THE INJURED AND CROOKED NOSE

Nasal trauma secondary to sports injuries or altercations is relatively common among men.

Most patients have complaints of difficulty breathing through the nose, and some may also point out an aesthetic deformity, such as a crooked shape. In the majority of cases, the patient is primarily interested in an open nasal airway. When offered surgery to correct a deviated septum, some may also ask for correction of the external deformity, thus returning the nose to the preinjured state (Fig. 23). A few patients may ask for additional refinements, such as reducing a dorsal hump or narrowing a wide tip (Fig. 24).

	Fig. 23. A and B, This 23-year-old man sustained a nasal fracture while playing basketball, which is the most common sport causing nasal injuries in our practice. Simple osteotomies and onlay grafts improved the external appearance of the nose, and a septoplasty opened the airway. The nose was essentially brought back to its preinjury state without other modifications.

	Fig. 24. A and B, This 17-year-old man was injured while playing baseball. His surgery consisted of septoplasty and osteotomies to return the nose to the midline. He requested minor dorsal modification and tip narrowing, which was accomplished with a double-dome technique and cephalic trimming.

Closed reduction techniques with or without septoplasty may be applied to a few select cases where the deformity is small. Roughly 50% of closed or open simple reductions fail and later require a reconstructive rhinoplasty. These failures relate to the fact that because nasal bone fractures are irregular, they do not heal evenly and may undergo callus or spicule formation. It therefore seems prudent to wait, allow for the posttraumatic edema to resolve, and then perform septorhinoplasty. Patients who have had prior unsuccessful rhinoplasty prove particularly challenging at the time of revision because the surgeon is faced with a greater degree of scarring, intranasal adhesions, loss of intrinsic skeletal support, and functional difficulties (Fig. 25).

	Fig. 25. A, This 32-year-old man fractured his nose and then had four prior nasal surgeries. The middle third of his nose was deviated off to the right. The left upper lateral cartilage was avulsed from the nasal bone and depressed inward. Conchal cartilage grafts were needed to achieve symmetry. Spreader grafts and alar rim grafts were necessary in addition to medial and lateral osteotomies and an extensive septoplasty with Iysis of adhesions. B, The patient was very happy with his result because his nose was now larger, wider, more symmetric, and he could breathe.

Patients need to be informed that a perfectly straight nose is very difficult to achieve because obstacles, such as severe deflection of the bony pyramid, a deviated and buckled septum, cartilage memory, overall facial asymmetry, and the healing process itself, may compromise this effort. In many cases, if questioned, the patient admits that a deviation of the nose was present prior to the most recent injury. The surgeon should note and point out any facial asymmetry. The primary goals of surgery should be (1) to restore a patent nasal airway and (2) to restore the nose to its preinjury appearance or better.

Osteotomies are standard and intuitively obvious; in cases where one nasal bone is significantly taller or more convex, then nasal bone trimming or intermediate osteotomies may be necessary. The most common obstacle to sufficient straightening of the nasal dorsum is inad equate correction of a high anterior septal deviation. Camouflage techniques utilizing crushed cartilage onlay grafts are particularly useful, especially in cases where a slight C-shaped depression persists after the use of osteotomies or spreader grafts (Fig. 26). In cases where there is collapse of the upper lateral cartilages or nasal valve compromise, spreader grafts again may be utilized, often in conjunction with external valve grafts.

	Fig. 26. A and C, This 18-year-old man had a history of repeated nasal trauma and marked nasal airway obstruction. He disliked the marked broadness to his nasal dorsum and the overprojection of his nasal tip, which appeared too sharp to him. The postoperative results in B and D show effective narrowing of the dorsum and thinning of the nasal tip. Medial and lateral osteotomies as well as narrowing of the bony radix and separation of the upper lateral cartilages from the septum were necessary to narrow the nose. A double-dome technique was used to thin the nasal tip. A lateral crural overlay technique was used to decrease the projection and improve rotation of the nose. The lateral view shows some rounding of the nasal tip secondary to the large amount of retrodisplacement obtained with the lateral crural overlay technique in a thick-skinned individual.