to disclose.

a
Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, 3901 Rainbow
Boulevard, MS 3010, Kansas City, KS 66160, USA; b Division of Facial Plastic and Reconstructive Surgery, Depart-
ment of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, 3901 Rainbow Boule-
vard, MS 3010, Kansas City, KS 66160, USA
* Corresponding author.
E-mail address: dkriet@kumc.edu

Facial Plast Surg Clin N Am 25 (2017) 537–546

http://dx.doi.org/10.1016/j.fsc.2017.06.005
1064-7406/17/Ó 2017 Elsevier Inc. All rights reserved.
538 Lu et al

nasal bones is transmitted to the septum through FRACTURE PATTERNS

this connection leading to concomitant septal
injury during nasal trauma. No universally accepted classification of nasal
The paired ULCs attach to the caudal aspect of fracture pattern exists although many clinical,
the nasal bone and dorsal aspect of the quadran- anatomic, and radiographic classifications have
gular (septal) cartilage. Cephalically, the ULCs been proposed.5,7,8,11,12 Nasal fractures can be
attach via fibrous union to the nasal bones and classified in 2 broad categories based on impact
can overlap the undersurface of the nasal bones force: lateral-type versus frontal-type injuries.
by as much as 11 mm.9 Laterally, the ULCs are Lateral-type injuries tend to be more common,
only loosely attached to the maxilla by a fibrous have fewer residual anatomic and functional
aponeurosis. Thus, the nasal bone and septal defects compared with frontal injuries, and are
attachments of the ULCs are the main contribu- more amenable to closed reduction.12,13 Frontal
tions to their stability and support of the middle injuries classically produce a posteriorly
vault. Internally, the ULCs help form the internal depressed fracture where the nasal septum is
nasal valve and contribute to the midline support always involved. They are more severe, have a
of the cartilaginous septum. The paired lower higher risk of residual deformity postsurgery, and
lateral cartilages (LLCs) provide little septal sup- are often associated with NOE fractures.
port but are essential in the aesthetics and contour Stranc and Robertson12 proposed a classifica-
of the nasal tip. In general, significant force is tion of lateral and frontal injuries based on
required to cause cartilaginous injury due to the anterior-posterior depth of injury in relation to the
soft and malleable quality of cartilage that allows nasal tip and concluded that deeper levels of injury
the dissipation of force. portended worse prognosis. In 1989, Murray and
The nasal septum plays a crucial role in the colleagues8 proposed a pathologic classification
nasal structure and understanding its anatomy system with 7 types of nasal fractures based on
is paramount in the management of nasal frac- a cadaver study. They illustrated that septal frac-
tures. The quadrangular cartilage comprises the tures occur if the nose is deviated more than
majority of the septum with bony contributions one-half a nose breadth from its original position
from the vomer inferiorly and perpendicular plate and emphasized the importance of septal man-
of the ethmoid posteriorly and superiorly. Inferi- agement for successful reduction. The variety of
orly, the quadrangular cartilage thickens and lies injury patterns and complexity of classification
within the bony groove of the maxillary nasal have precluded universal practical clinical applica-
crest. The dorsal and posterior septal cartilage tion of any of these schemes.
provides the primary support for the nasal Most isolated nasal fractures can be evaluated
dorsum and the caudal septum provides the pri- with several major characteristics in mind:
mary support for the nasal tip. Correction of 1. Unilateral versus bilateral involvement and
septal deformities secondary to trauma is crucial degree of comminution
in re-establishing premorbid form and function. In 2. Lateral-type versus frontal-type injury
children the septum remains as a major growth  Degree of bony deviation relative to nasal
center for the face until approximately 12 to width
13 years of age. Significant septal trauma can  Degree of depression of nasal dorsum
adversely affect midface development.10 3. Status of nasal septum
The external and internal carotid arteries supply 4. Presence of middle vault/cartilaginous
a rich vascular network in the nasal region. dislocations
Branches of the maxillary artery (sphenopalatine,
greater palatine, and infraorbital arteries), facial ar- Nasal fractures vary along a continuum be-
tery (superior labial and angular arteries), and tween a unilateral, nondisplaced, greenstick
ethmoid arteries (anterior and posterior) anasto- fracture to bilateral, severely comminuted, and
mose in a redundant fashion, predisposing nasal depressed nasal bone fractures with significant
fracture patients to epistaxis. Anterior or posterior septal involvement and concomitant adjacent
epistaxis may arise depending on the location of fractures. More aggressive surgical management
vessel injury, with anterior bleeds more commonly is necessary with increased severity. Closed and
seen than posterior. In most cases, nasal hemor- open treatments may have similar outcomes
rhage is either self-limited or readily controlled with appropriate patient selection for each oper-
with direct manual pressure, blood pressure man- ative treatment.14 In general, closed fracture
agement, and/or topical medications. Rare persis- reduction techniques are still considered first
tent cases can require nasal packing, operative line for mild nasal fractures.15 Treatment out-
intervention, or angiography with embolization. comes from closed reduction, however, are often
 Correction of Nasal Fractures 539

disappointing and secondary surgical correc- Nasomaxillary fractures may be missed during
tions are necessary in a sizable subset of pa- the evaluation of obvious nasal fractures and iso-
tients. Open structure stabilization and classic lated central facial injuries.19,20 The fracture line
rhinoplasty techniques are advocated for initial does not extend to the medial canthal tendon or
management of severe fractures by some lacrimal bone as in the classic NOE fracture and
investigators.16 exists in a more inferior location. Nasomaxillary
fractures will cause tenderness along infraorbital
INITIAL EVALUATION rim and intraorally along piriform aperture and
may be lead to deformities of the nose and orbit.
All patients evaluated for facial trauma should first Additionally, unrepaired nasomaxillary fractures
be evaluated in the framework of airway, breath- are a common cause of persistent nasal obstruc-
ing, circulation, and disability of cervical spine tion despite nasal fracture treatment.
and brain (ABCDs) as well as hemodynamic stabil-
ity.17 Once a patient is stabilized, a complete his- RADIOLOGY
tory and physical and review of systems should
be performed. Any neurologic or ophthalmologic Nasal fractures may be diagnosed with history and
symptoms should result in prompt consultation physical examination alone. Plain films have no
and communication with the appropriate spe- role in the management of nasal fractures with
cialties. Regarding the nasal fracture, history high false-positive reading as well as the inability
should elicit the method of injury, pretrauma and to distinguish old fractures.21,22 With increasing
posttrauma status of nasal airflow, history of sinus severity of trauma and concern for multiple
disease or allergies, and prior nasal injury or sur- injuries, high-resolution CT (HRCT) is the most
gery. Brisk epistaxis, septal hematoma, and appropriate imaging modality in the management
watery drainage indicative of possible cerebrospi- of nasal fractures. HRCT allows a physician to
nal fluid (CSF) leak must be identified and treated evaluate concomitant injuries, define the spatial
appropriately. alignment of displaced fragments, evaluate the
Physical examination of the nose should be bony septum, and aid in surgical planning. Addi-
approached in a stepwise, routine fashion. The tionally, 3-D reconstruction can be generated
nose can be classified into thirds and should be from HRCTs and provides helpful information in
examined from the frontal, lateral, oblique, and the anatomy of the fracture. In situations where
base views. In the upper third, examination should CT is undesirable or unavailable, high-resolution
identify deviation of the nasal pyramid, collapse of ultrasound (HRUS) is an alternative with compara-
the nasal bones, and broadening of the rhinion. ble sensitivity and specificity to CT.23–25 HRUS use
Telecanthus, or widening of the intercanthal dis- is limited by operator experience, study interpreta-
tance, should be noted as well. In the cartilaginous tion, and the fact that little information is provided
middle third, the ULCs may be collapsed medially other than nasal bone position.
or disarticulated from the nasal bones. The middle
vault may also be deviated relative to the upper MANAGEMENT RATIONALE
bony vault and nasal tip. In the lower third, the
nasal tip and base view should identify nostril Treatment of nasal fractures, as with any facial
asymmetry, caudal septal deviation, tip deviation, fractures, is predicated on the severity of the frac-
and nostril collapse. Lateral inspection may reveal ture, with the primary objective of restoring pre-
dorsal irregularities or telescoping of the nasal morbid form and function with the least invasive
bones as manifested by a saddled dorsum, method available. Management options fall into 4
increased nasolabial angle, and nasal foreshorten- major categories from least to most invasive:
ing. Bimanual palpation of the bony, middle, and 1. Observation
lower vault for step-offs, crepitus, and mobility 2. Closed reduction
can localize fractures and elucidate structural 3. Closed reduction with septoplasty
instability or collapse.18 Internally, the nasal 4. Open reduction with or without internal
septum should be examined for hematoma, frac- stabilization
ture, and dislocation. Nasal endoscopy may be
helpful for posterior septal abnormalities and for The optimal timing for surgical treatment is
control of epistaxis. within the first few hours after injury (often elapsed
It is imperative to evaluate concomitant para- by time of patient presentation) or 7 days to
nasal fractures of the orbit, NOE complex, and 10 days after injury when acute edema has begun
skull base because these can dramatically change to resolve. Unlike in other maxillofacial fractures
patient management and surgical approach. where the bony alignment is directly visualized,
540 Lu et al

nasal fractures require palpation and inspection of surgeon from inserting the elevator too far superi-
dorsal alignment to assess the adequacy of reduc- orly and injuring the skull base. The elevator is
tion. The surgeon must balance the severity of soft inserted between the depressed nasal bone and
tissue edema and the choice of treatment. Closed the nasal septum, parallel to the nasal dorsum.
reduction is best performed before fibrosis of frac- The depressed bone is pulled laterally and guided
ture lines, typically within 2 weeks after injury but into a neutral position. Centrally depressed frag-
up to 3 weeks after is described.26 A delay of ments require an anterior lifting motion with the
6 weeks or more when planning first-line open elevator. A palpable click may sometimes be
septorhinoplasty has been advocated to ensure appreciated after successful reduction. Asch or
complete resolution of acute inflammation.16 Walsham reduction forceps are helpful for
reducing the nasal septum and elevating a cen-
OBSERVATION trally depressed fragment. Each arm of the for-
ceps is inserted on either side of the septum
Patients presenting with nondisplaced fractures of parallel to the nasal dorsum. Using an upward
the nasal bone, nasal septum, and/or anterior nasal and outward force perpendicular to the dorsum,
spine without clinically relevant nasal deformities the septum is guided back into a neutral positon.
or airway obstruction are managed with close A judicious amount of force and placement of for-
observation. As in all nasal fractures, patients ceps anterior to the fracture line must be consid-
should be counseled to apply ice packs and ered to avoid torque on the skull base and
elevate the head of their bed to improve edema. potential CSF leak. An external splint is fashioned
All patients should be followed until swelling is over the nasal dorsum. Comminuted or loose
resolved to confirm that a deformity has not been nasal bones can be supported with intranasal
missed. Patients are typically seen for follow-up 7 packing between the nasal bones and septum.
days to 10 days after their injury when edema is The authors typically prefer absorbable packing,
resolved but closed reduction is not precluded. such as a Nasopore (Stryker, Kalamazoo, MI,
USA), cut to the desired size to avoid the need
CLOSED REDUCTION for packing removal. If nonabsorbable packing is
used, antibiotics should be administered for toxic
Closed reduction is effective for noncomminuted shock syndrome prophylaxis.
and mild nasal fractures with or without dorsal Early studies on patient outcomes with closed
septal disruption. In the typical case, one side is reduction found high rates of patient satisfaction,
laterally displaced, the opposite side is medially with only 3% to 9% of patients pursuing second-
depressed, and free-floating segments may be ary septorhinoplasty after initial reduction.29,30
centrally depressed. Some investigators still Comparatively, surgeons were satisfied with their
advocate local and topical anesthesia for closed results on average 37% of the time compared
reduction with unilateral or minimally displaced with patient satisfaction 79% of the time in a sum-
fractures.27 If local anesthesia is desired, the mary of 13 early publications.31 More recent
nasal cavity is prepared with cotton pledgets studies have noted a persistent deformity and
soaked in a topical anesthetic and vasocon- need for subsequent septorhinoplasty after closed
strictor, an infraorbital nerve block injection is per- reduction in 11% to 50% of patients.32–35 The ac-
formed, and intravenous sedation can be curate measurement of true patient satisfaction
administered if available for comfort. General has also come into question when considering
anesthesia is commonly preferred over local the discrepancy between patient and surgeon
anesthesia for management of nasal fractures satisfaction.36
with evidence supporting significant improvement
in appearance and function of nose, decreased CLOSED REDUCTION WITH SEPTOPLASTY
subsequent corrective surgeries, and patient
satisfaction with anesthesia.28 The authors have An unreduced septal fracture is widely accepted
found that the time required for closed reduction as the most common cause of residual deformity.
with a short general anesthetic is significantly Cadaver studies by Murray and colleagues37 and
less than the time required to adequately locally Harrison38 have illustrated a consistent C-shaped
anesthetize a patient in the office setting. Addi- septal fracture accompanying nasal fractures
tionally, the comfort of both patient and surgeon deviated by at least half the nasal bridge width.
is improved. Studies of prospectively analyzed patients reveal
A Boies elevator is placed against the external closed reduction with acute septoplasty yields sig-
nose to measure the distance from the medial nificant improvement in nasal breathing quality of
canthus to the nostril rim. This prevents the life as compared with closed reduction alone.39
 Correction of Nasal Fractures 541

Thus, deviation of the nasal bridge greater than rhinoplasty techniques and failures of closed
50% and/or septal injury causing nasal obstruction reduction have resulted in support for the open
are indications for concurrent septoplasty. The treatment of nasal fractures as an initial manage-
authors typically use Doyle splints after septal ment strategy. Consensus exists regarding the
work for additional support. need for open treatment with increasingly com-
With the rise of endoscopic surgery, endoscopic plex nasal fractures. For example, in nasal frac-
submucosal septoplasty techniques have been tures associated with an NOE or Le Fort II/III
applied to this paradigm as well. In a retrospective fracture, the use of open fixation techniques is
review of 90 patients undergoing closed reduction well established. Controversy abounds, however,
combined with endoscopic septoplasty, persistent regarding indications, timing, and surgical tech-
nasal deformity requiring subsequent surgery niques for the initial open treatment of isolated
was reduced to 3.3% and investigators noted nasal fractures. Research is focused on accu-
improved visualization of posterior septum.40 rately identifying patients who will inevitably fail
Radiologic aids, such as use of C-arm, fluoros- closed reduction and would benefit from incurring
copy, and intraoperative ultrasound-guided the risks and costs of initial open treatment. Some
reduction, have been studied, with some evidence investigators advocate a trial of closed reduction
supporting reduced complications and need for in the operating room followed by immediate
reoperation.41–43 conversion to open treatment if a deformity
In a retrospective review of 49 patients, the persists.16,31
surgical revision rate was lower in patients with Severe septal fractures, comminuted fractures,
septal deformity treated with an open approach cartilaginous fractures, and a destabilized nasal
to the nasal pyramid compared with those framework are proposed indications for open
treated with closed reduction and conventional reduction or open septorhinoplasty.26,44 As with
septoplasty (75% vs 6.5%). The investigators any patient, surgeons must integrate treatment
hypothesize that patients requiring septoplasty goals, unique anatomic factors, concomitant
have more severe nasal fractures, and subse- injuries, and social circumstances with clinical
quent revision can be decreased with an open judgment in formulating their management plan.
approach to these patients. One crucial area to Advantages of open treatment include direct visu-
consider when evaluating a posttraumatic nasal alization of tissues for diagnostic accuracy and
septum is the L-strut. The L-strut refers to surgical access for rigid stabilization. Early skeletal
1-cm strips along the caudal and dorsal aspects stabilization may also prevent further anatomic
of the quadrangular cartilage that is critical to distortion from osseous malunion and soft tissue
nasal tip and dorsum support as well as external contracture that can complicate secondary surgi-
nasal appearance. Septal deformities not cal intervention. Conversely, delaying open treat-
involving the L-strut often cause airway obstruc- ment allows the septal fractures to heal and may
tion but seldom affect nasal appearance.16 Con- increase the amount and quality of septal grafting
ventional septoplasty avoids manipulation or material available. Concerns exist regarding strip-
disruption of the nasal L-strut due to its critical ping periosteum from severely comminuted nasal
role in nasal airway and framework. Accordingly, bone fractures that may cause devitalization and
septal deviation due to L-strut deformity is often necrosis of the bone. The high initial cost of treat-
inadequately treated with conventional septo- ment and the higher risk of complication with more
plasty alone. Open septorhinoplasty techniques, aggressive treatment must also be considered.
such as septal batten grafting and columellar In contrast to traditional open reduction and
strut manipulation, may be necessary in these internal fixation in other areas of maxillofacial
cases. In nasal trauma patients, a higher degree trauma, plate or wire fixation is described but not
of L-strut involvement should prompt the sur- preferentially used for isolated nasal fractures.45,46
geon to consider an open approach to the nasal Implant complications include bone erosion, skin
pyramid. The authors avoid conventional septo- breakdown, hardware infection, migration, and
plasty on these patients to preserve tissue for localized pain. The need for hardware removal
future grafting. may further complicate future rhinoplasty proced-
ures. The term, internal stabilization, as applied to
OPEN TREATMENT PRINCIPLES acute treatment of nasal fractures, may include
rhinoplasty techniques, such as grafting and su-
Historically, open treatment of traumatic nasal ture fixation, to restore structural integrity. Intra-
deformities was reserved for treatment failure nasal splinting, such as Doyle splints, may be
after closed reduction. Surgery was typically used on a case-by-case basis for additional sup-
delayed by at least 6 months after injury. Evolving port, especially if septal mucosal flaps are raised.
542 Lu et al

General anesthesia is recommended and timing at the narrowest portion of the midcolumella.
for surgery can range from 1 week to more than This approach provides excellent exposure and
6 weeks after injury. Traumatic nasal deformities control of the nasal tip and cartilaginous middle
may be corrected using traditional septorhino- vault in severe fractures. Septal fractures are
plasty techniques many months or years after readily addressed through this approach and the
injury as a secondary procedure. This article fo- disrupted L-strut can be readily treated with carti-
cuses on open reduction for nasal fractures in lage grafting as needed. Similar to the endonasal
the acute setting. approach, exposure of nasal bone fractures may
be inadequate if reduction and fixation is required.
OPEN SURGICAL APPROACHES In certain cases, extensive dorsal and alar lacera-
tions may disrupt blood supply to columellar flap
Several approaches may be considered for open and preclude the use of this approach.
repair, depending on the location of injury and
type of reconstruction anticipated. Common
approaches include OPEN TREATMENT WITHOUT INTERNAL
STABILIZATION
1. Coronal
2. Endonasal rhinoplasty Open treatment without internal stabilization refers
3. External rhinoplasty to fracture reduction with the creation of medial
4. Use of existing lacerations and/or lateral osteotomies. If a septal injury exists,
septoplasty and septal reduction are performed
The use of medial canthal and subciliary inci- first. Closed nasal bone reduction is then used. If
sions have been reported but are less cosmetically persistent bony asymmetry exists, osteotomies
favored and should be avoided.47,48 are created for further reduction. The fracture line
The coronal approach provides excellent expo- often presents an existing osteotomy. Depending
sure of the superior nasal complex as well as other on fracture location, medial/lateral osteotomies
upper facial skeletal injuries if concomitant zygo- are created on the contralateral side. Dorsal
matic arch, NOE, and frontal sinus fractures exist. hump reductions and rasping techniques can
It also allows for calvarial bone harvest and recon- further smooth out the bony contour. Considering
structions. The cartilaginous middle vault and tip the destabilized nasal pyramid, rasping should be
of the nose are not well exposed or treated with used gently. The osteotomies increase the sur-
this approach. The incision is well hidden in the geon’s ability to manipulate the nasal bone
hairline but may be complicated by alopecia or position. Although effective at reduction, some
temporal wasting, and there is a small risk of fron- surgeons argue that without internal stabilization,
tal nerve injury. this technique further destabilizes the nasal skel-
The endonasal intercartilaginous approach al- eton and creates more variability in healing. In non-
lows for good dorsal nasal exposure but does traumatic rhinoplasty patients, osteotomies are
not give the opportunity to address the nasal tip rarely performed in conjunction with a fixation
cartilages. Intercartilaginous incisions between technique due to continued periosteal and septal
upper and lower lateral cartilages meets a trans- support. For trauma patients, varying disruption
fixion incision at the caudal end of septal cartilage. of periosteal and septal support may influence
Subperiosteal dissection through the intercartilagi- the success of osteotomies without fixation. Fibrin
nous incision allows for exposure of the nasal glue has been proposed as a method of potential
dorsum and root. Subperichondrial dissection stabilization for more comminuted fractures in
along the septum allows for treatment of septal some patients.49,50
fractures. This approach avoids external incisions
and addresses the septum as well as the middle
OPEN TREATMENT WITH INTERNAL
vault. The exposure of the nasal bones and
STABILIZATION
dorsum may be inadequate, however, for true fix-
Grafting
ation of these structures. An endonasal delivery
approach provides similar dorsal exposure but Severe structural instability or significant loss of
also gives the surgeon control of the nasal tip. dorsal bone or cartilage requires additional carti-
This approach combines intercartilaginous and lage or bone grafting (split calvarium). Bone or
marginal incisions, allowing the LLCs to be deliv- cartilage may be used to suspend the collapsed
ered as bipedicle chondromucosal flaps. septum to the graft, resuspend LCLs, and re-
The external rhinoplasty approach involves establish the nasofrontal angle (105 –120 ). Small
bilateral marginal incisions along the caudal bone fragments that no longer contribute to the
border of the LLC and a transcolumellar incision structure of the nasal complex should be removed
 Correction of Nasal Fractures 543

to avoid serving as further nidus for infection. A fixation to maxillary bone periosteum can be
cantilever technique for a graft that extends from used for further fixation. When disarticulation of
above the nasion to just beneath the cephalic ULC occurs, the main aim is to suture the carti-
border of the alar cartilages is frequently used lages back to the nasal bone. Small-gauge drills
(Fig. 1). Fixation to the stable nasal root is may be used to fashion fixation holes within the
completed. Further plate fixation may be per- nasal bones. Internal nasal packing should be
formed from distal undersurface of the graft to used to further support the ULC and re-establish
the anterior nasal spine. premorbid position.
Cartilage grafting from the posterior septum, ear,
or rib may be used to correct asymmetry using
traditional rhinoplasty techniques. Spreader grafts
POSTOPERATIVE MANAGEMENT
can be placed to lateralize depressed ULCs and In the first postoperative week, patients are
support dorsal L-strut fractures (Fig. 2). Caudal instructed to elevate the head during sleep,
septal battens or extension grafts may be used to abstain from nose blowing, and avoid use
support the deviated caudal L-strut and to control of aspirin or blood thinners. Ice packs are used
the projection and rotation of the LLCs and nasal to minimize edema. If nonresorbable intranasal
tip. Cartilaginous lacerations or transection of the packing was used, antibiotics are given for toxic
LLC may be supported with crural strut grafts. shock prophylaxis until removal. Nonresorbable
sutures and the external nasal splint are removed
5 days to 7 days postoperatively. Patients may re-
Suture Fixation
turn to sports and normal activities 4 weeks after
With caudal septal dislocation along the maxillary treatment. The future risk of nasal fracture is dis-
crest, reduction of the septal cartilage and suture cussed and protective facial masks are suggested

Fig. 1. (A) Severely comminuted nasal fractures in addition to type 2 NOE. (B) Plating of central bony segments
with attached medial canthal tendons to frontal process. (C) Cantilever technique using split calvarial bone graft
to replace severely comminuted nasal bones. (D–F) Frontal, oblique, and lateral views of patient 6 months post-
surgery. On lateral view, the nasal radix is still slightly low but the patient declined revision.
544 Lu et al

Fig. 2. (A) Nasal bony pyramid with deviation to the right and depression of left ULC. (B) Patient after closed
reduction of nasal bones with endonasal spreader graft to ULC on the left.

to patients involved in sporting activities for 6 surgical technique. More research is necessary
weeks to 8 weeks to prevent nasal reinjury. to establish practice standards. Treating surgeon
must integrate the utility of each technique with
POSTOPERATIVE IMAGING their surgical experience, the anatomic factors
present, and patient goals in choosing the appro-
Postoperative imaging is not typically performed priate management plan.
except in severely comminuted fractures. Intrao-
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