Naso-Orbital-Ethmoid Fracture Repair Techniques: A Systematic Review.

PURPOSE: Naso-orbital-ethmoid (NOE) complex fractures present a challenge to repair. The classification system used to categorize the fracture type was established in 1991 based off the medial canthal tendon attachment. The primary objective was to systematically review the literature outlining repair techniques for NOE fracture after the adoption of the Markowitz classification system. METHODS: A systematic search was performed in PubMed, Embase, and Web of Science to identify peer-reviewed research. Eligible studies were peer-reviewed articles reporting on operative techniques used to repair NOE fractures in adult patients after 1991. Two investigators independently reviewed all articles and extracted data. Level of evidence was assessed by Oxford Center for Evidence-based Medicine guidelines. RESULTS: This review identified 16 articles that met inclusion/exclusion criteria representing 517 patients. One article outlined a closed reduction technique with transnasal wiring. The remaining articles discussed open approaches with various exposure techniques, most common being the coronal incision. Miniplates and screws were most often implemented for rigid fixation as well as transnasal wiring to repair disrupted medial canthal tendon and canthal bearing bone in Type 2 and 3 NOE fractures. Ten of the studies included in this review had a level of evidence of 4. CONCLUSIONS: NOE fractures present a complex fracture pattern and challenge to repair. New exposure techniques and multidisciplinary approaches have been described. However, fixation techniques have remained relatively consistent through the years. Surgeon preference and comfort with performing the specific techniques leads to the best patient outcomes. With the low level of evidence referenced, more robust research is needed to evaluate these techniques.

The Fish Bone Technique: An Innovative Approach for the Bony Nasal Pyramid.

Among many contributions to the world of art and science, Renaissance artist Leonardo da Vinci created the technique known as sfumato. In this technique, da Vinci considered that the regions to be highlighted should be lit up, while the regions to be hidden should be darkened. Drawing parallel with the face, we can work on the anatomical structures underlying the skin and create a favorable surface anatomy for the entire face, including the nose. However, to achieve the ideal hourglass shape of the nose, the bones must be shaped, and a variety of osteotomies are described and used to achieve this. The new and innovative Fish Bone technique, described in this article, allows for the bony nasal pyramid to be shaped and adapted to the hourglass shape, resulting in a harmonious contour, with smooth transitions and preservation airway.

A Novel Balloon Catheter Dilation Apparatus for the Treatment of Depressed Nasal Bone Fracture.

The nasal bone fracture is the most common type of facial bone fracture. Closed reduction with metal reduction instrument is commonly conducted for the treatment of a depressed nasal bone fracture which often leads to iatrogenic injury. In this article, a new balloon catheter dilation apparatus for nasal bone fracture is hypothesized by the authors. This device aims to repair nasal bone fracture via dilated balloons under fractured nasal bone and used as nasal internal packing system after operation. Compared with the conventional approach, it is proposed that this balloon dilation apparatus could be a potential powerful, less invasive approach to treat depressed nasal bone fractures.

Lateral Osteotomy for the Surgical Treatment of the Asian Wide Nose.

OBJECTIVE: Narrowing of the nasal dorsum allows for a more pleasing moderate width. We here introduce a lateral osteotomy technique that is less traumatic and easier to perform than commonly used procedures in Asian and share our experiences in the application. METHODS: After a blunt dissection of the periosteum at the mucosal side of the nasal bone, all patients who underwent treatment using nasal osteotomy at the level of the maxillary nasal process were retrospectively analyzed. The bony nasal width, height, and the nasal lateral wall slope of bone before and after surgery were measured. The postoperative outcomes, complications, and patient satisfaction were analyzed and evaluated. RESULTS: From January 2008 to January 2018, nasal dorsum narrowing was implemented in 106 patients. On average, nasal width was significantly decreased and no change in nose height after the nasal osteotomy. The nasal width was significantly reduced by 8.51 ± 2.16 mm compared with before surgery. The slope of the nasal lateral wall was reduced from the mean of 155.0 ± 7.63-degree preoperation to the mean of 135.25 ± 7.50-degree postoperation. The follow-up period ranged from 6 months to 4 years, with an average of 10.3 months. CONCLUSIONS: This type of nasal bone base osteotomy is a simple and feasible method for the treatment of wide Asian noses with a high patient acceptance and stable postoperative results. LEVEL OF EVIDENCE: Level IV.

A Simple and Minimal Invasive Method in Reduction of Depressed Nasal Bone Fracture by Using a Foley Catheter Ballooning Technique.

The nasal bone fracture is the most common type of facial bone fracture. Closed reduction with metal reduction instrument is commonly conducted for the treatment of a type II nasal bone fracture. The authors defined a new catheter dilation technique and used it in patients with type II depressed nasal bone fractures. Preoperative and postoperative nasal appearance and radiologic examination of the patients were compared. There was a statistically significant improvement in the nasal appearance of all patients. No recurrence or dorsal irregularity has been observed. This new, easily applicable catheter dilation method of closed reduction may be a simple and less invasive solution to treat type II nasal bone fractures.

Perfecting the Outcome of Nasal Bone Fracture in the Pediatric Population With a Navigation System.

BACKGROUND: The trend of using navigation systems for treating facial bone fractures is increasing. Nevertheless, any detailed recommendation on using a navigation system to treat nasal bone fracture has never been discussed. Plastic surgeons are prone to do closed reduction of nasal bone fractures with remnant posttraumatic edema in the pediatric population. This study hypothesized that the navigation system benefits this population's treatment of nasal bone fractures. METHODS: The authors evaluated the medical records, plain x-ray, and facial computed tomography scans of 44 pediatric patients (below the age of 18) with nasal bone fractures treated with a closed reduction from May 2021 to December 2022. Preoperative and postoperative computed tomography scan were used to assess the outcome. RESULTS: The average age for 44 pediatric nasal bone fracture patients was 10. Fifteen were female, while males were 29. All cases were successfully corrected clinically and radiologically without noticeable complications. CONCLUSIONS: Using navigation systems to correct nasal bone fractures provides additional benefits for the pediatric population. This technique is especially useful if the fracture is located at the junction between the nasal bone and nasal process of the maxilla and is combined with concurrent old nasal bone fractures.

The Efficacy of Sequential Intranasal Packing Removal in Overcorrected Nasal Bone Fracture: Evaluation With Computed Tomography.

BACKGROUND: Despite the evolution of new techniques to treat nasal bone fractures, closed reduction with appropriate palpation and inspection is one of the critical basic tools to treat nasal bone fractures properly. Despite its rarity, overcorrection after closed reduction of the nasal bone fracture could happen even with experienced surgeons. This study hypothesized that sequential packing removal is mandatory for optimal outcomes based on the preoperative and postoperative Computed Tomography scans in overcorrected cases. This is the first study to evaluate the efficacy of sequential nasal packing removal assessed by facial CT scans. METHODS: In this retrospective study, we evaluated the medical records and preoperative and postoperative facial Computed Tomography scans of 163 patients with nasal bone fractures treated with a closed reduction from May 2021 to December 2022. Preoperative and Postoperative CT scan was routinely used to assess the outcome. Merocels were used for intranasal packing. In overcorrected cases based on immediate postoperative CT scan, we routinely removed the intranasal packing on the overcorrected side first immediately. On postoperative day 3, we removed the remaining intranasal packing on the other side. We assessed additional postoperative CT scans on postoperative two to three weeks. RESULTS: With sequential packing removal starting on the day of surgery, all overcorrected cases were successfully corrected clinically and radiologically without noticeable complications. Two representative cases were presented. CONCLUSION: Sequential nasal packing removal provides significant benefits in overcorrected cases. An immediate postoperative CT scan is also vital to do this procedure. This strategy is advantageous if the fracture is significant and there is a substantial possibility of overcorrection.

Nasal Bifidity: An Unusual Pediatric Congenital Anomaly and Review of the Literature.

Congenital nasal anomalies are rare, with an estimated incidence of 1/20,000 to 40,000 live births. Hyperplasia and duplication anomalies are the most uncommon, comprising about 1% of reported cases. The authors present the case of a 6-year-old girl who presented to our institution with an isolated congenital bifid nasal septum. Parents reported a visibly abnormal nose since birth, and it had been continuously monitored by the parents and pediatrician. She demonstrated no history of difficulty breathing or other nasal concerns and was otherwise growing and developing normally. On physical examination, she was breathing comfortably through her bilateral nasal airways. Her nasal examination revealed a widened mid-vault with deep dorsal grooving and a bifid tip. Magnetic resonance imaging demonstrated an isolated bifid nasal septum without other facial malformation or intracranial extension. She underwent an open septorhinoplasty. Intraoperatively, the authors identified an anomalous dorsal nasal bone extension with a resultant bifidity in the body and caudal portions of the septum. Ostectomy and cartilaginous repositioning allowed for an autogenous reconstruction without the need for grafting. She subsequently recovered well without postoperative complications and continues to have improved nasal appearance with maintenance of function. A review of recent literatures revealed 2 other cases that are similar in presentation. The authors proposed that embryologically there might have been a change in expression of bone morphogenetic protein in the frontonasal area leading to caudal extension of the nasal bone. This in turn interferes with the fusion of nasal septum resulting in the bifid septum and dual dome morphology.

The Barn Doors Greenstick Fracture-A New 3D Geometry for Common Osteotomies in Rhinoplasty: The First 50 Patients with 1-Year Follow-up.

The "barn doors greenstick fracture" is a new concept that includes three contiguous greenstick fractures: one in the central compartment of the nasal dorsum (nasal bones) and two on the lateral walls of the bony nasal pyramid. The present study aimed to describe this new concept and to report the first esthetical and functional outcomes. This prospective, interventional, and longitudinal study was performed on 50 consecutive patients undergoing primary rhinoplasty by spare roof technique B. The validated Portuguese version of the Utrecht questionnaire (UQ) for outcome assessment in esthetic rhinoplasty was utilized. Each patient answered the questionnaire online before surgery and 3 and 12 months after surgery. In addition, a visual analog scale (VAS) was used to score nasal patency for both sides. The patients also answered three questions (yes or no): (1) "Do you feel any step on your nasal dorsum?" if yes: (2) "Is that step visible?" (3) "Does it bother you?"A statistically significant improvement in UQ scores postsurgery was found, demonstrating a high satisfaction index in this patient population. Additionally, the preoperative and postoperative mean functional VAS scores showed a significant and consistent improvement on both sides (right and left). Twelve months after surgery, a step at the nasal dorsum was felt by 10% of the patients, but it was visible just in 4%, which were two females with thin skin.The barn doors greenstick concept provides a new approach to achieve a real and sustainable smooth transition in the dorsal and lateral walls. The association of the two lateral greensticks and the already described subdorsal osteotomy allows a real greenstick segment in the most critical esthetic region of the bony vault-the root of the nasal pyramid.

The Management of Posttraumatic Nasal Deformities.

Nasal bone fractures are the most common fractures of the facial skeleton and are often accompanied by bony, cartilaginous, and soft tissue injuries. These injuries are often complex, and when untreated or inadequately treated, can lead to posttraumatic nasal deformity. The most common deformities are the crooked nose and the saddle nose. Both deformities may result in significant cosmetic and functional concerns. The treatment of these deformities can be complex, requiring careful evaluation of the nose and thoughtful planning to correct the cosmetic deformity and restore functional integrity. The rhinoplasty surgeon will benefit from having a large repertoire of techniques to achieve these repairs. In this article, we discuss the options and concepts for the management of nasal bone fractures as well as complicated posttraumatic nasal deformity. Level of evidence is not available.

An Anatomic Analysis of the Bony Vault: From the Perspective of Osteotomy in Rhinoplasty.

BACKGROUND: Osteotomy is one of the most traumatic but critical procedures in rhinoplasty. A detailed preoperative analysis of the bony vault is essential to performing a successful osteotomy. OBJECTIVES: This study aimed to analyze bone thickness along the osteotomy path in primary rhinoplasty patients. METHODS: Preoperative 3-dimensional facial bone computed tomography images of 250 patients who underwent primary rhinoplasty were analyzed, and their bony vaults categorized based on symmetry. The bone thickness was measured at 3 points along the lateral and at 2 points along the medial and intermediate osteotomy paths. RESULTS: Of the 250 patients analyzed, 88 (35.2%) had asymmetric and 162 (64.8%) had symmetric bony vaults. The mean thickness of the bony vault was thickest at the middle level of the lateral osteotomy path, and the bony vault was thicker in male patients at all points of medial and lateral osteotomies. Furthermore, in the asymmetric bony vault, the deviated side was thicker than the contralateral side along all osteotomy paths. In particular, the deviated side was thicker, and the contralateral side was thinner, in the asymmetric bony vault than in the symmetric bony vault at the middle level of the lateral osteotomy path. CONCLUSIONS: The thickness of the bony vault differs according to osteotomy path and gender. The lateral osteotomy, especially at the midpoint of the deviated side in male patients, is crucial in achieving a more controlled fracture.

Inverted-V Deformity: An Anatomic Study.

BACKGROUND: The inverted-V deformity is an unwanted aesthetic consequence of dorsal hump resection. Despite their attachment to the nasal bones, the upper lateral cartilages (ULCs) can separate from the nasal bones, creating a step-off after cartilaginous dorsal hump removal. OBJECTIVES: The mechanism of how the ULCs can separate from the nasal bones despite their attachment was studied to improve understanding of the inverted-V complication and its prevention. METHODS: A dorsal hump resection (bony and cartilaginous) was performed on 12 fresh cadavers to observe the effect on the ULCs. As a secondary study, the effect of different preventative maneuvers was investigated. RESULTS: Cartilaginous dorsal resection destroys the spreader mechanism of the T-frame and impacts the stabilization of the ULCs, resulting in them becoming free-floating. This causes them to migrate in a posterior, medial, and cranial direction relative to the nasal bones. The dynamic attachment of the ULCs to the nasal bones is key in this mechanism and allows actual separation of the ULCs from the nasal bones to result in the inverted-V deformity. Caudal traction to the ULCs re-tensions these attachments, pulling the ULCs against the nasal bones again. CONCLUSIONS: This anatomic dissection study has established that the connection between the nasal dorsum and ULCs is not a static fusion but is dynamic. This attachment can be used in primary rhinoplasty to prevent inverted-V deformity by applying caudal traction to the ULCs when reconstructing the dorsum which will tension the ULCs toward the nasal bones.

Isolated Medial Maxillary Buttress Displacement in Naso-Orbito-Ethmoid Fractures: A Surgical Indication to Resolve Nasal Airway Obstruction.

PURPOSE: The aim of this study was to present a case series emphasizing low medial maxillary (pyriform) buttress displacement in naso-orbito-ethmoid (NOE) fractures as an operative indication, in the absence of the typical NOE surgical indications (medial canthus displacement, midface bony comminution, nasal bone collapse, and orbital indications), to prevent nasal airway obstruction. METHODS: Five cases of minor NOE fractures are reviewed, where only the low medial maxillary buttress was displaced. The typical surgical indications for NOE repair were absent. RESULTS: In each case, the pyriform buttress was medially and posteriorly displaced, creating nasal airway obstruction in each patient. The medial canthal tendons were all nondisplaced, there was no diplopia, and the other 2 cardinal buttresses (infraorbital rim and nasofrontal junction) were minimally displaced or greensticked. In the acute setting, patients were treated with open reduction and internal fixation. With delayed presentation, septorhinoplasty or osteotomy and fixation were used. Among the patients who had adequate follow-up, nasal airway obstruction was resolved. CONCLUSIONS: This series suggests that, in NOE fractures with isolated displacement at the medial maxillary buttress, nasal airway obstruction should be considered an operative indication (independent of the classical indications) in order to prevent or resolve nasal airway obstruction.

Overcorrection of Nasal Bone Fracture Reduction Can Be Minimized by Packing Removal.

ABSTRACT: We experienced 16 cases of overcorrection among 524 cases of packing following nasal bone fracture (NBF) reduction. In these cases, the packing was removed immediately.From July 2017 to October 2020, 535 cases of NBF were reduced by closed reduction. Nasal packing was applied in 524 cases (97.9%). In all cases, postoperative X-rays (both nasal bone lateral view and Water's view) were taken. The degree of overcorrection was measured in the nasal bone lateral views.Among the 524 patients who underwent nasal packing, overcorrection was noted in 16 cases (3.1%). The average degree of overcorrection was 2.09 ±â€Š0.70 mm. In these patients, the packing was removed immediately and X-rays were taken directly after packing removal. The degree of overcorrection decreased; however, no significant difference was found (1.83 ±â€Š0.71 mm, P   =  0.081, [paired t test]).In this study, overcorrection was noted in 3.1% of patients in whom nasal packing was applied. After packing removal, the degree of overcorrection decreased but was not significant. Postoperative X-rays should be taken after reduction of NBF and nasal packing, and if overcorrection is noticed, the packing should be removed immediately.

Preservation Rhinoplasty: Assessment of Anatomical Safe Boundaries on Computed Tomography.

BACKGROUND: Nasal dorsum reconstruction is a crucial step of the rhinoplasty. For avoiding complications, techniques that preserve natural dorsal anatomy becomes popular recently. In preservation techniques, ethmoidal bone surgery may take part in the vast majority of defined techniques. Therefore, detailed anatomical knowledge is essential to avoid severe complications, especially cerebrospinal fluid leakage. Based on these, this study aimed to investigate anatomical safe boundaries of preservation techniques based on the measurements on computed tomography. METHODS: A total of 100 patients who underwent paranasal computed tomography were enrolled in this retrospective study. Five groups were selected based on the age distribution. The distance of the dorsal osteotomy line to cranial base, amount of cartilaginous/bony septum overlaps under nasal bones, cartilaginous/bony septum length anterior and posterior to the nasal hump starting point, and anteroposterior distance of perpendicular plate was measured. RESULTS: The mean distance between the starting point of the nasal hump and the cribriform plate was 29.5 mm. The amount of bony overlap above the cartilaginous septum was 10.9 mm in females and 10.5 mm in males. The length of septal cartilage posterior to nasal hump was 0 mm in 39 of 100 patients (39%) and the mean value was 2.38 mm in all populations. The mean distance from the starting point of the perpendicular plate to the cribriform plate was 28.17 mm. CONCLUSIONS: Perpendicular plate may take part in the constitution of the nasal hump. Therefore, delicate surgery with appropriate tools needed for avoiding the risk of skull base injury. LEVEL OF EVIDENCE: Level of Evidence: 3 (Therapeutic).

Introduction of Digital-Assisted Multidisciplinary Treatment in the Functional and Morphological Reconstruction of Naso-Orbital-Ethmoid Fractures.

ABSTRACT: This study summarizes the process of digital-assisted multidisciplinary treatment (MDT) of naso-orbital-ethmoid (NOE) fractures and evaluates the treatment outcomes. From October 2018 to December 2020, 39 patients with NOE fractures were treated in our department, 21 of whom were diagnosed and treated by a multidisciplinary team. After preoperative multidisciplinary discussions and personalized virtual surgical planning, they received MDT with the assistance of a surgical navigation system. The other 18 patients received traditional single-disciplinary treatment, that is, no preoperative multidisciplinary discussions. Oral and maxil-lofacial surgeons performed surgical design and digitally-assisted surgery alone. After the operation, treatment outcomes were evaluated in terms of aesthetic appearance and function. The duration of preoperative preparation and postoperative aesthetic outcomes were not significantly different in patients who received single-disciplinary treatment and MDT ( P > 0.05). However, postoperative functional outcomes were significantly better in patients who received MDT ( P < 0.05). Furthermore, no significant complications were found. Digital-assisted MDT has a high application value in repair and appearance reconstruction, especially restoring functionality after NOE fracture; thus, it should be promoted in clinical practice.

A Novel Septoplasty Technique for Patients With Nasal Fractures.

ABSTRACT: Nasal structures have both functional and cosmetic significance. These structures maintain the shape of the nose and regulate the nasal airflow. During trauma, fractures of the nasal bone are frequently associated with nasal septum deviations. This can lead to the nasal bone collapsing and nasal obstruction. The septoplasty technique is a major surgical intervention to improve nasal obstructions, with the submucosal resection of the deviated septum. In the past, septoplasty was deferred until the nasal bone fracture was healed to reduce the postoperative risk of saddle-nose and flat nose deformities. Advances in technology have enabled surgeons to attempt septoplasty together with a closed reduction of the nasal bone fraction. It is most important to preserve the septal support structure during surgery. Hence, we advocate that the nasal septum be reset in the midline rather than removed, by modified endoscopic septoplasty.

Lamb Head as a Training Model for Septoplasty and Rhinoplasty.

Septoplasty and rhinoplasty are difficult operations to learn and teach. Many modalities have been proposed to make the teaching process of these operations easier. In this study, it was investigated if lamb heads were good training models to teach septoplasty and rhinoplasty to trainees or experienced surgeons. In the first part of the study, 21 lamb heads were dissected according to a dissection protocol and several anatomical distances were measured to compare them with human cadavers. In the second part, eight lamb heads were dissected and different preservation rhinoplasty techniques were practiced. The study on 21 lamb heads used showed that the lateral crura were 17.8 × 11.6, the average interdomal distance was 8.1 mm, and the average domal width was 3.7 mm. The average length of the upper lateral cartilages was 31.1 mm laterally and 21.2 medially. The average length of the nasal bones was 63.9 mm, and the width was 16 mm. In the second part of the study, 8 lamb heads were used to experience where high-strip techniques were used in 5 and the Cottle technique in 3. This study revealed that lamb heads should be considered as an excellent training model for septoplasty and rhinoplasty. Its very low cost, ease of availability, and close similarity to the human cadavers can be counted as the main advantages. This study also proved that it was not only a tool for beginners, but also a very helpful tool for experienced surgeons to try new methods.

Modification of Nasal Dorsal Onlay Graft Based on Anatomic Findings of Rhinion Area.

BACKGROUND: The angulation of nasal bones and superior border of septal cartilage forms a slight convex profile at rhinion area. Taking this angulation into account, we bring forth a modification of dorsal onlay graft. METHODS: Sixty-one consecutive patients underwent primary rhinoplasty between the years of 2017 and 2020 were enrolled in the study. The angle between nasal bones and superior border of septal cartilage, angle of external dorsal contour, thickness of soft tissue at sellion and rhinion were measured on reformed computed tomographic scanning image. Three variants of dorsal onlay graft modification were designed. RESULTS: Sixty-one patients underwent primary nasal augmentation were enrolled in this study. Mean follow-up was 13.1 months. The angle between nasal bones and the superior border of the septal cartilage was 166.7° by mean. Mean angle of external dorsal contour was 180.2°. Thickness of soft tissue at sellion was 4.01 and 2.03 mm at rhinion by mean. All cases showed content dorsal profiles. Two patients (3.3%) presented discernible nostril asymmetry due to the deviation of the columellar grafts and underwent secondary surgery with satisfying outcomes. CONCLUSIONS: Modification of the dorsal onlay graft reserves nasal midvault to the most extent especially in small-humped nose and fits the dorsal contour properly. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Computed Tomography Analysis of Nasal Anatomy in Dorsal Preservation Rhinoplasty.

BACKGROUND: Subdorsal septal resection and radix osteotomy are distinctive surgical steps in preservation rhinoplasty. OBJECTIVES: The aim of this study was to evaluate the nasal bone thickness, the level of the septal bony-cartilaginous junction (K area), and the distances of the frontal sinus and skull base from the transverse osteotomy line in the Turkish population by means of conventional computed tomography (CT). METHODS: A retrospective evaluation was made of 203 consecutive preoperative paranasal CT scans of patients (classified in terms of age and gender) who had undergone rhinoplasty surgery between January 2020 and June 2021. The nasal bone thickness at the medial canthus level, and the distances between the transverse osteotomy line and the K area, the frontal sinus, and the cribriform plate were measured. RESULTS: The mean measurements were similar in terms of age groups (P = 0.402, P = 0.542, P = 0.134 and P = 0.276 for ages 18-30, 30-40, 40-50, and >50 years, respectively). The mean nasal bone thickness and the distance between the transverse osteotomy line and the K area showed statistical significance (P = 0.001 and P = 0.001, respectively). In both genders, the mean distances between the transverse osteotomy line and the frontal sinus and the cribriform plate were similar (P = 0.921 and P = 0.280, respectively). The nasal bone was thinner and the K area position more cephalic in females. CONCLUSIONS: CT plays an important role in preoperative planning. The need for resection of the ethmoid perpendicular bone may be greater in males when lowering the dorsal hump, and hence they may be more prone to skull base complications. It is therefore necessary to be more careful in the surgical stage of subdorsal septal excision in males.