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Efficacy of closed reduction of nasal fractures—a retrospective analysis with focus on factors affecting functional and aesthetic outcomes

  • Author Footnotes
    # I. Besmens and C Shahrdar have contributed equally to this work and share first authorship
    Inga S. Besmens
    Footnotes
    # I. Besmens and C Shahrdar have contributed equally to this work and share first authorship
    Affiliations
    Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
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  • Author Footnotes
    # I. Besmens and C Shahrdar have contributed equally to this work and share first authorship
    Charlotte Shahrdar
    Footnotes
    # I. Besmens and C Shahrdar have contributed equally to this work and share first authorship
    Affiliations
    Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
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  • Duveken B.Y. Fontein
    Affiliations
    Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
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  • Sophie Knipper
    Affiliations
    Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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  • Pietro Giovanoli
    Affiliations
    Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
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  • Nicole Lindenblatt
    Correspondence
    Corresponding author: Nicole Lindenblatt, MD, Department of Plastic Surgery and Hand Surgery, UniversityHospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland, Tel: +41 44 255 11 11
    Affiliations
    Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
    Search for articles by this author
  • Author Footnotes
    # I. Besmens and C Shahrdar have contributed equally to this work and share first authorship
Open AccessPublished:November 23, 2022DOI:https://doi.org/10.1016/j.bjps.2022.11.010

      Summary

      Background

      Nasal bone fractures are the most common type of facial bone fractures. While the nasal anatomy and closed reduction techniques of nasal fractures are well described, there is a paucity of data reporting on the need for revision rhinoplasty. The objective of this study is to analyze the factors affecting the outcome and need for revision rhinoplasty in patients who underwent closed reduction for nasal bone fracture.

      Methods

      From 2010 to 2020, a total of 417 consecutive patients underwent closed nasal reduction. Medical files of the patients were reviewed retrospectively. The rate of rhinoplasty after fracture consolidation was determined. Factors influencing the need for revision rhinoplasty were assessed using univariable and multivariable logistic regression analyses.

      Results

      Forty-seven patients (11.3%) required revision rhinoplasty after fracture healing. Patients who had suffered an additional septum fracture were more likely to undergo rhinoplasty. The risk of the need for open revision rhinoplasty after fracture healing was increased for patients complaining of airway obstruction at the time of cast removal after closed reduction.

      Conclusion

      A certain number of patients will require secondary revision rhinoplasty after closed reduction of a nasal fracture. Subjective airway obstruction at the time of cast removal after closed reduction is a predictor for revision rhinoplasty. Prospective studies are required to support the findings of this investigation.

      Keywords

      Introduction

      Nasal bone fractures are the most common type of facial bone fractures.
      • Greathouse ST
      • Adkinson JM
      • Garza R
      • et al.
      Impact of Injury Mechanisms on Patterns and Management of Facial Fractures.
      They are caused by different trauma mechanisms, including traffic accidents, assault, external trauma from other objects, or falls.
      • Kim KS
      • Lee HG
      • Shin JH
      • Hwang JH
      • Lee SY.
      Trend analysis of nasal bone fracture.
      Accurate initial treatment after diagnosis, including closed reduction if indicated, is essential to prevent deformity and functional impairment.
      • Lu GN
      • Humphrey CD
      • Kriet JD.
      Correction of Nasal Fractures.
      Numerous guidelines have been described to refine and optimize acute nasal trauma management, but restoration of pretraumatic form and function remains a challenge.

      Higuera S, Lee EI, Cole P, Hollier LH, Stal S. Nasal Trauma and the Deviated Nose: Plast Reconstr Surg. 2007;120(Supplement 2):64S-75S. doi:10.1097/01.prs.0000260722.91183.50.

      The need for secondary revision rhinoplasty for postreduction nasal deformity is said to range from 14 to 50 per cent.
      • Farber SJ
      • Nguyen DC
      • Parikh RP
      • Jang JL
      • Woo AS.
      Improving Results in Closed Nasal Reduction: A Protocol for Reducing Secondary Deformity.
      Posttraumatic septorhinoplasty can be challenging, and the result may not always be predictable, which makes optimizing the initial treatment key for decreasing the need for secondary surgery. While the nasal anatomy and closed reduction techniques of nasal fractures are well described,
      • Farber SJ
      • Nguyen DC
      • Parikh RP
      • Jang JL
      • Woo AS.
      Improving Results in Closed Nasal Reduction: A Protocol for Reducing Secondary Deformity.
      there is a paucity of data reporting on the need for revision rhinoplasty and potentially confounding factors. The objective of this study is to analyze the factors affecting the outcome and need for revision rhinoplasty in patients who underwent closed reduction for nasal bone fracture.

      Patients and Methods

      From 2010 to 2020, a total of 417 consecutive patients received a closed nasal reduction at our department after having suffered from a nasal fracture. Medical files of the patients were reviewed retrospectively and analyzed for patient demographics, fracture characteristics, patient workup, surgical intervention, and outcome. The fractures of patients who received a computed tomography as part of their diagnostic workup were staged according to the nasal fracture classification proposed by Rohrich and Adams.
      • Rohrich RJ
      • Adams WP.
      Nasal Fracture Management: Minimizing Secondary Nasal Deformities.
      The areas targeted during revision rhinoplasty were assessed.

      Closed nasal reduction technique

      All patients received an administration of intravenous antibiotics (usually a 2nd generation cephalosporin) preoperatively. Otrivin-soaked swabs were placed in each nostril and left in place for 5–10 minutes. Reduction was performed using an elevator instrument and anteriorly directed traction. Reduction of the lateral nasal walls was achieved by lateral rotation of the elevator device and continued traction, external digital palpation verified proper reduction. In the case of a septal injury, reduction of the septum was achieved using Ash forceps. Proper reduction was verified clinically (straight alignment and palpation, both digitally and with the elevator). After reduction, silicone splints (without "airway") were inserted in patients with septal affection; these were secured to the septum with—a U-suture through the septum with PDS 4-0 with a straight needle. Patients without a septal fracture received gauze tamponades only. An external thermoplastic nasal splint was used on all patients.

      Outcomes of interest

      The rate of rhinoplasty after fracture consolidation was determined. Factors influencing the need for revision rhinoplasty were analyzed.

      Statistical analysis

      Descriptive statistics included frequencies and proportions for categorical variables. Means, medians, and ranges were reported for continuously coded variables. The Chi-square test tested the statistical significance in differences in proportions. The t test and Kruskal–Wallis test examined the statistical significance of means and median differences. Univariable and multivariable logistic regression models tested the relationship between the need for rhinoplasty and several variables, namely age, sex, time between trauma and closed reduction, open versus closed fractures, concomitant septal fracture, concomitant other facial fracture, initial cosmetic disturbance, airway obstruction, time of gauze, splint and cast removal, premature gauze or cast removal by the patient, secondary fractures. R software environment for statistical computing and graphics (version 3.4.3) was used for all statistical analyses. All tests were two sided with a level of significance set at p <0.05.

      Results

      Between 2010 and 2020, closed nasal reduction was performed in 417 consecutive patients with nasal bone fractures (306 male and 111 female patients) (Table 1). Illustrative cases can be found in Figures 1 to 5. The median patient age was 30 years (interquartile range [IQR] 23–45 years). Overall, 371 (89 %) patients had a closed fracture, while 46 (11 %) patients had open fractures. One third of all patients (139 patients, 33.3 %) suffered from an associated nasal septum fracture. A septal deviation visible in computed tomopraphy and/or clinically was present in 135 patients (32.4%), and a dislocation of the septum was noted in 59 patients (14.1%). Concomitant facial fractures were seen in 56 patients (13.4%). At the time of initial presentation, a visible nasal deformity was noted in 415 (99.5%) patients. One hundred ninety (45.6%) patients complained of an additional subjective airway obstruction. Two hundred seventy-nine (66.9%) patients received a CCT. These fractures were staged according to Rohrich and Adams (Table 2).
      Table 1Patient variables and their effect on the need for revision rhinoplasty.
      VariableOverallSecondary RSPP value
      370 (88.7)47 (11.3)
      Age (y)Median3030270.3
      IQR23-4523-4520.5-43
      Sex, n (%)female111 (26.6)97 (26.2)14 (29.8)0.7
      male306 (73.4)273 (73.8)33 (70.2)
      Mechanism of traumaassault147 (35.3)128 (34.6)19 (40.4)0.4
      polytrauma7 (1.7)5 (1.4)2 (4.3)
      slipping116 (27.8)106 (28.6)10 (21.3)
      sports103 (24.7)93 (25.1)10 (21.3)
      traffic44 (10.6)38 (10.3)6 (12.8)
      Cosmetic deformityNo2 (0.5)2 (0.5)0 (0)1
      Yes415 (99.5)368 (99.5)47 (100)
      Airway obstructionNo225 (54)204 (55.1)21 (44.7)0.3
      Yes190 (45.6)165 (44.6)25 (53.2)
      Prior nasal fractureNo271 (65)248 (67)23 (48.9)0.01
      Yes46 (11)36 (9.7)10 (21.3)
      Imaging modality, n (%)CT285 (68.3)249 (67.3)36 (76.6)0.3
      x-ray132 (31.7)121 (32.7)11 (23.4)
      Type of fracture, n (%)closed371 (89)333 (90)38 (80.9)0.1
      open46 (11)37 (10)9 (19.1)
      Associated septum fracture, n (%)No278 (66.7)254 (68.6)24 (51.1)0.02
      Yes139 (33.3)116 (31.4)23 (48.9)
      Impression fractureNo259 (62.1)232 (62.7)27 (57.4)0.7
      Yes155 (37.2)136 (36.8)19 (40.4)
      Concomitant facial fracturesNo361 (86.6)322 (87)39 (83)0.6
      Yes56 (13.4)48 (13)8 (17)
      Septal hematomaNo409 (98.1)363 (98.1)46 (97.9)0.7
      Yes8 (1.9)7 (1.8)1 (0.1)
      Septal deviationNo282 (67.6)259 (70)23 (48.9)0.006
      Yes135 (32.4)111 (30)24 (51.1)
      Dislocation of the septumNo358 (85.9)321 (86.8)37 (78.7)0.2
      Yes59 (14.1)49 (13.2)10 (21.3)
      Mucosal disruptionNo394 (94.5)351 (94.9)43 (91.5)0.5
      Yes23 (5.5)19 (5.1)4 (8.5)
      Time to reduction (d)Median6660.9
      IQR4-94-94-9
      Septal splint placementNo375 (89.9)337 (91.1)38 (80.9)0.05
      Yes42 (10.1)33 (8.9)9 (19.1)
      Time to gauze removal (d)Median2220.2
      IQR2-32-32-3
      Premature gauze removal by patientNo312 (74.8)274 (74.1)38 (80.9)0.5
      Yes61 (14.6)56 (15.1)5 (10.6)
      Time to cast removal (d)Median7770.7
      IQR7-87-87-9
      Premature cast removal by patientNo331 (79.4)297 (80.3)34 (72.3)0.1
      Yes72 (17.3)59 (15.9)13 (27.7)
      Airway obstruction after cast removalNo306 (73.4)283 (76.5)23 (48.9)<0.001
      Yes52 (12.5)36 (9.7)16 (34)
      Time to Doyle removal (d)Median141490.4
      IQR8-148-14.27-14
      Airway obstruction at last follow-upNo363 (87.1)351 (94.9)12 (25.5)<0.001
      Yes54 (12.9)19 (5.1)35 (74.5)
      Patient content with result at last follow-upNo64 (15.3)27 (7.3)37 (78.7)<0.001
      Yes353 (84.7)343 (92.7)10 (21.3)
      Figure 1
      Figure 1(a) While ice skating, this 27-year-old female patient fell and sustained a dislocated nasal fracture (b and c). Because of an obvious axial deviation, the indication for closed reduction was given.
      Figure 2
      Figure 2(a-c) In the postreduction course, the patient complained of a persisting airway obstruction accompanied by an axial deviation, leading to the indication for revision rhinoplasty.
      Figure 3
      Figure 3(a-c) Twelve-month results after open revision rhinoplasty with septoplasty septal extension grafts, spreader flaps, osteotomies, lateral overlay, spanning sutures, and free diced cartilage.
      Figure 4
      Figure 4(a-c) This 22-year-old patient suffered a closed nasal fracture during a fall and underwent closed reduction for a visible axial deviation to the right. Six months postreduction, a deviation and airway obstruction persisted. At 12 months postreduction, the patient underwent open revision rhinoplasty.
      Figure 5
      Figure 5(a-c) Twelve-month results after open revision rhinoplasty with paramedian, lateral, and transverse osteotomies. Septoplasty was performed, spreader grafts were placed, transcutaneous, transosseous cerclage sutures were placed as well as tongue in groove and interdomal sutures, and free diced cartilage was applied over the nasal dorsum. Doyle splints and a cast were worn for 2 weeks postoperatively.
      Table 2Nasal fracture classification according to Rohrich and Adams and univariable logistic regression for revision rhinoplasty.
      Nasal fracture classification and univariable logistic regression for revision rhinoplasty
      Variablenumber of patients with CCTodds ratio2.5 %97.5 %p value
      279
      I. simple (unilateral)15Ref.
      II. simple (bilateral)153.50.38760.3
      III. comminuted
      • a
        unilateral
      232.90.38610.3
      • b
        bilateral
      690.60.07130.7
      • c
        frontal
      111.40.05380.8
      IV. complex

      (nasal bone & septal disruption)
      621.70.28340.6
      • a
        assoc.septal hematoma
      60.00.00200.9
      • b
        assoc.open nasal laceration
      472.40.38470.4
      V. assoc. NOE fracture/midface fracture313.30.50660.2
      Most nasal fractures were sustained by an assault mechanism (147 patients, 35.3%).
      Two hundred eighty-five patients (68.3%) received a computed tomography throughout their initial diagnostic workup. For 132 patients (31.7%), the diagnosis was based on x-rays.
      Forty-six patients (11%) had a history of at least one prior nasal fracture. In addition to the closed reduction of the nasal bones, open septum surgery was performed on 7 patients (1.7%). Septal splints were placed in 42 patients (10%). All other patients received gauze tamponades only.
      Closed reduction was performed on average 6 days posttraumatically (median, IQR 4–9). Gauze removal took place 2 days postoperatively (median, IQR 2–3). The cast was removed after 7 days (median, IQR 7–8). If Doyle splints were placed, they were removed 14 days postoperatively (median, IQR 8–14). Sixty-one patients (14.6%) removed the gauze themselves before the scheduled appointment, and 72 patients (17.3%) removed the cast themselves before the planned visit.
      At the time of cast removal, 52 patients (12.5%) complained of airway obstruction that had not been present prior to the trauma. For 47 patients (11.3%), an indication for rhinoplasty surgery was documented after fracture healing. Thirty-two of these patients underwent revision rhinoplasty at our institution. The average follow-up time was 37 weeks. For patients requiring revision rhinoplasty, the end date for nasal fracture follow-up was defined as the date when the indication for rhinoplasty was made. Revision rhinoplasty was performed 398 (range 214–592) days after the initial reduction. The indication for rhinoplasty was made to address persisting airway obstruction only in 10 cases and to address both airway obstruction and persisting cosmetic deformity in 18 cases. In four cases, solely a cosmetic deformity needed to be addressed. In these cases, deformities were deemed as such when a visible deviation or hump was present that had not been present prior to the trauma. In these cases, patients were asked to demonstrate pretraumatic photographs to get a better understanding of the posttraumatic deformity. Preoperatively, an additional evaluation by an ear, nose, and throat (ENT) surgeon was sought in 16 cases. The target areas addressed during revision rhinoplasty are documented in Table 3. In the majority of patients, the septum (87.5%) and the outer nose (81.3%) were addressed. In the postoperative regime, gauze tamponades were removed after 24 hours in 12 patients; 3 patients had gauze removal after 2–5 days. Seventeen patients received only the foam cubes. Septal splints were left in place for 5–7 days in 6 patients and for 10–14 days in 17 patients. Casts were removed after 5–7 days in 9 patients and after 10–14 days in 19 patients.
      Table 3Features of revision rhinoplasty including targeted areas and postoperative regime.
      Patients (%)
      ENT involvement before revision rhinoplasty16 (50)
      Areas addressed during revision rhinoplasty
      • Radix/dorsum (glabella to lateral canthus, nasion, dorsum, hump)
      15 (46.9)
      Septum28 (87.5)
      Outer nose (nasal bone/sidewalls, ULC)26 (81.3)
      Tip (lobule, alar cartilages, tip defining points, supratip point, volume/definition/width, rotation/projection, shape and skin envelope)20 (62.5)
      Base (alar basis, nostrils, columella)21 (65.6)
      Other13 (40.6)
      Postoperative treatment
      Septal splint placement23 (71.9)
      Gauze tamponade placement15 (46.9)
      Cast placement28(87.5)
      Patients who had suffered an additional septum fracture were more likely to undergo rhinoplasty (48.9% vs. 31.4%, p=0.02) The same was true for patients with septal deviation (51.1% vs. 30%, p= 0.006). Having suffered from a previous nasal fracture made it more likely that there would be a need for open rhinoplasty after fracture healing (21.3% vs. 9.7%, p=0.01). Patients who complained of an airway obstruction at the time of cast removal were significantly more likely to require rhinoplasty surgery (34% vs. 9.7%, p<0.001).
      According to Rohrich and Adams, no specific stage was found to be a predictor to the need for revision rhinoplasty in the future (Table 2).
      In multivariable logistic regression models, evaluating the risk of the need for open rhinoplasty after fracture healing (see Table 4) airway obstruction at the time of cast removal was an independent predictor of the need for open rhinoplasty after fracture healing (odds ratio [OR] 4.79, p=0.0004).
      Table 4Logistic regression model for prediction of revision rhinoplasty.
      Logistic regression model for prediction of secondary rhinoplasty
      2.5 %97.5 %
      Associated septum fracture1.790.714.440.21
      Prior nasal fracture2.010.745.070.15
      Placement of a septal splint1.330.305.240.69
      Septal deviation1.580.643.810.31
      Subjective airway obstruction
      at time of cast removal.
      4.791.9911.40<0.001
      low asterisk at time of cast removal.

      Discussion

      Closed treatment of nasal bone fractures has been described in detail for centuries.
      • Morrison LE.
      A History of Rhinoplasty.
      The restoration of pretraumatic form and function is the goal of closed nasal reduction.
      • Farber SJ
      • Nguyen DC
      • Parikh RP
      • Jang JL
      • Woo AS.
      Improving Results in Closed Nasal Reduction: A Protocol for Reducing Secondary Deformity.
      Even though this surgical intervention is considered a straightforward procedure, the incidence of postreduction nasal deformity requiring open revision rhinoplasty is as high as 14 to 50 per cent, according to Rohrich and Adams.
      • Rohrich RJ
      • Adams WP.
      Nasal Fracture Management: Minimizing Secondary Nasal Deformities.
      In our study, we analyzed which factors might be attributed to a higher risk of a residual postreduction nasal deformity, resulting in the need for revision rhinoplasty. Our analysis yielded several interesting findings.
      First, the median patient age was 30 years, and most nasal fractures were sustained by an assault mechanism (147 patients, 35.3%). Other studies have quoted assault as a cause for nasal bone fractures with a percentage as high as 60%.
      • Li L
      • Zang H
      • Han D
      • Yang B
      • Desai SC
      • London NR.
      Nasal Bone Fractures: Analysis of 1193 Cases with an Emphasis on Coincident Adjacent Fractures.
      Regarding age, other centers have reported similar data.
      • Loutroukis T
      • Loutrouki E
      • Klukowska-Rötzler J
      • et al.
      Violence as the Most Frequent Cause of Oral and Maxillofacial Injuries among the Patients from Low- and Middle-Income Countries—A Retrospective Study at a Level I Trauma University Emergency Department in Switzerland.
      In our study, neither patient age nor trauma mechanism had an effect on the need for later revision rhinoplasty. The majority of patients were male. This has been attributed to the higher incidence of interpersonal violence among males.
      • Yu H
      • Jeon M
      • Kim Y
      • Choi Y.
      Epidemiology of violence in pediatric and adolescent nasal fracture compared with adult nasal fracture: An 8-year study.
      Second, 46 patients (11%) had a history of at least one prior nasal fracture. These patients were more likely to require revision rhinoplasty. Previous nasal injury and potentially pre-existing deformity could complicate closed reduction as the technique is based on visual examination.
      • Farber SJ
      • Nguyen DC
      • Parikh RP
      • Jang JL
      • Woo AS.
      Improving Results in Closed Nasal Reduction: A Protocol for Reducing Secondary Deformity.
      Third, we saw that patients with an associated nasal septal fracture and a visible septal deviation were more likely to undergo revision rhinoplasty. A thorough assessment of the nasal septum is considered the most important step in determining aesthetic and functional outcomes in nasal fractures.
      • Verwoerd C.
      Present Day Treatment of Nasal Fractures: Closed Versus Open Reduction.
      Ash forceps are used for septal reduction, and the septum is splinted postreduction. A total of 29.5% (41) of our patients with a septal fracture received silicon splints; the remainder were treated with gauze packing only. However, visual inspection might not suffice to fully assess the postreduction septal alignment, and splinting techniques might be insufficient to maintain reduction, resulting in a later need for revision rhinoplasty.
      Fourth, in our cohort, 14.6% of patients removed the gauze packing prematurely or took off their cast prematurely in 17.3% of cases. This, however, did not have an impact on the likelihood of later revision rhinoplasty. Postreduction external splinting by means of a nose cast or a thermoplastic dressing is generally considered necessary

      Behrbohm H, Tardy ME, eds. Essentials of Septorhinoplasty: Philosophy, Approaches, Techniques. Georg Thieme Verlag; 2017:b-005-143328. doi:10.1055/b-005-143328.

      as a protection toward outside forces, but reduction per se is not held by a cast, thus premature removal seems to have no significant influence on overall outcomes.
      However, it needs to be considered that, as Farber et al
      • Farber SJ
      • Nguyen DC
      • Parikh RP
      • Jang JL
      • Woo AS.
      Improving Results in Closed Nasal Reduction: A Protocol for Reducing Secondary Deformity.
      stated, one week after closed reduction, the nasal bones remain mobile. In fact, some colleagues will manage any deviation or collapse with external manipulation of the nose with localized application of pressure until symmetry is reestablished. This approach is not performed in our department, so its potentially beneficial effect toward avoiding the need for revision rhinoplasty could not be addressed.
      Fifth, patients who complained of an airway obstruction at the time of cast removal were significantly more likely to end up requiring revision rhinoplasty surgery as described above. At our department, casts are generally removed seven days postreduction, and we typically wait for 3 months posttraumatically before the indication for secondary rhinoplasty is made. Considering our findings regarding airway obstruction, it might be beneficial to discuss an increased risk for the need of secondary rhinoplasty with the patient already at the time of splint removal if airway obstruction is present. But, of course, airway obstruction at this point might also still be due to swelling.
      There are several limitations to this study. It is a retrospective study and thus may be prone to observer bias. The conclusions need to be supported by prospective data for greater impact. Additionally, as we are presenting consecutive cases, patients were operated on by different surgeons. These adhere to a departmental standard concerning the intra- and postoperative regimes, but minor deviations based on personal preference might have been made. Additionally, it is possible that in some cases proper reduction might not have been achieved, consequently leading to residual airway obstruction or aesthetic deformity. This could, of course, not be identified in this retrospective analysis. It should be noted that the success of closed reduction was assessed only clinically. A computed tomography scan would have provided an objective assessment of the reduced nasal bones but that would not have been justified in our opinion in this early (median patient age was 30 years (IQR 23–45 years)) patient cohort. A purely clinical assessment is by definition prone to observer bias. However, it is common practice for the reduction of isolated fractures of the nasal bone, as well as objective measurements of nasal appearance and function, especially in the form of a patient reported outcome measurement, such as the 10-Item Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS)
      • Moubayed SP
      • Ioannidis JPA
      • Saltychev M
      • Most SP.
      The 10-Item Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) for Functional and Cosmetic Rhinoplasty.
      for these patients at the time of injury and at the final postoperative assessment are not available for this patient cohort, leading to a partly subjective assessment by the treating surgeon. A detailed assessment of the relative bony vs. cartilaginous contributions to the nasal skeleton was not performed for this cohort. This might have been a factor that contributed to the need for revision, and it itself could have been a significant contributor to closed reduction failure, and also, the pretraumatic nasal configuration of patients who ended up requiring revision rhinoplasty was not available; thus, minor, asymptomatic airway obstructions might have been present pretraumatically (with the patient not aware of them) and were only aggravated by the fracture. Lastly, some patients were lost to follow-up and may have undergone revision rhinoplasty elsewhere.
      Figure 6
      Figure 6Illustration of key points of our study.

      Conclusion

      Even though closed reduction of nasal fractures is frequently considered a straightforward procedure, a significant number of these patients will require secondary revision rhinoplasty. Associated nasal septal fractures may present a risk factor for the need for secondary revision surgery. Subjective airway obstruction at the time of cast removal after closed reduction was found to be predictive of revision rhinoplasty later on. Prospective studies are required to support the findings of this investigation.

      Ethical statement

      Approval to perform the study was given by the Cantonal Ethics Committee of Zurich.
      Switzerland (Ethical Approval ID 2020-00349). All patients gave written consent for data evaluation. Patients whose photographs are shown gave written consent to show full-face photographs.

      Conflict of interest statement

      All authors declare that there is no conflict of interest.

      Appendix. Supplementary materials

      References

        • Greathouse ST
        • Adkinson JM
        • Garza R
        • et al.
        Impact of Injury Mechanisms on Patterns and Management of Facial Fractures.
        J Craniofac Surg. 2015; 26: 1529-1533https://doi.org/10.1097/SCS.0000000000001805
        • Kim KS
        • Lee HG
        • Shin JH
        • Hwang JH
        • Lee SY.
        Trend analysis of nasal bone fracture.
        Arch Craniofacial Surg. 2018; 19: 270-274https://doi.org/10.7181/acfs.2018.02264
        • Lu GN
        • Humphrey CD
        • Kriet JD.
        Correction of Nasal Fractures.
        Facial Plast Surg Clin N Am. 2017; 25: 537-546https://doi.org/10.1016/j.fsc.2017.06.005
      1. Higuera S, Lee EI, Cole P, Hollier LH, Stal S. Nasal Trauma and the Deviated Nose: Plast Reconstr Surg. 2007;120(Supplement 2):64S-75S. doi:10.1097/01.prs.0000260722.91183.50.

        • Farber SJ
        • Nguyen DC
        • Parikh RP
        • Jang JL
        • Woo AS.
        Improving Results in Closed Nasal Reduction: A Protocol for Reducing Secondary Deformity.
        Plast Reconstr Surg. 2017; 139: 51-59https://doi.org/10.1097/PRS.0000000000002847
        • Rohrich RJ
        • Adams WP.
        Nasal Fracture Management: Minimizing Secondary Nasal Deformities.
        Plast Reconstr Surg. 2000; 106: 266-273https://doi.org/10.1097/00006534-200008000-00003
        • Morrison LE.
        A History of Rhinoplasty.
        Arch Otolaryngol - Head Neck Surg. 1959; 69: 667-673https://doi.org/10.1001/archotol.1959.00730030681002
        • Li L
        • Zang H
        • Han D
        • Yang B
        • Desai SC
        • London NR.
        Nasal Bone Fractures: Analysis of 1193 Cases with an Emphasis on Coincident Adjacent Fractures.
        Facial Plast Surg Aesthetic Med. 2020; 22: 249-254https://doi.org/10.1089/fpsam.2020.0026
        • Loutroukis T
        • Loutrouki E
        • Klukowska-Rötzler J
        • et al.
        Violence as the Most Frequent Cause of Oral and Maxillofacial Injuries among the Patients from Low- and Middle-Income Countries—A Retrospective Study at a Level I Trauma University Emergency Department in Switzerland.
        Int J Environ Res Public Health. 2020; 17: 4906https://doi.org/10.3390/ijerph17134906
        • Yu H
        • Jeon M
        • Kim Y
        • Choi Y.
        Epidemiology of violence in pediatric and adolescent nasal fracture compared with adult nasal fracture: An 8-year study.
        Arch Craniofacial Surg. 2019; 20: 228-232https://doi.org/10.7181/acfs.2019.00346
        • Verwoerd C.
        Present Day Treatment of Nasal Fractures: Closed Versus Open Reduction.
        Facial Plast Surg. 1992; 8: 220-223https://doi.org/10.1055/s-2008-1064653
      2. Behrbohm H, Tardy ME, eds. Essentials of Septorhinoplasty: Philosophy, Approaches, Techniques. Georg Thieme Verlag; 2017:b-005-143328. doi:10.1055/b-005-143328.

        • Moubayed SP
        • Ioannidis JPA
        • Saltychev M
        • Most SP.
        The 10-Item Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) for Functional and Cosmetic Rhinoplasty.
        JAMA Facial Plast Surg. 2018; 20: 37-42https://doi.org/10.1001/jamafacial.2017.1083