Nasal lengthening

A typical sequela of a mal reduced midface fracture is foreshortening of the nose. This results not only due to lack of skeletal support but also from scarring of the nasal soft tissues.

Lengthening of the nose is achieved with a modification of the Le Fort II osteotomy. It requires mobilization of the nasal bones as well as the entire internal nasal lining.

This procedure is performed with a combination of a coronal approach and a rhinoplasty approach.

An osteotomy is made at the nasal frontal junction coursing inferior and anterior to the infraorbital rim. It essentially follows the nasomaxillary groove inferior to the most lateral part of the pyriform aperture.

An osteotome is inserted at the nasofrontal region and directed at the posterior nasal spine. A finger can be placed at the posterior edge of the hard palate to orient the trajectory of the osteotome.

The nasal lining is carefully elevated and released from the bone. A periosteal elevator is placed into the osteotomy, to assist with mobilization and advancement of the segment.

The mobilized segment is then stabilized with 1.3 plates in the planned position (advanced).

A small strut of outer table calvarial bone is harvested from the parietal region as described in the coronal approach.

A groove can be prepared to avoid protrusion of the graft as well as to facilitate proper angulation.

The graft is secured with a miniplate.

The gap in the lateral nasal wall may also be grafted when necessary.

Keeping the patient’s head in a raised position both preoperatively and postoperatively may significantly improve edema and pain.

To prevent orbital emphysema, nose-blowing should be avoided for at least 10 days following NOE fracture repair.

The use of the following perioperative medication is controversial. There is little evidence to make strong recommendations for postoperative care.

• No aspirin for 7 days (nonsteroidal antiinflammatory drugs (NSAIDs) use is controversial)
• Analgesia as necessary
• Antibiotics (many surgeons use perioperative antibiotics. There is no clear advantage of any one antibiotic, and the recommended duration of treatment is debatable.)
• Nasal decongestant may be helpful for symptomatic improvement in some patients.
• Steroids, in cases of severe orbital trauma, may help with postoperative edema. Some surgeons have noted increased complications with perioperative steroids.
• Ophthalmic ointment should follow local and approved protocol. This is not generally required in case of periorbital edema. Some surgeons prefer it. Some ointments have been found to cause significant conjunctival irritation.

Postoperative imaging has to be performed within the first days after surgery. 3-D imaging (CT, cone beam) is recommended to assess complex fracture reductions. In centers where intraoperative imaging is available postoperative imaging can be performed at a delayed time.

For nasal fractures, postoperative CT imaging is usually not necessary except in severely comminuted fractures.

Remove sutures from skin after approximately 5 days if nonresorbable sutures have been used.

Apply ice packs (may be effective in a short term to minimize edema).

Avoid sun exposure and tanning to skin incisions for several months.

Diet depends on the fracture pattern and patients condition but there are usually no limitations.

Clinical follow-up depends on the complexity of the surgery, and the patient’s postoperative course.

In all patients with NOE trauma, all the following should be periodically assessed:

• Globe position
• Double vision
• Other vision problems
• Nasal airway status

Other issues to consider are:

• Facial deformity (incl. asymmetry)
• Sensory nerve compromise
• Problems of scar formation
• Anosmia
• Epiphora and dacryocystitis

Implant removal is rarely required. It is possible that this may be requested by patients if the implant becomes palpable or visible. In some countries it will be more commonly requested. There have been cases where patients have complained of cold sensitivity in areas of plate placement. It is controversial whether this cold sensitivity is a result of the plate, a result of nerve injury from the original trauma, or from nerve injury due to trauma of the surgery. Issues of cold sensitivity generally improve or resolve with time without removal of the hardware.