Absorbable plate as a perpendicular strut for acute saddle nose deformities.
ABSTRACT Nasal pyramid fractures accompanied by saddle nose deformities are not easily corrected by closed reduction. We used an absorbable plate as a perpendicular strut to support the collapsed "keystone area" and obtained good results.
Between September 2008 and June 2011, 18 patients who had nasal pyramid fractures with saddle nose deformities underwent surgery. Pre- and postoperative facial computed tomographic images and photographs were taken to estimate outcomes. The operative technique included the mucoperichondrial dissection of the nasal septum, insertion of an absorbable plate prepared to an appropriate length to support the "keystone area", and fixation of the absorbable plate strut to the cartilaginous septum.
Functional and esthetic outcomes were satisfactory in all patients. Eleven patients assessed the postoperative appearance of the external nose as 'markedly improved' and 7 patients as 'improved'. The 5 surgeons scored the results as a mean of 4.5 on a 5-point scale.
The use of an absorbable plate as a perpendicular strut requires no additional procedures because the plate is gradually absorbed. The mechanical strength provided by a buttress between the "keystone area" and the maxillary crest lasts for a long time before the strut is absorbed.
[show abstract] [hide abstract]
ABSTRACT: Current management techniques for acute nasal fractures result in a high incidence of posttraumatic nasal deformity (14 to 50 percent). Associated traumatic edema, preexisting nasal deformity, and occult septal injury account for most of these acute reduction failures. Working with a detailed patient history and a physical examination that included rigid nasal endoscopy, the authors formulated a clinical algorithm for acute nasal fracture management, the use of which can reduce the incidence of posttraumatic nasal deformity. In this article, the authors review the literature, then discuss their management techniques over the past 11 years in 110 cases with a 9 percent nasal revision rate. This low incidence of revision is attributed to complete nasal assessment (bony and septum), use of outpatient controlled general anesthesia, and primary septal reconstruction in cases with severe septal fracture dislocation.Plastic & Reconstructive Surgery 09/2000; 106(2):266-73. · 3.38 Impact Factor
Facial Plastic Surgery 11/1992; 8(4):220-3. · 0.96 Impact Factor
Article: Management of nasal fractures.[show abstract] [hide abstract]
ABSTRACT: Fracture of the nasal skeleton is a relatively common injury. Satisfactory treatment requires appropriate skills, diagnosis, and management. Some injuries require immediate attention; others are better treated in delayed fashion. Closed reduction provides satisfactory treatment in the majority of nasal fractures; however, open reduction often is a more appropriate choice. Injuries to the nasal septum should be recognized and given proper treatment.Otolaryngologic Clinics of North America 03/1991; 24(1):195-213. · 1.65 Impact Factor
Copyright © 2012 The Korean Society of Plastic and Reconstructive Surgeons
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Nasal pyramid fractures most commonly occur in the facial
skeleton and are usually treated by closed reduction. Although
nasal fractures are considered minor injuries, they have a high
incidence of posttraumatic nasal deformities (14% to 50%) .
In particular, traumatic collapse of the “keystone area” is likely to
cause saddle nose deformities, which are not easily corrected by
closed reduction or conventional septal surgery. In this study, we
employed absorbable plates to support the “keystone area” in an
attempt to improve the instability of a fractured septum under
the “keystone area” and to minimize saddle nose deformities. The
use of the absorbable plate as a strut led to optimal aesthetic and
Between September 2008 and June 2011, a total of 18 patients
who had posttraumatic saddle nose deformities that were not
corrected by closed reduction underwent a concomitant sup-
Absorbable Plate as a Perpendicular Strut for Acute
Saddle Nose Deformities
Jong Gyu Kim1, Seung Chul Rhee1, Pil Dong Cho1, Deok Jung Kim2, Soo Hyang Lee1
1Department of Plastic and Reconstructive Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang;
2Topclass Plastic Surgery, Seoul, Korea
Correspondence: Soo Hyang Lee
Department of Plastic and
Reconstructive Surgery, Ilsan Paik
Hospital, Inje University College of
Medicine, 170 Juhwa-ro, Ilsanseo-gu,
Goyang 411-706, Korea
Background Nasal pyramid fractures accompanied by saddle nose deformities are not
easily corrected by closed reduction. We used an absorbable plate as a perpendicular strut to
support the collapsed “keystone area” and obtained good results.
Methods Between September 2008 and June 2011, 18 patients who had nasal pyramid
fractures with saddle nose deformities underwent surgery. Pre- and postoperative facial
computed tomographic images and photographs were taken to estimate outcomes. The
operative technique included the mucoperichondrial dissection of the nasal septum, insertion
of an absorbable plate prepared to an appropriate length to support the “keystone area”, and
fixation of the absorbable plate strut to the cartilaginous septum.
Results Functional and esthetic outcomes were satisfactory in all patients. Eleven patients
assessed the postoperative appearance of the external nose as ‘markedly improved’ and 7
patients as ‘improved’. The 5 surgeons scored the results as a mean of 4.5 on a 5-point scale.
Conclusions The use of an absorbable plate as a perpendicular strut requires no additional
procedures because the plate is gradually absorbed. The mechanical strength provided by a
buttress between the “keystone area” and the maxillary crest lasts for a long time before the
strut is absorbed.
Keywords Absorbable implants / Nasal bone / Fractures, closed
Received: 10 Jan 2012 • Revised: 20 Feb 2012 • Accepted: 20 Feb 2012
pISSN: 2234-6163 • eISSN: 2234-6171 • http://dx.doi.org/10.5999/aps.2012.39.2.113 • Arch Plast Surg 2012;39:113-117
Presented at the 66th Congress of
the Korean Society of Plastic and
Reconstructive Surgeons, May 7-9,
No potential conflict of interest relevant
to this article was reported.
Kim JG et al. Absorbable plate for acute saddle nose
plementary procedure. The mean age of the patients was 34.2
years (range, 15 to 58 years). Seventeen patients were male and
one patient was female. Two of the male patients had a previous
history of submucous resection of the septal cartilage. One pa-
tient had a concurrent unilateral blowout fracture of the medial
orbital wall (Table 1).
Correction of nasal and septal fractures was attempted via the
closed approach. Because the reduced nasal bone and septum
were not maintained in their proper position and fell inwards,
we made a hemitransfixion incision followed by meticulous
submucoperichondrial dissection without tearing the septal mu-
cosa. After we identified the septal fracture site, a 2.0-mm-thick,
6-hole, 1.2×5.5×37 mm absorbable plate made of polylactic
acid copolymer (Biosorb, Linvatec, Tempere, Finland) was
prepared at an appropriate length to support the “keystone area”
(Fig. 1). Then, the depressed area was corrected and supported
by insertion of the absorbable plate strut between the nasal dor-
sum and the maxillary crest at the concave side of the fractured
septum (Figs. 2, 3). The absorbable plate strut was fixed to the
cartilaginous septum with 5-0 vicryl mattress sutures (Fig. 3).
Each nose was packed with Merocel and protected with a ther-
moplastic external nasal splint. The nasal packs were removed
3 days after surgery. Open reduction of blowout fracture was
performed first in the patient with the blowout fracture.
Facial computed tomographic scans were taken to assess pre-
operative and postoperative bony alignments (Fig. 4). The mean
follow-up duration was 8 months (range, 4 to 11 months). Each
patient assessed the postoperative appearance of the external
nose as ‘not improved’, ‘improved’ or ‘markedly improved’. Five
surgeons scored the results on a 5-point scale by photographic
Fig. 1. Trimming of an absorbable plate
(A) A 2.0-mm-thick, 6-hole, 1.2×5.5×37 mm bioabsorbable plate made of polylactic acid copolymer. (B) One hole was trimmed to fit the distance
between the “keystone area” and the maxillary crest.
Table 1. Information of patients
(NI, I, MI)
Slip down/septoplasty by SMR
Assault injury/concomitant with BOF
Sports injury/septoplasty by SMR
NI, not improved; I, improved; MI, markedly improved. SMR, submucosal resection; BOF, blowout fracture.
Vol. 39 / No. 2 / March 2012
Six patients had significant deformities of the nasal septum. Two
patients had severe saddle nose deformities as compared to nasal
fractures because they had undergone a submucous resection
Fig. 2. Schematic and CT images of an absorbable plate strut
(A) Schematic view of an absorbable plate strut
inserted to support the unstable nasal pyramid
after reduction. (B) Postoperative CT scan
demonstrating that the plate is positioned
perpendicular to the nasal dorsum for stronger
bearing force against the “keystone area”.
Fig. 4. Facial bone CT images
(A) Preoperative facial bone CT after trauma. (B) CT scan taken 7 months after surgery.
Fig. 3. Intraoperative endoscopic views of the septal cartilage
A B C
(A) A black arrow indicates the septal fracture site. A fractured and displaced septal cartilage is seen after wide mucoperichondrial dissection. (B) A black
arrow indicates the septal fracture site. The injured cartilaginous septum was manually reduced. (C) An absorbable plate strut is placed beside the reduced
Kim JG et al. Absorbable plate for acute saddle nose
The mean operation time was 39 minutes. Functional and
esthetic outcomes were satisfactory in all patients. Eleven pa-
tients assessed the postoperative appearance of the external
nose as ‘markedly improved’ and 7 patients as ‘improved’. The
5 surgeons scored the results as a mean of 4.5 points (range, 3
to 5 points) (Table 1). Surgical correction of traumatic saddle
nose deformity using an absorbable plate strut resulted in good
nasal projection and symmetry as well as continuous stability
of the “keystone area” without serious complications during the
follow-up period (Figs. 5, 6).
Bony pyramid fractures with minor septal injuries are generally
treated with closed reduction, bilateral intranasal placement of
silastic splints, and nasal packing. This treatment method is suffi-
cient for satisfactory outcomes in the majority of cases. However,
if unstable nasal fractures with significant septal injuries occur,
the aforementioned method cannot ensure accurate correction.
Even though temporary correction of immediate deformities is
feasible through closed reduction, it is difficult to maintain the
immediate postoperative state until the fractured nasal pyramid
is completely healed. In such cases, more invasive methods are
required to obtain desirable results [2,3].
There have been many studies of the appropriate support for
unstable fracture of the nasal bone and septum. Yabe and Mu-
raoka  fixed the septal cartilage to the frontal process of the
maxillary bone with a K-wire. However, they pointed out that
the method is not indicated in patients with an unstable frontal
process. Autologous tissues, such as conchal and costal carti-
lages, can be used to correct traumatic saddle nose deformities
. However, this technique may lead to donor site morbidities
and take much time to perform. Moreover, it is not easy to har-
Fig. 5. Pre- and postoperative photographs
(A) Preoperative lateral view of a patient with definite saddle nose
deformity after trauma. (B) Photograph taken 7 months after surgery
shows that the contour of the external nose is well maintained.
Fig. 7. Pre- and postoperative facial bone CT images
(A) Preoperative CT scan demonstrating collapse of the “keystone area.” (B) Immediate postoperative view of an absorbable plate supporting the
fractured nasal dorsum.
Fig. 6. Intraoperative views
(A) Preoperative photograph shows a depressed nasal dorsum that is
not successfully corrected by closed reduction. (B) Photograph taken
immediately after operation shows that the reduced nasal dorsum is
well maintained by supporting the “keystone area”.
Vol. 39 / No. 2 / March 2012
vest sufficient quantities of straight cartilage. Many studies have
proposed various methods of using synthetic materials, such as
molded Surgicel , absorbable bone pin (Neofix pin, Gunze,
Osaka, Japan) , polydioxanone foil (PDS, Ethicon, Nor-
derstedt, Germany) , and absorbable polymer membrane
(PolyMax, Synthes, Oberdorf, Switzerland) , which are bio-
mechanically similar to the septal cartilage and require about 7
months to be absorbed.
We attempted to make a direct strut for the “keystone area”
using an absorbable plate in order to support the unstable nasal
pyramid after reduction. The present study demonstrated the
reliability and safety of the bioabsorbable plate. It is thought that
the absorbable plate had strength enough to support the unstable
“keystone area” while this area healed completely.
Our procedure was restricted to patients with immediate
saddle nose deformities. The patients were left with a relatively
intact mucoperichondrium, especially after dissection, so as not
to expose the implanted absorbable plates. Meticulous dissection
of the mucoperichondrium was performed on both sides of the
septum. Since the commercially available 6-hole absorbable plate
was too long, we cut one hole off the plate to fit the distance from
the “keystone area” to the maxillary crest.
For stronger bearing force against the bony pyramid, the strut
was inserted perpendicular to the nasal dorsum (Fig. 7). The au-
thors present cases in which saddle nose deformities resulted due
to trauma of the “keystone area” and place emphasis on the allo-
cation of the strut between the “keystone area” and the maxillary
crest. However, placement of the strut could be modified to pro-
vide anatomic support for instability in any part of the nasal pyra-
mid. The well prepared strut was stable between the nasal bone
and the maxilla, but vicryl sutures were applied to completely fix
the plate to the septum. This step straightens the deformed carti-
Immediate saddle nose deformities caused by concurrent
traumas frequently occur in patients who have a history of sub-
mucous resection. Our technique can bring a solution to this
problem. The absorbable plate as an artificial strut is an excel-
lent substitute for autologous tissue and can provide enough
strength to maintain the proper shape of the nasal dorsum dur-
ing the healing period.
In conclusion, to correct immediate traumatic saddle nose
deformities, an absorbable plate strut is a good choice for suc-
cessful outcomes. There is no need to remove the plates, which
are gradually absorbed within 2 to 3 years . It is important
that this artificial strut be in contact with the “keystone area” and
maxillary crest. The mechanical strength provided by a buttress
lasts for a long time before the strut is absorbed. However, if the
septal mucosa is not intact, our procedure is not indicated. Two
cases were excluded from this series for this reason. It should
also be noted that because the plate is expensive, each patient’s
economic status should be considered when surgeons plan to
use our surgical method.
1. Rohrich RJ, Adams WP Jr. Nasal fracture management:
minimizing secondary nasal deformities. Plast Reconstr Surg
2. Verwoerd CD. Present day treatment of nasal fractures: closed
versus open reduction. Facial Plast Surg 1992;8:220-3.
3. Renner GJ. Management of nasal fractures. Otolaryngol
Clin North Am 1991;24:195-213.
4. Yabe T, Muraoka M. Treatment of saddle type nasal fracture
using Kirschner wire fixation of nasal septum. Ann Plast
5. Bilen BT, Kilinc H. Reconstruction of saddle nose deformi-
ty with three-dimensional costal cartilage graft. J Craniofac
6. Ducic Y, Hilger PA. A reliable absorbable intranasal bolster
for proper maintenance of fractured nasal bone position.
7. Chin T, Sakata Y, Amenomori S, et al. Use of a bioabasorb-
able bone pin fixation for nasal fractures. J Nihon Med Sch
8. Boenisch M, Nolst Trenite GJ. Reconstructive septal sur-
gery. Facial Plast Surg 2006;22:249-54.
9. Watzinger F, Wutzl A, Wanschitz F, et al. Biodegradable poly-
mer membrane used as septal splint. Int J Oral Maxillofac
10. Lee HB, Oh JS, Kim SG, et al. Comparison of titanium and
biodegradable miniplates for fixation of mandibular fractures.
J Oral Maxillofac Surg 2010;68:2065-9.