Nasal Septal Hematoma Drainage 

Author: Jessica Ngo, MD; Chief Editor: Arlen D Meyers, MD, MBA

http://emedicine.medscape.com/article/149280-overview#showall

Overview

The nose is the most frequently injured facial structure. In the setting of trauma to the anterior nasal septum, hematoma formation may occur.[1] Although septal hematomas are rare, early diagnosis and treatment is important to prevent abscess formation, septal perforation, saddle-nose deformity, and potentially permanent complications.[2,

3]

The anterior portion of the nasal septum is composed of a thin cartilaginous plate with a closely adherent perichondrium and mucosa. Submucosal blood vessels are torn as buckling forces pull the perichondrium from the cartilage. Subsequently, blood may collect between the perichondrium and the septal cartilage. Bacterial proliferation and abscess formation may then result from the presence of stagnant blood. A hematoma may become infected within 3 days of the trauma. See images below.

Normal nasal septum. Nasal septal hematoma.

The nasal septum is normally 2-4 mm thick. If the cartilage is fractured, blood can dissect through the fracture line and form bilateral hematomas; therefore, both sides should be examined. According to a study by Canty et al, the most common symptoms noted in children were nasal obstruction (95%), pain (50%), rhinorrhea (25%), and fever (25%).[4] Symptoms usually appear within the first 24-72 hours.

Nasal septal hematoma in adults typically occurs with significant facial trauma and nasal fracture. However, in children, nasal septal hematoma may be found with minor nasal trauma such as simple falls, collisions with stationary objects, or minor altercations with siblings.[5, 6, 7] Additionally, the presence of nasal septal hematoma with or without concomitant injuries should raise suspicion for child abuse, especially in infants and toddlers.

A careful examination is important for anyone who sustains nasal trauma. Signs of external trauma, such as nasal deformity, epistaxis, or significant pain, are associated with a septal hematoma. However, a septal hematoma may be present without any signs of external trauma.[1]

A septal hematoma can usually be diagnosed by inspecting the septum with a nasal speculum or an otoscope. Asymmetry of the septum with a bluish or reddish fluctuance may suggest a hematoma. Direct palpation may also be necessary, as newly formed hematomas may not be ecchymotic. The best way to palpate is to insert a gloved small finger into the patient’s nose and palpate along the entire septum, feeling for swelling, fluctuance, or widening of the septum. Blood clots should be suctioned to allow better visualization.

Indications

Urgent hematoma drainage is indicated for all nasal septal hematomas.[8]

Contraindications

No absolute contraindications exist to nasal septal hematoma drainage.

Anesthesia

Topical lidocaine or Pontocaine or injectable lidocaine without epinephrine can be used, not to exceed a dose of 5 mg/kg or a total of 300 mg.

For more information, see the Clinical Procedures topic Anesthesia, Topical.

Equipment

Topical anesthesia Light source (head lamp or otoscope) Nasal speculum Suction apparatus (Frazier suction tip) Gloves Needle, 18-20 gauge (ga) Syringe, 5 mL Scalpel, No. 11 blade Commercially produced nasal tampon

o Gelfoam (absorbable gelatin)o Surgicel (oxidized cellulose)

Small Penrose drain

Positioning

The patient is best positioned supine with some elevation of the head of the bed to allow drainage of blood out of the nose.

Technique

If a septal abscess is suspected, needle aspiration under topical anesthesia can be performed using an 18- to 20-ga needle.

Except in patients who present immediately after hematoma formation, specimens should be sent for gram stain and aerobic and anaerobic cultures. Systemic antibiotics should then be administered.

To drain the hematoma, incise the mucosa over the area of greatest fluctuance without incising cartilage. Bilateral staggered incisions should be made for bilateral hematomas to avoid a through-and-through perforation. See image

below. Incision of nasal septal hematoma. Suction out the clot; then irrigate with sterile normal saline. A small section of the mucoperichondrium should be excised to prevent

premature closure of the incision. See image below.

Excision of mucoperichondrium with ring forceps.

Place a small Penrose drain and suture it in place. See image below.

Placement of Penrose drain. Finally, pack both nostrils, as in anterior epistaxis, to reapproximate the

perichondrium to the cartilage. The drain and packing remain in place until the drainage stops for 24 hours; this usually takes 2-3 days.[9, 10, 11]

Broad spectrum antibiotics should be administered. If infection is suspected, the patient should be admitted for parenteral antibiotics.

The patient should follow up with an otolaryngologist without delay. Children should also be evaluated periodically for 12-18 months to avoid cosmetic deformities.

Prophylactic treatment with an antibiotic is recommended to cover Streptococcus pneumoniae and beta-lactamase–producing organisms. Although no clear consensus exists on the choice of antibiotic or duration of treatment, most case reports have used amoxicillin/clavulanate (Augmentin). If an abscess is suspected, clindamycin is recommended as initial therapy until culture results are available.

Pearls

Clinicians should have a high clinical suspicion for nasal septal hematoma in patients who have sustained nasal trauma.[12]

Septal hematomas should be drained as soon as possible to prevent long-term complications.

Prophylactic broad-spectrum antibiotics should be administered to cover Staphylococcus aureus, Haemophilus influenzae, and S pneumoniae.

Close follow-up with an otolaryngologist must be arranged to avoid potentially delayed complications.[13] Children should follow-up periodically for 12-18 months after initial treatment.

Complications

Though nasal septal abscesses are rare, they are the most common acute complications of septal hematomas.[14] Abscesses can result in the spread of bacteria into the paranasal and intracranial structures.[2] Further complications, including meningitis, intracranial abscesses, orbital cellulitis, and cavernous sinus thrombosis, may ensue.[15]

An expanding hematoma can cause pressure-induced avascular necrosis of the cartilage. Collapse of the nasal septum and loss of dorsal support can lead to depression of the nasal bridge and a subsequent saddle-nose deformity.[16]

Early drainage of the hematoma improves blood flow to the septal cartilage but may not reverse antecedent cartilage destruction. Therefore, the clinician must have a high index of suspicion of a nasal septal hematoma after any nasal trauma in order to initiate proper early surgical treatment.

Saddle Nose Rhinoplasty 

http://emedicine.medscape.com/article/840910-overview Author: A John Vartanian, MD, MS; Chief Editor: Arlen D Meyers, MD,

MBA

History of the Procedure

The oldest recorded text on the diagnosis and treatment of nasal deformities can be found in the Edwin Smith surgical papyrus from ancient Egypt, which dates to some 30 centuries ago. In approximately 800 BC, Ayur Veda of Sushruta (India) described a nasal reconstruction approach based on the transfer of a pedicled forehead skin flap. In the 16th century, Tagliacozzi of Bologna, Italy, used brachial-based delayed flaps to reconstruct the nose.

The science and art of rhinoplasty, as understood by most surgeons, remained essentially stagnant until the 19th century. In the 1840s, approaches to correcting nasal dorsal concavities were used by early pioneers, including Dieffenbach, who used a buried forehead flap to cover the nasal dorsum. The first paper on the treatment of the saddle nose can be attributed to John Orlando Roe's original article in 1887, "The deformity termed 'Pug-Nose' and its correction, by a simple operation."[1] In 1892, Robert F. Weir published his techniques for correcting the saddle nose.[2] In 1896, Israel applied a tibial bone graft to the nose. Treatment of the saddle-nose deformity tested the creativity of early nasal surgeons like Jacques Joseph. The treatment of saddle-nose deformities has continued to benefit from the contributions of countless pioneers of nasal surgery in the 19th century and masters of rhinoplasty in the 20th century.

An image depicting saddle nose deformity can be seen below.

Findings typical of a moderate-to-severe saddle nose include nasal dorsal concavity, shortened vertical nasal length, and loss of nasal tip support and projection.

Problem

Anatomic deformities can affect both the aesthetic and functional qualities of the nose. A saddle-nose deformity is most visibly characterized by a loss of nasal dorsal height. This deformity has also been described as a pug nose or boxer's nose, both of

which refer to various degrees of nasal dorsal depression. This often accompanies a shortened nose and compromised nasal support structures (see the images below).

Findings typical of a moderate-to-severe saddle nose include nasal dorsal concavity, shortened vertical nasal length, and loss of nasal tip support

and projection. Patient (former boxer) with moderate-

to-severe (type 3) saddle-nose deformity. Patient with a history of relapsing polychondritis and severe saddle-nose deformity (type 4).

Close-up view of auricular cartilage damage secondary to relapsing polychondritis with a saddle nose in the background.

The descriptive definition of the saddle-nose deformity represents a wide range of severity. Other features commonly observed in patients with significant saddle-nose deformities include the following:

Depression of the middle vault and dorsum

Loss of nasal tip support and definition Shortened (vertical) nasal length Overrotation of the nasal tip Retrusion of the nasal spine and caudal septum

Epidemiology

Frequency

The prevalence of saddle-nose deformities is difficult to assess. The prevalence is higher in population groups prone to facial trauma (ie, boxers, criminals, athletes), in persons with a history of intranasal cocaine use, and in individuals with a history of nasal surgery (eg, radical submucous septal resection, reductive rhinoplasty). A flat or concave nasal dorsal contour can resemble a saddle nose and is more prevalent in certain familial and racial groups. Some saddled noses may be more subtle, owing to thickened nasal skin soft-tissue envelope.

Etiology

A saddle-nose deformity can be congenital or acquired. Various degrees of nasal dorsal depression can be noticed as a part of individual, familial, syndromic, and racial characteristics. Most saddle-nose deformities are acquired. A common theme in all acquired saddle-nose deformities is a structural compromise of the nasoseptal cartilage leading to decreased dorsal nasal structural support. The most common causes of saddle-nose deformities are traumatic and iatrogenic.

Trauma

Direct trauma to the nose can fracture the cartilaginous and/or bony septum, hence compromising important support structures. Nasal bone depression due to trauma can also lead to a depressed dorsum. An unrecognized posttraumatic septal hematoma may become infected, causing irreversible cartilage damage and loss of support. In a study by Jalaludin, saddling was noted in 14% of patients with unrecognized or untreated septal abscesses.[3] In that study, the leading cause of a nasal septal abscess was trauma. Birth-related nasoseptal trauma can also appear with various degrees of nasal deformity that may be erroneously labeled as being congenital.

Surgical causes

Changes made to the nose after rhinoplasty or submucous resection of septal cartilage can result in a number of undesirable deformities, including a saddle-nose deformity. Tzadik and colleagues noted that, depending on the surgeon's skill, saddling rates varied from 0% to 2.6% (average, 0.4%) in patients who had undergone submucous resection of the nasal septum.[4]

Overresection of septal cartilage can lead to collapse of the middle vault and saddling. Removing too much septal cartilage can compromise the structural integrity of the dorsal L-shaped strut and increase the probability of postoperative or traumatic saddling of the nasal dorsum. No cartilage should be resected anterior to an imaginary

vertical line drawn from the rhinion (osseocartilaginous junction) to the nasal spine. During septal cartilage resection, leaving a minimum of a 10-mm dorsal-caudal L-shaped margin of cartilage is important. Arching the incisions, instead of creating right-angled corners, can also impart slightly greater structural integrity to the dorsal L-shaped strut.

Surgical overreduction of a nasal dorsal hump can produce an overly concave nasal dorsum. Additionally, an unidentified open roof deformity can further contribute to middle vault depression. Disharmonious changes in the nasal contour (eg, an overly projected nasal tip, an exaggerated supratip break) can also impart the impression of saddling. Inadequate support of the upper lateral cartilages and the middle vault may lead to its settling and relative saddling of the middle vault with time.

Medical causes

A number of medical conditions affecting the nose can result in damage to the septum and cartilaginous structures. The common pathway is damage to the cartilage; compromise in the structure; and various degrees of subsequent nasal dorsal saddling, as clinically observed. A number of conditions can affect the nasal septum and lead to a saddle-nose deformity.

Wegener granulomatosis Relapsing polychondritis Leprosy (Hansen disease) Syphilis Ectodermal dysplasia

Intranasal cocaine use leading to large septal perforation and cartilage loss can also produce saddling of the nose.

Wegener granulomatosis is characterized by necrotizing granulomas and vasculitis of the upper and lower respiratory tracts, including the nasal septum. The cycle of necrotizing granulomatous lesion and microabscess formation leads to cartilage destruction.

In relapsing polychondritis (see the images below), recurrent episodes of autoimmune cartilage inflammation and destruction result in damage to the cartilaginous structure of the ears, nose, larynx, trachea, and peripheral joints. In this rare disease, fibrotic tissue replaces collagen, elastin, and other matrix proteins found in normal cartilage; this process leads to the loss of healthy cartilage.

Patient with a history of relapsing polychondritis and

severe saddle-nose deformity (type 4). Close-up view of auricular cartilage damage secondary to relapsing polychondritis with a saddle nose in the background.

Overall, Hansen disease, or leprosy, is rare in the United States. However, it may be more common in the Gulf states (Texas and Louisiana), and it is endemic in certain areas of the world. The nasal mucosa is frequently involved, and septal ulceration and perforations are common. Nasal deformities, including saddling, are common in advanced cases.

Syphilis can cause intranasal ulcerative lesions that can lead to osteochondritis; cartilage damage; and, eventually, saddle-nose deformity.

Pathophysiology

General findings

Patients with saddle-nose deformities may have various degrees of nasal obstruction. Middle vault collapse is commonly observed in moderate-to-severe saddle noses. The inferomedial collapse of the upper lateral cartilages and corresponding narrowing of the internal nasal valve can produce significant obstruction that impairs nasal breathing. Large septal perforations often result in nasal saddling. Saddle-nose deformities with septal perforations can appear with nasal crusting, nasal obstruction, and whistling upon nasal airflow. In individuals in whom nasal airway compromise is noted, nasoseptal reconstruction should address important functional, as well as aesthetic, deficits of the patient's nose. An exact understanding of the deformity and dysfunction can allow for the proper selection of the best reconstructive option.

Classification

Regardless of the etiology, categorizing the severity of the saddle nose is helpful. The authors use a simplified system that classifies saddle-nose deformities on the basis of the anatomic deficits (see the image below), as follows:

Saddle-nose classification based on anatomic deficits. (1) Normal nose, appropriate nasal dorsal height, tip projection, and vertical nasal height. (2) Type 1 saddle-nose deformity, minor supratip or nasal dorsal depression, with normal projection of lower third of the nose. (3) Type 2 saddle-nose deformity, depressed nasal dorsum (moderate to severe) with relatively prominent lower third. (4) Type 3 saddle-nose deformity, depressed nasal dorsum (moderate to severe) with loss of tip support and structural deficits of the lower third of the nose. (5) Type 4 saddle-nose deformity, catastrophic (severe) nasal dorsal loss with significant loss of the nasal structures in the lower and upper thirds of the nose.

Type 1 - Minor supratip or nasal dorsal depression, with a normal projection of lower third of the nose

Type 2 - Depressed nasal dorsum (moderate to severe) with relatively prominent lower third

Type 3 - Depressed nasal dorsum (moderate to severe) with loss of tip support and structural deficits in the lower third of the nose

Type 4 - Catastrophic (severe) nasal dorsal loss with significant loss of the nasal structures in the lower and upper thirds of the nose

Most patients with a type 2, 3, or 4 saddle-nose deformity have functional nasal airway obstruction.

A practical classification method described by Tardy divides saddle-nose deformities into 3 categories, as follows:

Minimal - Supratip depression greater than the ideal 1-2 mm tip-supratip differential

Moderate - Moderate degrees of saddling due to loss of dorsal height of the quadrangular cartilage, usually with septal damage

Major - More severe degree of saddling with major cartilage loss and major stigmata of a saddle-nose deformity

Presentation

Complete history taking and physical examination is an important first step in evaluating the patient with a saddle-nose deformity. In particular, the history should include an investigation of the suspected etiology of the deformity, any history of nasal airway obstruction, any history of antecedent nasal trauma, the number of previous nasal surgeries, and any history of any autoimmune diseases. The use of intranasal cocaine or heroin should be investigated in patients with nasoseptal perforations.

Upon physical examination, the degree and location of saddling, the state of the nasal septum, the status of the internal and external nasal valves, and the structural integrity of the nasal support structures must be evaluated. A higher rate of septal perforations is found in patients who have a saddle noses. Endoscopic nasal examination can facilitate an accurate survey of all endonasal structures. The standard series of photographs should be obtained prior to surgical planning for rhinoplasty.

Indications

Indications for nasal reconstruction must be tempered by patient selection, the surgeon's experience, and the etiology of the deformity. Indications for surgery can be functional, aesthetic, or, most commonly, both. Examples are as follows:

Nasal airway obstruction secondary to middle vault collapse and/or incompetency of the internal or external nasal valve in a patient with a saddle-nose deformity

Nasal airway obstruction secondary to perforation of the loss of septal cartilage in the patient with a saddle-nose deformity

The patient's desire for aesthetic improvement

Relevant Anatomy

In-depth knowledge of the nasal anatomy is essential. The morphologic changes observed in a saddle nose are due to the loss of nasal skeletal support structures. These pathologic processes are discussed in the Pathophysiology section. The osseocartilaginous support framework includes the nasal bones, the upper and lower lateral nasal cartilages, the septum, the premaxilla, and their attachments to each other (see the first image below). The nasal septum plays a robust role in supporting the middle and lower thirds of the nose (see the second image below).

Nasal anatomy. The shape and function of the middle and lower thirds of the nose depend on the integrity of the nasal septum and on the quality

and shape of the upper and lower lateral cartilages.

Lateral view of the nasal septum. The primary support for nasal dorsal height and tip projection is determined by the size and integrity of the nasal septum.

Contraindications

Persons with contraindications for repairing a saddle-nose deformity include the following:

Patients with malignant, chronic, or autoimmune disease conditions (eg, relapsing polychondritis) in whom the reconstructed nose is at risk for continuing damage

Persons who abuse drugs intranasally and who have not demonstrated at least 12 months of sobriety (Nasal reconstruction is contraindicated in patients who have not definitively demonstrated complete rehabilitation from their substance abuse.)

Patients who are poor candidates for rhinoplasty in general, including unhealthy patients with poor perioperative risk profile and patients whose ability to follow the postoperative care regimen is limited (ie, patients with severe schizophrenia)

Patients with unrealistic expectations

Patients with relative contraindications include the following:

The patient with multiple previous rhinoplasties who now has scarred-down thin skin (The history of smoking or an unrealistic expectation by such a patient can also serve as reason[s] to delay or dissuade the patient from surgery.)

Aesthetic rhinoplasty in patients younger than 16 years Patients who are expected by habit or profession (mixed martial artists,

boxers) to experience repeated nasal trauma

Proceed to Workup

Imaging Studies

The standard series of photographs should be obtained prior to surgical planning for rhinoplasty.

Radiologic work-up is not necessary, unless required for medicolegal or insurance documentation.

Diagnostic Procedures

Endoscopic nasal examination can facilitate an accurate survey of the endonasal structures.

 

Medical Therapy

Medical treatment applies only to limiting the progression of those disease states that lead to cartilage destruction and eventual saddling. Diseases such as Wegener granulomatosis and relapsing polychondritis should be managed with the help of medical specialists (rheumatologists). In most individuals with saddle-nose deformities, treatment is aimed at surgical reconstruction of functional and aesthetic deficits.

Surgical Therapy

Depending on the degree of saddling, different reconstructive options can be used. Decisions regarding nasal reconstruction are concerned both with the choice of materials to be used and the type of reconstruction needed.

The history of nasal reconstruction is full of nasal implants and grafts taken from a variety of sources. The interesting list of grafts and implants used in reconstructing the nose seems almost limitless. Some historic grafts and implants used in the human nose include the following:

Autografts - Auricular cartilage, rib, patient's finger Homografts - Irradiated rib, pooled acellular dermis Xenografts - Leather, duck's sternum, bovine cartilage Precious metals - Titanium, gold, silver, metal alloys Inert bioimplants - Coral, ivory Synthetic compounds - Silicone, polytetrafluoroethylenes, polyamide mesh

Variable rates of success and failure have been noted with different implants and grafts. The selection of material in nasal reconstruction should center on balancing long-term biocompatibility, infection rates, extrusion rates, graft resorption rates, graft harvest site morbidity, and material availability. The ideal implant's profile satisfies all of these concerns. The ideal nasal implant has yet to be developed.

The ideal nasal implant should have certain characteristics, as follows:

It is noncarcinogenic. It is nonimmunogenic (no foreign body or inflammatory reaction). It is nonresorbable. It is easy to work with and malleable. It has a tactile feel similar to that of tissue (cartilage). It has a low or zero extrusion rate. It allows biointegration of the implant with the surrounding tissue. It is cost effective.

Autogenous materials

Autogenous materials are always preferred to alloplastic implants as far as infection rates, extrusion rates, and biocompatibility issues are concerned. Septal cartilage is the best choice but is often not present in sufficient quantity. Secondary sources of autogenous cartilage include auricular and rib cartilage. Cartilage harvested from the ear is especially well suited for use in the nose. Bone grafts harvested from calvarial,

iliac, and tibial bone sources can be used. Autogenous soft tissue materials include dermis and fascia.

Homografts

Homografts are harvested from healthy screened donors. Irradiated cartilage and sheets of pooled acellular dermal allografts (AlloDerm; LifeCell Corp, Houston, Texas) are the homografts most commonly used in nasal dorsal reconstruction.

Alloplasts

Synthetic implants offer the advantages of ready availability. However, in the nose, alloplasts have a tendency to behave like foreign bodies, with higher rates of infection, extrusion, and inflammatory reactions, as compared with those of autogenous grafts. Moreover, although alloplasts are well suited as filler material, most do not provide significant structural support to the nose.

Commonly available alloplasts include polyamide mesh (Mersilene; Ethicon, Sommerville, New Jersey), silicone-based implants (Silastic; Dow Corning, Midland, Michigan), expanded polytetrafluoroethylene (ePTFE) (Gore-Tex; WL Gore and Associates, Flagstaff, Arizona), and porous high-density polyethylene (PHDPE) (Medpor; Porex Surgical, Newnan, Georgia).

Proponents of alloplasts note that autogenous cartilage grafts are fraught with problems that must be considered. As mentioned before, septal cartilage is often of low quantity or nonexistent. Auricular cartilage is available; however, it is curved, it can potentially warp with time, it is of limited quantity, and it involves the morbidity of a second operative site. Rib cartilage is susceptible to warping and involves the morbidity of a second operative site. Also, some surgeons may be uncomfortable with the possible risks related to the thoracic surgical site. Bone grafts have been reported to undergo resorption. They are hard and can also result in donor-site morbidities.

At times, because of a number of factors, including strong patient preference against a second operative site, alloplastic implants may be used. ePTFE has been in use for a number of years, and positive reports have encouraged their wider use. Outcomes pertaining to synthetic implants are discussed in the Outcome and Prognosis section.

PHDPE implants have pore sizes of 125-250 µm, which allow access to immune cells and fibrovascular ingrowth. Sclafani, Thomas, and colleagues (1997) demonstrated the ingrowth of fibrovascular tissue into these porous implants, which confers increased resistance toward implant infection.[5] This ingrowth also anchors the implant to the surrounding native tissue.

Despite several promising reports, the long-term viability of these implants has yet to be evaluated. Alloplasts must be recommended only as a last resort and not as a convenient substitute for autogenous grafts. One significant disadvantage of nasal implants includes the changes to the surrounding tissue (scarring, skin atrophy), which may render less-than-optimal results in subsequent rhinoplasties. The authors' hesitancy to use any foreign materials in the nose is based on the authors' and other

colleagues' experience with the removal of displaced, infected, or extruding nasal implants placed by other surgeons.

Intraoperative Details

Nasal dorsal reconstruction using autogenous materials

For patients with no nasal airway obstruction and minor-to-moderate nasal dorsal saddling, onlay grafting techniques can be used. These grafts can be fashioned from septal cartilage or auricular cartilage. Onlay grafting can be used to augment the dorsum or to camouflage localized areas of depression. As Tardy described, auricular cartilage grafts can be individually placed as morselized pieces or as laminated or layered grafts. Small-to-medium dorsal depressions can also be camouflaged by using layers of laminated, or sandwiched, ear cartilage placed on the dorsum. Such layered or sandwiched grafts can be used to reconstruct not only the dorsum but also the caudal septum (see the image below).

Conchal cartilage can be used as layered or sandwich grafts to fill defects on the nasal dorsum and to reconstruct columellar support.

Grafts can be placed via endonasal or external (transcolumellar) rhinoplastic approaches. The precise creation of the subperiosteal pocket can help stabilize the graft placement site. Transcutaneous suture fixation can be used to prevent graft migration. The aesthetic look and the dorsal tactile regularity of the nose can be improved by morselizing the graft edges and by placing a layer of acellular dermis (AlloDerm) on top of the grafts. AlloDerm can be used for camouflaging small dorsal imperfections by providing a layer of cushioning. Alternatively, a layer of crushed cartilage or fascia can also provide a smoother reconstructed dorsum. A properly performed targeted osteotomy can result in the elevation of flat or depressed nasal bones.

Larger defects and deformities affecting the middle vault or the nasal dorsum require a more structural reconstructive approach. Fundamental to reconstructing the moderate-to-severe saddle nose is restoring middle vault function, reversing any internal valve narrowing, and reinforcing nasal tip and dorsal support mechanisms. The placement of spreader grafts is usually sufficient to address the internal nasal valve and middle vault collapse (see the image below).

Spreader grafts are rectangular sculpted pieces of cartilage placed between the upper lateral cartilages and septum. They serve to widen the internal nasal valve, widen the middle vault, and prevent collapse of flail upper lateral cartilages. Also, they can provide additional support to the dorsum.

More substantial dorsal augmentation (too great for placement of conchal or septal cartilage grafts) can be achieved by using a boat-shaped onlay graft fashioned from rib cartilage (see the image below). The cartilage is carved from the central core of the rib (as opposed to peripheral area) to minimize warping. Adams et al have demonstrated this phenomenon in their elegant studies measuring cartilage warping with time and location of harvest.[6] The sculpted graft is placed in a precise pocket and can be suture fixated for additional stability. If nasal tip projection and support structures are deficient, new support structure must be reconstructed.

Rib cartilage can be sculpted to serve as an onlay graft to augment the nasal dorsal contour.

L-shaped strut reconstruction

The reconstitution of dorsal-caudal and tip support structures can be achieved using the concept of the dorsal L-shaped strut. The L-shaped strut refers to the L-shaped dorsal-caudal nasoseptal support structure that should be present in the nose. An intact septum in the normal nontraumatized nose sufficiently serves this function. In the structurally compromised nose, new support structures must be constructed. A number of methods can be used to reconstruct a dorsal L-shaped strut.

The patient's own septal cartilage is readily available and well suited for reconstructing caudal and dorsal septal deficits. In patients lacking adequate septal cartilage, other cartilage sources can be used. Costochondral (rib) cartilage from the patient (harvested at the time of nasal reconstruction) can be used to re-create a dorsal L-shaped strut. This L-shaped strut usually has 2 components: a dorsal boat-shaped graft (for dorsal profile) and a columellar support pillar or strut (for nasal tip support; see the image below). The placement of a notch in the dorsal graft to fit the

columellar strut can stabilize this connection. The 2 components are suture fixated together. The rest of the nose is reconstructed based on this new support structure.

A columellar strut can be assembled with a boat-shaped dorsal graft to reconstruct dorsal-columellar L-shaped strut. Rib cartilage can be used to carve both components of the graft.

In a similar manner, bone can also be used for reconstruction. Gerow et al and others describe using bone harvested from a rib to reconstruct the dorsal L-shaped strut and to augment the premaxilla.[7]

Irradiated cartilage homografts can also be used to reconstruct articulated dorsal and caudal nasal support structures, although long-term resorption may be encountered with irradiated cartilage (as reported by Welling et al).[8] As such, the use of irradiated cartilage may be more appropriate in older patients in whom long-term resorption may be less of an issue.

The flying buttress graft combines a single or paired spreader grafts with a columellar strut. In this manner, the newly created L-shaped support structure can address middle vault collapse and internal valve incompetency and can increase tip and dorsal projection. This technique, combined with dorsal onlay grafting, may be used to fix slight-to-moderate middle vault defects along with improving nasal function. Naficy and Baker (1998) describe the use of the flying buttress in lengthening the short nose (a condition often present in the saddle-nose deformities).[9]

Remember that the nasoseptal reconstruction must be sufficiently strong and stable to last the entire lifetime of the patient. These goals can be realized in a higher percentage of patients by reinforcing structural and soft tissue elements of the nose in ways that correspond to the defects present and respond to predictable forces of long-term scarring.

Complications

Complications encountered after saddle-nose reconstruction can be categorized as medical, functional, or aesthetic. Complications vary with the amount and duration of surgery, the surgical approach to the nose, the amount of dissection, the number of previous surgeries, the use and choice of reconstruction materials, and the intrinsic patient factors.

Medical complications o Infection - Localized cellulitis, abscess formation, infected implant, or

infected graft harvest siteo Perioperative medical events - Atelectasis or pneumothorax with rib

cartilage harvesto Anesthesia related - Intubation-related injuries

Functional complications – Nasal obstruction due to inferior migration of spreader grafts, restenosis of the internal nasal valve, iatrogenic septal perforation, or synechia

Aesthetic complications o Graft related - Migration or displacement, warping, visibility of graft

through thin skin or with time, or resorption of grafto Alloplast implant related - Extrusion, displacement, or unnatural

implant contourso Transcolumellar incision related - Prolonged localized erythema, stitch

granuloma, scarring (rare), or nasal tip ischemia (very rare) o General rhinoplasty related - Loss tip definition or symmetry, polly

beak deformity or loss of favorable supratip break, inappropriate columellar show, alar-columellar disproportion, crooked nose deformity, or other well-recognized rhinoplasty complications

Outcome and Prognosis

Long-term outcomes at 10 years or longer are the standards by which rhinoplasty and nasoseptal reconstruction procedures should be judged and evaluated. Most available studies are limited by short follow-up, small numbers of patients, outcomes influenced by the surgeon's experience with a particular approach or technique, variability in intrinsic patient factors, and patient selection. Nevertheless, reviewing the available, albeit imperfect, data on the use alloplasts and the application of autogenous grafts is useful.

Alloplasts

The infection and extrusion rates of synthetic implants are of prime concern regarding their wider nonselective use in rhinoplasty. Most published studies reveal alloplast infection rates of 2-4%. True implant extrusion rates are difficult to ascertain because of variable patient follow-up intervals, patients lost to follow-up, and the lack of substantial long-term studies. On the basis of available studies, implant extrusion rates range from 0% to 9%.

Conrad and Gillman evaluated the use of ePTFE implants in 189 patients undergoing rhinoplasty.[10] Follow-up intervals varied from 3 months to 6 years (average, 17.5 mo) with 5 cases (2.6%) of implant removal secondary to infection. Two implants were removed because of chronic inflammation and soft tissue reaction. No cases of implant extrusion, migration, or resorption were reported.

Godin et al reviewed 309 patients who received ePTFE implants for a 10-year period.[11] With an average follow-up of 40.4 months (range, 5 mo-10 y), 10 implants (3.2%) were removed secondary to infection.

Niechajev's review of 23 nasal reconstructions using PHDPE nasal implants revealed successful aesthetic outcomes in all patients, with a mean follow-up of 2 years (range, 1-3 y).[12] In this study, 2 implant extrusions (9%) were treated with minor revision surgery, and 1 case of implant infection (4%) was treated with antibiotics.

Turegun et al used PHDPE implants in reconstructing the noses of 36 individuals with saddle-nose deformities and reported that no cases required implant removal.[13]

However, the follow-up in this study was generally short (8-18 mo), and the aesthetic and functional outcomes were poorly defined.

Romo et al used PHDPE nasal implants in 15 saddle-nose reconstructions and noted 1 major complication because of a twisted dorsal implant at 1-year follow-up. Of the 15 patients, 14 (93%) were pleased with their aesthetic outcomes (follow-up duration unknown). Despite attempts at precise contouring of the implant prior to its placement, the investigators noted demarcation of the lateral borders of a number of implants placed on the dorsum.

In another study, Romo et al applied PHDPE implants in 121 cases involving revision rhinoplasty and in 66 platyrrhine noses.[14] In most cases, the implant was used to augment the dorsum and reinforce the columella. From a total of 187 cases, 5 implants (2.7%) needed to be removed because of 3 early and 2 delayed implant infections.

Beekhuis' report of 70 patients with various degrees of nasal dorsal saddling who were all treated with rhinoplasty and polyamide mesh placement revealed 3 cases (4%) of implant removal (all because of infection).[15]

Autogenous material

In a review article about surgical correction of the saddle-nose deformity, Tardy describes his 20-year experience in using various autogenous grafts in nasal reconstruction with gratifying results and no major complications.[16] Infection rates with autogenous cartilage are low, and infections can be successfully treated with antibiotics. Rates of auricular cartilage warping are variable but approximately 4-7%. Cartilage extrusion rates are less than 5%, with most cases of extrusion resolving spontaneously.

Sherris treated 21 patients requiring caudal and dorsal septal reconstruction by using only autogenous material. Material used included septal cartilage; autogenous rib grafts; ethmoid bone; and, in one case, calvarial bone grafts. With an average follow-up of 19.8 months (range, 12-29 mo), no cases of infection, graft extrusion, or warping were noted. He noted one case (5%) of partial (rib) graft exposure, which resolved spontaneously without any sequelae, and one case (5%) in which (calvarial bone) graft resorption in the nasal tip area had been noted at 2-year follow-up. Aesthetic outcomes were "much improved" in 76% of the cases and "improved" in the remaining 24%.

Murakami et al used irradiated rib cartilage to reconstruct 18 saddle-nose deformities.[17] With a follow-up of 1-6 years (mean, 2.8 y), no cases of infection, extrusion, or noticeable resorption were noted. One (6%) graft had to be removed secondary to warping, and 2 (11%) displaced caudal struts had to be repositioned under local anesthesia. Long-term evaluation of irradiated cartilage grafts by Welling et al revealed progressive graft resorption with time.[8] Animal studies by Donald have also demonstrated the steady resorption of irradiated cartilage with time.[18] This resorption

may discourage the use of irradiated cartilage in younger patients, in whom long-term resorption may limit the lifespan of the nasal reconstruction.

Adams et al have demonstrated decreased rib cartilage warping rates when the cartilages were carved from central portion rather than peripheral portions of the harvested cartilage.[6] Gunter and colleagues significantly reduced their postoperative cartilage warping rates by internally stabilizing rib cartilage grafts by using Kirschner wires (K-wires).[19] Toriumi describes minimizing the risk of long-term warping by performing adequate symmetric carving of the graft, by not leaving any perichondrium on the graft, and by dissecting a precise subperiosteal graft insertion pocket.[20]

In the study by Gerow et al, the use of rib bone grafts for 16 saddle-nose reconstructions yielded good aesthetic results with no significant complications.[7]

Some of the cases described had continued good aesthetic results at long-term follow-up (7-10 y). Bone absorption was noted in all cases, but in no cases did the deformities recur.

Future and Controversies

The future of nasoseptal reconstruction continues to evolve on the basis of long-term results, the introduction of new techniques, and the use of increasingly biocompatible homografts and implants. The ideal alloplasts are yet to be found, but the search for new compounds may facilitate the development of an ideal alloplast. Future developments in bioengineering may allow the production of autologous soft tissue products (eg, cartilage). This advancement will eliminate the importance of material as a limiting factor in complicated nasal reconstructions. Until then, the intelligent and creative use of autogenous grafts can allow the surgeon to address an almost limitless array of nasal deformities, including the saddle nose.