Medial canthal approach to open nasal fracture repair provides good functional and cosmetic results

This year's American Society of Ophthalmic Plastic and Reconstructive Surgery research award was given to William R. Nunnery, MD, FACS and Jeremiah P. Tao, MD, for their work on nasal fracture repair. In this study they describe an approach to nasal fracture repair that involves a small medial canthus incision, similar to an external dacryocystorhinostomy incision, which provides wide access to the relevant nasal and orbital anatomy and good functional and cosmetic results.

With the patient under general anesthesia, the midface was prepped and draped, bilateral corneal protectors were placed and approximately 2 ml of one percent xylocaine with 1:100,000 epinephrine combined with 0.5 percent marcaine. The bilateral nasal vaults were packed with neosynephrine-soaked pledgets. The medial canthus was marked with methylene blue and 1-cm vertical skin incision was fashioned with a number 15 blade, 1mm anterior to the anterior horn of the medial canthal tendon, bilaterally. Care was taken to keep the angle of the blade in the coronal plane to avoid damage to the medial canthal tendon and the lacrimal sac. Homeostasis of the angular vessels was achieved with electrocautery and dissection was continued down to periosteum, which was then incised. Dissection in the subperiosteal plane was continued anteriorly across the nasion and over the ascending process of the maxilla, exposing all nasal fractures.

Drs. Nunnery and Tao retrospectively reviewed results of this approach in 21 consecutive patients with nasal bony fractures.

In all 21 patients the entire fractured nasal bridge was visualized. The fractures were reduced and fixated to the normal anatomic position using a microfixation system (1.0 model). The scars were well hidden and tolerated by all patients. At follow-up of six to 18 months, one patient underwent scar revision for depressed scar. Another required hardware removal secondary to tenderness associated with the microplate. There were no complications such as saddle nose, canthal dystopia, canthal webbing or nasolacrimal outflow obstruction. No patient needed or desired revision rhinoplasty.