Operative Technique in Plastic Surgery – Kevin C.Chung

with Kerrison rongeurs. D,E. A Bowman probe is
advanced through the canaliculus into the sac,
resulting in tenting of the lacrimal sac (white arrow). F.
A monocanalicular stent is placed. G,H. The lacrimal
sac flap is sutured to nasal mucosa with absorbable
sutures, and then the skin incision is closed.
PEARLS AND PITFALLS
Internal vs
external
approach
■ Most patients have good outcomes with either approach,
determined by patient and surgeon preference.
■ External approach is recommended for reoperations, patients with
inflammatory disease, tight internal anatomy (eg, deviated septum
toward the operative side), and patients with bleeding disorders or
blood thinners that cannot be stopped.
Intraoperative
bleeding
■ External DCR: visualize and cauterize the angular artery if it
crossed the incision site, prior to opening the osteotomy.
■ Internal DCR: epinephrine-soaked pledget packing helps slow
intraoperative bleeding. Suction Bovie cautery is also of use, but
take care to avoid too much heat exposure to the internal site, as
overlying skin burns can result.
Stent
duration
■ Classically, stents are kept in place for 12 wk after surgery. If two
monocanalicular stents are used, one can be removed at 6 wk and
the other retained until 12 wk. This gives the patient earlier relief
from epiphora during the recovery phase.
POSTOPERATIVE CARE
DCR is an outpatient surgery. Once the patient is deemed stable postoperatively,
he/she may be discharged home with a responsible adult. Postoperative
instructions should include the following:
■ Avoid straining, bending, heavy lifting, or strenuous activity for at least 1
week.
■ Ice pack or cold compresses can be used for the first 1 to 2 days to limit
swelling and bruising.

■ Nose blowing should be avoided for the first week to decrease the risk of
bleeding. To reduce the risk of nose bleed from nasal vasodilation, hot drinks
and food should be avoided for the first 1 to 2 days.
■ At the 1 week postoperative visit, the surgical site is evaluated for any signs of
impaired healing or infection, and any nonabsorbable sutures may be removed.
At 6 to 12 weeks after surgery, the silicone stent is removed in the clinic, and
the lacrimal drainage system is irrigated to confirm patency.
OUTCOMES
The DCR surgery is considered successful when the patient experiences total or
near-total relief from epiphora. Patients often still experience tearing under
circumstances in which reflex tears are normally expected (ie, emotion, ocular
surface irritation, etc.), as would any eye, which is not considered a surgical
failure. Surgeries fail for a variety of reasons, most relating to formation of
adhesions that block the drainage tract and prevent tears from flowing freely into
the nose.7
■ The reported success rates for external DCR range from 90% to 95%. The
success rate is improved by ensuring a large enough osteotomy, suturing the
lacrimal and nasal mucosal flaps to keep them from obstructing the healing
tract, and keeping the stents in place for several weeks postoperatively.
■ There is a wider range of reported success rates for endonasal (internal) DCR.
In the hands of an experienced surgeon, the success rate has been shown to be
statistically equivalent to the external approach. The success rate is improved
by ensuring a large enough osteotomy, avoiding excessive soft tissue
maceration of the nasal mucosa and lacrimal sac, limiting thermal injury with
cautery, and keeping the stents in place for several weeks postoperatively.
Intraoperative usage of the antimetabolite mitomycin-C has been
shown to decrease scar formation and thereby increase success rate of
the surgery, regardless of whether an external or endoscopic approach
is used.6,8 Postoperative mitomycin C eye drops have also been tried
but with less compelling effects.9
COMPLICATIONS
Intraoperative

■ Hemorrhage. To decrease this risk, hold blood thinners preoperatively, utilize a
block that contains epinephrine, and carefully visualize the anatomy to protect
major vascular structures.
■ Canalicular injury. Improper probing of the canaliculi can create a false
passage and damage the common canaliculus when opening the sac. This risk
can be decreased by using blunt probes and only advancing them along the
existing canalicular lumen where there is minimal resistance.
■ Orbital tissue injury. The use of drills and rongeurs can damage the structures
of the orbit. Care must be taken to establish the anatomic location of the
instrument with certainty prior to engaging it for bone removal. If fat is
encountered in the surgical field, that is an indication that the orbit has been
entered inadvertently.
■ Skull base fracture and CSF leak. This risk can be decreased by carefully
studying the preoperative imaging and taking note of the skull base contours
across the ethmoid sinuses. Endoscopic DCR surgeons must avoid bone
removal too far superiorly, to avoid breaching the fovea ethmoidalis or
breaking the cribriform plate. External DCR surgeons must avoid rocking or
twisting the rongeurs during bone removal, so that the skull base does not
crack. The operative site should be inspected for leakage of CSF, which will be
a clear fluid slightly more viscous than saline, which tests positive for beta-2-
transferrin. Appropriate postoperative neuroimaging and consultation with
neurology should be pursued if there is concern that a CSF leak has occurred.
Postoperative
■ Bleeding can occur postoperatively, typically from the nasal mucosal vessels.
Following the postoperative care instructions outlined earlier in the chapter
decreases this risk. Most postoperative bleeding is self-limited and can be
stopped by holding pressure against the nose for 5 to 10 minutes. For severe or
persistent bleeding, patients should be seen emergently.
■ Infection. It is rare to have postoperative infection after DCR, occurring only
about 1% of the time even without the use of systemic antibiotics.10 If an
infection does occur, the patient should be given a course of oral antibiotics
with broad coverage of typical skin and mucosal flora.
■ Extrusion/loss of the silicone stent tubing. The patient should be instructed not
to pick or pull at the tubing within the nose or at the eyelid puncta. If it
partially extrudes, it can sometimes be carefully advanced back into place. If it
fully extrudes, most surgeons advise allowing the patient to heal without the

tubing rather than returning to the operating room to place a new stent.
■ Lacrimal sump syndrome. Despite a patent osteotomy and normal results on
probing and irrigation, patients with sump syndrome continue to experience
tearing and mucous discharge due to an intact inferior pole of the lacrimal sac,
which collects a pool of drainage. The chance of this complication can be
decreased by creating a large osteotomy (at least 1 cm in diameter), ensuring
the bone is opened all the way down to the level of the nasolacrimal duct
entrance, and fully opening the lacrimal sac down to its inferior pole so that no
pocket remains to collect fluid.
■ Scarring of the ostium. After DCR, the bone or soft tissue can grow closed
over the osteotomy site. When this occurs, the patient’s epiphora returns and
surgical revision is necessary to reopen the drainage tract. The risk of this
complication can be decreased by creating a large enough osteotomy, clearing
away soft tissue around the lumen, and applying mitomycin C to the tissue
intraoperatively.
REFERENCES
1. Ali MJ, Joshi SD, Naik MN, Honavar SG. Clinical profile and management
outcome of acute dacryocystitis: two decades of experience in a tertiary eye
care center. Semin Ophthalmol. 2015;30(2):
118-123.
2. Balikoglu-Yilmaz M, Yilmaz T, Taskin U, et al. Prospective comparison of 3
dacryocystorhinostomy surgeries: external versus endoscopic versus
transcanalicular multidiode laser. Ophthal Plast Reconstr Surg. 2015;31(1):13-
18.
3. Cheng SM, Feng YF, Xu L, et al. Efficacy of mitomycin C in endoscopic
dacryocystorhinostomy: a systematic review and meta-analysis. PLOS One.
2013;8(5):e62737.
4. Dave TV, Mohammed FA, Ali MJ, Naik MN. Etiologic analysis of 100
anatomically failed dacryocystorhinostomies. Clin Ophthalmol.
2016;28:10:1419-1422.
5. Do JR, Lee H, Baek S, et al. Efficacy of postoperative mitomycin-C eyedrops
on the clinical outcome in endoscopic dacryocystorhinostomy. Graefes Arch
Clin Exp Ophthalmol. 2016:254(4):785-790.
6. Dulku S, Akinmade A, Durrani OM. Postoperative infection rate after
dacryocystorhinostomy without the use of systemic antibiotic prophylaxis.
Orbit. 2012;31(1):44-47.

7. Huang J, Malek J, Chin D, et al. Systematic review and meta-analysis on
outcomes for endoscopic versus external Dacryocystorhinostomy. Orbit.
2014;33(2):81-90.
8. Jawaheer L, MacEwen CJ, Anijeet D. Endonasal versus external
dacryocystorhinostomy for nasolacrimal duct obstruction. Cochrane Database
Syst Rev. Feb 24, 2017;(2):CD007097.
9. Mukhtar SA, Jamil AZ, Ali Z. Efficacy of external dacryocystorhinostomy
(DCR) with and without mitomycin-C in chronic dacryocystitis. J Coll
Physicians Surg Pak. 2014;24(10):732-735.
10. Qian Z, Tu Y, Xiao T, Wu W. A lacrimal sump syndrome with a large
intranasal ostium. J Craniofac Surg. 2015;26(5):e386-e388.

43
CHAPTER
Management of the
Microphthalmic or
Anophthalmic Orbit
Sarah M. Jacobs and Christopher B. Chambers
DEFINITION
A spectrum exists ranging from small eyes to complete absence of any ocular
tissue:
■ Nanophthalmos is defined as a small eye with otherwise normal internal
structures. The axial length of the eye is ≥2 standard deviations shorter than
average.
■ Microphthalmos is an eye with axial length less than 20 mm and additional
structural abnormalities.1
■ Clinical anophthalmos describes some cases of microphthalmia in which the
eye is so small that the patient appears anophthalmic. However, histopathologic
examination of the tissue does identify products of optic vesicle formation.
■ True anophthalmos involves the complete failure of primary optic vesicle
outgrowth resulting in the absence of any detectable eye tissue.1,2
ANATOMY
■ Nanophthalmos: In addition to short axial length, the sclera is thickened
relative to the eye, the anterior chamber angles are narrow, and the refractive
error is highly hyperopic. The small eye may or may not result in a hypoplastic
orbit.3,4
■ Microphthalmos: In addition to short axial length, the internal structures of the
eye are abnormal. Microphthalmic eyes can be associated with coloboma of the
uvea and/or lens, persistent fetal vasculature, Peters anomaly, glaucoma, and
anterior polar cataracts. An uncommon variant, microphthalmia with cyst
results from failure of the ocular embryonic fissure to close, leading to a small

rudimentary eye joined to a larger cystic cavity along the colobomatous
inferonasal sclera.5 The orbit on the affected side is hypoplastic.
■ Anophthalmos: There is complete absence of any ocular tissue. The eyelids
have a small palpebral fissure, and beneath the lids a rudimentary conjunctival
membrane is present covering the hypoplastic orbit.
PATHOGENESIS
■ Embryologic failure of the optic vesicle to develop normally from the cerebral
vesicle during the 4th to 8th week of gestation can lead to congenital absence
or malformation of one or both eyes.
■ Because the globe influences orbital growth, these ocular anomalies can result
in orbital and facial maldevelopment as well.
■ Nanophthalmos is typically sporadic, but autosomal recessive or autosomal
dominant forms have been described (NNO1 on chromosome 11p and NNO3
on chromosome 2q). It can occur as an isolated disorder, or as part of a
syndrome such as oculo-digital-dental syndrome (ODD), or autosomal
dominant vitreoretinochoroidopathy with nanophthalmos (ADVIRC).6
■ Microphthalmos occurs in approximately 10 per 100 000 live births. It can
occur sporadically, with some suspected association to fetal alcohol syndrome
or maternal infections during gestation, especially rubella, cytomegalovirus,
and herpes simplex virus. It is estimated that over half of cases occur in
conjunction with systemic abnormalities, including those occurring in the
setting of chromosomal anomalies, including Trisomy 13 (Patau syndrome),
Trisomy 18 (Edwards syndrome), or Wolf-Hirschhorn syndrome.7 In inherited
cases, mutations of the SOX2 gene on chromosome 3q are frequently
encountered.7 This condition can be associated with CHARGE syndrome
(Coloboma, Heart defect, Atresia choanae, Retarded growth, Genital
abnormality, and Ear abnormality), and PHACE syndrome (Posterior fossa
anomalies, Hemangioma, Arterial lesions, Cardiac abnormalities, and Eye
anomalies).
■ Anophthalmos occurs approximately 2 per 100 000 live births. It is most often
sporadic but can be associated with autosomal dominant defects of the SOX2
or RBP4 genes. Maternal deficiency of vitamin A during pregnancy can also
pose a risk of anophthalmia.
NATURAL HISTORY
■ Ocular volume drives the growth of the eyelids, fornices, and bony orbit. In

turn, hemifacial development parallels orbital development. Thus, a small or
absent eye leads to a hypoplastic orbit that can result in deformity of the
hemifacial skeleton (FIG 1).
■ At birth, the normal newborn eye is approximately 70% of its adult size. In
contrast, the newborn face is only 40% of its adult size. Rapid growth of the
facial skeleton and soft tissues occurs during early childhood, with the face
reaching 70% adult size by 2 years and 90% adult size by 5.5 years.8 The
degree of orbital and facial maldevelopment is different for each
microphthalmic child, depending on the amount of ocular tissue present and
the trophic influence that tissue exerts.
PATIENT HISTORY AND PHYSICAL EXAMINATION
As part of the initial assessment, the following questions should be considered as
they will guide further management throughout childhood:
■ Is the eye present or absent?
■ Is this a seeing eye?
FIG 1 • A,B. Hypoplastic orbit and hemiface secondary
to left microphthalmia.
■ Is the other eye present? If so, is it normal?
■ Are the orbits symmetric and appropriate in size?
■ Are the periocular and facial soft tissues symmetric and appropriate in size?
A coordinated multidisciplinary approach is needed for evaluation of
the microphthalmic or anophthalmic child, as approximately 50%

have associated systemic abnormalities and 25% have defined
systemic syndromes. This approach should include:
■ Comprehensive assessment by a pediatrician is needed, with particular
attention to the face, ears, and palate; feeding difficulties, which can indicate
neurologic or esophageal abnormalities; the cardiac system and genital
anatomy (due to association with CHARGE); and metabolic disturbances,
which may indicate pituitary dysfunction due to midline brain abnormalities.
■ Referral to subspecialists such as neurologist, cardiologist, endocrinologist,
nephrologist, and audiologist should be arranged if indicated.
■ In cases with systemic findings or a syndromic diagnosis, evaluation and
counseling by a pediatric geneticist is also recommended.
Ophthalmologic exam is recommended as soon as possible within the
first 2 to 3 weeks of life. This should involve:
■ Complete anterior and posterior assessment of both eyes to assess orbital and
ocular anatomy as well as visual function. In unilateral cases, the fellow eye
may have subtle findings such as coloboma, cataract, retinal dystrophy, or optic
nerve hypoplasia.9
■ Full cycloplegic refraction should be prescribed to maximize visual acuity of
seeing eyes. Eyeglasses with polycarbonate lenses should be used in order to
protect the globes from trauma.
IMAGING AND OTHER DIAGNOSTIC STUDIES
■ Preferential gaze testing (eg, Teller cards) or pattern visual evoked potential
(pattern VEP) can assess basic visual acuity in preverbal patients.
■ Flash visual evoked potential (VEP) testing can evaluate for any visual-
cortical function in patients with severe microphthalmia or apparent
anophthalmia.9
■ Facial photographs should be taken, including a ruler in the photo for scale.
■ Imaging with ultrasound of the eye and orbit to evaluate its structure and
detect ocular remnants or cysts.
■ MRI for detailed assessment of the soft tissues of the orbit and brain
■ Maxillofacial CT for assessment of the orbital and facial bones
NONOPERATIVE MANAGEMENT

■ Management focuses on utilizing the remaining vision in one or both eyes,
promoting appropriate growth of the orbit and face, and optimizing ocular
appearance.
■ FIG 2 outlines a treatment algorithm to accomplish these goals according to
varying degrees of severity. Parents should be counseled that a series of
procedures and/or devices will be needed over time to help the orbit expand in
parallel to the growth of the rest of the face.
■ Certain cases can be managed nonoperatively with placement of progressively
larger conformers:
■ Children with useful vision in the affected eye(s) should be fitted with a
series of clear conformers to progressively expand the lids, fornices, and orbit
while still allowing the eye to see through the device so that visual
development can occur (FIG 3).
■ Blind eyes measuring greater than 16 mm in length can be fitted with a series
of ocular prostheses to maintain the socket while also improving the
appearance of the eye.
■ If an eye is unable to tolerate wearing a prosthetic shell due to mechanical
irritation of the corneal surface, a graft can be placed to cover the cornea (FIG
4).
FIG 2 • Management framework for the microphthalmic
or anophthalmic orbit.

FIG 3 • A–C. A series of progressively larger
conformers can be made to maintain the socket,
exerting pressure to help the orbit expand and promote
appropriate facial growth. For eyes with meaningful
vision, clear material is used in order to avoid
deprivational amblyopia.
■ More severe cases can be managed with expandable devices placed into the
conjunctival sac that are then inflated or exchanged for larger devices over
time:
■ Inflatable chambers. A flexible chamber with an anterior port that is
nonsurgically seated into the conjunctival sac (FIG 5). A conformer holds the
implant in place. Every 2 to 3 weeks in the clinic, additional saline volume is
injected through the port into the chamber.
■ Self-expanding hydrogels. Hydrophilic osmotic expanders (polymethyl
methacrylate/polyvinylpyrrolidone), absorb up to 2000% their weight in water,
resulting in expansion of 8 to 10 times the original volume (FIG 6).10
Hydrogel hemispheres or spheres are placed beneath the eyelids onto the
conjunctival surface and secured in place with a temporary tarsorrhaphy.10–12
The gel is removed and exchanged for a larger-volume insert every 2 to 3
months, usually requiring a series of 2 to 4 hydrogels over the course of 4 to 12
months for adequate expansion depending on the initial size of the orbit (FIG
7).

FIG 4 • A–D. To improve tolerance of the scleral shell
prosthesis over the microphthalmic right eye, a mucous
membrane graft is harvested from the lower lip and
placed onto the ocular surface to protect the cornea.

FIG 5 • A,B. A noninvasive inflatable orbital expander.
The flexible chamber is seated into the conjunctival sac
with its port facing anteriorly. A conformer (shown here
resting on the glabella prior to insertion) is inserted over
the chamber to maintain it in place. The port can be
accessed with a needle and syringe to inject saline for
progressive expansion of the chamber volume.
SURGICAL MANAGEMENT
■ Most cases of microphthalmia or anophthalmia require surgical management
for orbital expansion. There are four goals of orbital expansion:
■ Stretch the periocular soft tissue to reduce the phimosis of the palpebral fissure
and enlarge the fornices. This stretching makes it possible to wear a more
appropriately sized conformer or prosthesis.13
■ Stimulate orbital bone growth. Animal models and human cases repeatedly
demonstrate that anophthalmic orbital volume does not increase at a normal

growth rate.14 Placing a device that exerts pressure within the orbit is effective
in stimulating expansion of the bony orbital walls.
■ Promote symmetric facial growth because the craniofacial skeleton is cued by
the bony orbit.15
■ Create space for a more permanent orbital implant. Having a larger orbital
implant enables wearing of a smaller-volume prosthetic, which often improves
the comfort and appearance for the patient.
FIG 6 • A–C. Hemispheric or spherical hydrogel
expanders increase in volume as they absorb water,
with the potential to reach full volume within about 30
hours after implantation.

FIG 7 • A–I. Orbital growth and improved symmetry with
a series of hydrogels. An infant diagnosed with bilateral
anophthalmia had placement of 0.9 mL hydrogel
spheres at 21 days of age. Progressive expansion of
the orbit can be seen in photos from 3 to 5 months of
age. At 5 months, the hydrogel was exchanged for a 1.5
mL volume. At 9 months, it was exchanged for a 2 mL
volume. By 14 months of age, the orbital expansion was
sufficient for placement of a dermis fat graft and
subsequent fitting with ocular prostheses. Ongoing
symmetric orbital and facial growth can be appreciated
at 2 years of age.

FIG 8 • A–E. A young boy with right microphthalmia is
treated with hydrogel expanders in the office. A 0.9-mL
hemisphere is placed onto the conjunctival surface.
Cyanoacrylate glue is used for temporary tarsorrhaphy
of the lids to hold it in place. When the hydrogel has
expanded to full volume, it is exchanged for
progressively larger hemispheres (1.5 mL, 2 mL) until
the desired orbital volume is achieved. A well-matched
prosthetic shell can then be worn.
T E C H N I Q U E S
■ There are multiple surgical methods for achieving expansion:
■ Rigid spherical implants within the orbit. Although these have the
advantage of creating direct pressure within the deep orbit to stimulate
growth, they are limited by the need for multiple surgeries to place serially

larger implants to promote progressive orbital growth (TECH FIG 1)
■ Injectable fillers. These substances allow placement of added volume into
the retrobulbar orbit without significant violation of the conjunctiva.
Hydroxyapatite (HA) fillers are commercially available and long-lasting,
making them a viable option for socket augmentation.16 An infraciliary
skin incision is made, the filler cannula is introduced and advanced to the
retrobulbar space and HA is then injected along the inferolateral orbital
wall. The cannula is withdrawn, and the incision is closed with absorbable
suture (TECH FIG 2). Serial injections can be performed to add more
volume as the child grows.
■ Hydrogel pellets can be injected into the retrobulbar orbit (TECH FIG
3).17
TECH FIG 1 • Rigid spherical orbital implants—shown
here in silicone, ranging 12 to 22 mm in diameter—
can be placed in the anophthalmic orbit to maintain
space and promote volume expansion. The implants
must be surgically exchanged for progressively larger
sizes to keep pace with facial growth as the child
grows.

TECH FIG 2 • A–D. Retrobulbar injection of
hydroxyapatite granules for orbital volume expansion
through an infraciliary incision. Postprocedural CT
scan demonstrates the radio-opaque filler along the
inferolateral deep orbit.
■ Inflatable orbital expanders. These devices are implanted into the orbit and
then accessed through an external port to progressively add volume over
time, thereby avoiding the need for serially exchanged conformers or
implants. Early designs had a port placed beneath the scalp connected to an
inflatable chamber in the orbit.18 A later design for an integrated orbital
expander design involved a globe-shaped chamber with an anterior
injection port implanted into the orbit and secured to the lateral orbital rim
via screw-fixated titanium plate (TECH FIG 4). Saline injections through
the anterior port inflate the chamber to accomplish gradual orbital
expansion.15,19

TECH FIG 3 • A–F. Hydrogel pellets are injected into
the retrobulbar space under anesthesia. Sagittal CT
scan shows their location and expansion. Clinical
photos demonstrate orbital growth and improved
hemifacial symmetry.

TECH FIG 4 • The integrated orbital expander is an
inflatable globe placed as an orbital implant, screw-
fixated with a bone plate to the lateral orbital rim.
Serial injections with saline through the anterior port
inflate the globe to promote orbital expansion.
■ The device is surgically removed when sufficient volume has been achieved.
■ When sufficient orbital expansion has been achieved by one of the above
methods, a dermis fat graft (DFG) should be placed as an autologous long-
term orbital expander.20
■ In infants and young children, the graft is harvested from the buttock (TECH

FIG 5).
■ An ellipse is outlined on the skin, first with ink and then reinforced with stab
incisions. The marked area should correspond to the surface area of the
socket where it will be implanted.
■ Dermabrasion is performed to remove the epithelium down to the level
where punctate bleeding is observed from the dermal vessels.
■ The graft perimeter is then incised with a scalpel. Dissection is carried down
through the fat in a wide cone, such that the harvested fat area is broader than
the dermal surface.
■ Hemostasis is obtained with bipolar cautery and then the incision is closed in
3 layers (fat, dermis, skin) with absorbable sutures.
■ The orbit is prepared with an orbitotomy incision, typically oriented
horizontally aligning with the palpebral fissure.
■ The DFG is tucked into the orbit through this incision and then the dermis is
sutured edge to edge with the conjunctiva using absorbable sutures (TECH
FIG 6).
■ After the graft is secured along its entire perimeter, a conformer is placed
and the lids are closed with temporary tarsorrhaphy.

TECH FIG 5 • A–D. Dermis fat graft harvest. Buttock
is marked with an ellipse. The outline is reinforced
with stab incisions and then dermabrasion is
performed to remove epithelium. The dermis is incised
with a blade and then broader dissection is carried
down through fat.
TECH FIG 6 • A–F. Dermis fat graft implantation. An
orbitotomy is made through the conjunctiva, allowing
insertion of the dermis graft into the orbit. The graft is
secured edge to edge with conjunctiva to reform the
socket surface. A conformer is placed over the graft
and then the lid is closed with a temporary

tarsorrhaphy. The dermis conjunctivalizes as it heals,
creating a stable surface for prosthetic wear.
PEARLS AND PITFALLS
Multidisciplinary
approach
■ Ophthalmology, pediatrics, and relevant subspecialties
(genetics, neurology, ENT) work together to optimize care
outcomes.
Minimize
surgical
encounters
■ Repeated transconjunctival surgery creates traumatic
conjunctival scarring, which impedes good results.
■ The risks of repeated general anesthesia to the neurocognitive
development of young children are still uncertain.21,22
Retaining
hydrogels
■ Conjunctival hydrogel placement can be performed in the
office with topical anesthesia, using cyanoacrylate glue rather
than sutures to tarsorrhaphize the lids (FIG 8).
Dermis fat
grafts
■ For bilateral cases, a single larger ellipse can be harvested then
divided in two.
■ As the fat volume can be unwieldy during graft placement,
placing the sutures systematically at the cardinal points first (12
o’clock and 6 o’clock and followed by 3 o’clock and 9 o’clock)
helps retain the graft in the orbit during insertion.
■ In contrast to DFG in adults, fat atrophy does not occur to a
significant degree in pediatric dermis fat grafts.
Trends in
treatment
■ Management of the microphthalmic or anophthalmic orbit is
moving toward goals of fewer invasive procedures, less
exposure to anesthesia, and maximum symmetric growth.
■ At present these goals are best accomplished via serially larger
conjunctival hydrogels, followed by dermis fat graft after
sufficient expansion is achieved.
OUTCOMES
■ Expansion of the bony orbit by surgical or nonsurgical means can enable near-
normal facial growth, thereby improving cosmesis.
■ Expansion of the eyelids and conjunctival fornices can enable wearing of an
ocular prosthesis, which further improves cosmesis.

■ Serial conformer therapy only directly expands the anterior orbital soft tissues,
but the pressure created does induce some secondary expansion of the bony
orbit. In one series of 61 microphthalmic eyes in 44 children, satisfactory
symmetry was achieved in 21 cases with conformer therapy alone.13
■ The sequence and timing of treatments must be tailored to each child to
achieve the best outcome.
COMPLICATIONS
■ Inadequate expansion, with residual hemifacial hypoplasia.
■ Contracted conjunctival fornices, with inability to wear prosthesis.
■ Infection, exposure, or extrusion of orbital implant.
■ Secondary hypertrophy of dermis fat graft, requiring later debulking.
REFERENCES
1. Shaw GM, Carmichael SL, Yang W, et al. Epidemiologic characteristics of
anophthalmia and bilateral microphthalmia among 2.5 million births in
California, 1989-1997. Am J Med Genet A. 2005;137(1 suppl):36-40.
2. Williamson KA, Fitzpatrick DR. The genetic architecture of microphthalmia,
anophthalmia, and coloboma. Eur J Med Genet. 2014;57(8 suppl):369-380.
3. Nouri-Mahdavi K, Nilforushan N, Razeghinejad M, et al. Glaucoma in
patients with nanophthalmos. J Ophthalmic Vis Res. 2011;6(3 suppl):208-214.
4. Singh OS, Simmons RJ, Brockhurst RJ, Trempe CL. Nanophthalmos: a
perspective on identification and therapy. Ophthalmology. 1982;89(9
suppl):1006-1012.
5. Weiss AM, Koussef BG, Ross EA, Longbottom J. Complex microphthalmos.
Arch Ophthalmol. 1989;107:1619-1624.
6. Yardley J, Leroy BP, Hart-Holden N, et al. Mutations of VMD2 splicing
regulators cause nanophthalmos and autosomal dominant
vitreoretinochoroidopathy (ADVIRC). Invest Ophthalmol Vis Sci.
2004;45:3683-3689.
7. Verma AS, Fitzpatrick DR. Anophthalmia and microphthalmia. Orphanet J
Rare Dis. 2007;2:47.
8. Farkas LG, Posnick JC, Hreczko TM. Growth patterns in the orbital region: a
morphometric study. Cleft Palate Craniofac J. 1992;29:
315-318.
9. Ragge NK, Subak-Sharpe ID, Collin JRO. A practical guide to the
management of anophthalmia and microphthalmia. Eye. 2007;21:

1290-1300.
10. Maxxoli RA, Raymond WR, Ainbinder DJ, Hansen EA. Use of self-
expanding, hydrophilic osmotic expanders (hydrogel) in the reconstruction of
congenital clinical anophthalmos. Curr Opin Ophthalmol. 2004;15(5
suppl):426-431.
11. Quaranta-Leoni FM. Congenital anophthalmia: current concepts in
management. Curr Opin Ophthalmol. 2011;22(5 suppl):380-384.
12. Hou Z, Yang Q, Chen T, et al. The use of self-inflating hydrogel expanders in
pediatric patients with congenital microphthalmia in China. J AAPOS.
2012;16(5 suppl):458-463.
13. Wavereille O, Francois Fiquet C, Abdelwahab O, et al. Surgical and
prosthetic treatment for microphthalmia syndromes. Br J Oral Maxillofac
Surg. 2013;51(2 suppl):e17-e21.
14. Kennedy RE. Growth retardation and volume determination of the
anophthalmic orbit. Trans Am Ophthalmol Soc. 1972;70:278-297.
15. Tse DT, Pinchuk L, Davis S, et al. Evaluation of an integrated orbital tissue
expander in an anophthalmic feline model. Am J Ophthalmol. 2007;143(2
suppl):317-327.
16. Kotlus BS, Dryden RM. Correction of anophthalmic enophthalmos with
injectable calcium hydroxylapatite (Radiesse). Ophthal Plast Reconstr Surg.
2007;23(4 suppl):313-314.
17. Schittkowski MP, Guthoff RF. Injectable self-inflating hydrogel pellet
expanders for the treatment of orbital volume deficiency in congenital
microphthalmos: preliminary results with a new therapeutic approach. Br J
Ophthalmol. 2006;90(9 suppl):1173-1177.
18. Gossman MD, Mohay J, Roberts DM. Expansion of the human
microphthalmic orbit. Ophthalmology. 1999;106(10 suppl):2005-2009.
19. Tse DT, Abdulhafez M, Orozco MA, et al. Evaluation of an integrated orbital
tissue expander in congenital anophthalmos: report of preliminary clinical
experience. Am J Ophthalmol. 2011;151(3 suppl):470-482.
20. Heher KL, Katowitz JA, Low JE. Unilateral dermis-fat graft implantation in
the pediatric orbit. Ophthal Plast Reconstr Surg. 1998;14(2 suppl):81-88.
21. Graham MR, Brownell M, Chateau DG, et al. Neurodevelopmental
assessment in kindergarten in children exposed to general anesthesia before the
age of 4 years: a retrospective matched cohort study. Anesthesiology.
2016;125(4 suppl):667-677.
22. Davidson AJ, Disma N, de Graaff JC, et al. Neurodevelopmental outcome at

2 years of age after general anaesthesia and awake-regional anaesthesia in
infancy (GAS): an international multicentre, randomised controlled trial.
Lancet. 2016;387(10015 suppl):239-250.

44
CHAPTER
Section X: Nasal
Reconstruction
Nasal Tip Hemangioma
T. Kwan-Wong and Jugpal S. Arneja
DEFINITION
■ Infantile hemangiomas is a benign, proliferative, vascular tumor of infancy
that has a defined, although unpredictable natural history.
■ Infantile hemangiomas is the most common pediatric benign tumor, affecting
between 4% and 10% of children in their 1st year of life.1
■ Approximately 60% of infantile hemangiomas involve the head and neck
regions,2 and of these, a small percentage affect the nose.
■ Nasal tip hemangioma can cause significant deformity, affecting the
psychological and emotional well-being of the patient and the family.
ANATOMY
■ Nasal contour is determined by draping of the nasal skin over a framework
formed by the nasal bones in the cephalic third, by the upper lateral cartilages
in the middle third, and by the paired lower lateral cartilages and the caudal
septum in the caudal third.
■ Nasal tip hemangioma usually resides in a subcutaneous plane—although
cutaneous manifestations are not uncommon—and can extend between the
medial crura of the lower lateral cartilages and occasionally into the columellar
region as well.3,4
■ Hemangioma extending between the lower lateral cartilages tends to splay
the medial and middle crura of the lower lateral cartilages from each other and
can occasionally dislocate the lower lateral cartilages, by displacing the
cephalic edge of the cartilage into the nasal passage.

PATHOGENESIS
■ Infantile hemangiomas is histologically characterized by proliferating
endothelial cells with varying luminal sizes, which tend to be smaller during
the proliferative phase, becoming larger during the involutional phase.
■ Involution is reflected by slowing of endothelial proliferation, apoptosis of
existing endothelial cells, and replacement of vascular tissue with adipocytes
and connective tissue.
NATURAL HISTORY
■ Infantile hemangiomas is not present at birth but becomes apparent within the
first few weeks of life.
■ The initial presentation of an infantile hemangioma may manifest as a
localized telangiectasia, blanched spot, or area of ecchymosis.1,2,5,6
■ The natural course of infantile hemangioma is relatively predictable:
■ The proliferative phase (0 to 1 year) is characterized by rapid growth.
■ The involutional phase (until 7 to 10 years) when the hemangioma shrinks
and fades
• Complete involution in 50% of children at 5 years of age, 70% by 7 years5,7
• Nasal tip hemangiomas is slower to regress than those in other parts of the
body.
■ Involutional phase (greater than 10 years) when the involutional process has
completed
• Even after involution, there are often residual stigmata such as residual
fibrofatty tissue, atrophic/redundant/telangiectatic skin, and persistent
deformity of nasal cartilage in about 50% of patients.3–7
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A thorough history should be obtained, including information about onset,
progression, prior treatments, and symptoms of the nasal tip hemangioma.
■ Physical examination (FIG 1)
■ Local—size, location, distortion of nasal cartilages, involvement of nasal
vault, skin quality, presence of any scars, signs of active infection, ulceration.

FIG 1 • A,B. A bulbous, pigmented hemangioma is
evident at 6 months of age. (Reprinted from Arneja JS,
Chim H, Drolet B, Gosain AK. The “Cyrano nose”:
refinements in surgical technique and treatment
approach to hemangiomas of the nasal tip. Plast
Reconstr Surg. 2010;126:1291, with permission.)
■ Regional—determine presence of any other lesions. Assess for any airway,
visual, or auditory involvement that may necessitate earlier intervention.
■ Systemic—rare with isolated infantile hemangioma of the nasal tip
• Beardlike distribution may indicate airway involvement.
• Large plaquelike distributions may suggest PHACES syndrome.
IMAGING
■ Imaging is usually not required.
■ Ultrasound may be useful to delineate flow within and the depth of the lesion.
■ MRI may be used to delineate the extent of the hemangioma and its relation to
the underlying nasal framework.
DIFFERENTIAL DIAGNOSIS
■ Hemangioma
■ Vascular malformation (lymphatic, venous, arteriovenous)
■ Dermoid cyst
NONOPERATIVE MANAGEMENT
■ Nonoperative options are usually considered as adjunctive rather than
definitive treatments.
■ Mainstay of nonoperative management is propranolol and corticosteroid

therapy.1–3,8
■ Propranolol is first-line medical therapy, and many practitioners feel this
medication to be superior to oral corticosteroid treatment alone.
• Dosing—1 to 3 mg/kg/d divided into TID dosing
• Rare complications include hypoglycemia and limb cyanosis, while almost
never bronchospasm and hypotension.
■ Oral or intralesional steroid therapy ideally is used during proliferative phase
(FIG 2). Steroid therapy can be administered for up to three treatment cycles.
FIG 2 • A,B. After completion of treatment with
intralesional steroids and pulsed dye laser therapy, the
lesion has decreased in size and cutaneous
manifestations have resolved in the patient in FIG 1,
shown here at age 3 years. (Reprinted from Arneja JS,
Chim H, Drolet B, Gosain AK. The “Cyrano nose”:
refinements in surgical technique and treatment
approach to hemangiomas of the nasal tip. Plast
Reconstr Surg. 2010;126:1291, with permission.)
• Can slow and sometimes arrest growth, but has little effect on regression.
Response is usually seen within 1 week of initiating treatment.
• Oral corticosteroid—2 to 3 mg/kg/d of prednisolone for 8 weeks
• Intralesional corticosteroid—20 mg of triamcinolone directly into the lesion
SURGICAL MANAGEMENT
■ Although precise timing of surgery is controversial, several principles exist:
■ Children begin experiencing psychosocial stigma from their peers around the

age of 5 to 7 years. Consequently, surgical correction is usually timed prior to
school age.3,4,6,7
■ Surgical correction is usually preceded by adjuvant medical therapy to reduce
the size.
■ Surgery is usually not undertaken prior to the involutional phase unless the
hemangioma causes significant airway obstruction and normal skin quality is
important (see FIG 1 & 2).1
Preoperative Planning
■ Type of approach is determined based on the location of the lesion to be
debulked or resected and orientation of the skin redundancy to be resected.
■ Determine if any lower lateral cartilage or columellar reorientation or
reconstruction is needed.
Positioning
■ The patient is positioned supine on the operating table with a shoulder roll and
neck hyperextension. Limbs and pressure points are adequately padded and
protected.
Approach
■ Techniques differ principally with respects to scar placement and ability to
control transverse and vertical skin excess.
■ The open tip rhinoplasty is the generally preferred technique because it
permits good visualization of the entire nasal tip, as well as excellent control
of both horizontal and vertical dimensions.
■ The nasal subunit approach attempts to hide the incisions within the junctions
of the nasal subunits, providing good control of horizontal skin redundancy
but with limited vertical control.
■ The Rotterdam (extended L rhinotomy) trades more extensive scarring for
excellent access to the nasal tip and dorsum and is useful in controlling
extreme cutaneous redundancy.
■ Epinephrine containing local anesthetics should be used prior to skin incision.
It provides hydrodissection, hemostasis, and postoperative analgesia.
T E C H N I Q U E S

■ Open Tip Rhinoplasty Approach
■ A transverse transcolumellar incision is made at the junction of the middle
and distal thirds of the columella (TECH FIG 1).
■ This incision may be adjusted proximally toward the columellar-lip
junction if the hemangioma extends into the columella.
■ Extended rim incisions are made, connecting to the columellar incision
medially and proceeding along the length of the alar rim laterally.
■ The rim incision should be kept close to the nasal skin of the alar rim to
avoid resection of vestibular lining, which can cause rim retraction.
TECH FIG 1 • Markings for an open tip rhinoplasty
approach. The transcolumellar incision is connected to
alar rim incisions to provide access to the nasal tip
and dorsum.

■ Nasal Subunit Approach
■ An incision is planned along the lateral aspect of the nasal dorsum, curving
around the junction between the nasal tip and ala before proceeding medially
and inferiorly around the medial aspect of the soft tissue triangle and into the
lateral columellar region (TECH FIG 2).
■ Depending on the size and location of the hemangioma, it may not be
necessary to use the full length of the incision.
TECH FIG 2 • Markings for the nasal subunit
approach. The full incision may not be needed
depending on what areas of the nose need to be
accessed.
■ Rotterdam/Extended L Rhinotomy Approach
■ Markings are made for an inferior rhinotomy. Starting from the alar-cheek
sulcus, the proposed incision follows the alar rim before traversing the
columella and across the contralateral alar rim and then cranially along the
alar-cheek sulcus.
■ The extended L component is then marked by connecting the inferior
rhinotomy markings with a line that courses cephalically along the

nasomaxillary junction before curving medially across the nasion (TECH
FIG 3).
TECH FIG 3 • Markings for the Rotterdam/extended L
rhinotomy.
■ Elevation and Resection of the Hemangioma (Open
Tip Rhinoplasty Approach)
■ Using tenotomy or sharp-tipped scissors, the hemangioma with its overlying
skin is dissected free from the lower lateral cartilages (TECH FIG 4A).
■ If the hemangioma invades the nasal columella, dissection should proceed
between the medial crura of the lower lateral cartilages.
■ Using sharp scissors or a no. 15 blade scalpel, hemangioma and fibrofatty
tissue is sharply resected from the nasal skin in a subdermal plane (TECH
FIG 4B).
■ Caution should be taken throughout to ensure that sufficient thickness of
nasal skin remains for flap perfusion and to avoid inadvertently “button
holing” through the skin.
• A finger may be placed on the superficial surface of the nasal skin to

provide constant tactile feedback regarding the depth of resection.
■ If the hemangioma involves vestibular lining, it is preferable to allow it to
naturally involute to avoid alar rim retraction, which can result from
overaggressive resection in this area.
TECH FIG 4 • A. Dissection of the hemangioma
begins in a plane between the hemangioma and nasal
cartilage. B. Sharp excision of the hemangioma from
the overlying nasal skin, ensuring uniform and
adequate skin flap thickness, with lower lateral
cartilage reconstruction.
■ Lower Lateral Cartilage Reconstruction
■ The shape and position of the lower lateral cartilages are assessed.
■ If the lower lateral cartilage has been dislocated by the hemangioma, it
should be resuspended to the upper lateral cartilage using sutures.5
■ Interdomal sutures using 6-0 polydioxanone (PDS) are placed to
reapproximate the medial and middle crura of the lower lateral cartilages if
they have been splayed apart by the hemangioma (TECH FIG 4A).
■ Transdomal sutures are placed using 6-0 PDS to restore domal projection if
the intercrural angle has been flattened by mass effect of the hemangioma
(TECH FIG 4B).
■ Skin Resection and Closure (Open Tip Rhinoplasty

Approach)
■ The nasal skin is redraped over the cartilaginous framework, and the
redundant skin is marked out and sharply trimmed (TECH FIG 5A).
■ Skin resection should be conservative to avoid undue tension, which can
produce nasal distortion, blunting of the nasal tip, or alar rim retraction.
■ With the open rhinoplasty approach, vertical skin excess can be corrected
by adjusting the resection at the tip of the columellar flap, whereas
horizontal skin excess can be controlled by adjusting the margin of
resection at the columellar-rim flap.5
■ The skin is approximated using rapid absorbing 5-0 polyglactin 910 (Vicryl
Rapide), and if alar rim incisions were used for access, the vestibular lining is
closed using 5-0 polyglactin 910 (Vicryl) (TECH FIG 5B).
■ If alar rim incisions were used, a silicone-conforming stent is inserted into
the nares and secured using tape.
TECH FIG 5 • A. The nasal skin is loosely redraped
over the nasal framework, and the skin excision is
marked. Markings should err toward being more
conservative to avoid undue tension during closure,
which can cause nasal distortion. B. The final result
after hemangioma excision, reconstruction of the
lower lateral cartilages, and excision of resultant skin
excess. Following this, Silastic-conforming stents are
inserted and secured with tape.

PEARLS AND PITFALLS
Timing
■ Surgery should be delayed until involution is completed and/or
cutaneous manifestations are resolved, unless there is
airway/visual axis obstruction or life-threatening symptoms.
■ Surgery should be completed prior to school age to minimize the
psychosocial impact experienced by the patient and parents.
Nonsurgical
therapies
■ Propranolol should be considered for first-line medical therapy.
Reduction in volume and color is often seen within 24–48 hours
of initiating therapy.
■ Adjunctive corticosteroid therapy may be used in an intralesional
or oral fashion.
■ Pulsed dye laser can be used to treat telangiectatic skin changes.
Surgical
access
■ Location of the hemangioma and the vectors of skin excess will
help determine the type of incision used. The authors prefer the
open tip rhinoplasty approach for its exposure and ability to
control both horizontal and vertical skin excess.
■ Use of local anesthetic with epinephrine provides hemostatic,
analgesic, and hydrodissective benefits.
Hemangioma
resection
■ If the hemangioma involves vestibular lining, it is preferable to
leave residual hemangioma in these areas and to allow it to
involute naturally.
■ Overaggressive resection of tumor can cause nasal tip blunting,
nostril-tip disproportion, or a “skeletonization” appearance of the
lower lateral cartilages.
Lower lateral
cartilage
reconstruction
■ Reconstruction and reapproximation of the lower lateral
cartilages using domal creation and/or interdomal sutures may be
necessary, especially if the hemangioma is large and/or involves
the columellar region.
Minimize risk
of alar rim
retraction
■ If alar rim incisions are to be used, stay close to the cutaneous
rim to avoid resecting vestibular lining.
■ Skin resection should be conservative, with closure being done
under virtually no tension.
■ Silicone intranasal conforming stents should be used for 3 months
post-operatively.
POSTOPERATIVE CARE
■ If alar rim incisions are made, silicone intranasal stents should be placed

intraoperatively and left in place for at least 3 months to minimize the effects
of scar contraction.
■ Sutures should not be used to hold the stent in due to the risk of inadvertent
columellar trauma if the suture is pulled through.
■ Parents should be taught how to remove the stents for cleaning of the
surgical site and how to replace and resecure the stents using tape.
■ Scar massage may be started approximately 4 weeks following surgery.
OUTCOMES
■ Good cosmetic results with high patient and parental satisfaction can be
expected following resection of nasal tip hemangiomas (FIG 3).3,4,7
■ There is rarely a risk of recurrence if the resection is performed after the
proliferative phase has passed.
■ Families should be prepared for the possibility of secondary procedures such
as repeat resection, scar revision, and laser therapy for cutaneous sequelae or
secondary rhinoplasty.
FIG 3 • Surgical correction was performed on the
patient in FIGS 1 and 2 at 5 years of age and served to
“sculpt” the final appearance of the nose. A,B. The
postoperative result is shown 1 year later. Combined
medical and surgical management resulted in an
optimal aesthetic result in this patient. (Reprinted from
Arneja JS, Chim H, Drolet B, Gosain AK. The “Cyrano
nose”: refinements in surgical technique and treatment
approach to hemangiomas of the nasal tip. Plast
Reconstr Surg. 2010;126:1291, with permission.)

COMPLICATIONS
■ Infection
■ Hematoma
■ Necrosis of skin flap margins
■ Alar rim retraction and/or stenosis
■ Poor nasal tip definition
■ Nasal tip distortion
■ Hypertrophic/keloid scarring
REFERENCES
1. Drolet B, Esterly N, Frieden I. Hemangiomas in children. N Engl J Med.
1999;341:173-181.
2. Chen T, Eichenfield L, Friedlander S. Infantile hemangiomas: an update on
pathogenesis and therapy. Pediatrics. 2013;131(1):99-108.
3. Arneja J, Gosain A. The Cyrano nose: refinements in surgical technique and
treatment approach to hemangiomas of the nasal tip. Plast Reconstr Surg.
2010;126(4):1291-1299.
4. Waner M, Kastenbaum J, Scherer K. Hemangiomas of the nose: surgical
management using a modified subunit approach. Arch Facial Plast Surg.
2008;10(5):329-334.
5. Jackson I, Sosa J. Excision of nasal tip hemangioma via open rhinoplasty—a
skin sparing technique. Eur J Plast Surg. 1998;21(5):265-268.
6. Warren S, Longaker M, Zide B. The subunit approach to nasal tip
hemangiomas. Plast Reconstr Surg. 2002;109(1):25-30.
7. Van der Meulen J, Gilbert P, Roddi R. Early excision of nasal hemangiomas:
the L-approach. Plast Reconstr Surg. 1994;94(3):465-473.
8. Drolet B, Frommelt P, Chamlin S, et al. Initiation and use of propranolol for
infantile hemangioma: report of a consensus conference. Pediatrics.
2013;131(1):128-140.

45
CHAPTERNasal Septal Hematoma
Whitney L. Quong and Jugpal S. Arneja
DEFINITION
■ Hematoma of the nasal septum is a relatively rare, yet potentially serious
consequence of trauma to the nose where blood accumulates between the
cartilaginous/bony portion of the septum, and its overlying
mucoperichondrium/mucoperiosteum. Any degree of craniofacial trauma
should urge evaluation for the condition.
■ Without prompt recognition and intervention, a septal hematoma may
precipitate future cosmetic distortion, including secondary infection, resulting
in septal abscess and/or ultimately a saddle nose deformity.
■ Incision and drainage is the mainstay of treatment, but immediate
reconstruction with autograft or homograft is an option if there is structural
defect in the nasal septum.
ANATOMY
■ The nasal septum comprises cartilaginous, membranous, and bony
components (perpendicular plate of the ethmoid, vomer, premaxilla, maxillary
crest, and palatine crest) covered by mucoperichondrium and mucoperiosteum
layers (FIG 1). The septum is typically 2 to 4 mm thick.
■ The blood supply of the nasal septum is derived from the sphenopalatine and
the anterior and posterior ethmoid arteries, along with contributions from the
superior labial artery (anteriorly) and the greater palatine artery (posteriorly).
These vessels travel in the overlying mucous membrane and penetrate the
mucoperichondrium through vascular canals. It is through diffusion that the
cartilaginous septum receives its blood supply. The Kiesselbach plexus (Little
area) is a region where the chief blood supplies to the internal nose converge

and is found in the anteroinferior third of the nasal septum.
■ Bleeding into the potential space between the cartilage and its overlying
mucoperichondrium leads to a septal hematoma (FIG 2), whereas external
bleeding from Kiesselbach plexus results in epistaxis.
PATHOGENESIS
■ Nasal septal hematoma typically results from trauma to the nasal complex,
with even minor trauma causing the condition. Rarely, chronic irritation of the
septum by nasogastric tube has also been found to precipitate the condition.1
■ Children are particularly prone to developing septal hematomas, as the
pediatric cartilage is soft and prone to buckling,2 and the mucoperichondrium
is only loosely adherent to the underlying cartilage.1
■ The precise mechanism for development of nasal septal hematoma has not
been defined, but has been proposed to occur when mechanical force to the
nasal cartilage precipitates leakage or rupture of the mucoperichondrial vessels
in the septum.
■ If the mucosa remains intact, extravasated blood strips the mucoperichondrium
and/or mucoperiosteum from cartilage/bone as it accumulates within a closed
space.
■ Where vessel compromise is coincident with fracture of the septal cartilage or
bony components, blood may dissect through the fracture and form a
hematoma.

FIG 1 • The nasal septum is formed by cartilaginous,
membranous, and bony components.
FIG 2 • A septal hematoma is formed when there is
accumulation of blood into the potential space between
the cartilaginous septum and the overlying
mucoperichondrium.
NATURAL HISTORY

■ When not promptly recognized, extravasated blood continues to expand
between the perichondrium and cartilage. Eventually, the increased pressure
causes collapse of the vessels supplying the septal cartilage. Pressure-induced
ischemia, avascular necrosis, and liquefaction can result rapidly within 24 to 72
hours.
■ Where there is significant necrosis and destruction of the septal cartilage, the
structural integrity of the septum is compromised, and a saddle nose deformity
may be the end result.
■ Necrosed tissue may also act as a nidus for infection and abscess development.
Bacteria isolated from septal abscesses are predominantly those species of the
normal nasal flora, which include Staphylococcus aureus, Streptococcus
pneumonia, group A β-hemolytic streptococcus, and Haemophilus influenzae.3
Collagenases produced by these bacteria serve to accelerate cartilage
liquefaction.
■ Meningitis, cerebral abscess, subarachnoid empyema, and cavernous sinus
thrombosis have also been reported as complications of septal hematomas.3
■ Because the development of septal hematoma may be delayed up to 48 to 72
hours from initial trauma,1 sequential evaluation is recommended.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Though relatively rare—occurring as a consequence to only 0.8% to 1.6% of
nasal traumas1—one should be suspicious for septal hematoma when there is
any history of craniofacial trauma.
■ A full head and neck examination should be performed to evaluate for any
coincident injuries. In children, the possibility of abuse must be explored.
■ On history, progressive nasal obstruction is the most commonly reported
symptom. Report of facial pain/headache, epistaxis, and fever are also common
symptoms. Clinical features elucidated on physical examination that increase
the pretest probability include hyperemia of the nasal mucosa, enlargement of
the septum, swelling/ecchymoses of the nasal dorsum, external nasal
deformity, and purulent rhinorrhea.1 Presence of any of these features should
prompt further history about preceding nasal trauma, upper respiratory tract
infections, or dental procedures.
■ With nasal septal hematoma on the differential diagnosis, focused intranasal
examination of the nasal septum is required. Direct anterior rhinoscopy to
evaluate the nasal septum may be performed with nasal specula. In addition to
the septum, the inferior turbinate, a portion of the middle turbinate, and

possibly the nasopharynx should be visualized. Both sides of the nasal septum
must be evaluated.
■ The nasal mucosa is normally pink, without ulcerations, crusting, or bleeding.
The septal hematoma is visualized as a lateral bulging (unilateral, or bilateral),
with purple/dusky fluctuance. Palpation of the septum, by inserting a gloved
finger into the nostril, may aid identification of a fluctuance. If such fullness
persists even after topical administration of a vasoconstrictive agent such as
oxymetazoline, the diagnosis of septal hematoma is highly likely.
IMAGING
■ If the diagnosis is an isolated nasal septal hematoma, without other indication,
no further imaging studies are required.
■ If the septal hematoma has further developed into a nasal septal abscess,
computed tomography scanning of the head and neck region with contrast
enhancement should be considered to evaluate for intracranial extension.
Particularly, where there is extensive facial cellulitis, focal neurologic defects,
altered consciousness, meningismus, severe headache, failure to improve with
treatment, delay in diagnosis and treatment, or isolation of an unusual/virulent
microorganism, further radiologic imaging is recommended.4
DIFFERENTIAL DIAGNOSIS
■ Nasal septal abscess
■ Deviated nasal septum
■ Nasal septal polyp
■ Nasal fracture
NONOPERATIVE MANAGEMENT
■ In a cooperative patient presenting soon after injury and where necrosis and
infection are not suspected, the hematoma may be evacuated in the clinic or
emergency department. Under local anesthetic, a simple aspiration with needle
(FIG 3) and syringe can be performed, and the nose subsequently packed and
reassessed 48 to 72 hours later.

FIG 3 • A needle and syringe can be used to enter the
hematoma and evacuate the accumulated clot.
■ For a more organized hematoma, incision and drainage in the operating room
is suggested.
■ In a pediatric patient, if significant necrosis is suspected, or if immediate
reconstruction is likely to be required, management in the operating room with
incision and drainage under general anesthetic is recommended.
SURGICAL MANAGEMENT
■ Antibiotics should be administered upon identification of a septal hematoma.
Coverage should include the common upper respiratory tract microorganisms,
with amoxicillin-clavulanate recommended for uncomplicated cases, and
clindamycin used where abscess is suspected or known.
■ If there is compromise to the structural integrity of the nasal septum, as is
commonly seen with delayed identification of a hematoma or abscess,
immediate reconstruction can be considered. This is particularly supported in
the pediatric population, for whom loss of portions of the cartilaginous septum
may ultimately have a long-term effect on the growth of the facial skeleton.5

Preoperative Planning
■ To anesthetize the septum, pledgets soaked in an equal part mixture of 4%
lidocaine and 0.05% oxymetazoline should be packed into the nares. Adequate
contact of the pledgets with the septum should be ensured. After 10 minutes, a
small amount of 1% or 2% lidocaine with epinephrine can be injected into the
septum.
Positioning
■ Place the patient supine, ensuring adequate access, visualization, and lighting
of the nasal septum.
Approach
■ After the septum is anesthetized, thorough examination of septum should be
permissible. With a nasal speculum, the full extent of the hematoma should be
evaluated, and both sides of the septum visualized.
T E C H N I Q U E S
■ Aspiration
■ With a needle attached to a syringe, pierce the hematoma and aspirate the
cavity. Blood should be amenable to being withdrawn with little force. If
there is concern regarding infection, send the aspirate for culture and
sensitivity. This step may also be performed in the clinic/emergency
department if the diagnosis is unclear, or as a temporizing measure prior to
operative management.
■ Hemitransfixion Incision
■ A hemitransfixion incision is made at the junction of the membranous
septum and the lower border of the nasal septal cartilage to further explore
and evacuate the hematoma. Residual clot should be suctioned, and the cavity
irrigated with saline. Necrotic cartilage should also be debrided.
Subsequently, any defect in the cartilage can be assessed, and the need for
reconstruction considered.

■ Septum Reconstruction
■ Defect in the septal cartilage following debridement of the necrotic tissue
can be reconstructed immediately. In this case, the surgeon may consider
converting to an open tip approach for direct access to the nasal base and
septum; the precise amount of the cartilage defect can be evaluated, and
approach for reconstruction considered.
■ Three principal methods of cartilage reconstruction are advocated: the
“exchange technique” using posterior septal components to reconstruct the
anterior defect, a “mosaicplasty” piecing together residual cartilage with
fibrin glue, and reconstruction with a cartilage autograft or homograft.7
■ An “exchange technique” is suitable where larger pieces of
cartilaginous/bony septum remain in the posterior septum.
■ From the dorsal portion of the septum, a portion of the cartilage can be
harvested and implanted into the defect as an autogenous septal graft.
■ Guide sutures may be used to position the graft into anatomic position, and
transverse mattress sutures used for fixation.
■ If a defect still exists, and there is insufficient cartilage, a graft from the
osseous septum may also be taken.
■ This exchange technique is not recommended in children, however,
because disruption of the posterior septum may ultimately affect septal and
midface growth.
■ For multiple small cartilaginous septal components underlying the
hematoma—that is the septum has fractured but not necrosed—a
“mosaicplasty” can be performed. In this technique, the septal fragments are
held together with fibrin glue and used to patch the defect. Although
relatively simple, it has been suggested that this technique may not be the
most effective in preventing or treating a saddle nose deformity.6
■ A cartilage autograft or homograft is possibly the most preferred method of
reconstruction. Cartilage is typically consistent, appropriately elastic,
amenable to shaping, and typically heals uneventfully. There is debate as to
its ideal source, with conchal, tragal, costal, or preserved donor cartilage
being options.
■ When using preserved donor cartilage, there is typically not as significant
limitation in size or volume as in comparison to employment of an
autograft. Although different constructions including the “L-shaped” and

“angular-shaped” types have been described, possibly the “boomerang-
shaped” (TECH FIG 1) design is the most preferred. The boomerang shape
is proposed to best resist mechanical stress, as it provides supports to both
the Little area, as well as the anterior nasal spine.6 Ultimately, if a graft is
used, it should be fit to the size of the defect and provide support to the
nose.
TECH FIG 1 • The boomerang-shaped cartilage graft
provides support to the anterior spine and Kiesselbach
plexus area and is resistant to mechanical stress.
■ Preventing Reaccumulation: Drain, Wick, or Quilt
■ A few different measures are available to prevent reaccumulation of the
hematoma. Into the hemitransfixion incision, an iodoform wick can be
inserted, or a penrose drain may be stitched in place (TECH FIG 2A).
Alternatively, and preferred, a quilting stitch (with an absorbable suture) can
be performed, which runs back and forth across the septum in a random
pattern to firmly press the mucoperichondrium against the cartilage and
eliminate dead space (TECH FIG 2B).

TECH FIG 2 • To prevent reaccumulation of the
hematoma, (A) a penrose drain may be stitched into
place temporarily, or (B) a quilting stitch (with an
absorbable suture) can be performed to firmly press
the mucoperichondrium against the cartilage and
eliminate dead space.
■ Nasal Packing
■ Vaseline gauze packing is placed with or without suturing of the mucosa to
the septum.
PEARLS AND PITFALLS
Bilateral
hematoma
incisions
■ For bilateral septal hematomas, the hemitransfixion incisions should
be staggered/nonopposing, as to avoid a through-and-through
perforation of the septum.
Securing
the
cartilage
graft
■ To further secure the cartilage graft into the defect in an effort to avoid
migration, silicone sheets can be placed on the mucosa, and mattress
sutures used through the silicone sheet, mucosa, perichondrium, and
cartilage graft. The sheets may be kept in place for up to 10 days.