Web Log – August 2012 – KTVB Nose Surgery Segments

I broke my nose recently and now have a bump on top and it is a little crooked.  How should I go about getting it fixed?

Sometimes when you have an impact to the nose, you just have a bloody nose and some swelling and that is it.  If it is obviously crooked, you cannot breathe, or the bleeding will not stop, you should seek help at the Emergency Department that has access to consultants.  The Emergency Medicine Physician will evaluate you and decide if any immediate specialty treatment is necessary.  Most commonly in Boise, that treatment is provided by an ENT / Head and Neck surgeon , but may be provided by a Plastic Surgeon as well.  If the nasal bones are grossly deviated, they can be moved and splinted with some improvement.  If the nose will not stop bleeding, it can be packed.  Most importantly, you want to make sure that there is no septal hematoma to be drained.
What sort of long lasting damage can there be from a serious nasal fracture?
If a septal hematoma is undrained, as the blood is absorbed, it can also damage the central cartilage support to the nose and cause warping or a saddle deformity.  If the septum or nasal bones are significantly fractured to one side, the airway can be blocked and you might not be able to breathe from one nostril.  Then there are the aesthetic problems.  There is frequently a dorsal hump.  The nasal bones and septum displacement may or may not cause breathing problems, but they will possibly make the nose look crooked.  Unless there is associated laceration or crush injury, the tip usually is not damaged.
When should someone with a nasal fracture be seen by a Plastic Surgeon?
Unless there is gross deviation, uncontrolled bleeding, or septal hematoma, being seen by a surgeon is not an emergency.  It is not a bad idea, however, to be seen within days to weeks be make sure that nothing major has been missed in the Emergency Department.  Ideally, the surgeon should be comfortable with aesthetic as well as functional airway problems.  Being seen also establishes any related functional or aesthetic problems are indeed secondary to the trauma and therefore more likely to be covered by an insurance company without argument.  A visit to the Plastic Surgeon also allows a photographic record as well as plan for future care to be made.  At that point, it is best to wait at least 6 months, if not a year, before doing a surgery.

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Last week, we discussed how to approach a broken nose when it happens and learned that surgery for some injuries may need to be delayed for up to one year.  So whether there was previous trauma or not,  if you have trouble breathing from your nose or do not like how it looks, what is the next step?

Have a consultation with an appropriately trained surgeon.  For nose surgery, that is only a Board Certified Plastic Surgeon or ENT Facial Plastic Surgeon who has had good rhinoplasty training and experience.  Most other cosmetic providers will not offer rhinoplasty because it is a challenging procedure in even the best of hands.  Then, you should look carefully in the mirror and decide specifically what features bother you.  You cannot be happy unless you know what you want.
What complaints might you hear from a patient?
For breathing difficulties, is it one side or both, complete or incomplete, constant or variable?  The septum may be deviated or the turbinates – structures which warm the air – may be enlarged. Is there a bump on the dorsum or does the nose deviate to one side? This is usually due to nasal bones and the keystone area where it joins the cartilage.  Are the tip cartilages too full, too boxy, or too projecting?  Is the base too wide?  Is the chin too small in comparison?
Once the patient has identified what bothers them, how do you proceed from there?
I then see if the complaints match my assessment.  If not, the patient may have a minimal defect and be inappropriate for the cost and risks of surgery.  I show the patient results of patients whom I have operated upon and critically discuss the outcomes.  If the patient does not have realistic expectations, then I would not offer an operation.  If there are airway issues, these can be submitted to insurance and the cosmetic portion billed separately.

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Last week we discussed factors to consider before undergoing nose surgery.  What are the different options for reshaping a nose?

There are two main ways to approach a nose, open or closed.  In an open rhinoplasty, an incision is made on the columella, or narrow underside of the nose.  The incisions are then transitioned to the inside of the nose and trace around the rim – deep enough that they cannot be seen – in the shape of a gull wing.  The tip skin is then carefully lifted off of the cartilage that forms the nasal tip and on up to the dorsum.  This is a great incision because  you can see the anatomy well, do complex repairs to the tip cartilages and more easily access the interior of the nose from above.  The problem is that the tip stays swollen longer.
What about the closed approach?
In a closed rhinoplasty, only interior incisions are made – usually along the septum and deeper underneath the tip cartilages.  Access is quicker and sufficient to operate on the septum and the dorsum and recovery is quicker.  It is also nice because changes to the dorsum are easier to see.  On the other hand, there is limited access to the tip cartilages and there is less visibility for complex repairs.  I only use it if I plan to do either no tip alterations or just minimal ones.  Most modern rhinoplasty teaching emphasizes an open approach and it is the one I usually use.  With either incision, the nose is often broken in from the size to narrow the dorsum when it has been widened by taking a hump down – like closing in the open roof cut off the top of an A-frame house.
What is recovery like?
A plastic or metal splint is usually molded over the dorsum to set any fractured bones and to assist with adhering the skin correctly.  This is usually removed in about one week. There may be some gauze packing if the nasal bones need to be supported from the inside as well and it is removed between 1 to 3 days.  If there was airway work, there may be internal splints – that are removed at one to two weeks.  Some patients have bruising under their eyes which improves in about a week.  There is usually some swelling over the dorsum and tip which is not evident do the casual observer for more than a few weeks, but is evident to the patient an surgeons for several months.  The result continues to mature for months to years afterwards.  The patient may feel subconscious, but sometimes family members do not even notice.

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