Immediate functional and cosmetic open rhinoplasty following acute nasal fractures: our experience with Asian noses

Aesthetic Outcomes of Rhinoplasty Performed in the Early Posttrauma Period after Nasal Bone Fracture

The optimal timing of rhinoplasty for patients with nasal bone fractures remains controversial. We investigated whether the timing of rhinoplasty after nasal trauma affects the aesthetic outcome of the procedure. A total of 41 adult patients with nasal bone fractures who underwent rhinoplasty between 2006 and 2021 were enrolled in this study. A visual analog scale (VAS) was used to indicate the assessor's satisfaction with the surgical outcome after a comparison of the pre- and postoperative facial photographs of each patient. Of the 41 patients, 28 underwent rhinoplasty within 14 days after nasal trauma (early rhinoplasty group), whereas 13 underwent rhinoplasty more than 14 days after nasal trauma (late rhinoplasty group). The rate of receiving spreader and shield graft was higher in the late rhinoplasty group (p = 0.043 and 0.018, respectively). Patients with type IV or V nasal bone fracture and patients with preoperative saddle noses had higher VAS scores than those with types I to III fractures and those without preoperative saddle nose (p = 0.003 and 0.020, respectively). There was no significant difference in overall aesthetic outcome between the early and late rhinoplasty groups. Both groups achieved significantly better radix height, dorsal height, and tip projection after rhinoplasty. The aesthetic outcome of rhinoplasty performed in the early posttrauma period is comparable with that of rhinoplasty performed more than 2 weeks after nasal bone fracture. Rhinoplasty can be considered a safe surgical treatment option for nasal bone fracture, even in the early posttrauma period. LEVEL OF EVIDENCE: : 4.

Aesthetic Outcome of Primary Rhinoplasty of Saddle Nose Deformity in Naso-Orbital Ethmoidal Fractures in Asian Patients

BACKGROUND

Saddle nose deformity following naso-orbital ethmoidal (NOE) fractures remain a challenging problem for the reconstructive surgeon. Early reduction and internal fixation allow for fracture stabilization but is unable to address the problem of the depressed nasal dorsum, especially after soft tissue shrinkage. The aim of this study is to evaluate the outcome of primary rhinoplasty in patients with NOE fractures.

MATERIALS AND METHODS

From 2016 to 2019, 9 patients presented to our department with NOE fractures complicated by saddle nose deformity underwent primary nasal reconstruction at the time of their fracture fixation. Life size (1:1) frontal and lateral postoperative photographs were taken. Three objective measurements were made, including the nasofrontal angle, tip projection, and radix projection. These measurements were compared between normal persons (group 1), preoperative patients (group 2), and postoperative patients (group 3). Nose aesthetic assessment was carried out via a panel assessment using a Visual Analog Scale of 5. Patient satisfaction was further assessed subjectively by the patient themselves using the Visual Analog Scale.

RESULTS

When comparing group 3 to 2, a significant reduction in the nasofrontal angles was found with an accompanying increase in the radix and tip projection ( P <0.05). No statistical significance between normal persons and postprimary rhinoplasty patients was noted between groups 1 and 3. Average patient satisfaction scored 3.86±1.07 compared with 3.63±0.84 by laypersons and 4±0.77 by specialists' panel.

CONCLUSION

Primary nasal reconstruction may be an alternative method for achieving optimum results following NOE fractures preventing the development of secondary saddle nose deformity with a shortened nose which may potentially be more difficult to correct.

Posttraumatic Augmentation Rhinoplasty Using an Osseocartilaginous Cantilever Graft

BACKGROUND

Augmentation rhinoplasty in Asians may be effectively accomplished with alloplastic materials. However, certain circumstances such as nasal bone fractures mandate the use of autologous grafts. The purpose of this study was to describe and evaluate the results of modified osseocartilaginous rib cantilever grafting for aesthetic and reconstructive rhinoplasty in patients with acute nasal bone fractures.

METHODS

Forty-three patients with nasal bone fracture underwent surgical reconstruction with an autogenous rib graft. Anatomic reconstruction and dorsal augmentation were performed using 1 piece of a carved osseocartilaginous rib graft each for the bony and cartilaginous parts of the nose. The average time to surgery was 6.5 days, and patient's subjective satisfaction was scored.

RESULTS

"Excellent" or "good" cosmetic outcomes were reported by 37 patients (86%). There were 3 cases of secondary revision. Donor-site morbidity was not an issue in any patient.

CONCLUSIONS

Anatomic reconstruction of the nasal dorsum and refining the nasal tip using an osseocartilaginous rib graft with the cantilever technique are effective in acute nasal trauma patients who wish to enhance their nasal profile in the primary treatment setting.

Lengthening of the Asian Nose

The Asian nose has its unique morphology and forms a significant proportion of noses treated by the rhinoplasty surgeon not only in Asia but also in other countries where the Asian diaspora resides. The anatomical features and dimensions of the Asian nose differ from noses of persons of African, Caucasian, Indian, and Middle Eastern origins, poses its own challenges, and warrants a unique set of techniques for its aesthetic improvement. In this article, we present an overview of the approach to the lengthening of the Asian nose, drawing from our own experience with managing the Asian nose and referencing the published literature on the subject.

Closed and Open Reduction of Nasal Fractures

AIM

The objective of this review was to determine the different types of surgical intervention in the management of nasal bone fractures, the outcomes, and complications associated with each intervention.

METHODS

A search was conducted using the PubMed and Cochrane Database of Systematic Review databases from January 1, 1997 until September 9, 2017. The search strategy was constructed using the Population Intervention Comparison Outcome framework with keywords related to nasal fracture and its treatment. Two sets of independent researchers performed the analysis. Qualitative analysis was performed using the Methodological Index for Non-Randomized Studies and National Institute for Clinical Excellence methodology for randomized controlled trial checklists.

RESULTS

The 4276 titles were obtained from PubMed database alone. Exclusion was made based on the title, abstract and full-text analysis. Finally, 23 papers were included and analyzed. Of the 23 papers, 13 (56.5%) were retrospective record review, 2 (8.7%) were randomized clinical trial or a randomized study and 8 case series (34.8%). 16 (69.6%) studies addressed closed reduction, 3 studies (13%) on open reduction and 4 studies (17.4%) addressed both open and closed reduction. The main focus in the outcome in all studies was accuracy of the anatomical reduction of the nasal bones. Three studies (13.0%) reported restoration of function such as breathing comfort or release in respiratory obstruction and another 3 (13.0%) addressed both cosmetic and breathing outcomes. Residual deformity was the most described complications in the studies (30.4%). In general, most of the studies were not of high quality as they lacked in some key elements in the Methodological Index for Non-Randomized Studies checklist.

CONCLUSION

Both closed and open reduction provided good outcomes in cosmetic and breathing. Septoplasty is recommended to be performed simultaneously with fracture reduction.

Asian Cleft Rhinoplasty: The Open Structural Approach

BACKGROUND

Asian cleft rhinoplasty is a unique procedure with specific challenges.

OBJECTIVES

This paper presents our experience with the use of an open structural technique for Asian cleft rhinoplasty utilizing a complete autologous approach.

METHODS

An open approach that reconstructs the malpositioned nasal cartilage was utilized. Centrally, the septocolumella graft fixed securely in the midline with extender spreader grafts was utilized to project and lengthen the nose. The dislocated lateral crura on the cleft side was completely detached from the accessory cartilages and mobilized off the vestibular lining. The deficient medial crura was lengthened with the lateral crural steal procedure. The resultant shortened lateral crura was then reconstructed with the lateral crural strut graft (LCSG). This gave the versatility needed to bring the tip cartilages into a more anatomic and symmetrical position. Tip suturing and grafting was performed and dorsal augmentation achieved through diced cartilage wrapped in deep temporal fascia. At closure, when indicated, a modified Tajima reverse-U excision of the vestibular lining was performed to correct the alar hooding on the cleft side. Alar base modifications were done as indicated.

RESULTS

From January 2010 to December 2015, 35 Asian patients underwent open cleft rhinoplasty. There were 18 female patients and 17 male patients. Twenty-nine patients were unilateral cleft and 6 were bilateral cleft. The mean follow up was 23 months. All patients were highly satisfied with the functional and aesthetic improvement of the procedure. The complications and revision rates were low.

CONCLUSIONS

The autologous open structural approach can predictably and consistently give excellent results for Asian cleft rhinoplasty. The result attainable is superior to results attainable before adopting this approach for our patients.

LEVEL OF EVIDENCE

4.

Corrective Septorhinoplasty in Acute Nasal Bone Fractures

Objectives

Closed reduction is generally recommended for acute nasal bone fractures, and rhinoplasty is considered in cases with an unsatisfactory outcome. However, concomitant rhinoplasty with fracture reduction might achieve better surgical outcomes. This study investigated the surgical techniques and outcomes in patients who underwent rhinoplasty and fracture reduction concomitantly, during the acute stage of nasal bone fracture.

Methods

Forty-five patients who underwent concomitant rhinoplasty and fracture reduction were enrolled. Nasal bone fractures were classified into three major types (type I, simple fracture; type II, fracture line that mimics nasal osteotomy; and type III, comminuted fracture) based on computed tomography images and preoperative facial images. Two independent otolaryngology-head and neck surgeons evaluated the surgical outcomes and telephone based survey were made to evaluate patients satisfaction.

Results

Among 45 patients, there were 39 males and 6 females. Type I was the commonest type of fracture with 18 patients (40%), while the most frequently used surgical technique for corrective surgery was dorsal augmentation with 44 patients (97.8%). The mean visual analogue scale satisfaction score of the surgeons and patients were 7.62 and 8, respectively, with no significant differences between fracture types.

Conclusion

Concomitant rhinoplasty with fracture reduction can be performed for acute nasal bone fracture patients, and it might lead to better aesthetic outcomes.

The role of septoplasty in the management of nasal septum fracture: a randomized quality of life study

Fracture of the nasal septum is a common injury. Fracture reduction using Ash forceps is the standard treatment for non-severely comminuted cases. In this study, septoplasty was compared to Ash forceps reduction of nasal septum fractures with regard to the quality of life outcome of patient breathing. Thirty consecutive patients with non-comminuted septal fractures were divided randomly into two groups. In group I, fractures were managed by closed reduction (using Ash forceps), while in group II, fractures were managed by septoplasty surgery. Each patient completed a validated quality of life scale for breathing (Nasal Obstruction Symptom Evaluation, NOSE) preoperatively and at 3 months postoperative. In group I, the mean difference between postoperative and preoperative NOSE scores was -28.33 (range -40 to -15), while in group II the mean difference was -44.33 (range -70 to -30). There was a significant improvement in nasal breathing quality of life in group II compared with group I (t-test, P=0.001). The results of this study showed a significant improvement in quality of life outcome with the use of septoplasty compared to closed reduction for acute septal fractures. Septoplasty could be recommended for patients with acute nasoseptal fractures to ensure better nasal breathing outcomes.