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Plastic surgery of nasal fractures
PLASTIC SURGERY OF NASAL FRACTURES* EDWARD S. LAMONT, M.D. HOLLYWOOD, CALIFORNIA
F
of the nose are freRACTURES quentIy overIooked. The initiaI sweIIing, coupled with frequent epistaxis and ecchymosis mask the normaI nasa1 contour, so that gross deformity may not be apparent. LateraI x-rays are often heIpfu1 but these too’ may be misIeading. Thorough examination may be painfu1 and the patient is a11 too ready to persuade the surgeon that there is no fracture. Many papers have been written on the signs, symptoms and treatment of early fractures.2,j,12,1j,16 Stress has been Iaid, not onIy on restoration of the bony vauIt, but aIso the carti1aginou.s structure and have ever the septum. Few rhinoIogists seen a thoroughIy straight septum in the aduIt which wouId Iead one to beIieve that incidenta nasal trauma suffered in chiIdhood resuIts in maIformation of growth. Too often a patient with a perceptibIy crooked septum can recaI1 no history of fracture. Unreduced nasa1 fractures are not onIy cosmeticaIIy unattractive but interfere with the physiology. ShouId the fracture occur earIy in Iife, growth of the structures may be impaired, and this must be kept in mind when reconstructive procedures are contempIated. (Fig. 7.) A severely traumatized nose shouId be considered fractured unti1 proved otherwise. When reducing an earIy fracture, the surgeon shouId attempt onIy to return the structures to their previous position. In this paper we shal1 dea1 primariIy with the deformities resuIting from un-
reduced nasa1 fractures, and report further on the experimenta and cIinica1 course of necrocartiIage. EVALUATION
OF THE
DEFORMITY
Pre-surgical Study. The surgica1 technic is eIastic and wiI1 depend on the type of deformity presented. In each case a pIaster cast is taken of the face. One side of the nose is measured and marked to indicate the desired size, shape and contour of the nose that wiI1 both correct the deformity and fit the patient’s face. If there is a depressed fracture or marked saddIe, modeIIing cIay is used to buiId up the deformity. Photographs are taken : profiIes, profiIes smiling, front view, the triangIe of the nose with the head tiIted backward. Nasal Septum. The presence of a deviated septum is not always an indication for a submucous resection. The Iatter shouId be performed onIy when it is causing a mechanica obstruction, or interfering with the norma physioIogy of the nose and accessory sinuses. Often a slight deviation in the presence of a vasomotor rhinitis or aIIergic condition wiI1 appear to be causing mechanica bIockage. Surgery on the septum wiI1 not aIIeviate this condition; the turbinates wiI1 merely bulge further to meet the waI1. The surgeon, therefore, shouId judge each case carefuIIy before performing a submucous resection. When this operation is indicated in cases of oId nasa1 fracture, it shouId be done thoroughIy. Merely removing a section of
* Presented in conjunction with colored surgical motion pictures as part of a series of FacuIty Lectures to the War-Time Graduate Medical Meetings (Army and Navy Genera1 Hospitals) Zone 24, under the auspices of the American MedicaI Association, the American College of Physicians and the American College of Surgeons. I44
-XIX.
No.
Lamont-NasaI
P.
a guiIty spur the : cartilagi nous septum, of the supposedIy or a smaI1 portion septum, wiI1 usuaIIy prove ohs Zructing
Fractures
American Journal of Surge rY
I 45
partner in causing the nose to be cro( lkczd. (Figs. 3, 4 and 6.) We have attempted many rnc:thoc dS in
A
FIG. I. Fracture of the nose with a depressed bridge, drzpped tip, flattened nostrik and disappearing columella. Complete reconstruction was required with insertion of a cartilage graft over the dorsum and within the coIumelIa.
quite disappointing both to the patient and the surgeon. UnIess sufficient ethmoid pIate, vomer, bony maxiIIary ridge and cartiIage are taken, the mucous membrane which becomes thickened after surgery mereIy bows over to its oId position. The surgeon shouId consider that once a submucous resection is done, the septum cannot be reoperated without danger of a perforation. When necessary, it has been found advisabIe to carry out the submucous resection four to five months foIIowing the nasa1 reconstruction. DispIacement of the septa1 cartiIage in the unreduced fractured nose is aImost the ruIe. The dispIacement not onIy interferes with the nasa1 physioIogy but is cosmeticaIIy unattractive as it protrudes from one nostri1 in many cases and often is a
reIocating the septum and hoIding it. in position. 4*g,13v14In some cases we have pierced it with a wire and run the Iatter to an opposite incisor; run a wire protected by a Iead pIate to the opposite aIa; made a circuIar incision aIong the septum to aIIow it to bend. We now use the foIIowing method and find it quite satisfactory: Prior to removing the required amount of septum from its inferior and anterior aspects, an one bIade Asch forceps is introduced, passing between the septum and disengaged coIumeIIa, the other paraIIe1 aIong the nasa1 ffoor. The cartiIaginous septum incIuding the vomer is tightIy grasped and forcibIy bent in the direction opposite to that of the deformity. After thorough Ioosening the septum is rocked severa times. The bIades of the Asch forceps are
146
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then passed upward, now grasping the cartilaginous septum and the ethmoid pIate; a simiIar procedure is repeated as
FIG.
Fractures
It is obvious that should a fracture disIocation occur during the growth and developmenta period, an interference with
2. Old nasal kacture with a twisted dorsum and a’markedly septum. A tota osteoplastic reconstruction was performed.
beIpw. Meticulous care is taken to sew the coIumelIa to the septum with interrupted siIk sutures. The resuIts have been quite satisfactory and we have had no untoward reactions. Brz’dge. The majority of fractures resuIt in injury associated with a disIocation of the nasaI bones. Less rareIy is the nasal process of the maxiIIary bone injured. With a shifting of the osseous structures, the upper IateraI cartiIages often suffer fracture or dislocation. (Figs. 2 and IO.) The upper IateraI cartiIages are a direct continuity of the CartiIaginous septum. Their posterior superior borders are in fibrous contact with the nasal bones and the ascending fronta process of the maxiIIa. The inferior border has a fibrous attachment to the Iower IateraI cartiIages.
AUGUST,,945
deviated
the bony and cartiIaginous bridge wiI1 affect the contour of the whoIe nose. Correction of the bony deformity is carried out by removing the anterior excess with bayonet bone saws, then performing a IateraI osteotomy through the nasa1 process of the maxilIary bones and deflecting the dista1 fragments mediaIIy. (Fig. 3.) A chise1 is introduced in the center of the osseous bridge between the nasal bones and the ethmoid pIate to gain greater freedom for the immobiIized maxiIIary fragments. The upper IateraI cartiIages are severed from the septum in the midIine and a hyperboIic wedge is taken on either side, which not onIy narrows the nose to the required measurements but aIso aIIows more breathing space.
NEW SERIES VOL.. LXIX, No. z
Lamont-NasaI
Tip. The contour and position of the nasa1 tip is determined by the lower IateraI cartiIages and the septum. Injury to
Fractures
American
Journal
of Surgery
147
IateraI cartilages may be buckIed and the tissues hypertrophied. (Figs. I and 9.) J **I Often the septum on the very tip may be
A
C
FIG. 3. Patient suffered a broken nose ten years ago. The septum was disIocated to the right and the Iower lateral cartilage on the same side was more prominent. A and c, depicting the associated congenitat deformity with a second degree hump, a dropped tip and reIativeIy Iong anteroposterior dimensions. B and D, after surgery: relocation of the septum into the vomer groove and complete reconstruction of the nose.
nasa1 structures may cause the tip to be droPP led, flattened, bent or asymmetricaL If the injury is of Iong standing, the Iower
bent causing the whoIe Iower half of t;he nose to be deviated to the affected Isicde. We have found the foIIowing procec dlIre
148
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Journal
of Surgery
Lamont-NasaI
Fractures
A
FIG. 4. A nasal fracture in chiIdhood caused a septl disIocation with deviation of the septum but no marked bIockage of breathing. The septum was relocated with an Asch forceps while carrying out the nasa1 pIastic operation.
FIG. 3. Author’s nasal saws: The handles are rounded and bevelIed to fit the operator’s paIm. Thumb rests on the two dorsal saws assure a firmer grasp. The teeth are in a doubIe row bevelted to a “V.” Guards constructed for the cutting edge of the saws prevent injury to the teeth while they are being autocIaved and handled.
NEW SERIES VOL.LXIX, No. z
Lamont-NasaI
be effective in the correction of‘ such a The septaI mucous membrane and on the affected side is undermined
EL !ormity.
Fractures
American Journal of Surgery
‘49
spine; each succeeding incision more forward. The knife is carried through to the opposite mucous membrane Iining anId a
FIG. 6. OId nasa1 fracture with dislocation of the septum. A and c show the twisted bridge, asymmetrica nostriIs and reIativeIy Iong anteroposterior tip dimensions. B and D, after surgery; the bridge and tip have been reconstructed in conjunction with Aocation of the septum.
rail sed. Two or three circuIar incisions are ma de on the septum extending from its mici-anterior aspect down to the nasa1
sIiver of septum removed in each posit .ion. The reffected mucous membrane is returned to position and severa throw Igh-
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Fractures
FIG. 7. Fracture of the nose suffered in childhood, resuIting in injury to the vomer and causing maIdeveIopment of the septum. A, B and c demonstrate the saddle bridge with a disappearing coIumeIIa. The plaster cast modeIIed with clay depicts the required cartiIage graft and plan of reconstruction. D, cartilage was prepared and sculptured to the required measurements. The grafts were then inserted intranasaIIy.
NEW SERIES VOL. LXIX.
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2
and-through staggered between the separated cartiIage.
sutures are taken sections of septal
Fractures
American
Journal of Surgery
151
and human cartilage, metals, paraffin and many others have been included. Several years ago we began to foIlow
FIG. 8. Old fractured n”,se in conjunction with a markedly deviated se;tum. A compIete nasal reconstruction was required. Two smaI1 rounded plates of cartiIage were placed immediately beneath the lower curve of the aIae to elevate their position. A thorough submucous resection was performed four months later.
Reconstruction of the Iower IateraI cartiIages shouId be done meticuIousIy. They are first dissected free without disturbing the nasal Iining and thoroughIy undermined away from their beds.* The requisite amount is then removed aIIowing the IateraI crus to &de mediaIty and form the new tip. We do not hesitate to go beIow the arch mediaIIy when attempting to decrease the antero posterior dimensions of the nasa1 tip. When necessary a suture is pIaced between the septum and the coIumeIIa-phiItrum ang1e.l The intranasa1 incisions are carefuIIy sutured with siIk. DEFORMITIES
REQUIRING
THE
ADDITION
OF
CARTILAGE
Various materiaIs have been used to reconstruct absent skeletal and cartiIaginous tissue of the nose.3,10*11 Human and ceIIuIoid, anima1 animaI bone, ivory,
the course of necrocartiIage both experimentaIIy and cIinicaIIy in the human.6v7 Experimental Method. Rib cartiIage is taken from patients in exitus and the perichondrium removed. It is fixed in formaIdehyde soIution (4 per cent formaIin) four days, washed, then refrigerated in coIorIess merthioIate solution I : I ,000. When cartiIage was required to repair a defect, a section was taken from the same piece and pIaced beneath the skin of the anterior abdomina1 waI1. In chronoIogica1 periods of time, i.e., a week, a month, six months, a year, two years and three years, the cartiIage was removed from the anterior abdomina waI1 and examined microscopicaIIy. Pieces of the same cartiIage were retained in the merthioIate solution, refrigerated and examined at the identicai times for comparison. Sections of autogenous rib cartiIage were simiIarIy folIowed for comparison.
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Fractures
A
B
FIG. 9. Injury to the nose resulting in flattened upper dropped tip, deformed nostrik and disappearing reconstruction with a cartilage graft to the columella.
A
IateraI cartilages, columella. TotaI
B
FIG. IO. Old fracture of the nose in conjunction with a congenital deformity. CompIete nasal reconstruction required with relocation of the septum into the vomer groove. The bridge was Iowered and the tip reconstructed to the required size.
NEW SERIES VOL. LXIX.
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Evaluation of Results. CartiIage removed from the pocket in the anterior abdominal waII and examined after one week, demonstrated the centra1 ceIIs to be bIue stained, with prominent nucIei. In some places the ceIIs were vacuoIated. The periphery stained pink with moderate dissolution of the cartiIage ceIIs. After forty-four days, microscopic examination of a simiIar piece of cartiIage removed from the anterior abdomina1 waI1 revealed a somewhat identica1 picture with little other change in the cartilage. One piece of necrocartiIage removed from the anterior abdomina1 waI1 after three years presented a solid piece of cartilage that grossIy resembIed freshIy prepared necrocartilage. When cut, its consistency was simiIar and there were no areas of disintegration. Microscopically, the cartiIage showed some fibrotic invasion of the periphery and the ceIIs stained pink. CentraIIy the cartiIage ceIIs accepted a bIuish stain and appeared simiIar to the sections examined after forty-four days. NASAL
DEPRESSIONS
REPAIRED
WITH
CARTILAGE
A pIaster cast of the patient’s face is taken and modeIIing cIay is utiIized to reconstruct the nasa1 defect. Refrigerated necrocartiIage is then, scuIptured to conform to the clay model. SeveraI smaI1 hoIes are bored in the cartiIage to aIIow the entrance of granuIation tissue and thus “rivet” the cartiIage in pIace. After the cartiIage has been scuIptured to the required measurements it is returned to the merthioIate soIution and refrigerated unti1 needed for the surgery. Surgical Method. Often a CartiIaginous strut when inserted intranasaIIy wiI1 improve the defect but wiI1 not gain the best cosmetic and functional resuIt. The presence of a depression of the bridge or a disappearing coIumeIIa is not an indication to forego the reconstruction of the remainder of the nose. If necessary, we may narrow the bridge, remove the required
Fractures
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American Journal of Surgery
amount of upper IateraI cartiIage, reconstruct the tip and carry out such procedures that wiI1 effect a more pIeasing resuIt. When cartiIage is empIoyed over
the
bridge,
the
upper
an incision and
Iower
is made Iateral
between
cartiIages
and
a
pocket created that will meet the size of the impIant. The Iatter is sprinkIed with suIfaniIamide
crystaIs,
inserted
and
the
incision in the mucous membrane sutured with bIack siIk. The nose is IightIy packed with gauze, and carefu1 adhesive tape dressings are applied. By preparing the cartiIage implant severa days prior to surgery and aIIowing it to refrigerate in an antiseptic soIution, it is handIed a minimum in the surgery and so offsets the threat of infection. CartiIage thus prepared may be empIoyed as framework for any part of the nose, i.e., a strut in the coIumeIIa from the tip to the nasal spine, or at the point where the phiItrum meets the coIumeIIa to repair a depression of the Iatter. Clinical Results. We have used necrocartilage intranasaIIy in seventy-five cases. Some in this series have been folIowed over a period of three years. CarefuI examination reveaIs no marked cIinica1 change of these cartiIaginous implants. We have lost cartiIage in onIy two cases. Both were at the coIumeIIar-phiItrum juncture for repair of a depression. In the first, the patient suffered a severe bIow on the nose one week after surgery. In the second, we believe the pocket was made too small to house the strut of cartilage and as a resuIt it began to extrude the day foIIowing surgery. In comparison, the clinica course of necrocartiIage is simiIar to that of autogenous cartiIage. Its advantages are obvious in that no chest operation is necessary, it may be modeIIed before surgery, the quantity is not Iimited, and, too, we beIieve that aIIowing it to remain for a time in refrigeration gives it an opportunity to curl in vitro rather than in vivo.
I54
American Journal of Surgery
Lamont-NasaI
CONCLUSIONS I. The unreduced fractured nose must be reconstructed physioIogicaIIy as we11 as cosmeticaIIv. 2. NecroiartiIage has proved a vaIuabIe adjunct in repairing nasa1 depressions. 3. CarefuI preoperative study is mandatory to gain the required result. REFERENCES I. AUFRICHT, GUSTAVE, A few hints and surgical de-
tails in rhinoplasty. Laryngoscope, 53: 3 I 7, 1943. 2. BROWN, JAMES B. Reconstructive surgery of the nose. Nelson Loose Leaf Surgery, 8: 237-266, chap. II, 1940. 7. BROWN. JAMES B. Preserved and fresh hemotranspIants of cartilage. Surg., Gynec. PY Obst.,
.e
7: 599, 1941. 4. COHEN, SAMUEL. RoIe of the septum in surgery of the nasa1 contour. Arch. Otolaryngol., 31: 12-20, 1939. 5. FOMON, SAMUEL. The treatment of oId unreduced nasa1 fractures. Ann. Surg., 104: 107-117, 1936. 6. LAMONT, EDWARD S. PIastic surgery in recon-
Fractures
AUGUST.r!x~
strutting the partiaIIy absent nose. Ann. Otol., Rbinol. @ Laryngol., 53: 561-568, ,944. 7. LAMONT, EDWARDS. Reconstructive plastic surgery of the absent ear with necrocartiIage. Arch. Surg., 48: 53-72, ‘944. 8. LAMONT. EDWARD S. Reconstructive surgerv Y I of the nosein congenital deformity, injury and disease. Am. J. Surg., 65: 17-45. 1944. 9. METZENBAUM, MYRON. Dislocation of the Iower end of the nasal septum. Arch. Surg., 24: 78-88,
1936.
10. PEER, LYNDON A. Plastic surgery for 1942. Arch. Otofaryngol., 38: 171-189, 1943. I I. PIERCE, G. W. and O’CONNOR, G. B. Reconstructive surgery of the nose. Ann. Otol., Rbinol. ti Laryngol., i7: 437, 1938. 12. SAFIAN, J. and TAMERIN, J. Recent fractures of the Am. J. Surg., 31.: 10-23, 1936. 13. SPLINGER, SAMUEL. Traumatic deformities of the nasal septum. Ann. Otol., Rbinol. c~ Laryngol., 53: 274, ‘944. 14. SHEEHAN, J. E. Plastic Surgery of the Nose. New York, 1936. Paul Hoeber, Inc. 15. SMITH, FERRIS. Reconstructive surgery of the head and neck. NeIson Loose Leaf System. New York, 1928. Thomas Nelson and Sons. 16. STRAITH, C. L. and DE KLEINE, E. H. Modern management of the fractured nose. Collective Review. Internal. Abstr. Surg., 66: g-15, 1938.
nose..
F
of the nose are freRACTURES quentIy overIooked. The initiaI sweIIing, coupled with frequent epistaxis and ecchymosis mask the normaI nasa1 contour, so that gross deformity may not be apparent. LateraI x-rays are often heIpfu1 but these too’ may be misIeading. Thorough examination may be painfu1 and the patient is a11 too ready to persuade the surgeon that there is no fracture. Many papers have been written on the signs, symptoms and treatment of early fractures.2,j,12,1j,16 Stress has been Iaid, not onIy on restoration of the bony vauIt, but aIso the carti1aginou.s structure and have ever the septum. Few rhinoIogists seen a thoroughIy straight septum in the aduIt which wouId Iead one to beIieve that incidenta nasal trauma suffered in chiIdhood resuIts in maIformation of growth. Too often a patient with a perceptibIy crooked septum can recaI1 no history of fracture. Unreduced nasa1 fractures are not onIy cosmeticaIIy unattractive but interfere with the physiology. ShouId the fracture occur earIy in Iife, growth of the structures may be impaired, and this must be kept in mind when reconstructive procedures are contempIated. (Fig. 7.) A severely traumatized nose shouId be considered fractured unti1 proved otherwise. When reducing an earIy fracture, the surgeon shouId attempt onIy to return the structures to their previous position. In this paper we shal1 dea1 primariIy with the deformities resuIting from un-
reduced nasa1 fractures, and report further on the experimenta and cIinica1 course of necrocartiIage. EVALUATION
OF THE
DEFORMITY
Pre-surgical Study. The surgica1 technic is eIastic and wiI1 depend on the type of deformity presented. In each case a pIaster cast is taken of the face. One side of the nose is measured and marked to indicate the desired size, shape and contour of the nose that wiI1 both correct the deformity and fit the patient’s face. If there is a depressed fracture or marked saddIe, modeIIing cIay is used to buiId up the deformity. Photographs are taken : profiIes, profiIes smiling, front view, the triangIe of the nose with the head tiIted backward. Nasal Septum. The presence of a deviated septum is not always an indication for a submucous resection. The Iatter shouId be performed onIy when it is causing a mechanica obstruction, or interfering with the norma physioIogy of the nose and accessory sinuses. Often a slight deviation in the presence of a vasomotor rhinitis or aIIergic condition wiI1 appear to be causing mechanica bIockage. Surgery on the septum wiI1 not aIIeviate this condition; the turbinates wiI1 merely bulge further to meet the waI1. The surgeon, therefore, shouId judge each case carefuIIy before performing a submucous resection. When this operation is indicated in cases of oId nasa1 fracture, it shouId be done thoroughIy. Merely removing a section of
* Presented in conjunction with colored surgical motion pictures as part of a series of FacuIty Lectures to the War-Time Graduate Medical Meetings (Army and Navy Genera1 Hospitals) Zone 24, under the auspices of the American MedicaI Association, the American College of Physicians and the American College of Surgeons. I44
-XIX.
No.
Lamont-NasaI
P.
a guiIty spur the : cartilagi nous septum, of the supposedIy or a smaI1 portion septum, wiI1 usuaIIy prove ohs Zructing
Fractures
American Journal of Surge rY
I 45
partner in causing the nose to be cro( lkczd. (Figs. 3, 4 and 6.) We have attempted many rnc:thoc dS in
A
FIG. I. Fracture of the nose with a depressed bridge, drzpped tip, flattened nostrik and disappearing columella. Complete reconstruction was required with insertion of a cartilage graft over the dorsum and within the coIumelIa.
quite disappointing both to the patient and the surgeon. UnIess sufficient ethmoid pIate, vomer, bony maxiIIary ridge and cartiIage are taken, the mucous membrane which becomes thickened after surgery mereIy bows over to its oId position. The surgeon shouId consider that once a submucous resection is done, the septum cannot be reoperated without danger of a perforation. When necessary, it has been found advisabIe to carry out the submucous resection four to five months foIIowing the nasa1 reconstruction. DispIacement of the septa1 cartiIage in the unreduced fractured nose is aImost the ruIe. The dispIacement not onIy interferes with the nasa1 physioIogy but is cosmeticaIIy unattractive as it protrudes from one nostri1 in many cases and often is a
reIocating the septum and hoIding it. in position. 4*g,13v14In some cases we have pierced it with a wire and run the Iatter to an opposite incisor; run a wire protected by a Iead pIate to the opposite aIa; made a circuIar incision aIong the septum to aIIow it to bend. We now use the foIIowing method and find it quite satisfactory: Prior to removing the required amount of septum from its inferior and anterior aspects, an one bIade Asch forceps is introduced, passing between the septum and disengaged coIumeIIa, the other paraIIe1 aIong the nasa1 ffoor. The cartiIaginous septum incIuding the vomer is tightIy grasped and forcibIy bent in the direction opposite to that of the deformity. After thorough Ioosening the septum is rocked severa times. The bIades of the Asch forceps are
146
American Journal of Surgery
Lamont-NasaI
then passed upward, now grasping the cartilaginous septum and the ethmoid pIate; a simiIar procedure is repeated as
FIG.
Fractures
It is obvious that should a fracture disIocation occur during the growth and developmenta period, an interference with
2. Old nasal kacture with a twisted dorsum and a’markedly septum. A tota osteoplastic reconstruction was performed.
beIpw. Meticulous care is taken to sew the coIumelIa to the septum with interrupted siIk sutures. The resuIts have been quite satisfactory and we have had no untoward reactions. Brz’dge. The majority of fractures resuIt in injury associated with a disIocation of the nasaI bones. Less rareIy is the nasal process of the maxiIIary bone injured. With a shifting of the osseous structures, the upper IateraI cartiIages often suffer fracture or dislocation. (Figs. 2 and IO.) The upper IateraI cartiIages are a direct continuity of the CartiIaginous septum. Their posterior superior borders are in fibrous contact with the nasal bones and the ascending fronta process of the maxiIIa. The inferior border has a fibrous attachment to the Iower IateraI cartiIages.
AUGUST,,945
deviated
the bony and cartiIaginous bridge wiI1 affect the contour of the whoIe nose. Correction of the bony deformity is carried out by removing the anterior excess with bayonet bone saws, then performing a IateraI osteotomy through the nasa1 process of the maxilIary bones and deflecting the dista1 fragments mediaIIy. (Fig. 3.) A chise1 is introduced in the center of the osseous bridge between the nasal bones and the ethmoid pIate to gain greater freedom for the immobiIized maxiIIary fragments. The upper IateraI cartiIages are severed from the septum in the midIine and a hyperboIic wedge is taken on either side, which not onIy narrows the nose to the required measurements but aIso aIIows more breathing space.
NEW SERIES VOL.. LXIX, No. z
Lamont-NasaI
Tip. The contour and position of the nasa1 tip is determined by the lower IateraI cartiIages and the septum. Injury to
Fractures
American
Journal
of Surgery
147
IateraI cartilages may be buckIed and the tissues hypertrophied. (Figs. I and 9.) J **I Often the septum on the very tip may be
A
C
FIG. 3. Patient suffered a broken nose ten years ago. The septum was disIocated to the right and the Iower lateral cartilage on the same side was more prominent. A and c, depicting the associated congenitat deformity with a second degree hump, a dropped tip and reIativeIy Iong anteroposterior dimensions. B and D, after surgery: relocation of the septum into the vomer groove and complete reconstruction of the nose.
nasa1 structures may cause the tip to be droPP led, flattened, bent or asymmetricaL If the injury is of Iong standing, the Iower
bent causing the whoIe Iower half of t;he nose to be deviated to the affected Isicde. We have found the foIIowing procec dlIre
148
American
Journal
of Surgery
Lamont-NasaI
Fractures
A
FIG. 4. A nasal fracture in chiIdhood caused a septl disIocation with deviation of the septum but no marked bIockage of breathing. The septum was relocated with an Asch forceps while carrying out the nasa1 pIastic operation.
FIG. 3. Author’s nasal saws: The handles are rounded and bevelIed to fit the operator’s paIm. Thumb rests on the two dorsal saws assure a firmer grasp. The teeth are in a doubIe row bevelted to a “V.” Guards constructed for the cutting edge of the saws prevent injury to the teeth while they are being autocIaved and handled.
NEW SERIES VOL.LXIX, No. z
Lamont-NasaI
be effective in the correction of‘ such a The septaI mucous membrane and on the affected side is undermined
EL !ormity.
Fractures
American Journal of Surgery
‘49
spine; each succeeding incision more forward. The knife is carried through to the opposite mucous membrane Iining anId a
FIG. 6. OId nasa1 fracture with dislocation of the septum. A and c show the twisted bridge, asymmetrica nostriIs and reIativeIy Iong anteroposterior tip dimensions. B and D, after surgery; the bridge and tip have been reconstructed in conjunction with Aocation of the septum.
rail sed. Two or three circuIar incisions are ma de on the septum extending from its mici-anterior aspect down to the nasa1
sIiver of septum removed in each posit .ion. The reffected mucous membrane is returned to position and severa throw Igh-
150
American Journal of Surgery
Lamont-NasaI
Fractures
FIG. 7. Fracture of the nose suffered in childhood, resuIting in injury to the vomer and causing maIdeveIopment of the septum. A, B and c demonstrate the saddle bridge with a disappearing coIumeIIa. The plaster cast modeIIed with clay depicts the required cartiIage graft and plan of reconstruction. D, cartilage was prepared and sculptured to the required measurements. The grafts were then inserted intranasaIIy.
NEW SERIES VOL. LXIX.
No.
Lamont-NasaI
2
and-through staggered between the separated cartiIage.
sutures are taken sections of septal
Fractures
American
Journal of Surgery
151
and human cartilage, metals, paraffin and many others have been included. Several years ago we began to foIlow
FIG. 8. Old fractured n”,se in conjunction with a markedly deviated se;tum. A compIete nasal reconstruction was required. Two smaI1 rounded plates of cartiIage were placed immediately beneath the lower curve of the aIae to elevate their position. A thorough submucous resection was performed four months later.
Reconstruction of the Iower IateraI cartiIages shouId be done meticuIousIy. They are first dissected free without disturbing the nasal Iining and thoroughIy undermined away from their beds.* The requisite amount is then removed aIIowing the IateraI crus to &de mediaIty and form the new tip. We do not hesitate to go beIow the arch mediaIIy when attempting to decrease the antero posterior dimensions of the nasa1 tip. When necessary a suture is pIaced between the septum and the coIumeIIa-phiItrum ang1e.l The intranasa1 incisions are carefuIIy sutured with siIk. DEFORMITIES
REQUIRING
THE
ADDITION
OF
CARTILAGE
Various materiaIs have been used to reconstruct absent skeletal and cartiIaginous tissue of the nose.3,10*11 Human and ceIIuIoid, anima1 animaI bone, ivory,
the course of necrocartiIage both experimentaIIy and cIinicaIIy in the human.6v7 Experimental Method. Rib cartiIage is taken from patients in exitus and the perichondrium removed. It is fixed in formaIdehyde soIution (4 per cent formaIin) four days, washed, then refrigerated in coIorIess merthioIate solution I : I ,000. When cartiIage was required to repair a defect, a section was taken from the same piece and pIaced beneath the skin of the anterior abdomina1 waI1. In chronoIogica1 periods of time, i.e., a week, a month, six months, a year, two years and three years, the cartiIage was removed from the anterior abdomina waI1 and examined microscopicaIIy. Pieces of the same cartiIage were retained in the merthioIate solution, refrigerated and examined at the identicai times for comparison. Sections of autogenous rib cartiIage were simiIarIy folIowed for comparison.
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Fractures
A
B
FIG. 9. Injury to the nose resulting in flattened upper dropped tip, deformed nostrik and disappearing reconstruction with a cartilage graft to the columella.
A
IateraI cartilages, columella. TotaI
B
FIG. IO. Old fracture of the nose in conjunction with a congenital deformity. CompIete nasal reconstruction required with relocation of the septum into the vomer groove. The bridge was Iowered and the tip reconstructed to the required size.
NEW SERIES VOL. LXIX.
No. z
Lamont-NasaI
Evaluation of Results. CartiIage removed from the pocket in the anterior abdominal waII and examined after one week, demonstrated the centra1 ceIIs to be bIue stained, with prominent nucIei. In some places the ceIIs were vacuoIated. The periphery stained pink with moderate dissolution of the cartiIage ceIIs. After forty-four days, microscopic examination of a simiIar piece of cartiIage removed from the anterior abdomina1 waI1 revealed a somewhat identica1 picture with little other change in the cartilage. One piece of necrocartiIage removed from the anterior abdomina1 waI1 after three years presented a solid piece of cartilage that grossIy resembIed freshIy prepared necrocartilage. When cut, its consistency was simiIar and there were no areas of disintegration. Microscopically, the cartiIage showed some fibrotic invasion of the periphery and the ceIIs stained pink. CentraIIy the cartiIage ceIIs accepted a bIuish stain and appeared simiIar to the sections examined after forty-four days. NASAL
DEPRESSIONS
REPAIRED
WITH
CARTILAGE
A pIaster cast of the patient’s face is taken and modeIIing cIay is utiIized to reconstruct the nasa1 defect. Refrigerated necrocartiIage is then, scuIptured to conform to the clay model. SeveraI smaI1 hoIes are bored in the cartiIage to aIIow the entrance of granuIation tissue and thus “rivet” the cartiIage in pIace. After the cartiIage has been scuIptured to the required measurements it is returned to the merthioIate soIution and refrigerated unti1 needed for the surgery. Surgical Method. Often a CartiIaginous strut when inserted intranasaIIy wiI1 improve the defect but wiI1 not gain the best cosmetic and functional resuIt. The presence of a depression of the bridge or a disappearing coIumeIIa is not an indication to forego the reconstruction of the remainder of the nose. If necessary, we may narrow the bridge, remove the required
Fractures
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American Journal of Surgery
amount of upper IateraI cartiIage, reconstruct the tip and carry out such procedures that wiI1 effect a more pIeasing resuIt. When cartiIage is empIoyed over
the
bridge,
the
upper
an incision and
Iower
is made Iateral
between
cartiIages
and
a
pocket created that will meet the size of the impIant. The Iatter is sprinkIed with suIfaniIamide
crystaIs,
inserted
and
the
incision in the mucous membrane sutured with bIack siIk. The nose is IightIy packed with gauze, and carefu1 adhesive tape dressings are applied. By preparing the cartiIage implant severa days prior to surgery and aIIowing it to refrigerate in an antiseptic soIution, it is handIed a minimum in the surgery and so offsets the threat of infection. CartiIage thus prepared may be empIoyed as framework for any part of the nose, i.e., a strut in the coIumeIIa from the tip to the nasal spine, or at the point where the phiItrum meets the coIumeIIa to repair a depression of the Iatter. Clinical Results. We have used necrocartilage intranasaIIy in seventy-five cases. Some in this series have been folIowed over a period of three years. CarefuI examination reveaIs no marked cIinica1 change of these cartiIaginous implants. We have lost cartiIage in onIy two cases. Both were at the coIumeIIar-phiItrum juncture for repair of a depression. In the first, the patient suffered a severe bIow on the nose one week after surgery. In the second, we believe the pocket was made too small to house the strut of cartilage and as a resuIt it began to extrude the day foIIowing surgery. In comparison, the clinica course of necrocartiIage is simiIar to that of autogenous cartiIage. Its advantages are obvious in that no chest operation is necessary, it may be modeIIed before surgery, the quantity is not Iimited, and, too, we beIieve that aIIowing it to remain for a time in refrigeration gives it an opportunity to curl in vitro rather than in vivo.
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American Journal of Surgery
Lamont-NasaI
CONCLUSIONS I. The unreduced fractured nose must be reconstructed physioIogicaIIy as we11 as cosmeticaIIv. 2. NecroiartiIage has proved a vaIuabIe adjunct in repairing nasa1 depressions. 3. CarefuI preoperative study is mandatory to gain the required result. REFERENCES I. AUFRICHT, GUSTAVE, A few hints and surgical de-
tails in rhinoplasty. Laryngoscope, 53: 3 I 7, 1943. 2. BROWN, JAMES B. Reconstructive surgery of the nose. Nelson Loose Leaf Surgery, 8: 237-266, chap. II, 1940. 7. BROWN. JAMES B. Preserved and fresh hemotranspIants of cartilage. Surg., Gynec. PY Obst.,
.e
7: 599, 1941. 4. COHEN, SAMUEL. RoIe of the septum in surgery of the nasa1 contour. Arch. Otolaryngol., 31: 12-20, 1939. 5. FOMON, SAMUEL. The treatment of oId unreduced nasa1 fractures. Ann. Surg., 104: 107-117, 1936. 6. LAMONT, EDWARD S. PIastic surgery in recon-
Fractures
AUGUST.r!x~
strutting the partiaIIy absent nose. Ann. Otol., Rbinol. @ Laryngol., 53: 561-568, ,944. 7. LAMONT, EDWARDS. Reconstructive plastic surgery of the absent ear with necrocartiIage. Arch. Surg., 48: 53-72, ‘944. 8. LAMONT. EDWARD S. Reconstructive surgerv Y I of the nosein congenital deformity, injury and disease. Am. J. Surg., 65: 17-45. 1944. 9. METZENBAUM, MYRON. Dislocation of the Iower end of the nasal septum. Arch. Surg., 24: 78-88,
1936.
10. PEER, LYNDON A. Plastic surgery for 1942. Arch. Otofaryngol., 38: 171-189, 1943. I I. PIERCE, G. W. and O’CONNOR, G. B. Reconstructive surgery of the nose. Ann. Otol., Rbinol. ti Laryngol., i7: 437, 1938. 12. SAFIAN, J. and TAMERIN, J. Recent fractures of the Am. J. Surg., 31.: 10-23, 1936. 13. SPLINGER, SAMUEL. Traumatic deformities of the nasal septum. Ann. Otol., Rbinol. c~ Laryngol., 53: 274, ‘944. 14. SHEEHAN, J. E. Plastic Surgery of the Nose. New York, 1936. Paul Hoeber, Inc. 15. SMITH, FERRIS. Reconstructive surgery of the head and neck. NeIson Loose Leaf System. New York, 1928. Thomas Nelson and Sons. 16. STRAITH, C. L. and DE KLEINE, E. H. Modern management of the fractured nose. Collective Review. Internal. Abstr. Surg., 66: g-15, 1938.
nose..