Management of Comminuted Nasal Bone Fracture with Septal Deviation

Initial Assessment and Approach

Septal correction must precede any nasal bone realignment work, as the position of other nasal structures is largely determined by septal position, according to the American Academy of Otolaryngology 1

Position the septum into the midline using a transverse root osteotomy, as recommended by the American Academy of Facial Plastic and Reconstructive Surgery 2
In most cases, place a strut between the medial crura for support and realignment, according to the American Rhinologic Society 1
A strut allows resection of the most caudal part of the deviated septum without risking columellar retraction, as noted by the American Academy of Otolaryngology 1

For severe bony deviation without dorsal lowering, use the "opening a book" technique, which involves working from the less deviated side, performing lateral osteotomy followed by medial osteotomy and outfracturing, as described by the European Rhinologic Society 3, 4, 5
Perform lateral osteotomy on the opposite side followed by infracturing, and smooth irregularities using a fine rasp, as recommended by the American Academy of Facial Plastic and Reconstructive Surgery 2, 4, 6
To minimize destabilization of the osseous framework, preserve periosteal and mucosal attachments of the nasal bone, and use the smallest possible manipulative force necessary to achieve reduction, according to the American Rhinologic Society 3, 7

For unilateral concavity in the middle third of the nose, use spreader grafts if concavity is associated with nasal valve collapse, and use simple onlay grafts if airway is adequate, as recommended by the American Academy of Otolaryngology 8, 9
For the nasal tip, reshape, reorient, and restructure alar cartilages using a combination of conservative reduction, suture repositioning, and grafting techniques, according to the American Academy of Facial Plastic and Reconstructive Surgery 1

When complete correction is impossible using reduction and osteotomy techniques alone, consider camouflaging techniques, such as using onlay techniques to visually straighten concave or depressed nasal bones, as described by the European Rhinologic Society 9
Apply dorsal onlay grafts to hide residual deviations, and use septal cartilage cut in thin wafers with minimal crushing as the material of choice, according to the American Rhinologic Society 8, 9

Short nasal bones are a relative contraindication for osteotomies, as they risk bony communication while yielding limited results, as noted by the American Academy of Otolaryngology 9
Intermediate osteotomies performed halfway up the nasal bone risk visible irregularities or step-off deformities, especially where skin covering is thin, according to the American Rhinologic Society 8, 10
If the nose has no hump, a unilateral vertical osteotomy will achieve limited results since movement toward the septum is restricted by the dorsal plateau, as described by the European Rhinologic Society 5