Dec 7

The Best Way to Treat A Broken Nose: Usually it is better to wait and get it corrected right the first time

Category: Uncategorized,

Almost every day we see a patient or two who have a crooked nose, with the obvious question of how can it be fixed. What most patients and even many surgeons still do not realize is that correction of a crooked nose is truly one of the more difficult things to achieve with rhinoplasty. So how do we suggest you get it done?

First scenario, is in the acute situation, say after a car accident or some other injury.  You may or may not go to the Emergency Room at the nearest hospital, where they may or may not even notice your nose depending on the level of other injuries. Occasionally you may also have a nose bleed, which then causes the ER doctor to place some Merocel or other packing to stop the bleeding.  What’s next?

If the ER doc calls and you are lucky enough to have a specialist come in to see you it may be either a “plastic surgeon” or an “ENT.” The problem here is that you have no idea if this doctor really has genuine expertise in the nose or rhinoplasty in particular. Let me be clear, obviously either of these doctors can manage the acute trauma and have treated patients with broken noses before. The issue I am raising is that rhinoplasty is perhaps the most exacting of all plastic surgery procedures- as the difference of a millimeter can really be the difference between a straight nose and a crooked nose, or a straight profile or small bump.

What we find is that there are many surgeons who still recommend a “simple” closed reduction of the fracture. In other words, they can numb the nose and surrounding area and simply push the broken bone back to its original position. If you live in Canada or if the present health care reform package in the House passes, this will likely be the course of treatment the vast majority of people will receive. And truthfully, if there is a simple non-comminuted, non depressed fracture and no deviation of the septum, this treatment will suffice.

But in the majority of other cases we have found that simple closed reduction does not correct all of the problems. In our experience, in the majority of cases the nasal fracture is not so simple. Oftentimes the septum and/or the upper lateral cartilages are involved. So what does that mean and how does that change the treatment algorithm?

The problem is that if the fracture results in deviation of the septum and/ or upper lateral cartilage, closed reduction will not address these areas. In general, if the septum is fractured, it must be corrected, both to correct your new breathing obstruction and also to allow for the fractured bone to move to its original position, and more importantly have the bone stay there.  If the septum fracture is not repaired, we have found that over time the bone can drift back to a crooked position due to the pressure from the septum.

As for the upper lateral cartilage, this comes into play when the nasal bone is depressed (pushed in) due to the fracture. Nasal anatomy teaches us that the upper lateral cartilages slide under the nasal bones in their upper connection. Therefore, when the nasal bone gets fractured in, the upper lateral cartilage can and often does get pushed in along with it resulting in an internal valve collapse. Unfortunately, the reverse is not true- if the nasal bone is pushed back out, as in a closed reduction, this does not necessarily lead to the upper lateral cartilage moving as well.

Often times, in the acute situation when there is facial and nasal swelling as well as other potential injuries, some of these nuances can and often are missed on initial examinations. As a result, with experience we have learned that it is often better to simply wait a few weeks to allow for all the swelling to settle allowing us to better assess the full extent of injury. What we have learned is that by doing so we are able to correct all of the associated injuries, which means that we can have a high success rate in achieving a happy patient who does not have to have revision surgery down the road.

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30 comments

30 Comments so far

  1. Valerie January 10th, 2011 3:09 pm

    Hello,

    My name is Valerie.
    I broke my nose 2 months ago (not the nasal bone).
    I saw differents Ents and one told me to wait a year to get surgery because my nose will still heal and move.
    What do you think ?

    Thank you for your time.

    Valerie

  2. admin January 11th, 2011 9:10 am

    Hi Valerie,

    Sorry to hear you broke your nose. If you fractured your septum and it is dislocated (i.e., the cartilage in the middle has been pushed over), then you do not need to wait a year to get it fixed. It will not likely improve on its own. Once the initial swelling and inflammation has settled, it is OK to proceed with corrective surgery.

    All the best,

  3. david May 11th, 2011 11:28 pm

    hi i had rhinoplasty a year ago and about a month ago i broke my nose my nose isnt crooked but my family dr said i have a deviated septum how long before i can get the deviated sseptum corrected, also since i already been through rhinoplasty would that make it more difficult for the surgeon or easier pleaseee help thank you!

  4. admin May 12th, 2011 9:46 am

    Hi David,

    If the deviated septum is causing you breathing problems a month after the injury, you can see a surgeon at any time to consider having it fixed. The question of difficulty depends on whether the septum was touched during your previous rhinoplasty. If it was, a revision septoplasty can be a little more challenging, but it should not present a problem for an experienced rhinoplasty surgeon. All the best,

  5. Nat August 17th, 2011 11:05 am

    I tripped about 10 days ago and then I lost my balance and went all the way down hitting my nose on the concrete. The impact for my face was only from about 8-10 inches off the ground and it was not a hard hit. In fact I didn’t even know I had hit my nose until I looked in the mirror. There was no pain and no bleeding. But within 2 minutes it was already swollen and bruised in two spots. It was black at the bridge, and I had a red line down around the ball of my nose. The bruised spots were tender for about a week but only if I touched them. The swelling appears to be gone now. I don’t think it’s broke, but I worry that the septum may be deviated to the left just a tad bit. It’s not really visable, but it feels that way to the touch. It didn’t hurt or bleed and since it doesn’t look broken I’m wondering if it’s okay to do nothing?

  6. admin August 19th, 2011 9:43 am

    Hi Nat,

    At this point, it will not hurt matters to take a wait and see approach. The only thing that is important to treat right away is a septal hematoma, where blood collects under the lining of the septum and can cause damage to the septal cartilage. You would know it if you had one, because a septal hematoma causes significant internal swelling and severe nasal obstruction on both sides. After 10 days, it is OK to wait for residual swelling to go down and see how your nose looks. If you are not experiencing breathing problems and do not see a significant cosmetic deformity, you may not need any further treatment.

  7. Nat August 21st, 2011 7:42 pm

    Thank you so much for getting back to me. I did get scared enough to visit my family physician on Friday. He said my septum appears just slightly deviated, but no airway blockage and it appears straight on the outside, so he recommended that I do nothing. He said I still have swelling and the appearance could still change. I am noticing some flat spots on what I think is the lower lateral cartilage, and a dip at the anterior septal angle, judging by some online pictures and charts of the nasal cartilage anatomy. If that cartlilage is damaged, can it repair itself? Will I always have the flat spots? Or can the spots get worse and dip in more? I can send you pictures if you need to see. Also, is it safe for me to blow my nose, or exercise? I’m afraid of doing anything that can make the cartilage collapse if that’s possible.
    Thank you so much again for taking the time to respond.

  8. Nat August 26th, 2011 6:28 am

    Just wanted to let you know that it appears everything is taking care of itself! The flat spots are rounding back out! And my nose appears to be straightening! Still some slight discoloration in spots but all in all, it’s looking good! Thanks again!

  9. Karen August 29th, 2011 6:25 pm

    I fell 16 days ago on the sidewalk and straight into a wall with my face, resulting in a closed nasal fracture. The ER doctor did not give me any guidelines on how to treat it – he just said if I didn’t like the way it healed I could always see a plastic surgeon later on.
    The bruising and swelling is mostly gone now, but there is a little bump to the left of the bridge of the nose where I assume the bone fragment is sitting. I saw the x-ray of it – it appears to be about 2-3 mm of bone fragment sitting almost parallel to the bone but in the soft tissue next to it.
    My question is t his – most reports state that closed reduction had to be done within 14 days of the incident – I am past that point and am just now researching what if anything could be done. Is there any harm in leaving it alone with the obvious gap in the bone or can this still be fixed without surgery?

  10. admin August 31st, 2011 8:52 am

    Hi Karen,

    You’re describing a chip fracture that usually occurs at the edge of the bone where it joins the cartilage. The small chipped fragment can often be popped back into place but this can be harder to do beyond 2 weeks if the bone fragment has become less mobile. An ENT/Plastic Surgeon will be able to tell you more after an examination.

    There is usually no problem with leaving it alone since a small 2mm bone defect generally has no effects other than cosmetic contour irregularity. If you find that the contour issue bothers you once swelling has settled, it is usually straightforward to smoothen the bone surgically. All the best.

  11. William October 10th, 2011 8:31 pm

    I got punched on the bridge of my nose about 12 years ago. I had a number of fractures in the bridge of my nose and was told that, since it appeared straight, it should just heal naturally. It has healed, however, there is a hard bump (bone or cartilidge ?) under the skin on the side of my septum. It doesn’t really obstruct my breathing but is annoying when it comes to blowing/cleaning my nose. What do you think potentially happened during the fracture that caused this ? Is this common during a fracture such as this ? How difficult is this to repair ?
    Thanks, William – –

  12. admin October 11th, 2011 7:38 am

    Hi William,

    A fracture of the nasal bones is sometimes accompanied by a fracture or dislocation of the septal cartilage and/or bone. A healed septal cartilage fracture is likely what you are feeling inside your nose. If it is bothering you enough, you might consider consulting with a rhinoplasty surgeon to explore further and hear more about your options for correction if desired.

  13. Anand October 18th, 2011 10:50 am

    Dear Drs. Litner & Solieman,

    My name is Anand, i was assulted by couple of people last week. when the guys started attacking me, i lost blance and fell down on my face hitting the ground. My eyes and nose was sowllen up and was bleeding from my nose, when i got to the hospital, the doctors took x-ray of my face and had a little quick look at my face. They told me not to blow through my nose and told me to come back after a week, beacuse the swelling was kind of big and was around my nose and eye. In these last couple of days my swelling around the eye and nose have gone down and i was able to breathe through my nose but now i notice the shape of my nose is’nt how it was use to be, the right side of the nose bridge has gone abit flat(like i lost weight on one side of the nose compare to the other side of the nose) I went back to see the doctor today(after a week) where i had an appointment with some facial surgery doctor, i explained to him about the inncident and also told him when i am eating food and when i bite i feel pain around my nose areas. The doctor inspected my face(around my nose area) he then told me there are some fractures around my nose and it should heal in time, and also my nose is deviated. He said evrything seems to be fine but if i need a surgey to strighen my nose it could be done after 3months, apart from that dont blow my nose or play any contacting sports and eat slow deit food. The thing what worries me is that he also said when i first whent hospital the doctor should have been pushed my nose back into place there and then. Isit still possible for me to push my nose back into place? is there any other way of getting my nose back into streight? sorry for taking too much space on your page. Hopes to hear from you soon.
    Thank you.

  14. admin October 19th, 2011 9:14 am

    Hi Anand,

    I’m sorry to hear about your assault and I hope there were no other serious injuries. On the question of your nasal fracture, it is sometimes not useful to consider pushing the bones back initially (called a closed reduction) since there is a lot of swelling and it can be hard to see if the procedure has made the nose completely straight. For that reason, many patients who have had a closed reduction still find once things heal that the nose looks a little crooked and many go on to require an open reduction in the operating room. After about a week, the bones start to set and a closed reduction becomes much more difficult if not impossible. Now that swelling is down, it should be possible to evaluate what needs to be done to restore your nose to its preinjury appearance. All the best,

  15. Jenn October 25th, 2011 6:51 pm

    Hi,

    my names Jenn, I broke my nose a few years ago, i had a really bad cold and I blow my nose and pushed to hard with my thumb and my cartilage snapped my doc told me it would move back but it never did and he didn’t fully believe me about how i broke it but its true, it sticks out through the skin in my nose and I can’t breath well with it….they couldn’t even get a camera up the one side cause it hurt to much to try and get it in, i gave up working out for a while because I can’t use my nose so I used my mouth and its not easy. I was just wondering if ppl are covered for that with ohip to get it fixed or? And what does it mean if every so often my noses starts bleeding but only one side? as it is i can’t breath and that makes it worse….to the point where I have troubles laying down because i can’t get air that well through my mouth when my nose bleeds:S makes it harder to sleep because i can’t get enough air. Thank you.

  16. admin October 26th, 2011 1:13 pm

    Hi Jenn,

    If your septum is crooked, this causes abnormal air flow through your nose that can make some areas of the lining over the septum prone to dryness and occasional nosebleeds. Surgery can often improve this issue as well. If the deviation is severe enough to cause obstructed breathing as it seems with you, it will often be covered by insurance. All the best.

  17. Erick January 15th, 2012 11:39 am

    Hello, recently I was mugged and was left with a slightly crooked nose. I had a broken nose and a deviated septum. My surgeon schedule my surgery on the 17th, which is 2 weeks after my mugging. He said he would perform a septoplasty and a closed reduction of my nasal fracture.

    My question is whether it will be too late by then to perform a closed reduction. I keep reading online that I cannot wait more than 14 days, it will be 14 days by the time I have the surgery. I’d like to trust in my doctor’s word, but reading otherwise online isn’t very assuring.

  18. admin January 16th, 2012 10:13 am

    Hi Erick,

    Thanks for your question and sorry to hear about your recent trauma. It really depends on what your surgeon means by closed reduction. In the traditional sense, this means pushing on the broken bones to try to straighten them. The chances for this being successful are diminished at two weeks after the fracture in our opinions. However, your surgeon may be intending to do osteotomies if necessary, which means breaking and re-setting the bones. Check with him to be sure.

  19. Jerry January 20th, 2012 4:41 pm

    Hi, I broke my nose on jan 8th. I went to the er right after it happened wich was about 11:30pm. I had x-rays done and the doctor told me there seemed nothing wrong with the bone…so I let it heal and after like a week I decided to make an appointment with my doctor because most the swelling had went down and also the black eye went away and I could really tell my nose was crooked. When I went there they told me to go get a ct scan done yesterday which was the 19th. After the ct scan it showed that I have indeed broke my nose. Now I have an apt with an ent specialist Tuesday the 24th, which is like 16days after the incident. I was wondering what I should be prepared for and what do you think they might do? Do you think they will just reset it or do you think since it’s going to be 16days that they might need to do surgery on it. Thank you for your time.

  20. admin January 20th, 2012 5:14 pm

    Hi Jerry,

    Xrays are notoriously bad at picking up nasal fractures, so most ENTs and plastic surgeons do not bother getting one. Generally, we can tell if the nose has been fractured on physical examination alone. Sixteen days after injury may be a little late to reset the bones through a closed reduction. It may still be possible depending on how mobile the bones are at that point. There is a good chance, though, that the surgeon will recommend an open reduction under anesthesia and possibly a septoplasty if you’ve also fractured your septum. Good luck.

  21. heather April 12th, 2012 6:02 pm

    Hello –
    My daughter slammed her head back into the bridge of my nose about a month ago (upper, sort of to the left a little). I am pretty sure it was fractured or broken (the pain was worse than childbirth!). I could feel a small dent in it, and it looked a little crooked but I kept pressing it back over and after a few days it looked normal. Now, all of a sudden there is a hard red bump that is sensitive to the touch on the upper side where the dent was. It appeared overnight. My nose still hurts if I crinkle it up or if I blow it, but I can breathe fine and thought it had healed. Is this a permanant thing? What is it? What step do I take next to correct it? Thank you!!

  22. admin April 18th, 2012 1:11 pm

    Hi Heather,

    It’s hard to know what you’re seeing without examining your nose. There could be a small bone chip/fragment left over from the fracture. A hard bump can also be what’s called a bony callous (the bone’s natural response to injury is to form new bone to heal the fracture). If you’re still pressing on the area a lot, you may just be causing some irritation of the skin and soft tissues. Best to have it looked at.
    All the best,

  23. Lola August 26th, 2013 9:11 pm

    Hello

    I got deviated nasal septum and i do manny sports specially soccer so when i start running its hard to breath for me, so do you recommend me to do a surgery to fix my nasal septum?

  24. developer August 28th, 2013 9:33 am

    Hi Lola,

    The short answer is yes. Exercise intolerance because of difficulty breathing through your nose is one good reason to consider septoplasty to correct a deviated septum. All the best.

  25. Christian August 29th, 2013 1:14 pm

    Hello
    I broke my nose about six years ago and it’s slightly crooked. I don’t have any trouble breathing but I’d like to fix its appearance. I consulted with both a plastic surgeon and otorhinolaryngologist. Both offers very different procedures one is septoplasty and the other would well reconstruct my nose. I am having difficulty in choosing the right doctor for this surgery.

  26. developer September 16th, 2013 9:48 am

    Hi Christian,

    Sorry for the delay in answering your question. It is hard to give an answer without examining you but I will give you some general information that may be of help. Septoplasty alone is a good option for those who are having breathing trouble due to a deviated septum. The procedure should help with breathing but may not correct a crooked nose. This is because, often, an external deviation or crookedness may involve the nasal bones and/or the part of the septum that supports the nasal bridge or tip. These are not corrected by septoplasty alone and will often require a rhinoplasty approach if the goal is to straighten your nose as much as possible. Since it sounds like that is your primary focus, I would make sure you ask of whomever you choose what is causing your crookedness and how specifically the surgeon intends to correct it. The answer should be explained to you in a way that makes sense to you. If it does not, keep searching.

  27. catherine guinane December 5th, 2013 4:40 am

    Hello,
    So my story begins with being punched in my nose on the right side. Resulting in a curved and crooked nose, deviated septum, and nasal fracture. I had surgery and everything on the inside is fine now. But my nose is still crooked. The doctor told me to just push on where I see its broken with my finger and it will straighten itself in about 6 weeks. Or have a rinoplasty, but i read that my situation has a high failure rate.What do I do? Scared and sad.

  28. developer December 6th, 2013 12:07 pm

    Hi Catherine,

    It’s good to hear that your functional concerns have improved after surgery. It is possible to have asymmetric swelling after surgery that can make the nose still look crooked – this should hopefully resolve with time. We are not big believers that pushing on the bones after surgery will straighten them, although it cannot hurt. Sometimes, a rhinoplasty is required to fully address cosmetic concerns. Talk to your surgeon about your concerns at your next visit and hopefully you will see continued improvement.

  29. Chris December 30th, 2013 6:12 pm

    Hello. My 20 y.o. son was assaulted this past weekend, sustaining a “comminuted, depressed fracture of the left nasal bone. There is a nasal septal deviation”. The doctor at the E.R. told him to see his ENT if the bones were out of place for a reduction between 6-10 days. He would like like to get the deviation repaired as well as have rhinoplasty for cosmetic reasons (wants smaller nose). Question: Do you think he should have the reduction done in a few days or wait until he has the rhinoplasty to have everything done at one time. How long should he wait to have the rhinoplasty after this fracture? Thank you for your time and attention in this matter.

  30. developer December 31st, 2013 12:16 pm

    Hi Chris,

    We’re sorry to hear about your son’s injuries. In our experience, closed reduction has a relatively high failure rate because a deviated septum or other causes of a crooked nose are not addressed with this procedure and, so, it can fail to straighten the nose entirely. If he is already considering rhinoplasty for cosmetic reasons, he can wait to have everything done at once with the one procedure. We generally wait to perform open reduction of a fracture or a more involved rhinoplasty until the swelling has gone down completely so we can better assess crookedness and be more accurate and precise with our correction. A 4 to 6 week time frame is reasonable for this. Your son should visit a rhinoplasty specialist to discuss his concerns in more detail. We would be happy to have a more detailed conversation with him. Please feel free to contact our office at 310-276-6800 so we can arrange a consultation. We also offer Skype consultations for those out-of-town or out-of-state. All the best.

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