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Arnold Lee • Aric Park
support for the nose from which the upper and lower
lateral cartilages are suspended. An in-depth understand­
ing of the shape, position, and strength of the lower lateral
cartilage will prove invaluable in reconstruction of defects
involving the nasal alae and tip. Even areas that are not
covered by cartilage, such as the soft tissue triangles, must
be reconstructed with a supporting framework or risk
contraction of the overlying flap or graft.
In evaluating the mucosal lining of the nose, the skin
of the vestibule is made up of stratified squamous epithe­
lium. This transitions to the typical pseudostratified cili­
ated columnar epithelium of the inner lining of the nose
just beyond the vibrissae of the vestibule. The thickness
of the lining is important to note as reconstruction with
thick flaps may lead to obstruction of the external nasal
valve. Additionally, use of thinner skin grafts in areas
normally covered by mucosa can lead to significant crust­
ing and ozena. Finally, placing mucosa in areas normally
covered by stratified squamous epithelium will lead to
easy bleeding and irritation due to its proximity to the
outside environment and desiccation.
REPAIR OF SURFACE DEFECTS
Repair of superficial cutaneous nasal defects should be
based on the size, color, texture, and curvature of the area
to be repaired. While many options exist for a given defect,
we will approach this issue by dividing the nose into upper
two thirds and lower third to simplify the surgical options
available. Overall, the goal of surgical reconstruction of
unilateral defects should be to replace tissues with those
similar in texture and color. The subunit principle should
be applied whenever possible. When planning for closure
of defects, scars should ideally come to rest in the areas
between subunits.
NASAL DEFECTS OF THE UPPER TWO THIRDS
OF THE NOSE
The upper two thirds of the nose consists of the nasal
dorsum and lateral nasal walls extending from the gla­
bella to the caudal aspect of the nasal bone. The skin
tends to be relatively thin, less sebaceous, and more mobile
compared to the lower third of the nose. This region is
supported by the nasal bones and the upper lateral carti­
lages. For very small cutaneous lesions primarily over the
nasal bones, closure by secondary intention remains an
excellent option. Primary closure is possible in this region
due to the relative mobility of the soft tissue envelope.
Scars that are placed along the relaxed skin tension lines
(RSTL) and at the junction of aesthetic subunits tend to
camouflage best.3
Larger lesions in this region can be reconstructed
with full-thickness skin grafts (Figure 36-2). This is ideal
for the lateral nasal side walls, which has relatively thin,
complete excision and reconstruction of the entire subunit.
Lesions or defects involving less than 50% of such subunit
are often able to be closed without further sacrifice of
surrounding unaffected tissue. When the nose and the
entire face are viewed in this manner, the surgeon is able
to plan the nasal reconstruction by breaking down even a
very large defect according to the subunits it encompasses
and formulate a plan for repair by approaching each
affected subunit as an individual entity. This principle
applies mostly to subunits that are convex such as the
nasal tip, alae, dorsum, and columella. This concept is
critical due to the natural tendency of skin flaps to con­
tract into convex circular mounds of tissue if unopposed
by a structural framework to support it. Skin grafts that
are supported by a framework of bone or cartilage will
resist this contracture and largely keep their form, making
them ideal in reconstructing concave areas such as the
nasal sidewalls.2
The quality of the skin to be repaired is very impor­
tant in nasal reconstruction. The upper third of the nose,
consisting of the nasal dorsum and lateral walls, has a
thicker skin with more laxity. The middle third skin is thin
and elastic. Skin grafts and local flaps do well in recon­
structing this region. The lower third, consisting of the
nasal tip, alae, soft tissue triangles, and columella, has
thicker, sebaceous, less pliable skin, which poorly matches
most skin grafts. The thick, stiff nature of the skin can
make local flaps less reliable and may necessitate the use
of pedicled flaps, as we will discuss later. The skin of the
dorsal nose tapers to the rhinion, where it is the thinnest.
In patients with large defects, the opposite side may be
used to estimate the quality of the skin to be repaired.
Underlying the skin is loose areolar tissue followed by
the musculature of the nose. These are connected by an
aponeurotic system of fibrous tissue that is contiguous
with the superficial muscular aponeurotic system (SMAS).
The framework of the nose consists of paired quad­
rangular nasal bones, upper lateral cartilages, lower
lateral cartilages, and the septum. The septum acts as the
Figure 36-1  Nasal subunits—dorsum, paired lateral sidewalls, nasal tip,
nasal alae, columella, soft tissue triangles.
Sidewall
Tip
Columella
Dorsal
Alar-nostral sill
Soft
triangle

CHAPTER THIRTY-SIX  Nasal Reconstruction
457
vascularized bed must be in place for successful uptake.
Of note, the skin grafts must be supported with either a
bony or cartilaginous framework. Without this, the graft
will shrink due to contraction of myofibroblasts. During
the healing process, the surrounding recipient skin can
supply the full-thickness skin graft up to 3 ml away by
nutrient and oxygen diffusion. Once the graft is harvested,
the surgeon thins the graft by removing the subcutaneous
fat until the white portion of the dermis is visible. This
increases the likelihood of vascularization and subsequent
graft viability. It is worth noting that overaggressive thin­
ning of the graft can lead to loss of the dermal layer,
shiny skin and falls within the natural shadows of the
nose. Grafts are most commonly harvested from the
preauricular region due to the excellent color and texture
match. When additional skin is required, skin from the
supraclavicular fossa, nasolabial fold, neck, upper eyelid,
or postauricular region can be used (Figure 36-3). A
template of the defect is created using the foil from a
suture packet, which bends easily to fit the contours of
the nose. This is transposed to the proposed donor site.
As with all skin grafts, a healthy vascularized wound
bed is necessary for graft survival. If the periosteum or
perichondrium has been removed with the lesion, a
Figure 36-2  Full-thickness skin graft. A, Large superficial defect involving the lateral nasal side wall and nasal dorsum. After discussion of treatment
options with the patient, he elected for repair with FTSG. B, FTSG harvested from excess skin in supraclavicular fossa. Bolstering sutures placed to prevent
seroma formation. C, Secondary defect in supraclavicular fossa closed. D, Repair after 2.5 months. E, Close-up of repair at 2.5 months. Some residual
hypervascularity is evident around the healing wound.
A
B
C
E
D

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Arnold Lee • Aric Park
the pivot point, and distal distortion. Multiple modifica­
tions have been made on the original design with improved
outcomes. We often follow the modifications described by
Zitelli in our flap design. The angle of rotation has been
decreased to less than 50 degrees per flap, or less than
leaving the patient with a split-thickness skin graft and
the potential for postoperative contracture with irregular­
ity of color and texture. The graft is then placed into the
defect and any excess skin is gently trimmed. When trim­
ming the edges of the skin graft, we find it helpful to first
trim one side of the graft to fit, which is then sutured into
place. The second side is then trimmed and inset and so
on until the remaining three sides are subsequently cut to
fit the defect. Basting sutures are applied between the
graft and the vascularized bed with fast absorbing gut
suture to prevent seroma or hematoma formation (Figure
36-4). Central basting sutures prevent the graft from
lifting off the bed, while peripheral sutures keep the graft
aligned in proper position. Those sutures that remain at
the first postoperative visit at 5 to 7 days are then removed.
When possible, we try to use local flaps because of the
advantage of similar skin color, thickness, and contours
as the missing tissue. In the upper two thirds of the nose,
transposition flaps such as the bilobed and rhomboid flap
may be used with excellent results.
Bilobed flaps are the most commonly used flaps for
repair of smaller nasal defects (<1.5 cm) in our practice,
our “workhorse” flap (Figure 36-5). They are based on a
random blood supply. The initial bilobed flap as described
by Esser uses two equal flaps with a 90- and 180-degree
rotation. The amount of rotation and large flaps led to
excessive tension on the surround tissues, buckling around
Figure 36-3  Locations for skin graft donor sites on the head and neck.
Figure 36-4  Basting sutures applied to prevent seroma formation.

CHAPTER THIRTY-SIX  Nasal Reconstruction
459
circular lesion. From the pivot point, a Burow’s triangle
is marked to account for the standing cone deformity that
will occur from the rotation of the flaps. The closure of
this limb of the flap will create the first linear scar. We,
therefore, attempt to place one side of the Burow’s triangle
at the junction of aesthetic subunits when possible, such
as at the supra-alar crease.
Once the pivot point is determined and the Burow’s
triangle is marked, we then mark out two arcs: one from
the pivot point to the most distal edge of the defect and
one from the pivot point to the midpoint of the defect. We
use a piece of foil to measure the arc of rotation rather
100 degrees for the arc of the entire flap.4 In general, for
the upper two thirds of the nose, a laterally based flap
works best. This allows for the majority of the scars to lie
within the shadowed lateral nasal wall and can allow for
the two relatively linear incisions to lie within junctions
of aesthetic subunits.
The initial step in designing the flap is to determine
the point of rotation, or the pivot point. This point must
be situated sufficiently away from critical adjacent struc­
tures such as the lower eyelid, which may cause distortion
when the flap is transposed. The pivot point is approxi­
mately one radius of the defect away from the edge of a
Figure 36-5  Zitelli modification of a bilobed flap. A, Superficial defect after MOHS resection of squamous cell cancer involving the lateral nasal side wall,
nasal dorsum, and nasal tip about 1.5 cm in diameter. B, Bilobed flap designed with laterally based pedicle. The initial flap is equal in size to the defect,
while the second flap measures about 80% of the original defect. Burow’s triangles have been included in the planning to excise excess tissue and prevent
dog ears. C, The flap has been mobilized from the SMAS layer. D, Inset of the flap with closure of the dog ears. E, Repair after 4 months. F, Repair after 8
months.
A
D
E
F
B
C

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Arnold Lee • Aric Park
A
B
C
“pincushioning” of the circular flaps compared to a sub­
cutaneous dissection. Once widely undermined, the flaps
are released along the markings, keeping the incisions
between the two arcs. The flaps are gently rotated into
position and the tension on the flap is assessed. If there is
too much tension, the releasing incision along the second
lobe is lengthened beyond the lower arc, taking care not
to narrow the base of the flap excessively. The incisions
are then meticulously closed in layers. This flap is gener­
ally limited to defects no larger than 1.5 cm in diameter,
as larger flaps will tend to distort surrounding structures
when closing the primary and the resulting secondary
defects.
In the superior nasal dorsal region, a transposition
flap from the glabella works well to repair cutaneous
defects. This region has abundant loose skin in com­
parison to the nasal dorsum and often a unilobed flap
such as a banner or rhomboid flap can be used (Figure
36-6). Scars may be oriented vertically to hide in
than a straight ruler as the curvature of the nose can add
significant extra length to the pivot point. It is between
these arcs that our lobes will be marked. The first flap is
drawn the same size as the defect. Again, the foil from a
suture packet can be used to make a template of the
original defect for creation of the primary lobe to ensure
adequate size. The second lobe is marked approximately
20% smaller than the original defect to ease in closure. A
Burow’s triangle is extended from the second lobe to
account for the eventual standing cone deformity. The
angle between the defect and the secondary flap can be
adjusted between 90 degrees and no more than 100
degrees to allow for the closure of the secondary defect to
lie at the junction of aesthetic subunits.
Once the markings are complete, wide undermining
in the sub-SMAS plane ensues prior to making any
releasing incisions. The advantage to undermining in
this plane is that it is relatively avascular, the blood supply
to the flaps is preserved, and there is less postoperative
Figure 36-6  Rhomboid flap. A, Defect with incision through tissue of the glabella. B, Wound after
rotation of flap. Note the scars are oriented to hide in the vertical and horizontal rhytids. C, One-month
postoperative film.

CHAPTER THIRTY-SIX  Nasal Reconstruction
461
inherent laxity of the cheek skin. These random flaps can
reach from the lateral nasal sidewall to the nasal tip. The
main limitation of the flap occurs when it is carried too
far superiorly, at which point distortion of the lower eyelid
can occur, leading to ectropion. The flap is marked out
along the ipsilateral melolabial crease. The height of the
defect is measured and used as the width of the flap. The
medial border of the flap is marked out precisely within
the existing melolabial crease, and a Burow’s triangle is
designed to taper distally into the crease as well. The
lateral limb is extended no higher than the level of the
existing glabellar rhytids in the region. Here, undermining
is performed in the subcutaneous plane, taking care to
avoid injury to the supratrochlear and supraorbital neuro­
vascular bundles.
Defects larger than 1.5 cm in diameter can often be
addressed using a superiorly based melolabial flap (Figure
36-7). The skin color and texture can match that of the
skin of the nasal dorsum well, but often the flap needs to
be thinned of the subcutaneous fat to match the thickness.
Generally, defects up to 3 cm can be repaired with these
flaps, although the width of the flap is dependent on the
Figure 36-7  Melolabial flap. A, Superficial defect involving the nasal ala. A superiorly based melolabial flap was designed to close the wound with minimal
tension. B, Post flap inset. Note the recreating of the nasolabial sulcus. C, Patient after 3 weeks. There is some hyperplasia and edema of the nasolabial
sulcal incision. This was treated early with intralesional Kenalog. D, At 3 months post surgery, the supra-alar fullness and edema have resolved, leaving a
well-camouflaged scar in the nasolabial sulcus.
A
B
C
D

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Arnold Lee • Aric Park
too close to the alar margin. The movement of the flap
can distort the margin very easily. Care must be taken in
repairing the nasal tip to properly assess the size of the
defect using a bendable or pliable template to take into
account the convexity of the tip. Because the thicker skin
in this region has very poor elasticity, very little margin
for error exists in the flap design and a very tight closure
can easily result if the convexities are ignored. For defects
of the nasal tip, laterally based bilobed flaps work well,
whereas medially based flaps can be used with alar defects.
The amount of tension that the wound is under can con­
tribute to postoperative alar retraction with dehiscence or
scarring, limiting its use in larger defects.
The ala and the alar margin require special attention
in planning a reconstruction. These regions are composed
of fibrofatty tissue and are devoid of underlying cartilage
and therefore are subject to a high rate of distortion due
to scar contracture if not properly supported. For smaller
lesions, less than 1.5 cm, involving the alar margin, a
composite graft offers a simple one-stage solution. A com­
posite graft contains two or more layers of tissue. It is an
excellent graft for defects of the alar margin as it can
retain the natural thin and delicate quality of the ala
without the use of thick, bulky flaps. Due to the lack of a
large vascularized bed on which to place the composite
graft, it is inherently limited in size by diffusion of
nutrients through the wound bed. In practice, we find
that defects up to 1.5 cm can be repaired through
this technique; attempts at grafting larger defects may
result in necrosis of the graft due to the graft’s high meta­
bolic demands. Also a limitation of this technique is that
the skin eventually takes on the characteristics of the ear
and becomes thin and shiny. The composite graft, there­
fore, may not be ideal for an individual that has a very
thick sebaceous alar skin due to the mismatch in skin
texture.
Harvesting the graft is relatively uncomplicated. First,
a template is created of the defect to be repaired using a
piece of foil. This is then transferred onto the skin over
the root of the superior helix or posterior concha. In our
practice, the most commonly used donor area is the root
of the helix (Figure 36-8). We particularly like this area
because the helical margin very closely mimics the alar
margin. The graft is excised in full thickness, with overly­
ing skin, subcutaneous tissue, cartilage, subcutaneous
tissue, and underlying skin en bloc. We will typically
harvest a slightly larger graft than the defect and trim the
skin to the appropriate size. This leaves a flange of carti­
lage that can be placed into the undermined defect in a
“tongue in groove” method as described by Skouge.7 This
will allow for a greater surface area to be in contact with
the vascularized wound bed as compared to a graft that
is sutured into position end to end. The skin edges are
sutured, and for partial-thickness defects, through-and-
though basting sutures are placed to keep the graft well
apposed to the wound bed. A light dressing is applied and
inferior border of the defect to ensure a sufficiently wide
flap base. In men, the border of the bearded and non-
bearded skin is marked. If possible, only the non–hair-
bearing skin is used for the flap. The nasal defect is
undermined in the sub-SMAS plane and releasing inci­
sions are made sharply. The Burow’s triangle is elevated
along with the flap. This can be very useful if the flap was
improperly planned and slightly shorter than anticipated.
The cheek skin is undermined in the subcutaneous plane
widely and advanced until the donor defect is closed with
as little tension as possible. The cheek defect is first closed.
This takes tension off of the nasal closure and thus can
allow for accurate trimming of the flap to fit the defect.
Once transposed and inset, the flap is closed in layers.
Disadvantages of this flap include potential blunting
of the nasofacial sulcus and asymmetry of the sulcus;
however, these problems are easily resolved with minor
secondary procedures.5
An alternative to the melolabial flap for lesions of the
nasal dorsum to nasal tip is the nasal dorsal flap of Reiger.
We find this to be an excellent alternative in closure of
defects in the middle third. This is a random-based flap
that uses loose skin from the glabellar region to assist in
closing defects. In performing this procedure, the skin,
subcutaneous, and SMAS layers are lifted off the nasal
dorsum above the periosteum, the flap is then rotated
downward, and the loose skin around the glabella is mobi­
lized to close the subsequent defect in a V-to-Y advance­
ment. A standing cone deformity may develop at the
caudal aspect of the flap. The advantages to this flap are
that it allows for a single staged repair with excellent color
and texture match. This closure, however, does not follow
the subunit principle and will leave visible scars in exposed
areas. Defects greater than 2.5 cm will lead to significant
deformity from closure of the secondary defect. Addition­
ally, it requires the mobilization of a large amount of
healthy skin, which may be at risk of necrosis in smokers
or those with microvascular disease.6
NASAL DEFECTS OF THE LOWER THIRD
OF THE NOSE
The lower third of the nose is divided into the nasal tip,
ala, columella, soft tissue triangles, and sill. As with small
lesions of the upper two thirds, primary closure is a viable
alternative for very small defects. The thick skin of the
nasal tip does not lend itself well to skin grafting, as the
graft will have a noticeable difference in coloration and
texture match with the surrounding recipient site. As with
lesions of the upper two thirds of the nose, a local flap
repair is preferred because of the advantages previously
discussed. The technique of choice for lesions up to 1.5 cm
in diameter is reconstruction with a bilobed flap. The
design is the same as previously discussed but with some
specific aspects to consider. When determining a pivot
point, the surgeon must be very careful not to orient it

CHAPTER THIRTY-SIX  Nasal Reconstruction
463
PARAMEDIAN FOREHEAD FLAP
For large defects of the nasal surface, the paramedian
forehead flap is our reconstructive technique of choice. It
is able to provide covering for defects ranging from a
single subunit to nearly the entire soft tissue envelope of
the nose. Based on the supratrochlear artery running
between the corrugator and frontalis muscles, the flap has
an excellent blood supply and can support long pedicles,
often extending well into the hairline. The vascular supply
runs in a vertical direction and can often be identified with
the patient is instructed to apply an antibiotic ointment
to the graft and donor site incisions three times per day.
For lesions between 2 to 3 cm in diameter of the ala and
alar margin, a superiorly based melolabial flap can be
very effective. These flaps are well vascularized and can
therefore support cartilage grafts. The flap is designed as
described in the previous section. Disadvantages of this
flap for reconstructing the nasal ala is the loss of the
superior alar crease as well as possible blunting of the
nasofacial sulcus. However, these problems are easily
resolved with minor secondary procedures.
Figure 36-8  Composite grafting. A, Defect after resection of basal cell cancer involving the alar margin, soft tissue triangle, and lower lateral cartilage.
The defect measures 1 cm in diameter. B, On frontal view, there is noticeable collapse of the right ala due to loss of cartilage. C, A two-layer composite
graft was used to repair the defect. The soft tissues were undermined to allow a flange of cartilage to be inserted in a tongue in groove fashion. D, The
superior crus after closure of the initial defect. E, Repair after 12 months. There is some slight notching of the alar rim on 45-degree view; however, note
the excellent color and texture match of the skin. F, The auricular defect is almost imperceptible.
A
B
C
D
E
F

464
Arnold Lee • Aric Park
of rotation. Thicker pedicles increase the tension on the
tissue being rotated and may increase the likelihood of
flap failure. The flap is then dissected in the subcutaneous
plane for 1 to 2 cm distally, unless the patient is a smoker.
In nonsmokers, hair follicles can be removed from the
distal end of the flap with a sharp pair of iris scissors. At
this point, dissection proceeds to just above the perios­
teum in the subgaleal plane. The dissection continues
inferiorly as much as needed until adequate mobility of
the flap is achieved. If required, the pedicle can be dis­
sected to the level of the supratrochlear foramen well
below the supraorbital rim. The flap is thinned of all galea
and frontalis muscle, taking care to visually identify and
a hand-held Doppler.5 The skin texture and color provide
an excellent match to the native skin of the nose (Figure
36-9).
The flap is designed by making a precise template of
the defect using a suture foil packet to outline in three
dimensions the skin needed. This is then transferred to
the forehead and retraced along the distribution of the
supratrochlear artery. The flap proceeds in a vertical
direction along the path of the artery. It is imperative
when tracing the template to ensure that it is oriented
correctly for the later transposition. In our experience, the
use of the Doppler device enables us to narrow the pedicle.
A narrow pedicle (<1.5 cm) allows for an improved arc
A
B
C
D
E
F
Figure 36-9  Forehead flap cont. A, The proposed excision of nasal melanoma along aesthetic subunits. B, Defect of the nasal tip and nasal dorsum.
C, The supratrochlear artery marked out using a hand-held Doppler. D, A foil template of the nasal defect transposed over the forehead. E, Undermining of
the forehead secondary defect. F, The transposed flap onto the nasal defect.

CHAPTER THIRTY-SIX  Nasal Reconstruction
465
preserve the blood vessels coursing though the subcutane­
ous layer. The flap is rotated 180 degrees away from the
eye. Once the defect has been repaired, the exposed raw
surface of the pedicle can be covered with a small piece
of acellular dermal graft, which can decrease the dripping
of transudate during the postoperative period. The donor
defect of the forehead is closed primarily with wide under­
mining of the surrounding forehead skin in the subgaleal
plane, taking care to preserve the periosteum. Galeotomies
can be used to assist in closure of the forehead donor site
by making incisions perpendicular to the vector of tension
with a No. 15 blade (i.e., parallel to the incision line).
Each galeotomy can provide approximately 2 to 3 mm of
length, and when multiple ones are made in series, up to
5 to 8 mm of extra length can be obtained. In addition,
intraoperative tissue expansion with a moist 4 × 8–cm
gauze pad placed under the undermined forehead flaps
and left in place while the nasal defect is sutured can
result in an extra 3 to 4 mm of pliability. If the defect is
too large for primary closure, healing by secondary inten­
tion is preferable to skin grafting. Potential complications
from surgery include flap necrosis and scarring on the
forehead. Necrosis is often alleviated by keeping the
flap thick distally as the feeding vessels run through
G
H
I
J
K
L
Figure 36-9, cont’d G, Closure of the secondary defect. The surrounding tissues were undermined and underwent intraoperative tissue expansion.
This allowed for primary closure of the initial defect. H, The exposed surface of the forehead pedicle is covered with an alloderm graft to prevent excessive
weeping and improve postoperative comfort. I, Flap division occurs after 3 weeks. Note the edema of the tip. J, At 1 week after flap division, the swelling
has improved. K, At 3 months after surgery, the large linear scar over the forehead is barely noticeable. L, Some residual fullness of the nasal tip and dorsum
is present at 1 year. The patient was offered revision to further thin the flap over his dorsum and side walls; however, he was very happy with his results
and deferred further surgery.

466
Arnold Lee • Aric Park
small risk of a pneumothorax. Cadaveric cartilage offers
similar benefits of autogenous cartilage but has disadvan­
tages, including the potential for late reabsorption and
risk of infection from allographic material.
When recreating a nasal subunit, it is imperative to
lay down a support even in areas without significant car­
tilage or risk future contraction of the covering graft or
flap. For nasal tip reconstruction, a Peck graft can act to
restore proper tip rotation. If further projection is desired,
a second graft can be secured to the first. In performing
support work with cartilage or bone, it is important that
one designs the framework 2 to 3 mm smaller than the
actual subunit. This is to ensure that when the cover is
applied, the resulting repair will be of the desired size and
contour. If a cartilage graft is placed that equals the
desired size of the defect, once the layers have been fully
reconstructed, the surgeon will find a repair that is too
large in comparison to the initial defect.
INTERNAL NASAL LINING
Recreating the lining of the nose is of tremendous impor­
tance for its physiologic function as uncontrolled postop­
erative scarring can lead to vestibular stenosis and nasal
airway obstruction. Lining for the nasal cavity can be
created with either skin grafts or local mucosal flaps. Skin
grafting has several downsides, the first being a need for
a well-vascularized bed on which to lay the graft down.
Typically with full-thickness defects, this bed is not avail­
able as the support graft, be it cartilage or bone, acts as
a barrier for osmosis and nutrient supply to a healthy
graft. In defects where a vascularized bed of perichon­
drium is still present, a skin graft has an excellent chance
for success. Postoperatively, patients may notice ozena, as
the natural mucociliary clearance of the native mucosa
has been lost with the grafted skin. This leaves pedicled
mucosal flaps from the nasal septum as the optimal choice
when approaching full-thickness defects. Often, the
septum will be available for lining the defect in most skin
cancer excisions. This allows the surgeon to harvest a large
flap of mucosa to rotate and to create a lining.
HINGE OVER FLAPS
For alar margin defects, the skin and scar from the healed
margins can be mobilized and turned inward to recreate
the lining. This leaves a larger cutaneous defect than the
original, which can be covered with local or pedicled flaps
as the surgeon sees fit. Unfortunately, the blood supply to
the turned-in flaps can be variable and does not allow for
large defects to be closed in this manner.
CHONDROCUTANEOUS LINING FLAPS
Local flaps designed to harvest vestibular skin can be
used for small defects inferior to the nasal valve. The
the subcutaneous tissue. Scarring of the forehead should
be a secondary concern as scars tend to heal well and
natural contraction will make a large postoperative defect
on the forehead much less apparent.
After approximately 4 weeks, the pedicle is divided
and the flap is thinned and inset into the rest of the nasal
defect. The eyebrow is replaced into its preoperative posi­
tion and the pedicle is inset into the forehead as an
inverted V. Further refinement of the nasal flap can be
performed as needed in subsequent procedures.
REPAIR OF PARTIAL AND FULL
THICKNESS DEFECTS
SUBSURFACE FRAMEWORK AND LINING
When repairing partial- and full-thickness defects, the
subsurface framework and lining, in addition to the skin
covering, may need to be reconstructed. Even those sub­
units that lack a true cartilaginous framework, such as
the soft tissue triangles, must be repaired with a cartilage
graft or risk later contraction of the triangle and subse­
quent deformity. A well-vascularized bed is imperative for
the survival of these nonvascularized grafts. Each missing
piece of cartilage or bone should be crafted to create a
symmetric nose. The other half of the nose can be used
as a template to fashion the cartilage grafts. In cases
where the lesions extend through the midline, the sur­
geon’s knowledge of the relevant anatomy and local sub­
units can guide them in the reconstruction.
CARTILAGE GRAFTS
Cartilage support is most easily obtained from septal car­
tilage. Typically, the septum remains intact after most
excisions of skin cancers. Whether or not the mucosa is
being harvested for mucosal rotation flaps, a large segment
of cartilage may be obtained for use in repairing defects.
It is important to ensure that a dorsal and caudal strut of
at least 1.5 cm is left intact to prevent potential saddling
of the nose in the postoperative period. This strut of car­
tilage acts as the base for all reconstructive efforts in the
repair of larger nasal defects.9 If the amount of cartilage
harvested from the septum is insufficient for the defect,
other sources to aid with the repair include conchal car­
tilage, autogenous rib graft, and cadaveric rib graft.
Conchal cartilage has the advantages of ease of harvest
without significant morbidity. It is limited in the gross
quantity of cartilage available, and its curvature actually
can be advantageous when recreating a nasal tip or other
curved structure. Autogenous rib graft offers large quanti­
ties of cartilage, enough for a total nasal reconstruction in
many cases. The cartilage is straight and easy to work
with; however, there is usually some moderate donor site
discomfort, and the procedure subjects the patient to a

CHAPTER THIRTY-SIX  Nasal Reconstruction
467
over the nasal spine, at the level of the septal perforators
from the superior labial artery, will provide adequate
nourishment to the flap.
For larger defects of the lining involving the superior,
middle, and inferior vaults, a de Quervain flap can be used
effectively (Figure 36-10). The lower and middle vaults
are relined with a septal mucosal flap from the ipsilateral
side. A window of cartilage is removed from the nasal
septum, allowing for the contralateral mucosa to be
rotated inwards and the upper vault lining to be recre­
ated.10 This flap may jeopardize dorsal and tip support.
VESTIBULAR ADVANCEMENT
For small defects at the margin of the alae, the vestibular
skin can be mobilized and advanced inferiorly 2 to 3 mm
(Figure 36-11). As with covering flaps, this flap must be
secured in place to a firm support such as cartilage or risk
advantages of this technique are that the flaps are well
vascularized and can often support immediate placement
of cartilage grafts. Additionally, the skin of the vestibule
is thin and will not result in a thick, bulky ala with poten­
tial for obstruction of the nasal airway.
Intranasal lining flaps offer a one-stage repair for
larger defects. Cartilage grafts can be placed at the time
of surgery, decreasing the number of potential subsequent
procedures. The blood supply to the septal mucosa is
important to observe as reconstructing the lining of a full-
thickness defect often relies on flaps harvested from the
septum. Posteriorly, the septum is supplied from branches
of the sphenopalatine artery, and anterosuperiorly, from
branches of the ethmoidal artery. Anteroinferiorly, the
superior labial arteries contribute to the septal blood
supply. Due to its extensive anastomosing network, a
septal mucosal flap can be maintained with only one of
these blood supplies intact. A pedicle of 1–1.2 cm based
Figure 36-10  De Quervain flap. A, Chondromucosal flap, which is useful in cases of large defects of the nasal lining. B, The contralateral septal mucosa
can be mobilized where it attached cartilage to line the nasal vault.
A
B
Figure 36-11  Vestibular lining flap. A, The vestibular lining is incised and mobilized. B, The flap is then freed and mobilized inferiorly. Two small standing
cone deformities are left at the pedicles.
A
B

468
Arnold Lee • Aric Park
connected to its blood supply, is thinned as well and
replaced. In a third stage 4 to 6 weeks later, the pedicle
is divided and the flap is inset. Subsequent revision sur­
geries are then performed as needed. By proceeding in this
manner, a thin well-vascularized lining can be created
effectively (Figure 36-13).
CONCLUSION
Repairing nasal defects is a rewarding endeavor, posing
new challenges with each case that is encountered. Without
treatment, patients would be left disfigured, with the sub­
sequent psychological and social implications that can be
associated with severe injuries. While various techniques
exist to close and repair these defects, our experience has
shown us that perfecting and maximizing several key
techniques may be used with consistently excellent results.
Determining where and when to use these techniques is
based on a thorough knowledge of the regional anatomy
and the potential pitfalls associated with each reconstruc­
tive technique. While we have touched on our favorite
techniques in this chapter, this is by no means intended
to be taken as a comprehensive treatise on the subject. We
encourage further exploration into the depths of the field
to determine the techniques that best suit each individual
surgeon.
retraction. This technique is limited by the laxity of the
vestibular skin and may not be appropriate in patients
who have had significant scarring in the region, such as
from radiation.
TURN-IN FLAPS
Turn-in flaps require folding a local flap over onto itself
to provide both a skin covering and an internal lining
(Figure 36-12). Commonly, this technique is used in
repairing defects near the alar margin. Due to the inherent
thickness of the skin of the flap, however, the flap often
becomes bulky, leading to a formless shape with poor
match to the delicate surrounding skin of the ala as well
as nasal obstruction. These problems can be addressed
by using a multistaged reconstruction using a well-
vascularized, pedicled flap such as a paramedian forehead
flap. A template of both the cutaneous and internal defect
is created and transferred to the forehead. The flap is
elevated as previously described. Initially, the bulk of the
flap will impact both function and aesthetic form of the
nasal ala. In 4 to 6 weeks, the flap is divided at the alar
margin but left intact at the pedicle. The lining can now
be thinned of any excess subcutaneous tissue allowing
for a thin, vascularized lining. At this stage, cartilage
grafting is performed to support the alar margin as well
as the nasal tip and middle vault. The flap, which is still
Figure 36-12  Melolabial turn-in flap. A, A long melolabial flap is designed with enough excess to rotate a flap over. B, The secondary wound is closed.
Subcutaneous tissue is left on the flap to preserve the blood supply. C, The lining is closed, leading to a rotation of the flap 90 degrees. D, The flap is then
turned in and used to close the cutaneous defect. E, The final resulting flap and closure.
A
E
B
C
D

CHAPTER THIRTY-SIX  Nasal Reconstruction
469
A
B
C
D
E
F
Figure 36-13  Full-thickness defect repair. A, A large full-thickness defect of the left nose after MOHS resection of a basal cell cancer. The tumor was
deeply invasive, extending to the vestibular skin through the cartilage. B, The subunits involved are identified and mapped out for planning of repair. C, The
course of the supratrochlear artery is identified with Doppler ultrasound. D, A forehead flap is designed to cover the defect and resurface the lining of the
nasal vestibule as a turn-in flap. The narrow pedicle of the flap prevents strangulation of the supratrochlear artery. E, The flap is inset and the forehead defect
closed primarily after intraoperative tissue expansion. F, Base view of the resulting flap. Note the obstruction of the left nasal passage from the relatively
bulky flap.

470
Arnold Lee • Aric Park
G, Before pedicle division, a secondary procedure was performed through an incision along the alar margin. At this time, a conchal
cartilage graft was placed to support the left nasal ala. H, I, The flap was inset with further thinning of the nasal ala and recreation of the supra-alar crease.
J, Base view of the resulting repair shows some vestibular collapse with mild shifting of the nasal pyramid due to the force of scar contraction. Note the
patent airway after thinning of the turn-in flap and cartilage grafting. K, The supra-alar crease has been recreated with a satisfactory result. L, The residual
forehead scar is barely noticeable at 3 months.
5. Carucci JA. Melolabial flap repair in nasal reconstruction.
Dermatol Clin. 2005;23(1):65–71.
6. Reiger R. A local flap for repair of the nasal tip. Plast
Reconstr Surg. 1967;40:147.
7. Skouge JW. Skin grafting. New York: Churchill Livingstone;
1991.
8. Reece EM, Schaverien M, Rohrich RJ. The paramedian
forehead flap: a dynamic anatomical vascular study verifying
safety and clinical implications. Plast Reconstr Surg.
2008;121(6):1956–1963.
9. Millard DR. Various uses of the septum in rhinoplasty. Plast
Reconstr Surg. 1988;81:112.
10. Taghinia AH, Pribaz JJ. Complex nasal reconstruction. Plast
Reconstr Surg. 2008;121(2):15–27.
REFERENCES
1. Yalamachili H, Sclafani AP, Schaefer SD, Presti P. The path
of nasal reconstruction: from ancient India to the present. Fac
Plast Surg. 2008;24(1):3–10.
2. Burget GC, Menick FJ. The subunit principle in
nasal reconstruction. Plast Reconstr Surg. 1987;76:
239.
3. Gue L, Pribaz JR, Pribaz JJ. Nasal reconstruction with local
flaps: a simple algorithm for management of small defects.
PRS. 2008;122:130–139.
4. Zitelli JA. The bilobed flap for nasal reconstruction. Arch
Dermatol. 1989;125:957.
G
H
I
J
K
L
Figure 36-13, cont’d

471
C H A P T E R T H I R T Y - S E V E N 
Nasal Septal Perforation Repair
Marc Cohen • Jeffrey D. Rawnsley
The nasal septum plays a critical role in both the function,
as well as the aesthetics, of the human nose. Structurally,
the septum forms the foundation of the nasal pyramid
and acts as the central support element of the nose, pro­
viding support for the cartilaginous and soft-tissue com­
ponents of the nose and nasal cavity. Functionally, the
nasal septum, and its relation with the upper lateral car­
tilages, forms a critical portion of the internal nasal valve.
Disorders of the nasal septum can therefore cause both
structural and functional morbidity to the patient.
Nasal septal perforations can be a source of great
morbidity to a patient. Structurally, nasal septal perfora­
tions may weaken the foundational support of the nasal
pyramid so as to cause significant aesthetic deformities.
Functionally, septal perforations alter the airflow through
the nasal cavity, which in turn may lead to crusting,
epistaxis, and pain.
With these morbidities in mind, it is imperative that
the rhinoplastic surgeon be thoroughly comfortable
with the management of nasal septal perforations. In this
chapter, we review the relevant anatomy, etiology, patho­
physiology, and management of nasal septal perforations.
A review of the different surgical techniques will be
discussed as well the appropriate indications for each
approach.
RELEVANT ANATOMY
The nasal septum divides the nose into two separate nasal
cavities. Each nasal cavity is bounded by the nasal septum,
lateral nasal wall, and nasal floor. The nasal septum is
composed of a bony and cartilagenous framework covered
by a layer of mucoperichondrium and mucoperiosteum.
The bony components of the septum include the nasal
crest of the palatine bone, the nasal crest of the maxilla
and premaxilla, the vomer, the perpendicular plate of the
ethmoid, the nasal crest of the frontal bone, and the spine
of the paired nasal bones. The anterior septum is com­
posed of the quadrilateral cartilage, with its caudal most
projection extending beyond the nasal spine.
The lateral nasal wall is composed of the laminae
papyracea of the lacrimal bone, portions of the ethmoid
bone, and the inferior and middle nasal conchae or tur­
binates. The inferior, middle, and superior turbinates
are composed of a thin bone for structural support and
covered by an adherent mucoperiosteum. Stratified squa­
mous epithelium is found on the anterior tip of the inferior
turbinate, whereas pseudostratified ciliated columnar res­
piratory epithelium covers all other surfaces.
Knowledge of the blood supply to the septum and
lateral nasal wall is important for designing mucosal flaps
for septal perforation repair. Blood supply and innervation
of the nasal septum travel within the mucoperiosteal and
mucoperichondrial linings. The arterial blood supply
derives from the ophthalmic branch of the internal carotid
artery and the maxillary and facial branches of the exter­
nal carotid artery. The upper nasal septum is supplied
by anastomoses of the anterior and posterior ethmoid
arteries, which originate from the ophthalmic branch.
The external carotid artery contributes via a major branch
of the sphenopalatine artery that supplies the posterior
and inferior septum. The columella and caudal septum
receive blood supply from the septal branch of the supe­
rior labial artery. The septal mucosa itself contains
complex arteriovenous anastomoses and venous sinusoids
that can become engorged or constricted via neural or
extrinsic pathways.1
The blood supply to the lateral nasal wall is supplied
posteroinferiorly by the sphenopalatine artery via the pos­
terior lateral nasal artery and by the anterior and poste­
rior ethmoid arteries superiorly. The posterior lateral
nasal artery runs inferiorly on the perpendicular plate of
the palatine bone and courses downward at approximately
1 cm anterior to the posterior end of the middle turbinate
and approximately 1.5 cm anterior to the posterior end
of the superior turbinate. The posterior lateral nasal
artery occasionally gives off branches to the superior tur­
binate and is the predominant supplier of blood to the
middle and inferior turbinates.2
The arterial supply to the inferior turbinate runs in a
direction parallel to the turbinate and nasal floor. Thus,
in cases where relaxing incisions are needed to gain length
on a mucoperichondrial flap, these incisions should be
made immediately below the inferior turbinate bone so as
to avoid arterial disruption.3

472
Marc Cohen • Jeffrey D. Rawnsley
question. Several studies have shown that septal biop­
sies have very little diagnostic value.5,7 Frequently, septal
perforation biopsies are nondiagnostic even in the case of
known vasculitis or malignant disease. It is therefore sug­
gested that in patients with a clinically unremarkable
septal perforation, even in the absence of a diagnostic
history, biopsy of the edges does not add to the manage­
ment of the patient and should not be performed. Biopsy
should be reserved for patients in whom a clinical suspi­
cion of malignancy exists and repeated biopsies may be
needed to confirm the diagnosis.
MORBIDITY OF NASAL
SEPTAL PERFORATION
Patients with nasal septal perforations commonly have a
dry and obstructed nose. They also may complain of
crusting, bleeding, and a whistling noise during breathing.
Pathophysiologically, the airflow jet is directed toward the
posterior aspect of the perforation. This leads to an
increase in airflow turbulence, which in turn causes desic­
cation, bleeding, and crusting. These complaints are
usually associated with anterior, rather than posterior,
perforations. The reason for this finding is that by the time
the nasal airflow reaches the posterior nasal cavity, it is
sufficiently conditioned at that point. Likewise, smaller
perforations are less likely to cause symptoms as would
large ones.8
Lindemann et al.9 studied the effects of closure of
septal perforations on intranasal humidity and tempera­
ture. In a prospective study of 10 patients, surgical closure
of the perforation was shown to have a statistically sig­
nificant increase in nasal airway humidity and tempera­
ture. Moreover, clinical symptoms of recurrent epistaxis
and nasal dryness were shown to improve after repair. The
INCIDENCE AND ETIOLOGY
The incidence of nasal septal perforations in adults is
0.9%.4 In a retrospective review of 74 patients with nasal
septal perforations and ulcers, Diamantopoulos and Jones5
found that 80% of perforations were seen anteriorly, 11%
were located posteriorly or superiorly, and 9% were clas­
sified as total or subtotal. Although the size of the perfora­
tions varied, the majority (39%) had a perforation size of
1 to 2 cm in diameter with an almost equal distribution
of perforations less than 1 cm and greater than 2 cm.
Crusting, minor bleeding, and erythema were the most
common findings on initial presentation.
The etiology of nasal septal perforations is quite
varied (Table 37-1). The most common cause of perfora­
tion is the result of previous septal surgery. Other
causes include nose picking, cocaine use, vasculitis, malig­
nancy, and idiopathic.6 Proper workup of a patient with
a nasal septal perforation should include a thorough
history with specific attention to questions that address
the wide differential diagnosis.
The history should be followed by a complete nasal
endoscopy with documentation of the size and location of
the perforation as well as any other findings such as crust­
ing, bleeding, or granulation tissue. The septum should
also be inspected to assess the degree of remaining carti­
lage. This can be assessed by gentle palpation with a
cotton swab. In terms of laboratory studies, if the patient
does not have a history to suggest a traumatic etiology,
then a c-ANCA, antinuclear antibodies, rheumatoid factor,
and erythrocyte sedimentation rate tests are sufficient. If
any of these are positive, then a rheumatology referral
may be warranted.
The previously accepted dogma that all septal
perforations should be biopsied has recently come into
From Lanier (2007).
Table 37-1  Cause of Nasal Septal Perforation
Traumatic
Inflammatory/Infectious
Neoplastic
Other
Nasal surgery
Sarcoidosis
Carcinoma
Lime dust
Intranasal steroid sprays
Wegener granulomatosis
T-cell Lymphomas
Cryoglobulinemia
Nose ring piercing
Leishmaniasis
Renal failure
Cauterization for epistaxis
Systemic lupus erythematosus
Industrial exposure
Nose picking
Tuberculosis
Nasogastric tube placement
Syphilis
Dermatomyositis
Nasal cannula oxgen
AIDS
Nasal foreign body
Diphtheria
Illicit drugs
Rheumatoid arthritis
Crohn disease

CHAPTER THIRTY-SEVEN  Nasal Septal Perforation Repair
473
The majority of septal perforations that require surgi­
cal closure fall into two main categories: small- to medium-
sized anterior perforations and large central perforations.
Small posterior perforations are usually asymptomatic
and rarely require surgical intervention. The following is
a review of several techniques used to repair both types
of perforations. The review has been written to provide
the reader with an overview of the different approaches
and we recommend referring to the original reports for
further details on each specific technique.
Small- to Medium-Sized Anterior Perforations
Repair of nasal septal perforations can be achieved by
creating well-vascularized transpositions flaps to close
the septal defects. Several authors have described their
varying techniques and success with these procedures.
De Witt14 has described the use of a composite flap of
mucoperichondrium and a “button” of cartilage at the
posterior septum. The flap is created with the base at the
flap centered at the posterior edge of the perforation. This
composite flap is then rotated into the perforation site as
a door hinge. Neighboring mucoperichondrium is then
elevated to close the donor site. The author stated success
with this method on two patients.
In a similar fashion, Shikowitz15 describes using a
mucoperiosteal flap harvested from the bony septum,
which is rotated anteriorly to repair the septal defect. In
addition, acellular dermis and occasional autogenous car­
tilage is used to support the flap. Ninety percent of patients
had successful repair of their perforations, with all patients
having resolution of their symptoms.
Friedman et al.16 described their approach and expe­
rience with the inferior turbinate flap that was previously
described by Vuyk and Versluis.17 Their indication for use
of this flap is for small- to medium-sized perforations.
Using nasal endoscopes, the inferior turbinate is incised
from a posterior to anterior direction with the pedicle of
the flap at the anterior portion of the turbinate. The flap
is then rotated anteriorly and sutured to the rimmed per­
foration. Any exposed bone of the donor site is removed.
The pedicle is then taken down 3 weeks later under local
anesthesia. Seven of 10 patients had successful closure of
their perforation, and one patient required radiofrequency
ablation of a bulky flap.
The inferior turbinate flap provides a well-vascularized
local flap for repair of small- to medium-sized nasal septal
defects. However, disadvantages of this technique are that
it requires at least two staged procedures and may lead to
nasal obstruction from a bulky flap even after the pedicle
is taken down.
Repair of small- to medium-sized anterior perfora­
tions can also be achieved by extracting and repositioning
the quadrangular cartilage, a technique that was initially
described by Sulsenti. In this procedure, the quadrangular
cartilage is extracted and then replaced with the perfo­
rated end first. This places the perforation in a more
study provides further evidence to support the proposed
mechanism that intranasal dryness secondary to turbulent
airflow with septal perforations is responsible for the mor­
bidity of this condition.
MANAGEMENT OF NASAL
SEPTAL PERFORATIONS
The first step in the management of nasal septal perfora­
tions is to determine whether the perforation needs to be
closed. Often, small perforations are asymptomatic and
can be left alone. Also, patients with nasal septal perfora­
tions may have chronic rhinosinusitis and their symptoms
may be attributable to this condition rather than to the
perforation.10 In these circumstances, appropriate medical
therapy may provide more benefit than closure of the
perforation.
If the patient’s symptoms are minor with minimal
crusting, then the use of saline sprays or topical petroleum
jelly may be sufficient. With more severe crusting, saline
irrigation or similar sinus rinses may be needed.
For the patient who does require closure of the septal
perforation, two options exist: mechanical obturation and
surgical closure.
NONSURGICAL APPROACHES
The mainstay of nonsurgical treatment of septal perfora­
tions is the silicone button. Since the 1970s, the use of
both prefabricated and custom prostheses has shown
some benefit.11 Recently, Blind et al.12 studied the impact
of custom-made silicone buttons on the quality of life of
patients with septal perforations. Their results demon­
strated that the use of the silicone obturator led to a
decrease in epistaxis, crusting, whistling, dryness, and
obstruction in a majority of patients. Moreover, the major­
ity of patients who used the obturator had improved
quality of life scores as evidenced with use of a validated
questionnaire. The glaring finding in the study was that
only 38% of the patients still used their obturator after
the follow-up period. The most common reasons given for
not using the obturator included difficulty with position­
ing button, pain, and enlargement of the perforation,
rendering the obturator obsolete.
SURGICAL APPROACHES
As Kridel13 has stated, the goals of septal perforation
repair are closure of the perforation and restoration of
normal nasal physiology. To achieve these goals, the surgi­
cal approach must be tailored for each specific perfora­
tion. The size and location of the nasal septal perforation
will thus dictate whether to approach repair via a closed
or open technique, whether to use an interpositional graft,
or which vascular flap to use for repair.

474
Marc Cohen • Jeffrey D. Rawnsley
as an interpositional graft between the mucoperichon­
drium layers. If tension is found at closure, relaxing lon­
gitudinal incisions are made at the floor and superiorly if
needed. Their overall success rate of closure was 97%,
with 100% closure with perforations less than 2 cm. The
follow-up period ranged from 1 to 10 years.
Which Interpositional Graft to Use?
In a study by Mola et al.,27 New Zealand rabbits had
varying materials placed in their nasal septum. Histologic
analyses were performed at 3 months. Gore-Tex (Implan­
tech Associates, Ventura, CA) was found to cause the most
severe inflammatory reactions, followed by Dacron and
acellular dermis (Alloderm; Lifecell, Branchburg, NJ).
Autogenic cartilage demonstrated the least immune
response.
The use of porcine small intestinal submucosa (Sur­
giSIS; Cook Biotech Inc., West Lafayette, IN) for the
repair of septal perforations has also been shown to be
effective. With the use of SurgiSIS positioned between two
mucoperichondrial flaps, the authors reported a 100%
success rate of closure in 10 patients.28 In an adjunctive
study on rabbits, the placement of SurgiSIS interposi­
tioned between mucoperichondrial flaps demonstrated
evidence of cartilage regrowth.29
PERSONAL SURGICAL TECHNIQUE
Tissue Graft Selection
Closure of a septal perforation requires the reconstruction
of the three layers of the missing septum: bilateral mucosal
layers and a connective tissue layer to replace missing
cartilage. Interposition grafts have traditionally been
composed of either temporalis fascia or pericranium. More
recently the use of human acellular dermal grafts (Allo­
derm) have become increasingly popular due to the fact
that they avoid the time and morbidity of harvest as well
as the generally thicker nature of the material that eases
its use as an interpositional graft.
Graft selection is based on at least two competing
concepts. The use of pericranium and temporalis fascia
has a theoretically improved success rate over autologous
cartilage, due to the rapid neovascularization of these
thinner tissues, as well as the lower metabolic activity of
these grafts. Alternatively, however, much of the success
of closure of the septal perforation relies on complete
closure of the perforations. Due to the consistent fact that
most closures fail at the point of the suture line, the struc­
tural scaffolding of human acellular dermis allows remote
mucosalization from the edge of the mucosal flaps. This
is important in clinical situations where small, unilateral
defects due to incomplete closure or wound breakdown
persist after repair. The strength of the acellular dermal
graft serves as scaffolding for mucosa to heal upon. In
the senior author’s experience, these small unilateral and
posterior location, which no longer matches the perfora­
tion in the mucoperichondrium. Local mucoperichondrial
flaps are then used to allow a tension-free closure at the
perforation site. In a recent series, 87% had successful
closure of the perforation at a minimum of 2 years from
the time of surgery. However, successful closure was
obtained in only 60% of the patients with a greater than
1-cm perforation.18
Several authors have described using oral mucosal
flaps to repair nasal septal perforations. Both sublabial
and buccal flaps have been used with varying degrees of
success.19-22 In general, the flap is harvested and tunneled
into the nasal cavity at the gingivolabial sulcus. Meyer22
describes a three-staged procedure in which a buccal flap
is secured to a conchal cartilage graft. The pedicle is then
taken down at a later date. Kogan et al.21 describe their
technique of using a medially based sublabial flap without
the use of an interpositional graft. The flap is secured into
place with absorbable sutures and the donor site is closed,
obviating the need for a second procedure to transect the
pedicle. They report a 71% success rate based on their
experience with seven patients.
Large Perforations
For the repair of large nasal septal perforations, the crea­
tion of a large, well-vascularized flap that is not overly
bulky is a challenge. Several surgeons have described
techniques to accomplish this goal.
Paloma et al.23 report the use of a pericranial flap to
reconstruct large septal perforations. Via a bicoronal inci­
sion, a pericranial flap consisting of periosteum and sub­
galeal fascia is raised and rotated caudally 180 degrees
over the supraorbital rim. The flap is tunneled under the
glabella inserted into the nasal cavity after detachment of
the upper lateral cartilages. The flap is based on the deep
branches of the supraorbital and supratrochlear vessels.
The advantage of this approach is that it provides a well-
vascularized flap of autogenous tissue with an adequate
size to repair large septal defects.
Reports of using a free flap for subtotal septal defects
have been documented.24,25 The free flap is anastomosed
to the facial artery and vein and tunneled under the upper
lip. The flap is inset via an open rhinoplasty approach.
This technique is reserved for large perforations in which
local tissue for repair is unavailable.
Pedroza et al.26 reviewed their experience of 100
septal perforation repairs. Their technique shares many
of the same principles as several other authors in the lit­
erature. The authors use a “postcartilaginous” incision via
a closed approach, unless the perforation is greater than
2 cm, in which case the procedure is performed via an
open rhinoplasty approach. Bilateral mucoperichondrial
flaps are raised at the septum, nasal floors, toward the
attachment of the inferior turbinates, and superiorly
toward the junction of the upper lateral cartilages and
septum. A temporalis fascia graft is harvested and used

CHAPTER THIRTY-SEVEN  Nasal Septal Perforation Repair
475
exposing the anterior and caudal septum. Meticulous dis­
section is required throughout the procedure so as not to
perforate the septal flaps. Careful entry into the full sub­
mucoperichondrial plane on both sides of the septum is
performed sharply with careful attention not to weaken
the anterior and caudal septum with multiple knife cuts.
A Cottle elevator is then used to create a tunnel under­
neath the upper lateral cartilages on both sides of the
septum. The upper lateral cartilages are then sharply dis­
sected along the dorsum. This may be performed with a
No. 15 blade on to the Cottle elevator or with sharp
straight Iris scissors. Next, elevation of the mucosal flaps
is begun toward the perforation with elevation of the
mucoperichondrium surrounding the perforation. The rim
of the perforation is incised with a No. 15 blade along its
posterior, superior, and inferior edge, and careful blunt
dissection is then performed from the remaining septal
cartilage toward the perforation to avoid enlargement of
the septal defect.
The mucosa of the floor of the nose is then elevated
in a submucoperiostial plane. This is performed by first
creating a small incision along the ridge of the inferior
piriform aperture. Blind dissection is then performed in
a subperiostial plane with the Cottle elevator extending
up underneath the inferior turbinates and posteriorly.
Once this is broadly elevated on both sides, decussation
of fibers is performed sharply at the point where the
maxillary crest and cartilaginous septal intersection is
carefully divided, with careful attention again not to per­
forate the septal flaps. Backcuts are made underneath
the inferior turbinate for the full length of the turbinate
with a No. 15 or Beaver blade. Connection of this inci­
sion to the sub­periosteal plane of the mucuperiosteal flap
is then made to increase their mobility and advance
them as a bipedicled flap into the defect. Once there has
been complete release of the mucoperiosteal flaps, the
cartilaginous defect is addressed with the use of either
autograft or allograft. The graft is placed with adequate
overlap. It is then sutured first anteriorly with two septal
mattress sutures using 5-0 chromic suture to anchor the
graft. It is then unfurled over the septal cartilaginous
defect and sutured posteriorly as well. Septal flaps are
then advanced superiorly toward the superior edge of
the defect (Figure 37-1). The advancement of the flaps
is not strictly in a vertical direction as membranous
septum is recruited for its laxity in many cases, such
that an anterior-to-posterior direction advancement also
occurs (Figure 37-2).
If a tension-free closure is not obtained at this time,
further maneuvers are anticipated. The first includes the
fortuitous desire of the patient to have a dorsal reduction
discussed prior to surgery (Figure 37-3). Resection of
bone and cartilage of the dorsum will release the soft
tissue attachments and allow lowering of the dorsal
septum to relax the superior flap. If dorsal hump reduction
is not indicated, an incision can be made in the superior
occasionally bilateral defects in the mucosa will fill in
from the mucosal wound edge much as remucosalization
occurs over exposed bone and cartilage after septoplasty.
When autografts are harvested, the harvest should
include a generous amount of temporalis fascia or peri­
cranium that will allow overlay at least 1.5 cm beyond
the cartilaginous defect. The harvests of these grafts have
been well described and are techniques that most otolaryn­
gologists, facial plastic surgeons, and plastic surgeons
are familiar with (i.e., in the harvest of grafts for
tympanoplasty).
Operative Approach
While endonasal approaches have been popularized in the
past, they are rarely appropriate for most septal perfora­
tions except those that are small, low, and anterior, due
to the limit of exposure for larger perforations and patients
with small nostrils.
The success rate is also affected by size of the perfora­
tion, with larger perforations requiring broader under­
mining of surrounding mucosa to recruit into the defect.
This requires extensive exposure necessitating an external
approach. Septal perforation repair is one of the most
technically difficult procedures to obtain consistent
success due to the delicate nature of the tissues, oblique
angle of visibility that occurs through most of the surgery,
many pitfalls for enlarging the perforation, and produc­
tion of rents in the mucosal flap as the surgery proceeds.
Patient selection is also very important as perforations
over 1.5 cm in vertical height, especially in small noses,
often do not have sufficient nasal mucosa to allow com­
plete closure. In addition, if the septal perforation is due
to cocaine abuse, the vascularity of the tissue involved
may be permanently compromised. Preoperative screen­
ing may be necessary to ensure the surgeon that the
patient has discontinued cocaine, as ongoing use will
likely condemn the perforation repair to failure.
At the time of surgery, the patient is placed in the
supine position. General endotracheal intubation with a
RAE (Ring-Adair-Elwyn) tube is performed and the
throat is packed with saline-moistened gauze. The nose is
injected with 1% lidocaine with 1 : 100,000 epinephrine,
as is standard in an external rhinoplasty approach, with
infiltration of all septal and nasal mucosa. The patient is
then prepped and draped in the usual sterile fashion, and
careful intranasal examination is performed to confirm
the office examination. Any existing synechiae are identi­
fied, and the extent of the cartilaginous septal defect,
which may be masked by mucosa, is inspected using a
0-degree endoscope and contralateral palpation of the
septum.
Marginal incisions are then performed with a No. 15
blade, as well as a transcolumellar incision in an inverted-V
fashion using a No. 11 blade. The soft tissue envelope
is then undermined and a wide local exposure is begun
by sharply disarticulating the intercrural ligaments and

476
Marc Cohen • Jeffrey D. Rawnsley
cases, posteriorly based flap of mucosa from the inferior
flap is necessary to rotate mucosa into the defect for com­
plete closure (Figure 37-4).
Once the flaps are completely released, reapproxima­
tion of the flaps is possible. The flaps are closed with 6-0
chromic suture on a small cutting needle using Castroviejo
forceps. Once both septal perforations are closed in this
manner, the whole three-layer complex is reapproximated
with running 4-0 plain gut suture on a Keith needle to
“mattress together” all the elements. This also serves to
stabilize the mucosal graft. The upper lateral cartilages
are then reapproximated with 5-0 Prolene suture, and the
intercrural ligaments are carefully reestablished with tip
support if necessary either from a columellar strut or,
when appropriate, by suturing the medial crura to the
caudal septum in a tongue-in-groove fashion. Under some
circumstances, the membranous septum may be pulled
with undue tension that will cause tip rotation and colu­
mella retraction. This rarely is a long-term problem as this
will tend to relax over the course of the first 3 to 6 months.
The transcolumellar incision is closed with interrupted
6-0 nylon sutures in a mattress fashion, and the marginal
incisions are closed with 4-0 chromic suture. To stabilize
the lining and provide a healing moist environment, thin
Silastic sheeting is placed over the repaired septum and
held in place with 5-0 Prolene sutures through the ante­
rior septum. If gel foam is used as packing, frequent nasal
saline spraying in the nostrils at postoperative day 3 will
hasten its dissolution.
At 1 week postoperatively, the nasal splint and
transcolumellar sutures are removed. At 3 weeks post­
operatively, the Silastic sheeting is removed following
removal of the anterior retaining sutures. The repaired
septum can then be fully examined endoscopically.
flap approximately 5 mm below the upper lateral carti­
lages (along the length of the upper lateral cartilages) to
create a true bipedicled mucosal flap. This should be
performed unilaterally to ensure adequate vascularity on
closure of the dorsal septum from the contralateral side.
Complete closure of one side is a prerequisite of successful
long-term closure of the perforation. Although complete
bilateral closure is always preferable, incomplete unilat­
eral closure may still allow successful full-thickness
closure through postoperative remucosalization. In some
Figure 37-2  Vectors of mucosal recruitment.
Lower lateral
cartilage
Superoposterior
septum
Nasal
floor
Figure 37-3  Closure of septal perforation with dorsal reduction.
Upper lateral
cartilage
Dorsal septal
reduction
Back cuts
under inferior
turbinates
Figure 37-1  Typical three-layer closure of septal perforations.
Mucosal
flap closure
Temporoparietal fascial
or acellular dermal graft
sutured to cartilagenous
septum

CHAPTER THIRTY-SEVEN  Nasal Septal Perforation Repair
477
6. Dosen LK, Haye R. Nasal septal perforation 1981-2005:
changes in etiology, gender and size. BMC Ear Nose Throat
Disord. 2007;7:1.
7. Murray A, McGarry GW. The clinical value of septal
perforation biopsy. Clin Otolaryngol Allied Sci.
2000;25:107–109.
8. Grutzenmacher S, Mlynski R, Lang C, et al. The nasal airflow
in noses with septal perforation: a model study. ORL J
Otorhinolaryngol Relat Spec. 2005;67:142–147.
9. Lindemann J, Leiacker R, Stehmer V, et al. Intranasal
temperature and humidity profile in patients with nasal septal
perforation before and after surgical closure. Clin Otolaryngol
Allied Sci. 2001;26:433–437.
10. Bhattacharyya N. Clinical symptomatology and paranasal
sinus involvement with nasal septal perforation.
Laryngoscope. 2007;117:691–694.
11. Facer GW, Kern EB. Nasal septal perforations: use of Silastic
button in 108 patients. Rhinology. 1979;17:115–120.
12. Blind A, Hulterstrom A, Berggren D. Treatment of nasal
septal perforations with a custom-made prosthesis. Eur Arch
Otorhinolaryngol. 2009;266(1):65-69.
13. Kridel RW. Considerations in the etiology, treatment, and
repair of septal perforations. Fac Plast Surg Clin North Am.
2004;12:435–450, vi.
14. De Witt WS. A new method for closure of small to medium-
size nasoseptal perforations. Ear Nose Throat J.
2007;86:226–229.
15. Shikowitz MJ. Vascularized mucoperiosteal pull through flap
for closure of large septal perforation: a new technique.
Laryngoscope. 2007;117:750–755.
16. Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate
flap for repair of nasal septal perforation. Laryngoscope.
2003;113:1425–1428.
17. Vuyk HD, Versluis RJ. The inferior turbinate flap for closure
of septal perforations. Clin Otolaryngol Allied Sci.
1988;13:53–57.
SURGICAL OUTCOMES
The success of closure is enhanced with proper patient
selection; small perforations are more likely to be ade­
quately closed. Complete closure of the septal flaps bilat­
erally also greatly improves the likelihood of success with
complete repair. Meticulous closure and careful preopera­
tive selection of patients will ensure the highest rate of
success. Revision septal perforation repair is difficult and
usually not recommended; nevertheless, reduction in the
size of the perforation can provide significant improve­
ments in nasal physiology and symptoms.
REFERENCES
1. Cummings C, Haughey B, Thomas J, et al. Cummings
Otolaryngology: head and neck surgery. St Louis: Mosby;
2004.
2. Lee HY, Kim HU, Kim SS, et al. Surgical anatomy of the
sphenopalatine artery in lateral nasal wall. Laryngoscope.
2002;112:1813–1818.
3. Ribeiro JS, da Silva GS. Technical advances in the correction
of septal perforation associated with closed rhinoplasty. Arch
Fac Plast Surg. 2007;9:321–327.
4. Oberg D, Akerlund A, Johansson L, Bende M. Prevalence of
nasal septal perforation: the Skovde population-based study.
Rhinology. 2003;41:72–75.
5. Diamantopoulos II, Jones NS. The investigation of nasal
septal perforations and ulcers. J Laryngol Otol.
2001;115:541–544.
Figure 37-4  Order of backcuts for progressive mobi­
lization of mucosa.
1. Floor mucosa backcut
2. Superoposterior
bony septal backcut
3. Connection of
backcuts 1 and 2
4. Unilateral extension of
backcut 2 along dorsal
cartilaginous septum

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25. Murrell GL, Karakla DW, Messa A. Free flap repair of septal
perforation. Plast Reconstr Surg. 1998;102:818–821.
26. Pedroza F, Patrocinio LG, Arevalo O. A review of 25-year
experience of nasal septal perforation repair. Arch Facial
Plast Surg. 2007;9:12–18.
27. Mola F, Keskin G, Ozturk M, Muezzinoglu B. The comparison
of acellular dermal matric (Alloderm), Dacron, Gore-Tex, and
autologous cartilage graft materials in an experimental animal
model for nasal septal repair surgery. Am J Rhinol.
2007;21:330–334.
28. Ambro BT, Zimmerman J, Rosenthal M, Pribitkin EA. Nasal
septal perforation repair with porcine small intestinal
submucosa. Arch Facial Plast Surg. 2003;5:528–529.
29. Pribitkin EA, Ambro BT, Bloeden E, O’Hara BJ. Rabbit ear
cartilage regeneration with a small intestinal submucosa graft.
Laryngoscope. 2004;114:1–19.
18. Sarandeses-Garcia A, Sulsenti G, Lopez-Amado M, Martinez-
Vidal J. Septal perforations closure utilizing the backwards
extraction-reposition technique of the quadrangular cartilage.
J Laryngol Otol. 1999;113:721–724.
19. Tardy ME Jr. “Practical suggestions on facial plastic
surgery—how I do it.” Sublabial mucosal flap: repair of septal
perforations. Laryngoscope. 1977;87:275–278.
20. Heller JB, Gabbay JS, Trussler A, et al. Repair of large nasal
septal perforations using facial artery musculomucosal
(FAMM) flap. Ann Plast Surg. 2005;55:456–459.
21. Kogan L, Gilbey P, Samet A, Talmon Y. Nasal septal
perforation repair using oral mucosal flaps. Isr Med Assoc J.
2007;9:373–375.
22. Meyer R. Nasal septal perforations must and can be closed.
Aesthetic Plast Surg. 1994;18:345–355.
23. Paloma V, Samper A, Cervera-Paz FJ. Surgical technique for
reconstruction of the nasal septum: the pericranial flap. Head
Neck. 2000;22:90–94.
24. Mobley SR, Boyd JB, Astor FC. Repair of a large septal
perforation with a radial forearm free flap: brief report of a
case. Ear Nose Throat J. 2001;80:512.

479
C H A P T E R T H I R T Y - E I G H T 
Repair of Acute Nasal Fracture
Rami K. Batniji • Kamal A. Batniji
The nasal bones are the most commonly fractured bones
in the face. Acute nasal fractures may result in both nasal
deformity and nasal airway obstruction. However, some
controversy still surrounds the management of acute nasal
fractures, in that a review of the literature demonstrates
a lack of consensus with respect to the timing of repair of
the acute nasal fracture, the anesthesia used during repair,
and the type of procedure performed. Furthermore, post­
reduction nasal deformities reportedly requiring subse­
quent rhinoplasty or septorhinoplasty range from 14%
to 50%.
A thorough history of the mechanism of injury and a
detailed physical examination provide the surgeon with
information to adequately decide how to treat the acute
nasal fracture, with special attention dedicated to the
septum as improper reduction of the injured septum is the
usual cause for the high incidence of postreduction nasal
deformities. In this chapter, we review the management
of the acute nasal fracture.
INCIDENCE
Nasal bones are the most commonly fractured bones in
the face. While reports estimate the annual incidence of
nasal fractures in the United States as 52,000, the actual
number may be higher for a variety of reasons, including
the fact that severely traumatized patients with life-
threatening injuries may concurrently present with nasal
fractures that go unrecognized.1 The mechanism of injury
is usually blunt trauma and can be attributed to assault,
motor vehicle accidents, a fall, or a sports-related injury.2
Previous nasal surgery may have an impact on the inci­
dence of acute nasal fracture3; a patient who undergoes
rhinoplasty is at an increased risk of nasal fracture, par­
ticularly within the first year following the rhinoplasty
procedure.3
Nasal fractures in the pediatric population may be
overlooked. The pediatric nose is mostly cartilaginous and
the nasal bones are small; therefore, the pediatric nose is
softer and more compliant, therefore being less likely to
sustain displacement than the adult nose when fractured.
Despite these attributes, pediatric nasal fractures do occur.
A review of the pediatric facial fractures in the National
Trauma Data Bank demonstrated a 30.2% incidence of
nasal fractures in children and adolescent trauma patients
(aged 0 to 18 years).4 The most common mechanisms of
injury are motor vehicle collisions, violence, falls, and
sports-related injuries. Another potential cause of nasal
fracture in the pediatric population is birth trauma. Birth
trauma, from intrauterine forces, breech delivery, or
forceps-assisted delivery, may result in congenital devia­
tion of the nasal septum.5 Although these deviations can
be treated easily, expeditiously, and usually without com­
plication in the neonatal period, the identification of a
deviated septum can be overlooked. The pediatric nose
is very susceptible to septal hematoma following blunt
trauma. Unfortunately, childhood nasal trauma is often
underappreciated and nasal fracture and/or septal injury
is overlooked, resulting in external and internal nasal
deformities in adulthood.
MECHANISM OF INJURY
Murray’s seminal work in detailing the pathophysiology
of nasal bone fractures in fresh cadaver specimens pro­
vided valuable insight into the mechanism of injury for
nasal trauma.6 Nasal fractures are most commonly due to
a lateral force; this results in two fracture lines running
parallel on the ipsilateral thin nasal bone along the
dorsum, meeting at the junction of the thick and thin
bones (Figure 38-1). In this type of injury, the nose may
appear deviated due to the depression of the unilateral
bony fragment.
A frontal force must be of greater magnitude to
produce a nasal fracture because the nasal bones are but­
tressed by the frontal process of the maxilla, the nasal
spine, and the perpendicular plate of the ethmoid. The
resultant injury includes not only a nasal bone fracture
(which may be comminuted) but also a C-shaped fracture
in the septum extending from just beneath the dorsum of
the nose, inferiorly and posteriorly through the perpen­
dicular plate of the ethomid and curving anteriorly to the
inferior cartilaginous septum near the maxillary crest and
the angle of the vomer. Frequently, the inferior end of the
septum becomes dislodged from its groove and is deflected
obliquely into the nasal cavity (Figure 38-2). As a result,

480
Rami K. Batniji • Kamal A. Batniji
the ala and nostril on the deflected side can become
widened, while the opposite side can become flattened
and narrowed.
A high-impact frontal force injury to the nose, such
as that sustained during a motor vehicle collision, may
produce comminuted or compound nasal fractures. If a
patient sustains this type of injury, one must rule out a
nasal orbital ethmoid (NOE) complex fracture after the
cervical spine, skull, and ophthalmic injuries are cleared.
Signs of NOE complex fractures include telecanthus, epi­
phora, periorbital emphysema, clear rhinorrhea second­
ary to cerebrospinal fluid leak, and a flattened nasofrontal
root. Surgeons should have a low threshold for requesting
a noncontrast computed tomography (CT) scan of the
facial skeleton if the slightest clinical suspicion for an
orbital or facial fracture arises. Further work-up and
management of NOE injuries are beyond the scope of this
chapter.
DIAGNOSIS
Identification of a nasal fracture is primarily a clinical
diagnosis and plain radiographs are rarely, if ever, neces­
sary. Patients may experience epistaxis, edema, ecchymo­
sis, and nasal obstruction. Upon palpation, tenderness,
crepitus, and step-off deformities may be appreciated. An
obvious deformity may be appreciated, such as a con­
spicuous concavity or convexity of the nasal bones result­
ing in a twisted nose appearance. In the acute setting,
evidence of nasal deformity may be hidden secondary to
the masquerading effects of edema.
Avulsion of the upper lateral cartilage attachments
may also result in a concave appearance of the middle
third of the nose. The cephalic portion of the upper lateral
cartilage is attached to the caudal border of the nasal
bone. The medial portion of the upper lateral cartilage is
attached to the dorsal cartilaginous septum; this attach­
ment constitutes the internal nasal valve and has been
described as a 10- to 15-degree angle on intranasal exam­
ination.7 Placement of a cotton-tipped applicator in the
region of the internal nasal valve with subsequent improve­
ment in nasal airway obstruction confirms the diagnosis
of internal nasal valve collapse. Closed reduction of the
fractured nasal bone may reapproximate the avulsed
upper lateral cartilage to the caudal border of the nasal
bone. However, avulsion of the upper lateral cartilage
from the dorsal cartilaginous septum may require place­
ment of a spreader graft to address the concavity of the
middle third of the nose as well as improve nasal function
by reconstituting the internal nasal valve.8
Intranasal examination should be performed after
decongesting the nasal cavities. Topical oxymetazoline is
effective and, when mixed with 4% topical lidocaine, can
achieve both decongestion and anesthesia. Intranasal
Figure 38-1  The nasal bones. The nasal bony vault is pyramidal in
shape and forms the upper third of the nose. The nasal bony vault consists
of the paired nasal bones and the ascending frontal process of the maxilla.
The nasal bones are thicker and more dense superiorly and are progres­
sively thinner inferiorly. There is a transition zone of relatively thin bone
along the frontal processes of the maxilla from the piriform aperture to the
radix along the lateral nasal wall.
Figure 38-2  The nasal septum and patterns of septal fractures. The
septal (aka quadrangular cartilage) articulates with the anterior nasal spine
caudally, the perpendicular plate of the ethmoid posteriorly, and the vomer
inferiorly; the vomer articulates with the maxillary and palatine crests. The
septal cartilage typically rests along a groove at the midline; this is known
as the vomerine groove. The most common septal fracture is along this
junction between the vomerine groove and quadrangular cartilage. A high-
velocity injury or frontal impact can result in a more extensive septal fracture
through the thin central region of the septal cartilage and extending to the
bony cartilaginous junction.
Nasal
bone
High velocity
fracture
Septal
cartilage
Anterior
nasal
spine
Low velocity
fracture
Maxillary
crest
Vomer

CHAPTER THIRTY-EIGHT  Repair of Acute Nasal Fracture
481
examination is performed to evaluate the status of the
septum and identify mucosal injuries. If a bulge is appre­
ciated along the septum, this may signify a septal
hematoma. If a septal hematoma is suspected, a helpful
maneuver is to palpate the intranasal bulge with a cotton-
tipped applicator and, if compressible, a fine needle aspi­
ration can be performed. In the pediatric patient, the
nose tends to buckle and twist rather than fracture. As
such, there is a higher incidence of separation of the peri­
chondrium from the septal cartilage and subsequent
potential for hematoma formation. Digital photodocu­
mentation of the resulting nasal deformity can be obtained
for the medical record.
TREATMENT
TIMING OF REPAIR
Some controversy surrounds timing of repair for the acute
nasal fracture. Edema follows shortly after the initial
injury, making it difficult to allow for precise reduction.
Therefore, it is best to institute conservative measures to
minimize edema and allow for proper analysis of potential
deformity 3 to 5 days after injury.9 These conservative
measures include a soft diet, head-of-bed elevation, and
the application of an ice compress to the area of injury.
Definitive treatment can be carried out 5 to 12 days after
the initial injury. During this period, the fractured com­
ponents of the nasal bone can be easily manipulated.
However, if definitive treatment is delayed beyond this
time period, fibrosis may result in decreased mobility of
the nasal bones, making the closed reduction of the nasal
bone fracture more challenging.
ANESTHESIA
Another area of controversy in the management of the
acute nasal fracture is the type of anesthesia administered
during the surgical repair.10 Local anesthesia with intra­
venous sedation, for instance, minimizes the potential
risks of general anesthesia, such as nausea. General
anesthesia, however, provides the benefit of a controlled
airway as well as the opportunity for uncompromised
nasal examination, reduction, and manipulation. Typi­
cally, a topical vasoconstrictive agent such as oxymetazo­
line or 4% liquid cocaine is applied to cottonoid pledgets
and placed in the nasal passageway to minimize bleeding
while a local anesthetic, such as 1% lidocaine with
1 : 100,000 epinephrine, provides more robust anesthesia
and vasoconstriction.
Several factors should be weighed when deciding
between local or general anesthesia for the management
of nasal fractures. The first consideration is the patient’s
airway. If the surgeon anticipates significant bleeding
following reduction of the nasal fracture, then the surgeon
should consider the use of a short-acting general anes­
thetic while the airway is secured and protected.
Another consideration is the severity of the nasal
fracture, as well as the presence of an associated septal
fracture. Since one of the most common causes for persis­
tent nasal deformity following closed reduction of a nasal
fracture includes unrecognized septal fracture or inade­
quate reduction, the surgeon should consider the use of a
short-acting general anesthetic to properly address the
causes of the nasal deformity.11 Pediatric patients should
undergo reduction of the nasal fracture under general
anesthesia since they are not able to comply with local
anesthesia. Finally, patient comfort should also be consid­
ered when making this decision. While some patients
may tolerate reduction of nasal fracture under local
anesthesia, other patients may prefer a short-acting
general anesthetic.
CLOSED REDUCTION OF ACUTE NASAL
BONE FRACTURE
The authors prefer the use of the Boies elevator to perform
closed reduction of acute nasal bone fractures. The Boies
elevator is placed intranasally and the impacted nasal
bone is reduced, thus restoring the nasal length. The
thumb of the contralateral hand is placed over the nasal
bone externally to palpate subtle osseous movements
(Figure 38-3). If the impacted nasal bone is locked under
the ascending process of the maxilla, the Boies elevator is
used in an upward and outward motion to reduce the
fractured nasal bone; the instrument must not be inserted
too deeply, as it may rest under the nasal process of the
frontal bone and will be of no value. An external splint is
always used. Additionally, in an effort to minimize the
possibility of repeat impaction of the recently reduced
nasal bone, an internal nasal splint could also be used in
the form of nasal packing. A small amount of absorbable
packing (Gelfoam; Pfizer) covered with antibiotic oint­
ment strategically positioned intranasally along the medial
aspect of the nasal bone usually suffices in maintaining
the position of the reduced nasal bone; at the same time,
this is well tolerated by the patient and does not require
removal given its dissolvable nature. While a variety of
dorsal nasal splints are available, the authors prefer the
use of PS® Thermoplatic Nasal Splint (Aquaplast Corp.,
Wyckoff, NJ). First, liquid adhesive (Mastisol®, Ferndale
Laboratories, Inc., Ferndale, MI) is applied to the skin.
Then, the soft tissues of the nose are taped using 14-inch
paper tape; taping begins at the supratip break to drape
the soft tissue in this location intimately to the underlying
skeleton. Strips of different lengths are then applied in a
transverse fashion over the nose, avoiding excessive pres­
sure. The Aquaplast splint is then applied. The external
dorsal splint remains in place for 1 week.

482
Rami K. Batniji • Kamal A. Batniji
IMMEDIATE SEPTORHINOPLASTY
In the literature, some authors advocate an open approach
to the nasal pyramid at the time of initial repair using
accepted rhinoplasty techniques, including rasping, oste­
otomies, and cartilaginous resection or augmentation of
the dorsum.12 However, due to the numerous existing vari­
ables involved in an acute nasal fracture such as irregular­
ity and/or comminution, the nasal bones may not be easily
controlled via the external approach. Also, the healing
process and unavoidable fibrosis following surgical repair
of the acute nasal fracture may cause shifts in the nasal
structures. Ultimately, the absence of a detailed and elec­
tive preoperative consultation with the inherent imposi­
tion of a time-pressured decision for surgery may generate
a series of expectations and obscure the transparency
required in the patient’s personal decision to go through
an elective aesthetic procedure. Therefore, for patients
with acute nasal fractures who are interested in cosmetic
septorhinoplasty, it behooves both the surgeon and patient
to consider delaying treatment for at least a few months
for selected cases. However, it is clear that changes will
continue to evolve until approximately 1 year after any
given traumatic injury.13
REPAIR OF THE PEDIATRIC NASAL FRACTURE
While it is unclear whether disruption of the human pedi­
atric septal growth center affects the development of the
REPAIR OF SEPTAL FRACTURE
If the septum is deviated, it can be reduced with either an
Asch forceps or the Boies elevator to relocate the displaced
base to the midline. Following this, the septum should be
reevaluated to ensure that proper reduction is achieved.
If the septum remains posteriorly displaced or irreducible,
then the authors proceed with an open approach to the
septum via a hemitransfixion incision. Once bilateral
mucoperichondrial flaps are elevated, complete visualiza­
tion of the septum provides the opportunity to properly
identify the extent of the septal injury. In the authors’
experience, a small hematoma may be identified at the
bony–cartilaginous junction; this is evacuated with
suction. If the inferior aspect of the quadrangular carti­
lage remains dislodged from the vomerine groove, an infe­
rior strip of quandrangular cartilage can be resected, the
septum can be repositioned into the vomerine groove in a
swinging door fashion, and a figure-of-eight suture with
5-0 Monocryl can be used to keep the posterior caudal
septum attached to the anterior septal spine in the midline.
Once the hemitransifixion incision is reapproximated
using interrupted 5-0 plain gut sutures, internal nasal
septal splints are placed. Silicone septal splints are favored
to ensure atraumatic placement and removal. Prophylac­
tic gram-positive antibiotic coverage (typically cephalexin)
is prescribed following surgical repair and is continued
until the silicone splints are removed on postoperative day
7 (Figure 38-4).
Figure 38-3  Reduction of nasal fracture. The Boies eleva­
tor is placed intranasally. The surgeon’s contralateral thumb
is used to palpate the nasal bone to ensure adequate
reduction.
Nasal bone

CHAPTER THIRTY-EIGHT  Repair of Acute Nasal Fracture
483
complication ranges from 14% to 50%.15 Further analysis
of these data suggests the possible reason for such a high
complication rate is the use of closed techniques to repair
the fractured nasal bone, failing to address septal injuries.
Indeed, Rohrich and Adams demonstrated a much smaller
rate of 9% for posttraumatic nasal deformity following
reduction efforts when the septum is properly evaluated
and open treatment of the septum is performed when
indicated.16
CONCLUSION
A detailed history, including the mechanism of injury and
a thorough physical examination, provides important
information in the treatment of acute nasal fractures. Soft
tissue edema, which inevitably accompanies acute nasal
fractures, may limit the physical examination; therefore,
the decision for definitive therapy should be delayed until
the edema has resolved and any underlying acquired nasal
deformity can be fully appreciated. It is important to
identify and treat septal hematoma early in the process.
Definitive treatment should not be delayed beyond 2
weeks as fibrosis will settle in, making mobilization of the
fractured nasal bones more difficult. While there are dif­
ferent methods to reduce and treat acute nasal fractures,
it is important not to overlook the septum, addressing any
existing deviations or fractures at the same time as the
fractured nasal bones to minimize the incidence of pos­
treduction nasal deformities requiring subsequent surgical
interventions (Figures 38-5 and 38-6).
nose, there is clear evidence to support the importance of
such growth centers in animal models.14 Therefore, closed
reduction is the preferred method of treatment of acute
nasal fracture in the pediatric population. To facilitate a
thorough examination and complete reduction, general
anesthesia is used for the pediatric patient. The technique
for closed reduction is similar to that previously described.
However, there are a few caveats. For example, internal
splinting is typically performed with light absorbable
packing such as Gelfoam, thus obviating the need for
removal during the postoperative period. Finally, the
guardians of the pediatric patient should be properly
counseled with respect to the possibility of the child devel­
oping delayed nasal deviation and obstruction and may
therefore be informed of the possibility of a formal sep­
torhinoplasty in the future.
COMPLICATIONS
Potential complications following repair of the acute nasal
fracture include, among other possibilities, epistaxis and
septal hematoma. Epistaxis is usually self-limiting;
however, if persistent, oxymetazoline nasal spray, head-
of-bed elevation, and the application of a cold compress
can be used to decrease or stop bleeding. If a septal
hematoma is appreciated in the postoperative period, it is
dealt with in a manner similar to that described earlier
in this chapter. Posttraumatic nasal deformity following
reduction efforts is another potential complication. A
review of the medical literature demonstrates this
Figure 38-4  Reduction of septal fracture. Adequate exposure
to the fractured septum is achieved via a hemitransfixion incision. If
the septal fracture is along the junction between the vomerine
groove and quadrangular cartilage, a strip of cartilage can be
removed (shown in red) and the cartilage repositioned within the
vomerine groove. A figure-of-eight suture anchors the quadrangu­
lar cartilage caudally to the anterior nasal spine at the midline.
A
B
C

484
Rami K. Batniji • Kamal A. Batniji
Figure 38-5  Acute nasal fracture before (A) and after (B) reduction of nasal bone and septal fracture, 1 year postoperatively.
A
B
Figure 38-6  Acute nasal fracture before (A) and after (B) reduction of nasal bone and septal fracture, 1 year postoperatively.
A
B
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