You Broke Your Nose - Now, What Do You Do?

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A broken nose, or nasal fracture, is the most common facial injury. This is because the nose is the most prominent facial feature. In addition, the nasal bones are the thinnest in the body and, therefore, they are more subject to being broken.

Naturally, the key to proper treatment is to make the correct diagnosis. The following are signs and symptoms of a nasal fracture. All or some may be present.

• Swelling of the nose.
• Tenderness; soreness to touch.
• Bruising, particularly around the eyes.
• Nosebleed.
• Change in shape.
• Change in breathing.

You need to be examined if any of these features are present after an injury.

Only one feature of a broken nose represents an emergency. If there has been an injury to the internal nasal septum (the internal vertical partition that separates the left and right nasal passages, and there has developed a septal hematoma. A septal hematoma is blood accumulating under the covering of the cartilage and exerting pressure on the internal tissues. If not relieved, this collection of blood can cause destruction of the cartilage and even a partial collapse of the nose. The hallmark of a septal hematoma is that after the injury, the patient has nearly complete blockage of the nose and hardly any nasal breathing. It does require an examination by either an emergency room doctor or a specialist in facial surgery or plastic surgery. The septal hematoma which is not necessarily painful, can be dealt with quickly and the serious problems averted.

With respect to the typical management of the broken nose, an examination by a specialist is important and it should not be delayed. The risk of delay is that if a proper diagnosis is not made, then the mal-aligned broken fragments may begin to heal in their abnormal position. Typically, the window for examination and initial treatment is up to ten days. After ten days, the parts begin to weld together, where they are, and it is difficult to manipulate them back into the normal anatomic position.

The doctor will examine the inside of the nose to see if there is any fracture or injury to the nasal septum which could be causing airway obstruction. Obviously, he will look to see if that septal hematoma has developed.

The external examination of the nose is conducted to see if there has been a shift or fragmentation of the nasal bones and the cartilages attached to it. The doctor will be feeling for asymmetries and irregularities. Often, within the first hour or so, not much swelling has taken place. But typically, within 24 hours, swelling and bruising have presented themselves and maximize by 48 to 72 hours. If none of the serious issues such as septal hematoma are present, he will recommend being re-evaluated when the swelling has gone down such that the more accurate diagnosis can be made by look and feel. Typically, that time line is five to seven days after injury. Plans should be made, at that point, so that if there is to be a near-term correction, it can be done within the ten-day, first window of opportunity.

Let's assume that for whatever reason, the patient either doesn't have the nasal fracture recognized or procrastinates with respect to receiving treatment within the first ten days. If that is the case, the nose is going to have to go untreated and, therefore, maintain possibly both abnormal shape and inadequate breathing for at least two months. At that point the tissues have healed - welded together - and they can be operated upon. Prior to that, the fragments may be "egg-shell"-like and difficult to work with.

Therefore, in summary, the first window for treatment is within ten days. There is a period of no treatment for the next seven weeks or so and then at the two-month mark or thereafter, definitive treatment can take place.

-Robert Kotler, MD, FACS

Report on the National Rhinoplasty Survey

In the recent Aesthetic Surgery Journal there was a very interesting survey report. Because cosmetic nasal plastic surgery or rhinoplasty is such a complex and multifaceted operation, the researchers were trying to ascertain whether there are different methodologies between practitioners. They looked at pre-operative, operative and post-operative techniques to try to make an evaluation whether there was a correlation with such factors as specialty training and timing, type of practice (academic versus private, etc.) and length in practice. It also surveyed the issue of closed rhinoplasty and open rhinoplasty.

Here are some of the more interesting conclusions from the study that had responses from 1,923 practitioners. Some were plastic surgeons and some were facial plastic surgeons.

The most common age group for which rhinoplasty on males would be performed was 18 years of age; for females, 16 years.

Seventy-one percent of the respondents used general anesthesia more than 90% of the time.

Man-made nasal implants (instead of the patient's own tissue) are used a small majority of the time. Seventy-seven percent of respondents use them up to 12% of the time and 12% used them from between 6 to 10% of the time. The most popular were silicone, Gortex and Medpor.

Revision rates were reviewed and there was no significant difference between the revision rate between the two specialties (plastic surgery and facial plastic surgery). Nor was there any correlation in the revision rate with whether or not the operation was performed as an open rhinoplasty or closed rhinoplasty. Surgeons in practice for longer periods of time are more likely to be trained using the closed approach while the open approach has only recently become a more popular training technique.

The study also showed that facial plastic surgeons who are generally trained as head and neck (ear, nose and throat) surgeons are more likely to have a functional (breathing and sinus issues) component to their surgery; the plastic surgeons are more likely to perform purely cosmetic nasal plastic surgery. With respect to charges for revision surgery, 60% charged only a facility fee for revisions but 13% charged an additional surgeon's fee when making another trip to the operating room.

- Robert Kotler, MD, FACS

Related Topics:

• WebMD Video: Keys tio a Successful Nose Job
  
• Skin & Beauty Newsletter - Tips to look good, feel great

How Rhinoplasty Improves Your Smile

Photo Credit: Robert Kotler, MD, FACS

It is very important that the cosmetic nasal surgeon understand what makes the nose unsatisfactory. The patient in the photo has a very active depressor septi muscle which, as part of the muscles of facial expression, when employed, exerts a downward force on the nose. The profound drop of the tip of the nose with smiling, detracts from the smile itself.

The smile that tugs the nose downward makes the profile even less satisfactory. This is why it is very important that this be managed during the cosmetic nasal plastic surgery. It is not a complicated maneuver for the surgeon to perform. Through a hidden incision inside the nose, the surgeon works behind the lip to detach the muscle from its internal attachment to the nose. Then, the muscle no longer can tug on the nose during smile.

The constant smile-driven, downward pull upon the nose also has implications for aging. As we get older, the tip of the nose tends to droop naturally because of the effect of gravity, and the stretching and loosening of the connective tissue within the nose. So there is a case to be made for releasing that depressor muscle at rhinoplasty. Not only because it helps the smile but because it will slow the "aging" of the nose.

- Robert Kotler, MD, FACS

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Open Rhinoplasty vs. Closed Rhinoplasty

Open rhinoplasty vs. closed rhinoplasty - there is a lot of bandying about of these terms by perspective patients. The "open rhinoplasty" describes an operative technique by which an external incision is made to gain access to the interior of the nose. This is in distinction to the "closed rhinoplasty" in which all incisions are made entirely within the nasal interior.

There are disciples, defendants and proponents of each within the nasal cosmetic plastic surgery community. It is a matter of the surgeon's preference as to which technique he is most comfortable with for a given case. The nasal cosmetic surgery super-specialist will be adept at both techniques. He or she will choose a technique that seems appropriate for the case at hand.

Generally, younger surgeons appear to prefer the open technique because that is the way they have been trained. In the last twenty years that technique gained popularity, initially as a teaching device since it is easier for a student or trainee to see the nasal contour through the open approach. The more veteran nasal cosmetic surgeons were trained using the closed technique and generally were comfortable with it. But, it is not difficult for the highly experienced and specialized nasal surgeon to master the open rhinoplasty technique.

If you have never seen a photograph or a sketch of the open rhinoplasty, understand that using a horizontal incision connecting the two nostrils just below the tip, the skin is lifted as one would lift the hood of a car. Then one gets access to see the tip cartilages and when a certain instrument is placed through that opening, one can even see up to the bridge of the nose. No question that, for the novice and inexperienced surgeon or occasional rhinoplasty surgeon, this exposure is advantageous.

The open rhinoplasty tradeoff is the external scar which, while generally heals well, in some patients doesn't. Also, there is the uncertainty of how much tightening or contracture could take place during the healing.

The closed rhinoplasty, done entirely within the nose, does take greater manual dexterity and the technical facility to perform an operation "through a keyhole". Experienced surgeons will tell you that their visualization is not impaired, and in fact, this approach of course has been used for nearly 100 years with great success.




Of ultimate importance is that the surgeon be comfortable with his or her favorite technique. If you have confidence in the surgeon, have confidence in his or her judgment. Most likely, you will also be comfortable with the results that the chosen technique delivers.

If you are concerned about the visibility of the open rhinoplasty's incision, ask to see many before and after open rhinoplasty photographs, particularly close-ups. Then, you can evaluate for yourself the visibility or lack of visibility of the external incision.

- Robert Kotler, MD, FACS

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Second Chances for Your Nose

The recent Elle Magazine had a feature article written by an experienced medical writer in which she discussed the issue of a second nose job - the so called "secondary rhinoplasty." The operation is always challenging and there are as many ways to do these operations as there are surgeons to perform them.

A few weeks ago, I participated in a seminar where several lecturers and panel discussions dealt with the issue of the "nose job re-do's." Everyone agrees that it is difficult, less predictable and this often translates to a lower level of patient satisfaction. There are procedures employed, including transplanting portions of rib, cartilage and even skull bone in order to reconstruct a nose that has not fared well with the first operation. This is why the procedure becomes unpredictable; the fate of these tissues when implanted into the nose is often unpredictable.

I was a bit disappointed that hardly any attention was given to the alternatives to grafting and transplanting tissues, that is the use of injectable "fillers." The mission is the same, to replace tissue that has been over sculpted, over-removed leaving dips, depressions, pinches and scooped out bridges. There is a place for these filling injections, some of which are permanent. I think patients owe it to themselves to check out all of the alternatives, surgical and nonsurgical before committing to a second major nasal reconstructive surgery.

-Robert Kotler, MD, FACS

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• WebMD Video: Keys to a Successful Nose Job
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"Dr. Kotler, You Won't Remember Me But ..."

Yesterday I was at a party and happened to be talking to a friend when a bubbly and attractive lady walked over to us dressed with a big smile. She looked at me and nodded her head and then mentioned to my friend something she needed to say to him and said to me, "Hold on, I want to tell you something."

After her exchange with my friend, she turned to me and said, "Dr. Kotler, you won't remember me but 28 years ago, you did my nose."

This was a very nifty encounter because, in fact, I did remember this patient. While her last name had changed through marriage, when she told me her married name, I did remember her very well.

What was really touching was when she said, "I have to tell you that you really changed my life." And I must say I was very proud of the appearance of her nose. It was natural, it fit her face and obviously she has happily worn it for the last 28 years.

It was a particularly cute and unique happening because also attending the party was an internist whom I have known for many years. Just five minutes earlier we had been discussing some of the early days of our practices at one of the local hospitals. Our nose patient, Phyllis, had reminded me that we originally met, her husband had broken his nose playing basketball and was brought to the emergency room. The emergency room was at the very hospital my colleague and I had been discussing a few minutes earlier.

I recalled that ER episode and the fact that shortly after I took care of her husband, we had a discussion with Phyllis about what could be done for her nose.

I share this with you because in the 33 years that I have been in private practice and nearly 40 years of doing this work, I am continually reminded of the great power that changing one's nose has. Cosmetic nasal surgery for many patients is a major positive in their life and I am proud to be part of that.

Apropos of that let me share a letter than I received from a patient whose "before and after" photos are in my book, SECRETS OF A BEVERLY HILLS COSMETIC SURGEON. Prior to publication, I had written to her to ask for her permission to reproduce those before and after photographs in the book. I received an extremely gracious and positive response. She wrote that she was more than glad to print the visuals of her cosmetic nasal surgery and chin augmentation because, "If this encourages people to go forward and have it done and give them as much pleasure as these procedures have given me, then by all means, feel free to share them with your readers." This lady, now the mother of an 18-year-old was herself 18 years old when she had her nasal surgery.

As you can see from Marian's photos, there is even a difference in her hair style and makeup which she changed without prompting by us. I find that people tend to care more about their appearance after cosmetic nasal surgery and do everything they can to enhance their appearance.

- Robert Kotler, MD, FACS

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• WebMD Video: Keys to a Successful Nose Job
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Rhinoplasty Tip: All Noses are Unique

Patients don't want to have a new nose that looks obviously ethnically inappropriate. It is important that your cosmetic nasal surgeon to listen carefully to your desires. A patient must be comfortable and confident that there will be not radical changes in the nose. No one wants a nose that it looks almost "stuck on" and fake because of the surgeon's proclivity to deliver the same "boilerplate" nose for all comers.

Asian noses typically exhibit the following features:

• Low flat bridge.
• Wide nasal bones manifesting as wide bridge and middle third of nose.
• Round, sometimes flat tip.
• Thick skin.
• Wide nostrils with thick outer walls.
• Softer, weaker cartilage.

Hispanic noses vary with ancestry. Those whose genetic makeup have a predominance of Spanish (from Spain) genes tend to have lighter, thinner skin, stronger cartilage and other characteristics more suggestive of Caucasian noses.

Those Hispanics whose ancestry is skewed toward Central or South American Indians exhibit the following:

• High bridge with a prominent bump.
• Thick skin.
• Wide, oblong nostrils with thick outer walls.
• A wide plunging flat tip.
• Short upper lip.
• Softer, weaker cartilage.

African-American noses, anatomically, often have some features in common with Asian or Hispanic noses. There is a greater variety and combination of these elements. Here are the features that contrast most with Caucasian noses:

• Low flat bridge.
• Wide nostrils with thick walls.
• Disproportional width compared to length.

For Asian, Hispanic and African-American noses, more often there will be a need for the surgeon to raise the bridge and shore up the tip. Narrowing the nostrils, when needed, requires external incisions which must be artfully performed so that the incisions - tucked within the crease between the wing (outer wall and the wall of the nostril) and the cheek and upper lip is rendered nearly invisible.

Related Topics:

• WebMD Video: Keys to a Successful Nose Job
• Skin & Beauty: Ethnic Skin