Broken Nose Surgery Procedure
Broken nose surgery is also called either an open or closed reduction of a nasal fracture. Reducing a fracture is a general medical term to describe replacing any broken bone to it’s original position. A closed reduction doesn’t use a skin or mucosal incision while open reduction does. Injuries to the nose are very common. Most people have at some point bumped their nose. In the majority of times the injury is minor and nothing needs to be done. There may be bruising and swelling, possibly even a nose bleed initially, but it all resolves and no permanent changes or issues remain.
In a small minor of injuries the trauma is more substantial and medical intervention is necessary. For example the injury can involve a laceration of the overlying skin. This requires sutures, and possibly a scar revision several months to a year or so later in a very small minority of times. Factors which increase the possibilities of a scar revision include; the direction of the scar, infection, a burst fracturing of the skin, and addition crush injury to the underlying soft tissues.
The skin isn’t damaged in the majority of cases needing broken nose surgery; rather the cartilages and bones of the nose are broken. Some people are surprised that cartilage can be fractured just like bone. Indeed it takes less force to crack the nose septal cartilage. Furthermore the point of injury is lower, near the tip rather than higher near the eyes. When the cartilage is broken nothing abnormal ever shows up on x-rays. The diagnosis is made by examining the nose and not imaging it.
Just a quick comment in general on x-rays for nasal fractures and broken nose surgery. People, including emergency doctors, often request nasal x-rays. However these are seldom of value. When the x-ray shows conclusive evidence of a bony nasal fracture, it’s already evident on just examining the nose. When the examination is questionable and it’s unclear if there is a broken nasal bone, then the x-rays are also inconclusive. All the more true when it’s a matter of injury to the cartilage.
There are two reasons to treat a nasal fracture.
One reason to perform broken nose surgery is aesthetic and the other is functional. Aesthetically, if the nose looks twisted or bent, most people want it straight again. Functionally, if now there’s difficulty breathing, again the majority want the breathing restored.
People often talk about how the coach came onto the playing field and right there and then performed broken nose surgery by snapped the nose back into place. This does happen, but usually it could have been done with a lot less pain. However it highlights the valve of early intervention. With nasal fractures, the earlier the better. Swelling takes hours to occur. So there is a window of several hours when a simple adjustment can correct the situation. After that, surgeons generally wait till a week or so afterwards, when the swelling is coming down, before trying to reduce the fracture. Here again there is a window of opportunity. The nasal bones will fuse together in about 2 weeks. With children this period is shorter, sometimes a matter of a week. When the bones are getting ‘sticky’ it then takes a greater degree of pressure to move them, and when they have fused, the force needed is about the same as to fracture it in the first place. Therefore once this window closes, surgeons recommend waiting several months before attempting a repair. It’s uncommon for a surgeon to see a fractured nose within hours of the trauma so broken nose surgery usually happens the second week.
Broken nose surgery techniques varie between surgeons. Some prefer putting the patient asleep, as this allows for as much force as needed to be used. Others like to use local anaesthesia, by temporarily packing the inside of the nose and injecting local to the surrounding skin. I find neither of these methods is needed unless the fracture is extreme, and this only occurs in a very small minority. Unless the patient is particularly nervous, quite young, or suffers an anxiety disorder; there’s no need for any form of anaesthesia. This will sound unusually cruel, but in fact if the fracture is reduced carefully and most importantly very slowly, the degree of pain is surprisingly minimal. It’s unclear why but nasal bone fractures are not particularly painful generally speaking. This is clearly the case as the pressure applied to straighten a crooked nose would not be tolerated if performed on say a broken arm. That’s not to say broken arms aren’t corrected in the emergency by pulling on them, rather in those situations local aesthetic is mandatory.
The best way to perform broken nose surgery and to place the crooked nasal bones back into a straight position is to gently start to push against the side of the nose. By very, very slowly increasing the pressure over a minute (which feels like a very long time) generally the nose slowly starts to move to the midline. Sometimes there’s a sudden give, and the bones quickly drop into place. Other times the bones simply continue to shift till they come to rest in the middle. If the 2 week point is near, then sometimes the bones just won’t move. When this unfortunately happens, the best next step is to wait till most of the healing has happened and then proceed to rebreaking the bones with the patient asleep.
Another change which has occurred to broken nose surgery over the years is to abandon using instruments. In the past there were several surgical instruments some which were inserted inside the nose that increased the force against the nose compared to just using your hands. These are unnecessary and only increase the pain and discomfort experienced by the patient.
Some types of bony fractures are more likely to fail at broken nose surgery. Fractures where the nasal bone has broken in a way that the piece sinks into the nose and the side wall becomes depressed are known to be much less likely to be restored to normal. It’s a problem of remaining in place rather than being successfully repositioned. The bone isn’t able to be secured and often slowly falls back to the depressed position it occupied before the reduction. This still occurs even when packing is wedged into the nose to create an interior foundation the bony fragment can rest upon.
So what is the success rate of broken nose surgery? About 75% in my experience, which translates into about one in four will require an operation under aesthetic several months later. A nasal fracture is like a vase. Once it’s broken, although you can put all the pieces back together, it’s never going to be the same again. It’s the same with surgery (which can be looked at as a form of trauma, just controlled). A fractured nose is like Humpty Dumpty. “All the king’s horses and all the king’s men Couldn’t put Humpty together again”. It’s the same idea as Bob Dylan’s “you can never go back”.