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.

Full text

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Copyright © 2012 The Korean Society of Plastic and Reconstructive Surgeons
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INTRODUCTION
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%) [1].
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
functional results.
METHODS
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
Tel: +82-31-910-7320
Fax: +82-31-910-7814
E-mail: shyanglee@naver.com
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,
2009.
No potential conflict of interest relevant
to this article was reported.
Original Article

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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
assessment.
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.
AB
Table 1. Information of patients
CaseAge/SexTrauma
Follow-up
(mo)
Complication
Patient’s
assessment
(NI, I, MI)
MI
MI
I
MI
MI
MI
MI
I
I
MI
I
MI
MI
I
MI
I
I
MI
Doctor’s
assessment
(0-5)
5
5
4
4
5
5
5
4
5
5
4
4
5
3
5
5
4
5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
20/M
33/M
16/M
22/M
54/M
33/M
21/F
52/M
27/M
25/M
58/M
15/M
58/M
39/M
42/M
37/M
42/M
22/M
Sports injury11
10
10
9
9
8
8
5
4
10
9
9
7
9
8
7
6
5
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
Slip down/septoplasty by SMR
Motorcycle crash
Assault injury/concomitant with BOF
Slip down
Slip down
Fall down
Vehicle crash
Sports injury/septoplasty by SMR
Assault injury
Vehicle crash
Sports injury
Sports injury
Assault injury
Assault injury
Slip down
Vehicle crash
Assault injury
NI, not improved; I, improved; MI, markedly improved. SMR, submucosal resection; BOF, blowout fracture.

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115
RESULTS
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
earlier.
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”.
AB
Fig. 4. Facial bone CT images
(A) Preoperative facial bone CT after trauma. (B) CT scan taken 7 months after surgery.
AB
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
septal cartilage.

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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).
DISCUSSION
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 [4] 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
[5]. 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.
AB
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.
AB
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”.
AB

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117
vest sufficient quantities of straight cartilage. Many studies have
proposed various methods of using synthetic materials, such as
molded Surgicel [6], absorbable bone pin (Neofix pin, Gunze,
Osaka, Japan) [7], polydioxanone foil (PDS, Ethicon, Nor-
derstedt, Germany) [8], and absorbable polymer membrane
(PolyMax, Synthes, Oberdorf, Switzerland) [9], 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-
lage septum.
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 [10]. 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.
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