Operative Technique in Plastic Surgery – Kevin C.Chung

57
CHAPTER
Correction of Orbital Roof
Fractures
Samita S. Goyal and James Jensen
DEFINITION
■ Orbital roof fractures may occur in isolation but more often are a part of a
larger pattern of traumatic injury.
■ Classification1:
■ Nondisplaced fractures
■ Isolated blow-in fractures
• Orbital roof displaced inferiorly into orbit
• No involvement of supraorbital rim or frontal sinus
• Due to sudden increased intracranial pressure and shift of the cranium and
intracranial contents; usually associated with severe brain injury
• Leads to decreased volume of orbit and possible displacement of globe
• Most likely injury type to require surgical intervention
■ Isolated blow-up (blow-out) fractures
• Orbital roof displaced superiorly into anterior cranial fossa
• No involvement of supraorbital rim
• Due to increase in intraorbital pressure, hydraulic force, or shear strain
• Leads to increased volume of orbit
■ Roof (blow up or blow in) and supraorbital rim
ANATOMY
■ The orbital roof is a thin, slightly concave bone that separates orbital contents
and the anterior cranial fossa.
■ Includes the lateral extent of the floor of the frontal sinus
■ Consists primarily of the orbital plate of the frontal bone; lesser (posterior)

contribution is from the greater and lesser wings of the sphenoid bone (FIG 1)
■ The endocranial surface is characterized by multiple ridges and thin bones that
may have a role in fracture patterns.
■ The orbital surface is smooth and thin and includes the lacrimal fossa, a
depression in the anterolateral orbital roof that contains the lacrimal gland.
■ The supraorbital rim confers rigidity to the superior orbit.
■ Structures in proximity to the orbital roof include the following:
■ Orbital septum
■ Lacrimal gland
■ Superior rectus muscle
■ Superior oblique muscle
■ Levator palpebrae superioris muscle
■ Supraorbital and supratrochlear nerves
■ Superior division of the oculomotor nerve
■ Globe
PATHOGENESIS
■ Orbital roof fractures make up 1% to 9% of all facial fractures.
■ Likely to have craniofacial, intracranial, ophthalmic, or other bodily injuries
(isolated orbital roof fractures in adults are rare)
■ In adults, most commonly seen in men 20 to 40 years of age (89%–93%).2
■ More commonly seen in pediatric patients under 7 years of age3:
■ Children older than 7 years are more likely to sustain orbital floor fractures.
■ Young children have a high cranial:orbital ratio, incompletely pneumatized
frontal sinus makes less likely shock absorption than in older children/adults;
in high-energy impact situations, energy is more efficiently transmitted
through the orbital roof.
■ Most commonly due to high-energy impact injuries to the face
■ Etiology
■ Mechanical vapor compression (MVC) (high energy): higher risk of
comminution3
■ Fall: more likely linear pattern3
■ Assault
■ Commonly seen at the junction of middle and medial thirds of orbital roof

FIG 1 • Submental view of orbital skeletal anatomy
demonstrating that the majority of the roof is frontal
bone.
■ Concomitant facial fractures2:
■ Frontal sinus (95%)
■ Orbital rims (60%)
■ Naso-orbital-ethmoidal region (33%)
■ Orbital wall fractures (33%)
■ Le Fort fractures (27%)
■ Also associated with fractures of the cribriform plate, lateral orbital wall,
squamous portion of the temporal bone, and planum sphenoidale
■ Concomitant soft tissue injuries: 25% of all fractures involving orbit have
ocular injuries.4
NATURAL HISTORY
■ In pediatric fractures, orbital roof fractures may develop into growing
fractures3:
■ Growing skull fractures—cranial fracture combined with dural tear and brain

herniation in a growing brain—can lead to progression of osseous defect with
growth.5
■ Frontal and parietal regions more commonly affected
■ More likely to be seen in children less than 3 years of age (period of rapid
brain growth)
■ Suspect risk for development into growing fracture if imaging suggests
herniation of intracranial contents into orbital region
■ Isolated orbital roof “blow-in” fractures may autoreduce with resolution of
cerebral edema if the dura is reasonably intact and apposed to the bone.6
PATIENT HISTORY AND PHYSICAL FINDINGS
■ History
■ Blunt or penetrating facial trauma
■ Diplopia
■ Eye pain
■ Diminished visual acuity
■ Blindness
■ Physical findings
■ Superior orbital rim contour deformity
■ Periorbital or conjunctival ecchymosis and edema
■ Epiphora
■ Hypesthesia/paresthesia of supraorbital and/or supratrochlear nerves
■ Orbital emphysema
■ Soft tissue lacerations
■ Enophthalmos/hyperglobus (blow-out fracture)
■ Exophthalmos/hypoglobus/proptosis (blow-in fracture)
■ Extraocular muscle entrapment or imbalance (superior rectus muscle) with
disconjugate gaze
■ Blepharoptosis due to injury to the levator palpebrae
■ Afferent pupillary defect
■ Neurological comorbidity
■ Dural injury with cerebrospinal fluid (CSF) leak (clear rhinorrhea)
■ Intracranial hemorrhage
■ Pneumocephalus (implies dural disruption)
■ Meningitis
■ Brain injury
■ Ophthalmic comorbidity

■ Optic nerve compression or laceration
■ Detached retina
■ Retrobulbar hematoma
■ Globe rupture
■ Ptosis or lagophthalmos
■ Intraorbital foreign bodies
■ Extraocular motor nerve palsies
■ Orbital encephalocele/intrusion
IMAGING
■ Standard of care imaging modality: thin-slice (1 mm) computed tomography
(CT) scan1:
■ Axial, coronal, and sagittal views essential to provide complete assessment of
degree of displacement and impact on surrounding structure.
■ 3D views not essential, but can be helpful in badly displaced/comminuted
fractures, especially if utilizing a limited access approach
■ Advantages: rapid, available, provides ability to assess intracranial
content/injury
■ Magnetic resonance imaging (MRI): impractical as it is an insensitive exam of
the bone and some foreign objects; contraindicated in situations where metallic
foreign objects (bullet fragments) may be present in soft tissues (FIG 2).

FIG 2 • Comminuted orbital roof/frontal sinus fracture
with rim involvement in a 19-year-old following blunt
force trauma (baseball). The patient had a ptotic upper
lid secondary to inferior displacement of orbital roof
(indicted by leader in (A)). B. 3D CT scan
demonstrating the comminuted fracture. C. 3D CT bird’s
eye view of the fracture. D. Soft tissue envelope
demonstrating the depressed eyebrow associated with
the fracture.
NONOPERATIVE MANAGEMENT
■ Conservative, nonoperative management is often appropriate in orbital roof
fractures and indicated in
■ Isolated, nondisplaced, or minimally displaced orbital roof fractures
■ Initial nonoperative course in “blow-in” fractures associated with
intracerebral edema; observe for reduction of fracture fragment with
resolution of cerebral edema6
■ Children without signs of functional deficit (eyelid position/function,
extraocular muscle mobility) or significant displacement
■ Higher threshold to operate in children (more likely to tolerate conservative
management) but certain fracture patterns may have potential for growing skull
fractures (significant displacement and dural injury5).
■ Treatment:
■ Head of bed (HOB) elevation

■ Sinus precautions: employ techniques to minimize pressure within sinuses
(no nose-blowing, no sneezing with mouth closed, etc.)
■ Antibiotic course not proven to be necessary, but should be considered with
obvious evidence of sinus contamination of intraorbital or intracranial space
■ Pain management
SURGICAL MANAGEMENT
■ Initial assessment includes standard advanced trauma life support (ATLS)
protocol and appropriate prioritization of treatment plan.
■ Appropriate coordination of other surgical procedures
■ Emergent intervention warranted with: visual/neurological compromise,
retrobulbar hematoma, extraocular muscle entrapment, globe rupture, severe
brain injury (ie, herniation)
■ Indications for surgery:
■ Injury and functional compromise of orbital contents, including the levator
complex
■ Associated dural tear with prolapse of brain tissue into the orbit
■ Consider deferring procedure until edema mostly resolved, if isolated fracture
and no functional compromise is present.
■ Titanium or resorbable mesh fixation may be considered.
Preoperative Planning
■ Comprehensive ophthalmological assessment
■ Careful review of CT scan, preferably with scans displayed in the OR and
easily seen from the operating position
■ Careful clinical examination on table prior to surgery, to establish morbid state
to provide for comparison after reduction/fixation.
■ Forced duction test to establish the presence/absence of entrapment
■ Place corneal protectors with thickly applied ophthalmic ointment to be able to
assess correction of globe malposition and comparison to contralateral side.
■ Standard perioperative IV antibiotic dose
■ Infiltrate planned incisions and dissection planes with local anesthesia with
epinephrine (1:1 to 400 000).
■ Consider intraop radiographic imaging (CT O-arm) to evaluate reduction,
especially if limited access incisions are pursued.
■ Headlight helpful, especially in limited access approaches

Positioning
■ The table is turned sufficiently away from the anesthesia station to provide
access to each side and the head of the bed (usually 90 degrees).
■ Standard HOB elevation to minimize venous pressure
■ Prep and drape the entire upper face and midface (ie, both sides for intraop
comparison of contours following reduction).
■ Anchor drapes in hair-bearing scalp with staples.
Approach
■ Four approaches are described here. The first three are “limited access” and
applicable essentially to isolated orbital roof/superior orbital rim fractures
largely confined to the anterior orbit or lateral frontal sinus anterior table
without concomitant intracranial injury.
■ Lateral brow approach (TECH FIG 1A):
■ For limited fractures: Gives access to orbital surface of the roof and superior
orbital rim
■ Advantages: Quick, avoids unnecessary dissection, and tissue disruption
■ Disadvantages: Limited access, nerve traction injury, crush injury to
orbicularis oculi muscle, and subcutaneous atrophy from retraction,
postoperative brow malposition/asymmetry, risk for unfavorable scar, and
inability to safely reduce roof fractures with intrusion of intracranial contents
■ Supratarsal approach (TECH FIG 1A):
■ Similar to lateral brow approach in indication, advantages, and disadvantage,
except the added risk for levator damage and brow ptosis and the improved
mobility of the thinner tissue of the upper lid in translating the overlying
skin/subcutis to align with the fracture
■ Translaceration approach:
■ Used with associated laceration in open fractures
■ May consider extending laceration in one or more directions to provide
adequate exposure
■ Advantages: Speed, minimal unnecessary disruption of the tissue
■ Disadvantages: May disrupt frontalis, sensory innervation; limited exposure
and inability to safely reduce intracranial material in “blow-in” fractures
■ Coronal approach (TECH FIG 1B):
■ The standard approach for complex or comminuted orbital roof fractures
associated with intracranial injury and frontal sinus fractures

■ Necessary for transcranial approach to orbital roof beyond anterior third
■ Safe access for posterior orbital decompression
■ Safe access to address dural injury and reduction of cranial contents
■ Advantages: Provides the widest exposure, least risk for sensory nerve
damage, facilitates more accurate and faster reduction, and allows flexibility
of simultaneous access to adjacent injured anatomy necessary for
collaborating services, including split calvarial graft harvest if necessary
■ Disadvantages: Extensive scar, time-consuming, risk for motor nerve injury
(frontal branch of CN VII), risk for temporal hollowing, discomfort, and
longer recovery
■ If the fracture is extensive or comminuted or involves disruption of the barrier
between the brain and orbit, including dural injury, a conventional open
approach via some version of a coronal incision is indicated (most cases that
require operative intervention in collaboration with neurosurgical and/or
ophthalmological colleagues).
■ Surgical correction of the orbital roof per se may or may not require
immediate attention depending on the comorbidity and the urgency therein.
T E C H N I Q U E S
■ Lateral Brow Approach
■ Place incision on the lower border of the eyebrow if the skin is completely
intact to limit dissection through subcutis containing sensory nerves as they
emerge from the superior orbital rim (TECH FIG 1A):
■ Position incision laterally to limit transection of sensory nerves.
■ Distract skin/subcutis to center dissection vector on superior orbital rim.
■ Continue sharply through subcutis and orbicularis muscle to the periosteum
of orbital rim; if orbital septum is encountered, remain superficial to it, and
redirect dissection plane superiorly toward its insertion in the orbital rim
(TECH FIG 1B).
■ Identify periosteum, and locate any traumatic laceration to serve as edge
from which to dissect.
■ Dissect the periosteum from underlying bone fragments to provide sufficient
exposure of a periphery of intact, uninjured bones, 5 to 10 mm.

■ Document, whether by photography or a quick intraoperative sketch, the
configuration of fractured fragments to ensure correct reconstruction if
fragment removal is necessary to achieve anatomic reduction.
■ Reduce impacted fractures with fine dissector or elevator; may require
removal of small, centrally located fragment to provide for optimal leverage
of impacted fragments.
■ If a portion of the orbital roof is displaced, removal of fragments in the
superficial dissection to afford exposure necessary for adequate and stable
reduction may be required.
■ Reduction of multiple fragments may require stepwise approach; begin with
the most distal or obscured edge, and work toward the center of dissection
pocket.
■ Contour plate(s) appropriately.
TECH FIG 1 • Location of skin incisions (A) and
correct plane of dissection (B) in lateral brow and
supratarsal approaches.
■ Apply internally fixated plates and screws (titanium, primarily; resorbable
plating material may be considered in these fractures as they are not prone to
disruption by muscle action).
■ Irrigate thoroughly.
■ Perform careful layered closure of the periosteum if possible, muscle, and
dermis with resorbable suture, and fine nonabsorbable suture for a precise,

tension-free superficial layer closure.
■ Supratarsal Approach
■ Incision is placed in supratarsal crease, which may be difficult to find in very
edematous eyelids (see TECH FIG 1A).
■ Incise the skin and orbicularis concomitantly, encounter superficial tissue
(preseptal fat or SOOF), sharply dissect through this as well, and dissect
superiorly in the preseptal plane until the rim and/or fracture is encountered.
■ Distract the skin/subcutis to center dissection vector on superior orbital rim.
■ Continue sharply through the subcutis and orbicularis muscle to the
periosteum of orbital rim; if orbital septum is encountered, remain superficial
to it, and redirect dissection plane superiorly toward its insertion in the orbital
rim (see TECH FIG 1B).
■ Identify periosteum, and locate any traumatic laceration to serve as edge
from which to dissect.
■ Dissect periosteum from underlying bone fragments to provide sufficient
exposure of a periphery of intact, uninjured bones, 5 to 10 mm.
■ Document, whether by photography or a quick intraoperative sketch, the
configuration of fractured fragments to ensure correct reconstruction if
fragment removal is necessary to achieve anatomic reduction.
■ Reduce impacted fractures with fine dissector or elevator; may require
removal of small, centrally located fragment to provide for optimal leverage
of impacted fragments
■ If a portion of the orbital roof is displaced, removal of fragments in the
superficial dissection to afford exposure necessary for adequate and stable
reduction may be required.
■ Reduction of multiple fragments may require stepwise approach; begin with
the most distal or obscured edge, and work toward the center of dissection
pocket.
■ Contour plate(s) appropriately.
■ Apply internally fixated plates and screws (titanium, primarily; resorbable
plating material may be considered in these fractures as they are not prone to
disruption by muscle action).
■ Irrigate thoroughly.
■ Perform careful layered closure of the periosteum if possible, muscle, and

dermis with resorbable suture, and fine nonabsorbable suture for a precise,
tension-free superficial layer closure.
■ Translaceration Approach
■ Remove any temporarily placed sutures.
■ Explore wound to identify frontalis, corrugator, and procerus musculature;
identify supraorbital/supratrochlear nerves for gentle retraction.
■ If necessary, dissect length of sensory nerves to enable safe retraction.
■ Identify periosteum, and locate any traumatic laceration to serve as edge
from which to dissect.
■ Dissect periosteum from underlying bone fragments to provide sufficient
exposure of a periphery of intact, uninjured bones, 5 to 10 mm.
■ Document, whether by photography or a quick intraoperative sketch, the
configuration of fractured fragments to ensure correct reconstruction if
fragment removal is necessary to achieve anatomic reduction.
■ Reduce impacted fractures with fine dissector or elevator; may require
removal of small, centrally located fragment to provide for optimal leverage
of impacted fragments.
■ If a portion of the orbital roof is displaced, removal of fragments in the
superficial dissection to afford exposure necessary for adequate and stable
reduction may be required.
■ Reduction of multiple fragments may require stepwise approach; begin with
the most distal or obscured edge, and work toward the center of dissection
pocket.
■ Contour plate(s) appropriately.
■ Apply internally fixated plates and screws (titanium, primarily; resorbable
plating material may be considered in these fractures as they are not prone to
disruption by muscle action).
■ Irrigate thoroughly.
■ Perform careful layered closure of the periosteum if possible, muscle, and
dermis with resorbable suture, and fine nonabsorbable suture for a precise,
tension-free superficial layer closure.
■ Coronal Approach

■ Select incision pattern (TECH FIG 2A):
■ Zigzag or “stealth” incisions change direction and permit hair to more
effectively camouflage scar; also, provide for greater stretch of the scalp to
more easily evert.
■ Straight or slightly wavy incisions are faster but ultimately more visible.
■ Select incision placement:
■ Anterior hairline incision facilitates flap elevation and reduces visibility of
scar but may become visible with hairline recession.
■ Placement within hair-bearing scalp likely will provide best long-term
cosmetic result.
■ Hair grooming with clips or rubber bands vs shaving (not with a razor
blade).
■ Map (with palpation) course of superficial temporal artery.
■ Begin incision superior to temporal crest to avoid confusion of superficial
and deep temporal fascia.
■ If only a limited pericranial flap is necessary, incise the skin with scalpel
through the galea in relatively short segments (5–10 cm) with immediate
blunt (or sharp with scalpel) dissection in subgaleal plane anteriorly and
posteriorly.
■ Cauterize arteries or large galeal veins; avoid cauterization of the dermis or
subcutis to minimize risk of alopecia.
■ Apply Raney clips as soon as possible to stop dermal bleeding.
■ Extend incision through superficial temporal fascia with care to avoid the
superficial temporal vessels. In adults, well-developed periauricular
musculature will be encountered that will have to be divided.
■ Continue blunt dissection in the subgaleal plane anteriorly, using cautery as
necessary for any transcranial emissary vessels encountered, both superiorly
and laterally, leaving the deep temporal fascia and temporalis musculature
undisturbed and apposed to the cranium.
■ Continue in the subgaleal plane until the fracture becomes detectable, then
incise the pericranium with a 5- to 10-mm margin of intact bone, and
continue the dissection in the subpericranial plane over the fracture
fragments, with care taken to note the position of any fragments that become
dislodged during this maneuver.
■ Continue subpericranial dissection as necessary past the superior orbital rim
(TECH FIG 2B), but avoid if possible complete disruption of this plane with

respect to orbital roof fragments to maintain blood supply and optimize
healing.
■ If a large pericranial flap is likely to be necessary (eg, to provide lining of
disrupted dura/CSF leak over the orbital roof), then dissect in the
subpericranial plane between the temporal crests from the beginning, incise
the pericranium at the temporal crests, and continue scalp flap dissection
laterally in the subgaleal plane (again, leaving the temporalis muscle in place
if temporal bone access is not necessary).
■ If orbital roof is too comminuted, consider split calvarial bone graft to
restore structural integrity to the orbital roof (must have vascular bed and no
continuity with sinus cavity to succeed).
■ Once the fracture pattern is exposed, document, whether by photography or
a quick intraoperative sketch, the configuration of fractured fragments to
ensure correct reconstruction if fragment removal is necessary to achieve
anatomic reduction.
■ Reduce impacted fractures with fine dissector or elevator; may require
removal of small, centrally located fragment to provide for optimal leverage
of impacted fragments.
■ If a portion of the orbital roof is displaced, removal of fragments in the
superficial dissection to afford exposure necessary for adequate and stable
reduction may be required (TECH FIG 2C).
■ Reduction of multiple fragments may require stepwise approach; begin with
the most distal or obscured edge, and work toward the center of dissection
pocket.
■ Contour plate(s) appropriately.
■ Apply internally fixated plates and screws (titanium, primarily; resorbable
plating material may be considered in these fractures as they are not prone to
disruption by muscle action; TECH FIG 2D).
■ Irrigate thoroughly.
■ If fragments of the roof are not amenable to fixation, consider titanium or
other alloplastic materials to restore physical barrier between orbital tissue
and anterior cranial fossa.

TECH FIG 2 • A. Different options of coronal incision
placement. B. Surgical exposure of patient in FIG 2,
demonstrating biplanar approach (subgaleal
converted to subpericranial at level of fracture) and
displacement of fracture fragments into frontal sinus,
which essentially occupied the entire width of the
orbital roof fracture (no intracranial extension). The
arrow indicates the pericranial flap. C. Removal of
fragments reveals orbital roof fracture (arrow),
confined to orbital sinus cavity. D. Internal fixation with
transversely oriented contoured low-profile titanium

plates.
■ If a pericranial flap is necessary to inset intracranially at the anterior cranial
base/orbital roof, then a small cranial defect of 3 to 5 mm in vertical
dimension and variable width will need to be provided close to the level of
the roof (see technical description of cranialization of frontal sinus).
■ Anchor the pericranium with suture with or without fibrin glue.
■ Closure of the scalp is over a single-closed suction-fluted drain, emerging
postauricularly, and consists of interrupted resorbable suture in the
pericranium over the fracture repair, then interrupted resorbable sutures every
1 to 2 cm in the galea, and then running permanent suture or staples in the
skin.
■ Bolster dressing is optional.
PEARLS AND PITFALLS
Coronal
approach:
temporal
hollowing
■ Avoid disinsertion of temporalis musculature or exposure of
temporal fat pad.
Coronal
approach
injury to
frontal
branch of
CN VII
■ Begin dissection in subgaleal/subsuperficial temporal fascia plane,
progress with blunt dissection in this plane in the frontotemporal
region, and convert to subpericranial well superior to the course of
the nerve.
Raising the
pericranial
flap
■ Some find it easier to raise the pericranium off the already-raised
scalp flap than to raise it intact off the bone following subgaleal
scalp elevation because of desiccation; be sure to keep all tissues
well irrigated during the prolonged exposure with the coronal
approach.
Plate
orientation
■ One could argue in favor of orienting fixation plates to follow
relaxed skin tension lines, but low-profile miniplates are difficult to
palpate over the superior orbital rim and forehead.
Resorbable
■ Appropriately applied when strength is not necessary, but may

plating
material
cause seroma formation and bony resorption; not proven to be as
effective as titanium or porous polyethylene implants for orbital
roof restoration.
Change of
approach
■ Even if planning for a limited approach, always be prepared (and
prepare patient) for a coronal approach.
■ Have a full set of instruments available.
POSTOPERATIVE CARE
■ Immediate evaluation of vision in recovery room as soon as the patient is able
to be examined.
■ Elevation of the head of the bed
■ Sinus precautions: Employ techniques to minimize pressure within sinuses (no
nose-blowing, no sneezing with mouth closed, etc.).
■ Avoidance of contact activities (sports, gym, recess, etc.) for 6 weeks
■ Begin scar massage after incisional edema resolved (about 2 weeks
postoperatively).
■ Extraocular muscle exercises as needed
■ Consider a short course of prophylactic antibiotics to decrease risk for
postoperative infection (devitalized bone fragments).
■ Postoperative imaging is entirely dependent on the intra- and postoperative
courses.
OUTCOMES
■ Level 1 evidence in treatment of orbital roof fractures is lacking.
■ In children, roof fractures smaller than 2 cm2 are unlikely to lead to globe
malposition or development of encephalocele.3
■ Early intervention of orbital roof fractures with ophthalmological sequelae
decreases morbidity.5
■ That two-thirds of orbital roof fractures are associated with traumatic brain
injury underscores need for multidisciplinary approach.7
COMPLICATIONS
■ Globe displacement8
■ Retrobulbar hematoma
■ Meningitis
■ Persistent CSF leak due to inadequate repair of dural tear

■ Eyelid ptosis from injury to levator palpebrae superioris muscle
■ Injury to orbital structures: extraocular muscles, nerves, arteries, veins, and
globe
■ Blindness
REFERENCES
1. Righi S, Boffano P, Guglielmi V, et al. Diagnosis and imaging of orbital roof
fractures: a review of the current literature. Oral Maxillofac Surg. 2015;19:1-4.
2. Rinna C, Rocchi G, Ventucci E, et al. Bilateral orbital roof fracture. J
Craniofac Surg. 2009;20:737-742.
3. Coon D, Yuan N, Jones D, et al. Defining pediatric orbital roof fractures:
patterns, sequelae, and indications for operation. Plast Reconstr Surg.
2014;134(3):442e-448e.
4. Connon FV, Austin SJB, Nastri AL. Orbital roof fractures: a clinically based
classification and treatment algorithm. Craniomaxillofac Trauma Reconstr.
2015;8:198-204.
5. Havlik RJ, Sutton LN, Bartlett SP. Growing skull fractures and their
craniofacial equivalents. J Craniofac Surg. 1995;6:103-110.
6. Stam LH, Wolvius EB, Schubert W, Koudstaal MJ. Natural course of orbital
roof fractures. Craniomaxillofac Trauma Reconstr. 2014;7:294-297.
7. Cossman JP, Morrison CS, Taylor HO, et al. Traumatic orbital roof fractures:
interdisciplinary evaluation and management. Plast Reconstr Surg.
2014;133(3):335e-343e.
8. Kim JW, Bae TH, Kim WS, Kim HK. Early reconstruction of orbital roof
fractures: clinical features and treatment outcomes. Arch Plast Surg.
2012;39(1):31-35.

58
CHAPTER
Secondary Correction of
Enophthalmos
David C. Matthews, Samer Abouzeid, and Edward W. Kubek
DEFINITION
■ Enophthalmos refers to the posterior position of one eye relative to the
contralateral eye.1
■ Secondary post-traumatic enophthalmos refers to the persistence of
enophthalmos after attempted correction during the primary operation and is a
common sequela to orbital trauma.
■ Hypoglobus describes a vertical discrepancy in globe position.
■ Secondary post-traumatic enophthalmos is the most common secondary facial
deformity following primary surgery for facial trauma.2
■ Until the 1970s, enophthalmos was not considered correctable.
■ Tessier’s work demonstrated that both acute and late enophthalmos were
correctable.
■ In 1982, Kawamoto first reported his technique to correct long-standing post-
traumatic enophthalmos with osteotomies and bone grafting.3
■ These techniques were then repeated by Manson, Wolfe, and Gruss.4
ANATOMY
■ The bony architecture of the orbit forms two basic components, the orbital
frame (comprising the rim) and the orbital pyramid with its apex pointed
posteriorly (comprising the floor, roof, lateral wall, and medial orbital wall.
■ The optic nerve enters the orbit at the apex of an asymmetric pyramid where
the apex is oriented posteromedially and superiorly.
■ General dimensions of the bony orbit are 50 mm deep, 35 mm wide, and 40
mm high.1

■ Each of the pyramid’s four walls has a unique shape that contributes to globe
position.1
■ Four structures of surgical importance1:
■ The Hammer’s “key area,” or posterior part of the medial orbital wall (FIG
1).
■ S-Curvature of the posterior one-third of the orbital floor—any graft,
synthetic or autologous, must sit atop the ledge created by the palatine bone
posteriorly.
■ Greater wing of the sphenoid—anatomic reduction indicates proper
alignment of the lateral wall and rim with the zygoma.
■ Orbital rim position—failure to anatomically reduce a displaced orbital rim
(ie, the frame) prevents restoration of normal orbital shape and volume.
■ Four measurements of surgical importance denote safe distances of dissection
beyond key structures. Note that dissecting posteriorly to these distances will
still be insufficient for secondary correction of enophthalmos, if the posterior
margin of the defect is not defined.
■ Dissection should be limited to:
■ Medial wall—36 mm of the anterior lacrimal crest
■ Orbital floor—35 mm of the infraorbital foramen
■ Orbital roof—30 mm of the supraorbital notch
■ Lateral wall—25 mm of the frontozygomatic suture
PATHOGENESIS (OPTIONAL)
■ Post-traumatic, secondary enophthalmos occurs when the fracture pattern
expands the volume of the bony orbit and is either uncorrected (FIG 2A) or
reduced in the wrong position (FIG 2B):
■ As a result, the globe occupies a smaller percentage of the total space and
assumes a more posterior position.
■ The most common cause of secondary enophthalmos during the primary
operation is inadequate posterior dissection for fear of injuring the optic nerve
or globe,2 followed by inadequate reduction of medial wall fractures (FIG 3).5
■ Failure to re-establish the anatomic form of Hammer’s key area and/or the S-
curve of the posterior orbital floor can also lead to secondary enophthalmos,
even in cases where the orbital floor is intact.1

FIG 1 • Key areas of the orbit include the junction
between the zygomatic bone and greater wing of the
sphenoid. The palatine bone should be used as a
support shelf for the bone graft.
FIG 2 • A. Absent reduction of the orbital floor (see
black arrow) results in increased orbital volume leading
to enophthalmos. B. Inadequate reduction after remote
zygoma fracture demonstrates the ledge between the

zygomatic bone and the greater wing of the sphenoid.
■ Late atrophy of orbital fat is rarely demonstrated and is not a cause of
secondary enophthalmos5; furthermore, it should be the goal of the surgeon to
reduce all malpositioned orbital fat noted during the workup for secondary
correction.
NATURAL HISTORY
■ In the early postinjury period, clinical enophthalmos is usually masked by
swelling.
■ As edema subsides, postsurgical patients, or those who did not seek acute care,
may present with enophthalmos, in the presence or absence of diplopia.
■ Globe position and healing after the primary operation or injury is considered
stable at 6 months.2
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Normal physiologic anteroposterior variance between eyes is ≤2 mm.1
■ Discrepancies ≥3 mm can be evident to untrained observers.1
■ Normally, the globe functions as the fulcrum for the levator. Enophthalmia
displaces this fulcrum causing the upper lid to appear ptotic (FIG 4).
■ Patients may complain of eyelid thickening and impaired ability to fully open
the eye.
■ Preoperatively, the surgeon must document any numbness in the infraorbital
and zygomaticofacial nerve distributions.

FIG 3 • Orbital floor dissection should reach the palatine
bone (designated by the arrow).
■ Hertel exophthalmometry is a noninvasive way to measure globe position.
Normally, the cornea is 16 mm anterior to the lateral orbital rim. The Hertel
technique is not applicable in the acute setting and inaccurate when the lateral
orbital rim is displaced. In such cases, measurement relative to the ear canal
may be useful.5
IMAGING
■ A craniofacial computed tomography (CT) scan with 0.5-mm cuts should be
obtained and formatted for 3D reconstructions (see FIG 2).
■ The scan defines defects in the orbital floor, walls, and zygoma.
■ CT-guided volumetric analysis can be used but is limited by an inability to
predict bone resorption depending on type of bone graft (calvarial bone has
less resorption than iliac bone). This analysis may be more beneficial when
using preformed synthetic implants that do not resorb.6
SURGICAL MANAGEMENT
Preoperative Planning
■ CT scan should be studied well to evaluate the dimensions of the bone that

should be harvested to reconstruct the orbital floor.
■ Ophthalmologic examination should be documented preoperatively. A bedside
Snellen eye chart is helpful for documenting the examination at bedside.
■ Note any history of upper lid surgery for ptosis caused by enophthalmia
because secondary correction of enophthalmos in this setting requires reversal
of the prior upper lid operation.
■ Consider a coronal incision for secondary operations to reduce large medial
wall defects and old displaced zygomaticomaxillary complex fractures.
■ The choice between autologous, alloplastic, metal, and bioceramic implants is
guided by surgeon preference. Costlier prefabricated implants are typically
reserved for secondary operations.7
■ General principles for surgery
■ Wide subperiosteal exposure of the orbit is required to visualize the entire
defect.
■ A subtarsal lower lid incision extended laterally increases exposure.
FIG 4 • When the globe is in a posterior and inferior
position, the upper eyelid has no support, giving the
impression of ptosis.
■ Make an attempt to correct the entire defect with bone grafts.

■ If necessary, the periosteum of the anterior maxilla is elevated so that orbital
periosteum can be sutured to this layer to support the lower lid.
■ Orbicularis ocularis is closed as well as the skin.
■ In severe comminuted orbital fractures, remember that the infraorbital nerve
is the key for dissection of the floor.
■ Severe medial defects are approached through a coronal approach.
Patient Positioning
■ The patient should be in the supine position.
■ The endotracheal tube should be in the midline.
■ The eyes should be closed with ophthalmic ointment.
■ The face and upper shoulders will be scrubbed with Betadine and then the eyes
irrigated with balanced salt solution (BSS).
■ The head is draped, leaving the entire face in the surgical field.
T E C H N I Q U E S
■ Periorbital Repair
■ A transconjunctival or an infraorbital approach is made.
■ The transconjunctival approach:
• Infiltration of local anesthetic with epinephrine
• Incision is made posterior to the orbital septum; the incision should extend
to the orbital rim.
■ The infraorbital approach:
• Choose the highest subtarsal groove and make the skin incision.
• Separate subcutaneous tissue until reaching the orbicularis muscle.
• Incise the orbicularis transversely onto the orbital rim.
■ A periosteal elevator dissects in the subperiosteal plane, moving from the
fixed (unfractured) bone to the fracture site.
■ Periosteal elevation beyond 35 mm posteriorly endangers the optic nerve
(TECH FIG 1A).
■ After exposing the fractured area (including separation of the infraorbital
nerve from the periorbital fat), the bony defect should be fully visualized.
■ An autologous calvarial bone graft is taken from the parietal bone.

■ After exposing the parietal skull, the graft is outlined with ink based on
measurements from preoperative imaging.
■ A cutting bur is used to follow the outline through the outer table.
■ Bleeding from the diploe indicates proper depth.
■ The graft is harvested using thin osteotomes to circumferentially free the
outer table graft.
■ The bone graft should be placed without fixation to span the defect.
■ Ensure bony contact posteriorly, and stabilize the bone to the medial and
lateral shelves of the defect.
■ The graft should not extend beyond the inferior orbital rim anteriorly.
■ Multiple layers of bone can be stacked until the eyes are at the same level
and the “two thumbs pressure test” is similar bilaterally (TECH FIG 1B).
■ Though bone grafts are the preferred method of treatment, synthetic implants
can be used according to surgeon preference and availability of preoperative
imaging with 3D modeling.
■ To lessen the risk of ectropion, the malar periosteum should be resuspended.
■ Before closing the skin, examine the globe’s mobility with a forced duction
test.
■ Two to three stitches with Vicryl 5-0 should be used to approximate
orbicularis oculi edges.
■ Closure is performed in one skin layer with nylon 6-0 for the infraorbital
incision and Vicryl 6-0 Rapide to reapproximate conjunctivae for the
transconjunctival approach.

TECH FIG 1 • A. Elevation of the periorbita is
performed from regions of normal bone toward the
previous site of fracture. The elevator should not be
used to dissect further than 35 mm from the orbital
rim. B. Plates are placed on the buttresses, and any
gap is covered with bone graft.
■ Zygoma Repair
■ A coronal incision should be used to access the zygomatic arch.
■ The temporal fascia is elevated from the zygomatic arch toward the muscle
to protect the facial nerve.
■ The orbital contents can also be elevated from this approach.
■ The masseter muscle insertion on the zygoma is released with an elevator.
■ The zygomatic arch osteotomy is made in an oblique fashion.
■ The zygomaticofrontal fissure should also be cut or mobilized depending on
whether the fracture site is healed or not. (Usually, the fracture is along the
fissure.)
■ An osteotomy is made through the old orbital rim fracture (TECH FIG 2A).
■ A heavy bone hook—Ginestet hook—is used with a steady forward force to
mobilize the zygoma, and then lateral movements are made to free it
completely (TECH FIG 2B).

■ The landmark for placing the hook is at the intersection between a vertical
line passing through the lateral canthus and a horizontal line passing through
the tragus.
■ The zygoma is anatomically reduced.
■ Anatomic alignment of the lateral orbital wall and greater wing of the
sphenoid is a useful indicator of proper reduction.
■ The osteotomized and reduced zygoma is fixed with titanium plates and
screws (2.0 or 1.5 mm).
■ Plating should be performed to the orbital rim, frontozygomatic suture, and
zygomatic arch. Stable fixation at the lateral buttress must withstand the
inferior pull of the masseter.
TECH FIG 2 • A. Using either a mechanical saw or a
piezo saw, cuts are made along the frontozygomatic
suture, the temporozygomatic suture, and lateral to
the infraorbital nerve. B. A Ginestet hook should be
used to mobilize the zygoma by pulling steadily
forward, then outward, and inward.
■ Orbital Floor Repair
■ Evaluation of the orbital floor bony defect should be made; a size-matched
bone graft is harvested from the parietal skull.
■ Multiple layers of bone can be placed to achieve symmetric positions of the

globes.
■ A pseudotarsorrhaphy is performed at the end of the procedure:
■ A 5-0 Prolene horizontal mattress suture that involves the tarsus is placed
between the upper and lower eyelids for temporary closure (TECH FIG 3).
TECH FIG 3 • The pseudotarsorrhaphy stitch should
be lateral to the pupil, along the free edge of the
eyelid.
PEARLS AND PITFALLS
Physical
findings
■ Normal physiologic anteroposterior variance between eyes is ≤2
mm.
■ Discrepancies ≥3 mm can be evident to untrained observers.
Technique
■ Temporalis fascia should be elevated posteriorly along the arch to
protect the facial nerve.
■ Oblique bone cuts should be made to allow greater bony contact
and stability.
■ All muscles should be freed from the zygoma for greater mobility

of the segment.
■ Alignment of the lateral orbital wall and greater wing of sphenoid
ensures reduction is optimal.
■ Reapproximate the periosteum to avoid ectropion.
■ The malar periosteum should be resuspended.
■ Cautery should not be used on the orbicularis ocularis.
Postoperative
care
■ Eye examination should be performed when the patient is awake
after surgery.
■ Diplopia and eye position are assessed at 2 wk and 6 mo after
surgery.
POSTOPERATIVE CARE
■ An eye examination should be performed when the patient is fully awake.
■ Antibiotic ointment and eye drops are applied for several days.
■ Pain medications and antibiotics are given orally for 1 week.
■ The patient may shower 2 days after surgery but should avoid contacting the
incision line.
■ A CT scan may be performed 1 week postoperatively.
■ Removal of nylon stitches after 1 week.
■ Eye exercises should be done immediately after edema resolution.
■ Diplopia and eye position are assessed 2 weeks after the procedure and
allowed 6 months to stabilize.
OUTCOMES
■ Prepare patients for the possibility of subtle imperfections after secondary
operations.
■ Persistent diplopia from orbital trauma may not resolve with secondary
correction.
■ Final results will take 6 months to stabilize.
■ Repeat bone grafts can be performed if the correction is insufficient.
COMPLICATIONS
■ Optic nerve injury resulting in blindness
■ Infraorbital nerve injury and facial numbness
■ Infection or scarring of synthetic implants
■ Exposure or inflammatory reaction to synthetic implants
■ Nonresolution of the diplopia:

■ Consider muscle injury as the cause.
■ Strabismus surgery may be warranted in such cases.
■ Proptosis from postoperative retrobulbar hematoma is a medical emergency
requiring immediate exploration, lateral canthotomy, and immediate
evacuation.
■ Nonresolution of orbital dystopia.
■ Ectropion (more common with subciliary approach) and upper lid malposition.
■ Resorption of cranial bone graft with late recurrence of enophthalmos.8,9
REFERENCES
1. Holmes S. Reoperative orbital trauma: management of posttraumatic
enophthalmos and aberrant eye position. Oral Maxillofac Surg Clin North Am.
2011;23(1):17-29.
2. Chen CT, Huang F, Chen YR. Management of posttraumatic enophthalmos.
Chang Gung Med J. 2006;29(3):251-261.
3. Kawamoto HK. Late posttraumatic enophthalmos: a correctable deformity?
Plast Reconstr Surg. 1982;69(3):423-430.
4. Grant MP, Iliff NT, Manson PN. Strategies for the treatment of enophthalmos.
Clin Plast Surg. 1997;24(3):539-550.
5. Kellman RM, Bersani T. Delayed and secondary repair of posttraumatic
enophthalmos and orbital deformities. Facial Plast Surg Clin North Am.
2002;10(3):311-323.
6. Vignesh U, Mehrotra D, Dichen, Anand V, Howlader D. Three dimensional
reconstruction of late post traumatic orbital wall defects by customized
implants using CAD-CAM, 3D stereolithographic models: a case report. J
Oral Biol Craniofac Res. 2017;7(3):212-218.
7. Nkenke E, Vairaktaris E, Spitzer M, Kramer M, et al. Secondary
reconstruction of posttraumatic enophthalmos: prefabricated implants vs
titanium mesh. Arch Facial Plast Surg. 2011;13(4):271-277.
8. Gunarajah DR, Samman N. Biomaterials for repair of orbital floor blowout
fractures: a systematic review. J Oral Maxillofac Surg. 2013;71(3):550-570.
9. Gosau M, Schöneich M, Draenert FG, et al. Retrospective analysis of orbital
floor fractures: complications, outcome, and review of literature. Clin Oral
Invest. 2011;15(3):305-313.

59
CHAPTER
Section VIII: Nasal
Fractures
Closed Nasal Fracture
Correction
Benjamin C. Wood
DEFINITION
■ Nasal bone fracture is the most common type of facial fracture.1
■ The combination of the central positioning and anterior projection of the nose,
with the delicate nature of the thin nasal bones, increases the risk of fracture
from traumatic injury.
ANATOMY
■ The pyramidal shape of the nose is composed of skeletal and cartilaginous
structural components supporting the overlying skin and soft tissue (FIG 1).
■ The bony structure of the nose is composed of the paired, wedge-shaped nasal
bones in the midline, which articulate with the frontal process of the maxilla,
the nasal process of the frontal bone, and the ethmoid and vomer.
■ The cartilage structures of the nose include the paired upper lateral cartilages
and lower lateral cartilages and the septum, which is composed primarily of
the quadrangular cartilage.
PATHOGENESIS
■ The most common cause of nasal fractures is blunt trauma, typically due to
motor vehicle accidents, physical altercations, or sports-related injuries.2

FIG 1 • Nasal structural anatomy.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Delineate pertinent patient history, including mechanism of injury, time since
injury, and any pre-existing nasal deformity or previous nasal surgery.
■ Establish any prior history of nasal breathing difficulty, obstruction, or sleep
apnea, including use of allergy medications, nasal sprays, or inhalers.
■ External examination should focus on the severity of nasal deformity,
lacerations, epistaxis, cerebrospinal fluid drainage, and pain or step-off on
palpation.
■ It is important to determine whether there is suspicion of a naso-orbital
ethmoid (NOE) fracture on examination, which may warrant further evaluation
with imaging.
■ Internal examination using a nasal speculum to identify any mucosal
lacerations, septal deviation, or the presence of a septal hematoma.
■ Vasoconstrictive agents and topical anesthetic should be used to control
bleeding and facilitate a proper internal nasal examination.
■ Pediatric patients less frequently fracture the nasal bones but are more
susceptible to failure to identify a septal hematoma on examination.3
IMAGING

■ Nasal fractures are generally a clinical diagnosis, so radiographic imaging is of
minimal utility unless there is suspicion of a more complex facial fracture
pattern.
NONOPERATIVE MANAGEMENT
■ Patients with minimal nasal symmetry distortion and patent nasal airways may
be managed expectantly with observation and reassessment following
resolution of soft tissue edema.
SURGICAL MANAGEMENT
■ The timing of surgical management is dependent on the time since the injury
occurred.
■ Patients presenting within hours of the injury before substantial edema
develops may be amenable to immediate closed nasal reduction.
■ Patients presenting more than 3 or 4 hours after injury should have operative
intervention deferred until sufficient time has passed to allow for resolution of
edema to facilitate full visualization of the deformity.
■ The decision for closed vs open nasal reduction depends on the severity of the
injury.
■ Simple, unilateral or bilateral, fractures are generally amenable to closed nasal
reduction.
■ Comminuted, closed or open, fractures may be better addressed with an open
reduction.
■ Septal hematomas always require immediate evaluation to avoid septal
cartilage resorption and formation of a secondary nasal deformity.4
Preoperative Planning
■ Determine whether the procedure should be performed under a local vs a
general anesthetic.
■ Consider patient age, compliance, medical comorbidities, and expectations.
■ It is important to establish realistic patient expectations prior to surgery, as it is
not uncommon to have a residual minor deformity following closed nasal
reduction.
■ Should an unsatisfactory deformity persist after closed nasal reduction, the
patient may elect to have an open reduction and rhinoplasty in the future.
Positioning

■ The patient is placed in the supine position with arms tucked.
■ A shoulder roll may be placed for neck extension if necessary.
Approach
■ Placement of topical and injectable anesthetic agents is performed first to
allow for adequate time for the vasoconstrictive effect prior to beginning the
procedure.
T E C H N I Q U E S
■ Administration of Local Anesthetic
■ Typically, both topical and injectable anesthetics are administered.
■ Topical anesthetic is applied via pledgets soaked in either 4% lidocaine with
oxymetazoline (Afrin) or phenylephrine hydrochloride (Neo-Synephrine)
(TECH FIG 1A):
■ Place along nasal septum, middle turbinate, and nasal floor (TECH FIG
1B).
■ Leave in place for at least 7 to 10 minutes for the vasoconstrictive effect.
■ Inject 1% lidocaine with epinephrine submucosally along the septum and the
undersurface of the nasal bones and as a dorsal nasal and infraorbital nerve
block bilaterally.
■ Limit the volume of anesthetic injected so as not to obscure the deformity
and results of the reduction.

TECH FIG 1 • A. Application of topical anesthetic via
pledgets. B. Pledgets with topical anesthetic in place
(7–10 minutes).
■ Reduction of Bony Nasal Pyramid and Septum
■ First, measure the distance from the alar rim to the nasion of the medial
canthus by placing the Goldman or Boise elevator externally along the nose
(TECH FIG 2A):
■ This maneuver prevents advancing the elevator too far into the nasal vault
in the event that there is an injury to the cribriform plate.
■ Insert the elevator to the predetermined distance underlying the in-fractured
nasal bone, and apply upward and outward pressure (TECH FIG 2B):
■ Use the combination of external digital pressure with intranasal elevator
manipulation to assess adequate reduction of the nasal bone fracture.
■ The nasal septum is then reduced using direct, blunt pressure to the
displaced portion of the septum:
■ Alternatively, Asch or Walsham forceps may be used to straighten the nasal
septum with gentle manipulation of the septum into proper alignment
(TECH FIG 2C).

TECH FIG 2 • A. Measurement of the distance from
the alar rim to the nasion. B. Outfracture of the nasal
bone using a Boise elevator. C. Septal alignment
using Asch forceps.
■ Nasal Airway Assessment and Splint Application
■ Advance the elevator along the nasal floor to ensure that it passes to the
nasopharynx without difficulty.
■ Perform a nasal speculum examination to ensure patency and symmetry of
the nasal airways (TECH FIG 3A).

■ Apply a thermoplastic (Denver) external nasal splint to support and protect
the reduced nasal fracture (TECH FIG 3B).
■ Leave in place for at least 1 to 2 weeks depending on severity of fracture and
patient compliance.
TECH FIG 3 • A. Nasal speculum examination to
confirm symmetry and patency of nasal airway. B.
Thermoplastic external nasal splint in place.
PEARLS AND PITFALLS
Physical
examination
■ Identify whether a septal hematoma is present, and perform
hematoma evacuation immediately if needed, in order to prevent
development of a late deformity.
Timing of
surgery
■ Defer surgical intervention until edema has fully resolved
(generally 7–10 days) if the patient presents greater than 3–4
hours after injury in order to allow for optimal visualization of
deformity and reduction.
Anesthetic
administration
■ Allow adequate time for the vasoconstrictive effect of the topical
and injectable anesthetics to minimize bleeding with fracture
reduction.

Nasal bone
reduction
■ Measure distance from alar rim to medial canthus to prevent
advancement of the elevator too far into the nasal vault.
External splint
■ Leave in place at least 1–2 weeks or longer depending on severity
of fracture, patient activity level, and compliance.
Follow-up
■ Reassess patient after edema has fully resolved postreduction to
determine whether there is a persistent deformity that may require
open reduction and rhinoplasty.
POSTOPERATIVE CARE
■ Patients should maintain the external nasal splint in place for at least 1 to 2
weeks.
■ Apply ice for the first 24 hours and head elevation for the first 48 to 72 hours
to facilitate faster resolution of bruising and edema.
OUTCOMES
■ The goal of closed reduction is to minimize the nasal deformity in the least
invasive manner possible.
■ Although most patients experience significant improvement in nasal
symmetry, complete correction of the nasal deformity is unlikely in the closed
approach.
COMPLICATIONS
■ Persistent nasal deformity due to an undiagnosed septal hematoma or
unsatisfactorily corrected nasal deformity on closed reduction may result in the
need for open reduction, generally within 7 to 14 days.
■ Formal rhinoplasty may be performed, typically at 1 year, if necessary.
REFERENCES
1. Basheeth N, Donnelly M, David S, Munish S. Acute nasal fracture
management: a prospective study and literature review. Laryngoscope.
2015;125(12):2677-2684.
2. Mondin V, Rinaldo A, Ferlito A. Management of nasal bone fractures. Am J
Otolaryngol. 2005;26(3):181-185.
3. Higuera S, Lee EI, Cole P, et al. Nasal trauma and the deviated nose. Plast
Reconstr Surg. 2007;120(7 suppl 2):64S-75S.
4. Rohrich RJ, Adams WP Jr. Nasal fracture management: minimizing secondary
nasal deformities. Plast Reconstr Surg. 2000;106(2): 266-273.

60
CHAPTER
Open Treatment of Nasal
Fractures
Jeyhan Wood
DEFINITION
■ Open treatment of nasal fractures involves making an incision to provide
direct visualization of the fractures and achieve reduction or use of lacerations
that are already present.
■ The nose sits prominently on the central face and as such is the most
commonly fractured facial bone, compromising up to 50% of all facial
fractures1:
■ Nasal bone fractures can occur in isolation or be associated with other facial
fractures, such as those of the orbits, frontal bone, or midface.
ANATOMY
■ Nasal anatomy is complex, made up of the bony vault, cartilaginous vault
(paired upper lateral and lower lateral cartilages), bony septum, and
cartilaginous septum (FIG 1):
■ The nasal bones decrease in thickness caudally; therefore, most fractures
occur in the lower half of the bone.2
■ The “keystone area,” made up of the caudal aspect of the nasal bones, the
cranial aspect of the upper lateral cartilages, the perpendicular plate of the
ethmoid, and the cartilaginous septum, maintains support for the nasal dorsum
(FIG 1A).

FIG 1 • AP (A) and lateral (B) view of nasal anatomy.
ULC, upper laberal cartilage; LLC, lower lateral
cartilage.
■ The nose receives its rich blood supply from branches of both the external
and internal carotid arteries. Because of this, nasal fractures are almost
always associated with epistaxis, which most often stems from the
Kiesselbach plexus of the anteroinferior septum.2
■ Fractures can involve any of the above structures and in any combination,
leading to obvious external deformity and/or functional compromise with
difficulty breathing.
PATHOGENESIS
■ Nasal fractures are most often the result of motor vehicle accidents, falls,
altercations, and sports injuries.1,3
■ Nasal fractures are most often seen in males 15 to 30 years of age.
■ There is no single consensus for nasal fracture classification; however, nasal
fractures are often classified as lateral oblique vs frontal per the Stranc
classification.1,3 Higuera et al. have more recently proposed a clinical
classification system based on soft tissue vs bony injury, unilateral vs bilateral
involvement, and simple vs comminuted fractures.2
NATURAL HISTORY
■ Patients with untreated nasal fractures may experience an undesirable
appearance, chronic nasal obstruction, and chronic sinusitis. This is especially

true if a septal injury is not adequately addressed.2
■ With septal trauma, blood can accumulate between the mucosa and cartilage of
the septum (septal hematoma), which if left undrained can eventually lead to
fibrosis and resorption of the septal cartilage. This is demonstrated clinically as
a saddle nose deformity.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patient history:
■ Assess the mechanism of injury (including the vector and magnitude of the
force),2 timing of injury, and preoperative state regarding the ability to breath
out of each nostril.
■ Does the patient complain of a different appearance of the nose?
■ Does the patient have a history of previous nasal trauma or nasal surgery?
■ For significant maxillofacial trauma, the patient may need a complete trauma
workup and appropriate precautions taken (cervical spine immobilization).
■ Consider reviewing a photograph of the patient, such as a driver’s license, to
determine the patient’s premorbid appearance.2
■ Physical examination:
■ Perform an external exam looking for obvious nasal deformity (note caudal
and dorsal deformity),4 tenderness, epistaxis, edema, periorbital ecchymoses,
instability of nasal bones on palpation, step-offs, and crepitus:
• Depending on the timing of presentation, obvious deformity may be masked
by edema.
■ Note any lacerations or canthal disruption, which would indicate a naso-
orbital-ethmoid (NOE) fracture.
■ Perform an intranasal examination with a nasal speculum and adequate light
source, evaluating for septal hematoma, mucosal injury, septal deviation,
airway obstruction, and clear rhinorrhea, which could be a sign of a
cerebrospinal fluid (CSF) leak. Internal exam may be facilitated by using a
topical decongestant.
■ Assess for other facial fractures and consider nasolacrimal duct injury if the
medial orbit is injured.
■ Assess for uncontrollable hemorrhage. Nasal fractures may cause significant
bleeding, which usually stops with manual pressure. However, persistent
epistaxis may require nasal packing with Vaseline gauze or a Pope pack for
anterior bleeds or intranasal placement of a Foley catheter for posterior
bleeds:

• If bleeding is uncontrollable with these measures, consider interventional
radiology for embolization.
• If the patient is unstable without other obvious sources of hemorrhage,
consider ligation of the external carotid artery.
IMAGING
■ Imaging for isolated nasal fractures is often not indicated, as treatment is based
on physical exam findings.
■ Plain films miss cartilaginous injury and often cannot clearly identify bony
injury, with one study finding only 82% of nasal fractures successfully
identified on plain film5:
■ Waters view (occipitomental) (FIG 2A) and lateral nasal views (FIG 2B) are
the plain film examinations of choice, with demonstration of the orbits,
maxillae, zygomatic arches, and the nasal pyramid, sidewalls, and septum.
■ If nasal bones are found to be displaced on x-ray, then those patients are at
higher risk for long-term nasal deformity, and reduction is highly
recommended.4
■ The internasal suture, nasomaxillary suture, and even the coronal suture can
be mistaken for fractures on plain film.
■ Computed tomography (CT) with or without 3D reconstruction has largely
replaced all other modalities as far as clinical use (FIG 2C,D):
■ For maxillofacial CT scans, three views are ideal (axial, coronal, and sagittal)
for complete evaluation of the facial skeleton.
DIFFERENTIAL DIAGNOSIS
■ Nasal bone fracture/dislocation
■ Cartilage injury
■ Septal fracture/dislocation
■ Contusion
NONOPERATIVE MANAGEMENT
■ Indications:
■ Nondisplaced or minimally displaced fractures.
■ The patient desires no intervention.
■ Options for conservative treatment:
■ A splint for external protection
■ Elevation of the head of the bed to decrease edema

■ Ice application
■ Nasal saline irrigation and/or Afrin (oxymetazoline) for nasal congestion
■ Intranasal packing for epistaxis as needed
SURGICAL MANAGEMENT
■ Indications include severely displaced fractures and/or dislocations of the
nasal bones and/or cartilaginous vault (more than half the bridge width of the
nose), fracture/dislocation of the caudal septum, open septal fracture, persistent
deformity after attempted closed reduction,3 nasal fracture with substantial soft
tissue injury,2 or those with a delayed presentation (over 2 weeks since the
injury):
■ If presenting more than 2 weeks after the initial injury, consider delaying
open approach approximately 3 months to allow resolution of edema and
healing of fractures.
■ Some surgeons advocate open reduction as soon as the early edema has
resolved.2
■ It is important for patients to have realistic expectations of outcomes. Discuss
operative goals: fracture reduction and establishment of premorbid form and
function vs altering the appearance of the nose with a cosmetic rhinoplasty.
■ Discussion should also address the possible need for future nasal procedures.4
Preoperative Planning
■ Review patient history and imaging studies. Define patient goals and set
realistic expectations.

FIG 2 • A. Waters view of a patient with nasal trauma.
No definitive fracture was identified by radiological
exam; however, by clinical exam, the patient had
obvious nasal deformity with deviation of the dorsum to
the right. B. Lateral radiograph of the same patient
demonstrating no definite fracture. Nonspecific
irregularity of the tip of the nasal bone was noted. In a
different patient, axial (C) and coronal (D) CTs
demonstrate a displaced left nasal bone fracture.

■ Based on the nasal injury and surrounding injuries, plan the incisions that will
provide optimal exposure.
■ For significantly comminuted fractures with loss of dorsal support,
reconstruction beyond fracture reduction and fixation may be required (bone or
cartilage grafts, suturing techniques, osteotomies for incomplete fractures).
Positioning
■ The patient is positioned supine on the operating table with a shoulder roll
placed for gentle extension of the neck.
■ Cervical spine precautions are implemented as needed.
■ Arms are tucked.
■ The table is turned 90 to 180 degrees, based on surgeon preference.
Approach
■ Open treatment of nasal and septal fractures can be achieved through a variety
of incisions, including pre-existing adjacent lacerations, a coronal incision if
other facial fractures are present (such as frontal bone) that necessitate wide
exposure, an “open-sky”/glabellar approach, or an open rhinoplasty technique:
■ Advantages to the open approach include maximal surgical exposure
contributing to a more accurate anatomic diagnosis, the opportunity for
precise tissue handling, suturing, and grafting if needed.6
■ Wider exposure obtained with the open-sky approach is particularly valuable
in fractures of the cribriform plate with associated CSF rhinorrhea.7
■ Disadvantages of the open rhinoplasty approach include the need for a
transcolumellar incision, with wide dissection potentially leading to loss of
support, and prolonged nasal tip edema.6
■ The advantage to using a coronal incision is that the surgical scar is hidden
within the hairline.
T E C H N I Q U E S
■ General Fracture Management
■ For each approach, fracture management is similar.
■ Expose the fractures in the subperiosteal and subperichondrial planes

(TECH FIG 1A). Address septal fractures/dislocations first.
■ Septal fractures/dislocations may require a hemitransfixion incision for full
exposure:
■ If the septum requires excision of the fractured area, leave at least a 1-cm
dorsal and caudal L strut for support. Resection of the part of the vomer
and perpendicular plate of the ethmoid may be necessary in severe septal
fracture.3
■ The caudal septum may need to be reduced to the midline and reattached to
the anterior nasal spine using 5-0 polydioxanone as a figure-of-eight suture.
■ Reduce fractures using a Boies elevator intranasally and manual
manipulation (TECH FIG 1B). If the fractured segments of nasal bone
remain unstable, consider internal fixation using low-profile miniplates (0.3-
mm thickness) with 1.2 × 4-mm screws. For fractures with significant
displacement, larger plates (0.6-mm thickness) with 1.7 × 4-mm screws may
be used (TECH FIG 1C):
■ Use the intact frontal bone or maxilla as an anchor for plating severely
comminuted fractures.2
■ If using wires for internal fixation, 26- to 30-gauge wires are recommended
in order to prevent palpable sharp edges.2
■ Stabilization of the fracture fragments may also be accomplished using
thick absorbable sutures in figure-of-eight fashion.2
■ Do not strip small bony fragments of periosteum, as this may devascularize
the bony segments.

TECH FIG 1 • A. Fractures are exposed in the
subperiosteal and subperichondrial planes using a
periosteal elevator or freer elevator. B. Fractures are
reduced by a combination of internal manipulation with
a Boies elevator and external manual pressure. C.
Low-profile miniplates are used for internal fixation.
■ Approaches
■ For each approach, surgical preparation of the patient is similar.
■ Prep the face in standard sterile fashion using Betadine. Clean inside each
nostril with a Betadine-soaked cotton-tipped applicator.
■ Inject local anesthetic with epinephrine around the laceration, if present, into
the septum and circumferentially as a ring block around the nose.
■ Insert three Afrin-soaked pledgets into each nostril.
Use of Existing Lacerations
■ Open the existing laceration if it has been previously repaired (TECH FIG
1A).
■ Irrigate the wound with saline irrigation. Debride any nonviable tissue, and
remove any foreign bodies.
■ Address the fractures.
■ Close lacerations with monofilament absorbable suture in the deep dermis
and permanent monofilament suture in the skin (TECH FIG 1B).
■ Evaluate the nose for obvious residual deformity. Feel the dorsal nose with a
wet finger for any step-offs or irregularities, and address as needed.
■ Apply nasal splints.
Coronal Approach

Video p2-c060
■ Place the patient’s head on a Mayfield headrest.
■ Temporary tarsorrhaphies are placed to maintain corneal protection
throughout the procedure (TECH FIG 2A).
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