CME

Aesthetic Management of the Nasal

Component of Naso-Orbital Ethmoid Fractures
Jason K. Potter, M.D.,
D.D.S.
Arshad R. Muzaffar, M.D.
Edward Ellis, D.D.S.
Rod J. Rohrich, M.D.
Fred L. Hackney, M.D.,
D.D.S.
Dallas, Texas; and Seattle, Wash.

Learning Objectives: After studying this article, the participant should be able
to: 1. Discuss the critical anatomic structures of the nose that are affected in
naso-orbital ethmoid fractures. 2. Discuss the advantages of early, complete nasal
reconstruction of these fractures. 3. Apply a clinical algorithm to such nasal
reconstruction. 4. List the techniques used in aesthetic reconstruction of the
nose in naso-orbital ethmoid fractures.
Background: Fractures of the naso-orbital ethmoid complex pose challenging
management issues. Although basic treatment principles have been well described, the aesthetic management of the nasal component has not been adequately addressed in the literature.
Methods: When secondary nasal deformities occur, they are difficult to correct.
Optimal primary correction of the nasal deformity is accomplished using the
following four principles: (1) rigid fixation of the nasal pyramid and restoration
of nasal height and length; (2) restoration of tip projection; (3) septal reduction/reconstruction; and (4) lateral nasal wall augmentation.
Results: Successful management of naso-orbital ethmoid fractures is a complex
and challenging task. Both the bony and soft-tissue components must be addressed and the extent of the injury must be adequately diagnosed to avoid
omission of critical steps in the reconstruction. Inadequate treatment of nasoorbital ethmoid fractures can produce a severe cosmetic deformity that is very
difficult to correct secondarily.
Conclusion: The authors discuss the nasal component of naso-orbital ethmoid
complex injuries and detail the key principles in their algorithm for aesthetic
nasal reconstruction. (Plast. Reconstr. Surg. 117: 10e, 2006.)

aso-orbital ethmoid fractures are challenging injuries. The complex and delicate anatomy of the region, concomitant
facial injuries, and the recognized difficulty in
correcting late deformities contribute to the
problem. Late deformities include a shortened
palpebral fissure, telecanthus, enophthalmos,
ocular dystopia, and a shortened nose with a
saddle deformity.1 4
Significant advances have been made in the
management of these injuries, decreasing the
incidence of secondary deformities. The
anatomy,19 pertinent physical findings,1,3 8,10 14
and commonly associated fractures15,16 have previously been described. Computed tomography
From the University of Texas Southwestern Medical Center
and Seattle Childrens Hospital and Regional Medical Center.
Received for publication November 12, 2004; revised April
12, 2005.
Copyright 2005 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000195081.39771.57

10e

provides for an accurate preoperative diagnosis

and is capable of clearly delineating the extent
of the injury (Fig. 1). The combination of physical examination and images obtained through
computed tomography scans allows for the establishment of an operative treatment plan. Optimal results are achieved through open reduction, wide exposure of fractures, rigid internal
fixation,5,6,9,12,14,1720 and correction of orbital volume with immediate bone grafts.21,22 Existing
classification systems are based on the status of
the medial canthal ligament and the extent of
the fracture pattern.23,24 For instance, the classification of Markowitz et al.24 (Fig. 2) focuses on
the bony fragment attached to the medial canthal tendon-the central fragment-and offers
treatment guidelines based on the status of this
fragment.
Although many authors have contributed to
our understanding and the treatment of nasoorbital ethmoid fractures, there is a paucity of
literature on the aesthetic management of the
nasal component of these injuries. Optimal man-

www.plasreconsurg.org

Volume 117, Number 1 Naso-Orbital Ethmoid Fractures

Fig. 1. Computed tomography scans of severe comminution of the naso-orbital ethmoid complex. Note the significant posterior
displacement of the dorsal nasal component into the ethmoids.

agement of the nasal component of naso-orbital

ethmoid injuries is facilitated by adherence to an
algorithm based on four key reconstructive principles:
1. Rigid fixation of the nasal pyramid and restoration of nasal height and length
2. Restoration of tip projection
3. Septal reduction/reconstruction
4. Lateral nasal wall augmentation

We discuss our algorithm for the aesthetic

management of the nasal injury in naso-orbital
ethmoid fractures, and describe the execution of
these key principles.

ANATOMIC CONSIDERATIONS
The nose is composed of three vaults: lower,
middle, and upper.2529 The nasal septum serves a
different structural function in each vault. In the

11e

Plastic and Reconstructive Surgery January 2006

Fig. 2. Classification of naso-orbital ethmoid fractures. (Reprinted from Markowitz, B. L., Manson, P. N., Sargent, L., et al. Management
of the medial canthal tendon in nasoethmoid orbital fractures: The importance of the central fragment in classification and treatment.
Plast. Reconstr. Surg. 87: 843, 1991.)

lower vault, the septum lends support to the lower

lateral cartilages and nasal tip. In the middle vault,
the septum is contiguous with and supports the
upper lateral cartilages and dorsum. The septum
in the upper vault lies beneath the nasal bones,
providing little dorsal support.28 Unlike in the
lower and middle vaults, the main support in the
upper vault is bony.

Severe naso-orbital ethmoid fractures compromise dorsal support to the nose through loss of
both cartilaginous and bony support. There is extensive comminution of the perpendicular plate
of the ethmoid, vomerine bone, maxillary crest,
and nasomaxillary buttress (Fig. 1). This is accompanied by the comminution or severe displacement of the cartilaginous septum. The distal nose

Fig. 3. Dorsal nasal collapse associated with naso-orbital ethmoid fracture. Edema
present in the acute setting may camouflage the extent of the true deformity. Palpation
of the naso-orbital ethmoid complex is important in the clinical assessment of the patient.

12e

Volume 117, Number 1 Naso-Orbital Ethmoid Fractures

telescopes into the pyriform aperture with pressure applied to the tip23 (Fig. 3). The upper lateral
cartilages may be weakened by crush injury. In
addition, fractures of the pyriform aperture diminish support to the upper lateral cartilages. This
diminution in turn causes lateral displacement of
the cartilages and additional loss of dorsal nasal
support.25 Separation of the upper lateral cartilages from the lower lateral cartilages and from the
septum decreases tip support and projection and
may narrow the internal nasal valve. Finally, dis-

placement of the entire nasal pyramid posteriorly

and inferiorly produces a significant loss of nasal
projection and height.

MANAGEMENT ALGORITHM
Nasal fractures secondary to low-velocity
trauma can generally be managed with relatively
simple techniques29 (Fig. 4). However, higher-velocity frontal trauma associated with naso-orbital
ethmoid fractures results in an increasing degree
of comminution and loss of nasal support. The

Fig. 4. Nasal trauma algorithm. CT, computed tomography.

13e

Plastic and Reconstructive Surgery January 2006

importance of accurate reduction of acute nasal
fractures to minimize secondary nasal deformity
has been emphasized by Rohrich and Adams.30 In
their fracture classification, the nasal fracture associated with naso-orbital ethmoid injuries is the
most severe (type V), and early open reduction
with rigid internal fixation is recommended.30 To
optimally treat the nasal component of these complex injuries, four key principles of nasal reconstruction should be observed: (1) rigid fixation of
the nasal pyramid and restoration of nasal height
and length; (2) restoration of tip projection; (3)
septal reduction and reconstruction; and (4) lateral nasal wall augmentation.
Restoration of the Nasal Pyramid:
Reconstruction of Nasal Height and Length
Several authors have recognized the difficulty
in restoring dorsal nasal support.15,19,2325 Cruse et
al.15 recognized that if severe comminution of the
bony septum resulted in a depression of the nasal
dorsum, correction with primary fracture reduction was often incomplete. Stranc31 noted that restoration of the nasal airway and nasal profile during primary surgery is difficult in the presence of
severe septal damage. The importance of accurate
septal reduction and reconstruction in restoring
the nasal airway and profile has also been emphasized by Rohrich and Adams.30 The reason for
poor dorsal nasal support after primary fracture
reduction relates to the degree of comminution.
Ellis25 noted that comminution of the nasal bones
and frontal process of the maxillae makes reduction difficult and diminishes support for the soft
tissues, which then contract during wound healing. Comminution of the cartilaginous vaults further weakens the dorsal nasal support. Dorsal nasal augmentation restores form and support for
these weakened structures25 and limits the degree
of soft-tissue contracture. The use of primary cantilevered dorsal nasal bone grafts in restoring the
dorsal profile is well established.2325 Markowitz et
al.24 used dorsal nasal bone grafts in 42 percent of
naso-orbital ethmoid fractures.
Restoration of nasal length should be considered part of dorsal augmentation with dorsal nasal
grafts. Restoring nasal length, combined with
maintaining tip projection, as discussed below,
helps produce an aesthetically ideal result in the
long term.
Primary dorsal nasal grafts can also camouflage residual contour irregularities, especially at
the junction of the nasal bones and upper lateral
cartilages.25 The rapid shrinkage of the soft-tissue

14e

envelope makes delayed reconstruction of contour irregularities difficult and the result less aesthetically pleasing.
Dorsal nasal projection affects the perceived
intercanthal width.25 As the dorsal nasal projection increases, the intercanthal distance appears
to decrease. Thus, overprojection of the dorsum
when bone grafting is aesthetically more acceptable than underprojection.
The technique for dorsal nasal augmentation
depends on the degree of comminution of the
nasal bones. If the nasal bones are fractured at the
nasofrontal suture and are not significantly comminuted, then stabilization with rigid internal fixation is indicated. This stabilization is usually accomplished with miniplate fixation. Commonly,
the upper bony vault is severely comminuted, necessitating the use of a cantilevered bone graft
from stable bone in the nasofrontal area (Fig. 5)
The graft can be stabilized with a lag screw or a
miniplate. Gruss23 prefers a costochondral graft
with placement of the distal cartilaginous portion
of the graft in the nasal tip. Others prefer calvarial
bone grafts, which are primarily cortical bone, for
easier shaping without fracture.25 Calvarial bone
grafts are easily harvested from the relatively flat
posterior parietal region (Fig. 6). When utilizing
a costochondral graft, we prefer to harvest the
ninth rib, primarily because of the ease of harvest
and because this part of the ninth rib is straight.
The graft is carved into a keel shape, as described
by Sullivan et al.,32 and should be long enough to
reach the nasal tip and thereby restore nasal
length. The graft is inserted through the coronal
incision after dissection of a pocket on the nasal
dorsum. If insertion is difficult through the coronal incision, additional access can be gained
through an endonasal incision (Fig. 7).
Restoring Nasal Tip Projection
Often the lower cartilaginous vault is also
weakened, resulting in decreased tip projection
and support. This condition requires the placement of a columellar strut for correction.24,25 Columellar struts were used in 20 percent of cases
reported by Markowitz et al.24 When significant
loss of projection is present, we prefer to use rib
cartilage grafts for the columellar strut, because
they provide for a maximum increase in tip projection while maintaining the mobility of the tip;
the graft is secured to the nasal spine. The strut is
placed through an endonasal incision into a
pocket between the medial crura of the lower lateral cartilages extending to the anterior nasal

Volume 117, Number 1 Naso-Orbital Ethmoid Fractures

spine, and is stabilized to the caudal end of the
dorsal nasal graft with a small-gauge wire or suture.
The medial crura are sutured to the columellar
strut with a 5-0 polydioxanone suture to help
maintain tip projection. If additional tip projection is needed, a graduated approach is used, utilizing tip-suturing techniques and tip cartilage
grafts through an open approach.3336 Tip modification should be performed to resist the deforming forces of wound contracture and obtain the

Fig. 6. The flat parietal region provides relatively straight grafts

of adequate length for dorsal nasal reconstruction.

Fig. 7. Additional exposure for accurate graft positioning is provided with endonasal incisions.

optimal aesthetic result. Once the soft-tissue envelope has contracted, restoration of tip projection and contour in a delayed fashion is extremely
difficult.

Fig. 5. Dorsal nasal bone graft fashioned for reconstruction of

dorsal nasal support and nasal length. The graft may be fixated to
stable bone at the nasofrontal junction with a miniplate.

Reduction/Reconstruction of the Nasal Septum

The cartilaginous portion of the nasal septum
is often overlooked in the management of nasoorbital ethmoid fractures, especially type III nasal
fractures with frontal impact.30 Reconstruction of
the severely comminuted nasal septum to restore
dorsal nasal support is difficult. Because dorsal
nasal support is usually provided with an immediate graft, as outlined above, re-establishing dorsal support is a secondary indication for reducing
the septal fracture. Management of the septum
should aim to prevent posttraumatic airway ob-

15e

Plastic and Reconstructive Surgery January 2006

struction by reducing the septum to a midline
position.25 The severely displaced septum should
be reattached to the anterior nasal spine with a 5-0
polydioxanone figure-of-8 suture24,30,37 (Fig. 8).
Clear nylon suture is our preference to stabilize
the septum to the anatomically contoured dorsal
nasal graft.
Regardless of the technique, it is important to
provide nasal septal fixation and stabilization both
caudally and dorsally (Figs. 9 and 10) Simple intranasal manipulation with Asch forceps to reduce
the septum to midline and maintenance of position with intranasal splints may be adequate for
less severe cases.25,30,37 Submucous resection of the
cartilaginous septum to facilitate centralization of
the remaining septum is useful in simple nasal
fractures,30,31 but this technique may further compromise dorsal nasal support and should not be
performed in naso-orbital ethmoid fractures.

Fig. 9. Reduction of nasal septum and stabilization with Doyle

splints. (Reprinted from Rohrich, R. J., and Adams, Jr., W. P. Nasal
fracture management: Minimizing secondary nasal deformity.
Plast. Reconstr. Surg. 106: 271, 2000.)

Augmentation of the Lateral Nasal Dorsum

Another, often overlooked, facet in the management of naso-orbital ethmoid fractures is the
lateral nasal wall. While placement of a dorsal
onlay graft and restoration of tip projection create
a pleasing profile, the long-term aesthetic result
may be disappointing if the nasal bones and pyriform aperture are severely comminuted with secondarily decreased support for the upper lateral
cartilages. With healing and contracture of the
soft-tissue envelope, the skin develops a tethered
appearance over the lateral aspect of the dorsal
onlay graft, and a hollowness of the lateral nasal
dorsum results. This can be prevented by placing
onlay grafts primarily along the dorsal nasal side
wall to support the soft tissue. For this purpose, we

Fig. 10. Reduction of nasal septum and stabilization with Doyle

splints. (Reprinted from Rohrich, R. J., and Adams, Jr., W. P. Nasal
fracture management: Minimizing secondary nasal deformity.
Plast. Reconstr. Surg. 106: 271, 2000.)

prefer to use the residual shavings from the sculpting of the dorsal costochondral graft. If a rib graft
is not harvested, grafts of pericranium may be used
in a similar fashion (Fig. 11).

SUMMARY
Fig. 8. Midline fixation of dislocated septum using figure-ofeight suture. (Reprinted from Rohrich, R. J., and Adams, Jr., W. P.
Nasal fracture management: Minimizing secondary nasal deformity. Plast. Reconstr. Surg. 106: 271, 2000.)

16e

Successful management of naso-orbital ethmoid fractures is a complex and challenging task.

Both the bony and soft-tissue components must be
addressed and the extent of the injury must be

Volume 117, Number 1 Naso-Orbital Ethmoid Fractures

mity in naso-orbital ethmoid fractures requires a
thorough understanding of the structural pathology and the application of a management algorithm that includes these four key principles of
nasal reconstruction: rigid fixation of the nasal
pyramid and restoration of nasal height and
length; restoration of tip projection; septal reduction and reconstruction; and lateral nasal wall augmentation.
Rod J. Rohrich, M.D.
Department of Plastic and Reconstructive Surgery
The University of Texas Southwestern Medical Center
5323 Harry Hines Boulevard, E7.210
Dallas, Texas 75390-9132
rod.rohrich@utsouthwestern.edu

REFERENCES

Fig. 11. Pericranium harvested from the coronal approach is

used to provide lateral nasal contour grafts. Grafts are inset along
the lateral nasal wall and secured with resorbable suture. Improved access is provided with endonasal incisions.

adequately diagnosed to avoid the omission of

critical steps in the reconstruction. Inadequate
treatment of naso-orbital ethmoid fractures can
produce a severe cosmetic deformity that is very
difficult to correct secondarily. Previous recommendations have stressed the reduction of the
medial canthus and primary bone grafting and
have underemphasized the importance of nasal
reconstruction necessary for an optimal aesthetic
result. Optimal management of the nasal defor-

1. Blair, V. P., Brown, J. B., and Hamm, W. G. Surgery of the inner

canthus and related structures. Am. J. Ophthalmol. 15: 498, 1932.
2. Converse, J. A., and Smith, B. Canthoplasty and dacryocystorhinostomy in malunited fractures of the medial wall of the orbit.
Am. J. Ophthalmol. 35: 1103, 1952.
3. Converse, J. M., and Smith, B. Naso-orbital fractures. Trans. Am.
Acad. Ophthalmol. Otolaryngol. 67: 622, 1963.
4. Converse, J. M., and Smith, B. Naso-orbital fractures and traumatic deformities of the medial canthus. Plast. Reconstr. Surg. 38:
147, 1966.
5. Dingman, R. O., Grabb, W. C., and Oneal, R. A. Management of
injuries of the naso-orbital complex. Arch. Surg. 98: 566, 1969.
6. Duvall, A. J., and Banovetz, J. D. Nasoethmoidal fractures. Otolaryngol. Clin. North Am. 9: 507, 1976.
7. Gross, C. W., Teague, P. F., and Nakamura, T. Reconstruction
following severe nasofrontal injuries. Otolaryngol. Clin. North Am.
5: 653, 1972.
8. Smith, B., and Nightingale, J. D. Fractures of the orbit: Blowout
and naso-orbital fractures. Int. Ophthalmol. Clin. 18: 137,
1978.
9. Stranc, M. F. Treatment of naso-ethmoidal injuries with special
reference to canthal problems. In Transactions of the VIth International Congress of Plastic Surgery. Amsterdam: Excerpta Medica,
1975. Pp. 367369.
10. McIndoe, A. H. Diagnosis and treatment of injuries of the middle
third of the face. Br. Dent. J. 71: 235, 1941.
11. Mathog, R. H., and Bauer, W. Posttraumatic pseudohypertelorism (telecanthus). Arch. Otolaryngol. 105: 81, 1979.
12. Gruss, J. S. Fronto-naso-orbital trauma. Clin. Plast. Surg. 9: 577,
1982.
13. Dawson, R. L. G., and Fordyce, G. L. Complex fractures of the
middle third of the face and their early treatment. Br. J. Surg. 41:
254, 1953.
14. McCoy, F. J. Fractures of the naso-orbital ethmoid complex. In
N. D. Georgiade (Ed.), Plastic and Maxillofacial Trauma Symposium. St. Louis: Mosby, 1969. Pp. 117122.
15. Cruse, C. W., Blevins, P. K., and Luce, E. A. Naso-ethmoidalorbital fractures. J. Trauma 20: 551, 1980.
16. Beyer, C. K., Fabian, F. L., and Smith, B. Naso-orbital fractures:
Complications and treatment. Ophthalmology 89: 456, 1982.
17. Stranc, M. F. Primary treatment of naso-ethmoid injuries with
increased intercanthal distance. Br. J. Plast. Surg. 23: 8, 1970.
18. Converse, J. M., and Hogan, V. M. Open-sky approach for reduction of naso-orbital fractures. Plast. Reconstr. Surg. 46: 396,
1970.
19. Merville, L. C., and Real, J. P. Fronto-orbito-nasal dislocations:
Initial total reconstruction. Scand. J. Plast. Reconstr. Surg. 15: 287,
1981.
20. Morgan, R. F., Manson, P. W., Shack, R. B., and Hoopes, J. E.
Management of naso-ethmoid-orbital fractures. Am. Surg. 48:
447, 1982.

17e

Plastic and Reconstructive Surgery January 2006

21. Hansman, C. F. Growth of interorbital distance and skull thickness as observed in roentgenographic measurements. Radiology
86: 87, 1966.
22. Freihofer, H. P. M. Inner intercanthal and interorbital distances.
J. Maxillofac. Surg. 8: 324, 1980.
23. Gruss, J. S. Naso-ethmoid-orbital fractures: Classification and role
of primary bone grafting. Plast. Reconstr. Surg. 75: 303, 1985.
24. Markowitz, B. L., Manson, P. N., Sargent, L., et al. Management
of the medial canthal tendon in nasoethmoid orbital fractures:
The importance of the central fragment in the classification and
treatment. Plast. Reconstr. Surg. 87: 843, 1991.
25. Ellis, E. Sequencing treatment for naso-orbito-ethmoid fractures.
J. Oral Maxillofac. Surg. 51: 543, 1993.
26. Pollock, R. A. Aesthetic rhinoplasty. In M. J. Jurkiewicz, T. J.
Krize, S. J. Mathes, et al. (Eds.), Plastic Surgery: Principles and
Practice. Vol. 2. St. Louis: Mosby, 1990. P. 1506.
27. Sheen, J. H. Aesthetic Rhinoplasty. St. Louis: Mosby, 1978. P. 4.
28. Sheen, J. H., and Pollock, R. A. The surgical anatomy of the nasal
septum and the pathomechanics of septal deviation. In Abstracts
of the Fifth Annual Meeting of the American Association of Clinical
Anatomists. Palo Alto, Calif.: Stanford University, 1988. P. 59.
29. Pollock, R. A. Nasal trauma, pathomechanics and surgical management of acute injuries. Clin. Plast. Surg. 19: 133, 1992.

18e

30. Rohrich, R. J., and Adams, W. P. Nasal fracture management:

Minimizing secondary nasal deformity. Plast. Reconstr. Surg. 106:
266, 2000.
31. Stranc, M. F. A classification of injuries of the nasal skeleton. Ann.
Plast. Surg. 2: 468, 1979.
32. Sullivan, P. K., Varma, M., and Rozelle, A. A. Optimizing bone
graft nasal reconstruction: A study of nasal bone shape and
thickness. Plast. Reconstr. Surg. 97: 327, 1996.
33. Rohrich, R. J., Adams, W. P., and Deuber, M. A. Graduated
approach to tip projection in rhinoplasty. In J. Gunter, R. J.
Rohrich, and W. P. Adams (Eds.), Dallas Rhinoplasty: Surgery by
the Masters. St. Louis: Quality Medical Publishing, 2002. Pp.
333-358.
34. Hamra, S. T. Lengthening the foreshortened nose. Plast. Reconstr.
Surg. 108: 547, 2001.
35. Guyuron, B., and Varghai, A. Lengthening the short nose with
a tongue-and-groove technique. Plast. Reconstr. Surg. 111: 1533,
2003.
36. Byrd, H. S., Andochick, S., and Copit, S. Septal extension grafts:
A method of controlling tip projection shape. Plast. Reconstr. Surg.
100: 999, 1997.
37. Leipziger, L. S., and Manson, P. N. Nasoethmoid orbital fractures: Current concepts and management principles. Clin. Plast.
Surg. 19: 167, 1992.