Chapter 87. Post-traumatic rhinoplasty










895
87
Post-traumatic rhinoplasty
LUC CESTELEYN
PRINCIPLES, JUSTIFICATION AND
INDICATIONS
Post-traumatic deformities
Nasal trauma is the most frequent facial injury, usually
resulting from vehicle accidents and interpersonal violence.
In many cases, functional airway obstruction and exter-
nal deformities make the patient seek treatment.
e post-traumatic situation creates a signicant dis-
harmony of proportion: twisted and angulated noses upset
the owing line from the supraorbital rim to the tip of the
nose, as does an avulsed or depressed upper lateral carti-
lage (ULC), a deviated dorsal cartilaginous septum or an
asymmetric alar–cartilage complex.
ose patients who sustain sucient nasal trauma and
require relatively acute nasal reconstruction and rhino-
plasty compose a dierent category of patients presenting
for nasal cosmetic surgery. Many would have never consid-
ered surgery if acute trauma had not produced a deformity
or an airway insuciency. eir motivations are oen dif-
ferent from the patient troubled by a long-standing nasal
deformity, since they essentially wish the nose be restored
to its former pre-injury appearance and function. Others
will wish to correct a pre-existing deformity under the
justication of the recent nasal injury. Generally, trauma
patients are clearly well-motivated as a result of the nasal
injury.
EXAMINATION
Inspection and photographic documentation should pay
special attention to external deviation and contour defor-
mities. Even more important than assessing objective cri-
teria, which are utilized in prole planning, is the study of
standardized photographs, since the aesthetic appearance
predominates.
e width of nose and the alar base should be com-
pared with the intercanthal distance: in noses with
traumatically lowered dorsum, an illusion of widening
must be corrected. Manual palpation is necessary for
the position and symmetry of the bones, dorsal pro-
jection and the superior septal angle. Palpation of the
caudal septum and tip cartilages can yield valuable
information regarding the underlying deformities or
deviations.
e rhinoscope is necessary for inspection of the nasal
mucosae, the septum, the turbinates and the nasal valve.
External deformations should be correlated with internal
changes of the bony-cartilaginous septum and the lateral
sidewalls with the eect on the nasal tip. Airway evalua-
tion calls for anterior rhinoscopy before and aer vaso-
constrictive shrinkage, palpation of subtle abnormalities
of the septal cartilage, anterior nasal septum (ANS) and
oor of the nose.
Transillumination of the septum allows assessment of
trauma and residual cartilage in operated noses.
CONTENTS
Principles, justication and indications 895
Examination 895
Operation 896
Saddle nose deformity 896
Septal deformity 896
Twisted nose 899
Nasal airway obstruction 900
Post-operative care in combined septoplasty – turbinate surgery: Septal splinting – nasal packing 902
So-tissue deciency 902

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89587Post-traumatic rhinoplastyLUC CESTELEYNPRINCIPLES, JUSTIFICATION AND INDICATIONSPost-traumatic deformitiesNasal trauma is the most frequent facial injury, usually resulting from vehicle accidents and interpersonal violence.In many cases, functional airway obstruction and exter-nal deformities make the patient seek treatment.e post-traumatic situation creates a signicant dis-harmony of proportion: twisted and angulated noses upset the owing line from the supraorbital rim to the tip of the nose, as does an avulsed or depressed upper lateral carti-lage (ULC), a deviated dorsal cartilaginous septum or an asymmetric alar–cartilage complex.ose patients who sustain sucient nasal trauma and require relatively acute nasal reconstruction and rhino-plasty compose a dierent category of patients presenting for nasal cosmetic surgery. Many would have never consid-ered surgery if acute trauma had not produced a deformity or an airway insuciency. eir motivations are oen dif-ferent from the patient troubled by a long-standing nasal deformity, since they essentially wish the nose be restored to its former pre-injury appearance and function. Others will wish to correct a pre-existing deformity under the justication of the recent nasal injury. Generally, trauma patients are clearly well-motivated as a result of the nasal injury.EXAMINATIONInspection and photographic documentation should pay special attention to external deviation and contour defor-mities. Even more important than assessing objective cri-teria, which are utilized in prole planning, is the study of standardized photographs, since the aesthetic appearance predominates.e width of nose and the alar base should be com-pared with the intercanthal distance: in noses with traumatically lowered dorsum, an illusion of widening must be corrected. Manual palpation is necessary for the position and symmetry of the bones, dorsal pro-jection and the superior septal angle. Palpation of the caudal septum and tip cartilages can yield valuable information regarding the underlying deformities or deviations.e rhinoscope is necessary for inspection of the nasal mucosae, the septum, the turbinates and the nasal valve. External deformations should be correlated with internal changes of the bony-cartilaginous septum and the lateral sidewalls with the eect on the nasal tip. Airway evalua-tion calls for anterior rhinoscopy before and aer vaso-constrictive shrinkage, palpation of subtle abnormalities of the septal cartilage, anterior nasal septum (ANS) and oor of the nose.Transillumination of the septum allows assessment of trauma and residual cartilage in operated noses.CONTENTSPrinciples, justication and indications 895Examination 895Operation 896Saddle nose deformity 896Septal deformity 896Twisted nose 899Nasal airway obstruction 900Post-operative care in combined septoplasty – turbinate surgery: Septal splinting – nasal packing 902So-tissue deciency 902 896 Post-traumatic rhinoplastyCephalometric and lateral ‘so tissue’ RX examination is used to measure tip rotation (TR) (by the naso labial angle [NLA]) and tip projection (TP) (by angle sella-nasion and sellion to tip). e nasofrontal angle (125°–135°) and the columella lobular angle (CLA) or ‘double break’ (45°) should also be measured on lateral cephalograms.We found the Cottle test and the cotton-tip applica-tor technique useful (Figure 87.1a and b). By pulling the cheek laterally, the contribution of the vestibular por-tion (nostril, upper lateral cartilage (ULC) and alar rim) of the valve to airway obstruction can be tested. If there is a positive response to the cotton-tip applicator liing the caudal end of the ULC, the indication for spreader graing is obvious; similarly liing of the lower lateral cartilage (LLC) can diagnose alar collapse with the indi-cation for alar reinforcement by batton or lateral crural gras.OPERATIONPost-traumatic nasal reconstructionPrimary post-traumatic surgery is limited to symptomatic treatment of haemorrhage and reduction of major dislo-cations. In general, the reconstruction is planned 6–12 months aer the injury or the primary repair, at the time of maturation of scar tissue and stable deformity.Aer blunt trauma, a twisted saddle deformity with broad and attened pyramid and loss of septal height with columellar retraction and acute NLA must be cor-rected. e open approach is preferred, but sometimes a direct or endonasal approach in combination with a transoral access to a displaced ANS and caudal septum are chosen.SADDLE NOSE DEFORMITYSaddle nose deformity is the most common sequelae of direct nasal injury with displacement of fractured nasal bones and cartilage into the pyriform aperture, rarely as a result of loss of tissue, or unrecognized septal haema-toma. For correction, only homologous material is used (Figure87.2a through c). Septal cartilage, stacked or lay-ered, is the material of choice for dorsal onlay. Septal bone from the maxillary crest and the vomer can be used in the deep layers. Autogras of bone or cartilage from the nose seem to survive almost in toto in contrast with iliac bone or costal cartilage. If not available in quality or quantity, conchal ear cartilage is used. Dorsal gra of rolled ear cartilage lled with scarps of cartilage and bone have been used successfully. For severe defor-mities, we tend to use reliable calvarial bone, covered with cartilage and/or temporoparietal fascia, harvested through the same hemicoronal approach. In total col-lapse, a bony strut is xed in or at the ANS to support a dorsal gra xated in or at the glabella. Iliac bone gras are rarely used by us because of the morbidity, the second operation eld and variable resorption over time. Exceptionally, in young children, rib-cartilage is used because harvesting of unicortical calvarial bone is problematic and resection on the septum condemned. Ideally, the gras should be placed in a subperiosteal pocket at the cephalic dorsum and underneath the tip cartilages at the caudal end. To prevent pointed tips they should be onlay graed. In total reconstructions, the glabellar region and the lateral walls have to be graed: crushed cartilage, plumping bony fragments and thin bone plates are useful.SEPTAL DEFORMITYMajor septal deviations, from trauma, sometimes an occult injury in childhood, and usually in combination with deviated pyramids and compensatory hypertrophic inferior turbinates, cause functional airway obstruction with mild symptoms to obstructive sleep apnoea. Septal deviation can cause major asymmetry of the cartilagi-nous vault and the tip, creating a tension tip. erefore, a septoplasty must be performed with the rhinoplasty (usually before), which by narrowing the airway can (a)(b)Figure 87.1 Airway examination: (a) Cottle test and (b) Cotton-tip applicator technique. Septal deformity 897(a))b(i)c((c)ii(d)i(d)ii(d)iii(d)iv(d)v(d)vi(e)i(e)ii(e)iii(e)iv(e)viv )e(Figure 87.2 (a) Cartilaginous grafts (sutured together or not) for depression of cartilaginous dorsum. (b) (Osseo) cartilaginous grafts for dorsal augmentation or camouaging a deviation by asymmetrical placing. (c) Bony grafts can be wired at the ANS in total loss of tip support, for prevention of pinching tip onlay grafts are used. (d) Bone grafts to reconstruct severe saddling: subperiosteally at the nasal bones, below the sutured domes at the tip. Important saddle corrected by osteosynthesized osseous strut on the ANS, dorsal layered cal-vareal bone graft covered with temporoparietal fascia and modied long tip-columellar graft. (e) Early post-traumatic septorhinoplasty for total nasal destruction, septal collapse, saddle deformity and loss of tip support with calvarial bone grafts for tip support and covered with fascia grafts for dorsal reconstruction, the bone grafts in post-operative radiography and the residual coronal scar. 898 Post-traumatic rhinoplastycause decompensation of marginal airway problems due to deections or septal thickening in the valve area. If hump resection is needed it should be osteotomized as a monobloc, if necessary asymmetrically, imme-diately aer the extramucosal dissection, permitting a betterdorsal access to the septal deformity and sav-ing a one-piece hump for repositioning or as a graing material.If there is no need for bridge reduction, the ULCs are sectioned at the junction with the septum. Aer the lateral osteotomies, a medial osteotomy frees the osteocartilagi-nous aps and permits luxation of the bony septum to the midline. High deviations may cause recurrent pyramidal deviation as the roof is uncapped by lowering the dorsum; in such noses lateral and sometimes also an intermediate, osteotomy is indispensable. In ‘tension’ tips, the septoplasty will release the tip and inuence its position. Accordingly, the septoplasty should be performed before the tip-plasty, and total septorhinoplastic reconstruction is necessary to improve the nasal airway and maintain long-term success of the rhinoplasty.Cartilaginous septal deections result from traumatic fracture lines, creating angulations up to 90° and spurs. Vertical, oblique or horizontal septal angulations, the sites of old fractures, may be excised with conservative wedges, removing a small amount of normal adjacent cartilage or bone. e remaining cartilage is le attached to the contralateral mucoperichondrium for strength and sup-port aer realignment by suturing through an endonasal approach (Figure 87.3a).(a)(b)Figure 87.3 Septal surgery. (a) Excision of septal angulation at old fracture sites through endonasal approach. (b) ‘Swinging-Door’ technique to reposition lower septum. If bony septum is straight after sectioning of septum at point of maximal deviation. Disarticulation at the osseocartilaginous junction. Freeing the septum along the oor of the nose and swinging it to the midline with the opposing lining intact. Twisted nose 899In marked angulations of the septum, responsible for external deformations at the middle third, the columella and the aesthetic aspect of the NLA, as saddling of the middle third in case of loss of height (horizontal fractures) and columellar retraction in case of loss of length (vertical fractures), an open approach is preferred.Vertical fractures may create a lateral deviation of the nose and may be associated with a bulbous ULC impacted between the septum and the pyriform aperture, as well as with a lowering of the nostril sill.Horizontal angulations perpendicular to the anterior crest will create a saddle deformity of the middle vault, which cannot be treated with dorsal augmentation, leav-ing the airway obstruction untouched; the total height of the septum has to be restored (Figure 87.3b). Fractures with combined angulations can result in an impaction of the dorsum on the cranioanterior part of the inferior tur-binate. e ULC can be carried with the deviated septum.rough the open approach, L-strut fractures or mul-tiple incisions for straightening can be bridged or rein-forced with cartilaginous or thin bony gras to straighten and strengthen the crooked portions of dorsal or caudal septum.Total endomucosal excision of the cartilaginous septum and replacement as a straightened free gra, if needed, with additional support by gras can be carried out; according to Rees, follow-up did not reveal chondroma-lacia in cases of bony/cartilaginous septal reconstruction.Complications• Septal haematomas and infection.• Cerebrospinal uid (CSF) leak, due to disturbance of the cribriform plate aer high osteotomy of a deviated bony septum.• Septal perforations with symptoms, for example whis-tling or crusting and epistaxis can theoretically be repaired by sliding mucosal aps advanced anteriorly and posteriorly on the ipsi- and contralateral side. Inadequate blood supply and scarred host bed can lead to recurrence or larger perforations. e authors always prefer a more reliable closure with a horizontal myomu-cosal ap derived from the undersurface of the upper lip that can be performed with minimal discomfort to the patient (Figure 87.4).TWISTED NOSEA signicant post-traumatic deviation of the external pyramid is practically always accompanied by a deviated septum. Aer septoplasty, correction of the deviated bony pyramid through an open technique with modied oste-otomies: narrowing broad or asymmetric noses can be performed with a combination of medial, intermediate and low lateral osteotomies, and camouage graing. A sequential osteotomy technique begins with an intermedi-ate osteotomy on the long side (1) sequentially classic lat-eral (2) and fading medial osteotomy (3) on the long side, and medial (4) and lateral osteotomies (5) on the short side with full mobilization of the bony fragments to reform the pyramid in the midline (Figure 87.5a and b).Visual correction can be accomplished by asymmetri-cal shaping of the dorsal hump and inward fractures in the absence of high septal deviation. Eventually this can be lowered together with that portion of the cartilaginous septum associated with the ULC, so that upon infracture, the dorsal border of the nose lies in the midline.Osteotomies are transcutaneously performed with a 2-mm micro-osteotome and without stab incision or any subperiosteal elevation. Endonasal osteotomies are more aggressive and disrupt the so tissues more, are less pre-cise and may dive into an undesired path of an old frac-ture site with possible shattering of the lateral nasal wall. Webster’s triangle and the triangular bone at the pyriform rim cranial to the inferior turbinate are respected to pre-vent airway impingement. Spontaneous back-fractures can occur in previously fractured, sometimes thickened, bony structures. To control such occurrences and to pre-vent ‘rocker’ formation, transcutaneous superomedial and superolateral osteotomies are performed through the glabellar region. e same route is followed for the Figure 87.4 Septal perforation. Closure of septal perforations: myomucosal vestibular lip ap. 900 Post-traumatic rhinoplasty132ULC)a(45)b((c)i(c)iiFigure 87.5 Correction of twisted nose. (a and b) Sequential osteotomy technique: intermediate osteotomy on the long side (1) and sequential classic lateral (2) and medial (3) on the long side and medial (4) and lateral osteotomies (5) with full mobilization of the bony fragments. (c)i Crooked noses with dorsal deviations uncorrectable by standard rhinoplasty are treated with camouaging techniques including (c)ii dorsal septal grafting.mobilizing osteotomy of a deviated perpendicular plate of the ethmoid, a possible reason for persistent deviation.Deviations of the dorsum that are uncorrectable by standard approaches can oen be camouaged by various techniques such as septal and ULC overlap and gras of nasal septum, which are beyond the scope of this chapter. Camouaging an imperfectly straightened nose can be carried out with autogras removed during the septorhi-noplasty. ey can mask a high septal deviation or aug-ment a depressed area on one side by insertion o-centre to improve the contour (Figure 87.5c).In conclusion, the author strongly believes that the best results over time are obtained by the open approach and that lateral osteotomies are virtually always neces-sary for complete mobilization of the nasal bones and avoiding post-operative ‘dri’. e osteotomies must be performed transcutaneously with a micro-osteotome without periosteal undermining for preservation of periosteal attachment and a supportive sling or inter-nal splint for the mobile bones avoiding collapse into the pyriform aperture. Particularly in twisted noses, a Webster’s triangle should be respected with preservation of a triangle of bone not being narrowed and remaining lateral along the oor of the nose, thus preserving the full airway which is vital for patient comfort. Remembering the importance of camouage graing and strive for a high dorsum and a super strong tip, autogras of car-tilage, bone and fascia gras are primordial to improve the overall aesthetic outcome.NASAL AIRWAY OBSTRUCTIONAer conrmation of the patient’s complaint of nasal obstruction, functional tests (Cottle manoeuvre and cotton-tip applicator test) before and aer vasocon-striction, CT scan and inspection can diagnose the obstruction.Collapse of the middle vaultEvidenced by a pinched middle vault or oblique furrow, conrmed by a positive cotton-tip applicator test at the caudal end of the ULC, can be corrected with spreader gras. rough the open approach, a thick septal gra is harvested at the maxillary crest. e gra should be at least 15 mm by 2 mm to t passively in an intramucosal pocket between the septum and the ULC from the rhinion to the caudomedial end of the ULC. e gra opens the nasal valve angle by moving the ULC away from the septum and decreases the resistance to nasal breathing. In bilateral cases, the gras can cause a broadening of the dorsum, which can be camouaged by augmentation graing of the dorsum, liing the skin/so-tissue envelope (SSTE) and further opening the valve.Pinching can aesthetically be corrected by onlay gra-ing of crushed or morselized cartilage or by thin bone plates, acting as a batten being supported by the nasal bones.In cases of ULC-valve collapse with a horizontal defor-mity of the lateral wall due to disruption of the osseocar-tilaginous junction, a thin bony septal gra can be placed from a subperiosteal pocket of the nasal bone to under-neath the ULC through an intercartilaginous incision aer extramucosal dissection (Figure 87.6a and b).Airway narrowing at the alar marginCartilage buckling and fracture with concomitant airway narrowing at the alar margin, due to blunt trauma, can be corrected by batten gras from the ear, placed with the con-cave side down. If simultaneous alar retraction is present, composite chondrocutaneous gras are needed. ese gras are usually harvested from the contralateral cymba concha, because of approximating shape, with the skin component oversized to allow for contraction (Figure87.7). Nasal airway obstruction 901Inferior turbinate hypertrophyHypertrophic inferior turbinates, commonly on the concave side of the septal deviation, may cause airway obstruction and may interfere with septal repositioning. Outfracturing and lateralizing with a Boise instrument can be a conservative therapy in noses with large inferior meatus. Additional con-servative submucosal bony resection, mostly of the anterior part, can be performed through an incision along the length of the turbinate and submucoperiosteal elevation of the so tissue. e redundant so tissue is resected aer redraping.Our personal preference is resection of the anterior part aer infracture with a Cottle’s elevator. Articulated scissors are placed above the anterior tip of the turbinate and angled inferior and posterior at 45°. e cut is through mucosa and bone. With the exception of mulberriform degeneration, the posterior part of the turbinate is le untouched (Figure 87.8).Graft(a)(b)Figure 87.6 Correction of valve collapse – nasal obstruc-tion: Spreader graft placed intramucosally through an open approach; in bilateral collapse two separate spreader grafts can be placed, or one broader graft can be used as an ‘inlay’ between the ULC (Sheen’s spreader technique to correct a col-lapse of the middle third of the nose).(a)i(a)ii(a)iii(b)Figure 87.7 Alar collapse – nasal obstruction resulting from (a)i abnormal LC and corrected with (a)(ii and iii) cartilaginous grafts from the ear as batten grafts for abnormal LC. (b) Chondrocutaneous graft for alar retraction with soft tissue deciency and correc-tion/expansion of collapsed/scarred lateral vestibular wall (composite graft from inner side of crus helicis).Figure 87.8 Resection of inferior turbinate: Submucous conservative resection. 902 Post-traumatic rhinoplastyPOSTOPERATIVE CARE IN COMBINED SEPTOPLASTY  TURBINATE SURGERY: SEPTAL SPLINTING  NASAL PACKINGAlthough continuous suturing of the septum provides stability, we believe supplemental intranasal splinting is useful with extensive surgery in post-traumatic septal collapse. So 1-mm thick reinforced Silastic sheets (Dow Corning, Midland, MI) cut to line the septum, are always placed at both sides of the septum for 1 week, allowing the mucoperichondrial septal aps to remain reapproximated in the midline, protecting lacerations and avoiding adhe-sions or synechiae. Nasal packing with Merocel™ (lami-nated nasal dressing, Medtronic Xomed, Jacksonville, FL) in antibiotic ointment, in slight over-correction of the former septal deviation, support the Silastic and prevent dorsal collapse. Antibiotic prophylaxis is preferred dur-ing the period (3–5days) of routine nasal packing. Aer removal of the septal splints, routinely at day 7, but some-times longer if the epithelial surfaces are not yet healed and synechiae formation should be prevented, the patient is advised to ‘mechanically’ apply ointments for several weeks post-operatively to prevent crusting and adhesions and to support the recuperation of the mucosae.SOFTTISSUE DEFICIENCYReplacing traumatic loss of so tissues or loss of total frag-ments of the nose calls for local aps. e median fore-head ap is the workhorse, sometimes in combination with nasolabial and advancement aps, but this will not be discussed in this chapter.Top tips • Create high smooth dorsum and over-supported tip. • Harvest calvarial bone, fascia grafts and conchal cartilage. • Open technique respecting integrity of the SSTE. • Transcutaneous atraumatic micro-osteotomies for precision. • Minimal resectioning, realistic repositioning and cam-ouage grafting. • Reconstruct airway by septal and valve reconstruction, splinting and tamponade. • Alar base surgery with alar cinch and perialar readapta-tion on ANS. • Plaster of Paris with forehead extension for immobilization.

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