See how an acute nasal fracture is reset along with septal deviation correction.
Using a novel, high definition point-of-view camera Dr. Thomas Lamperti narrates an intra-operative video showing how he fixes a deviated septum with a septoplasty. He then goes on to show you how a closed nasal fracture reduction is performed using no incisions. You can jump straight to the nasal fracture reduction portion of the video at the 4:20 mark.
You'll also see how the septoplasty incisions are sutured closed and what type of dressing is placed after broken nose repair.
"This is Seattle Facial Plastic Surgeon, Dr. Thomas Lamperti. Today I'm going to show you how we fix a broken nose and deviated septum. We'll start off fixing the deviated septum using a septoplasty. We'll use a closed, hidden incision, as you can see I'm making on the left side. This is called a Killian incision. And it is placed just on top of the outer edge of the cartilage of the septum. Next we're using an instrument to elevate gently the skin lining, or mucosa, off of the cartilage in this area. We're entering a plane just underneath the perichondrium. This is a bloodless plane and allows us to very nicely dissect more posteriorly towards the back where the bone of the septum is. Once we've encountered this plane of dissection we'll then use a Freer elevator to more widely undermine elevate this skin flap. Now that we have the access that we need on the left side I'm now making an incision in the cartilage of the septum. We leave about 1.5 centimeters of cartilage in front of us before we make the cartilage incision. And now we can raise a similar skin flap on the right side. I'm elevating it off of the cartilage and bone on the right side of the septum. You can see that I'm doing this via the incision in the left side of the nose. And now we're using a swivel knife to make our upper cut in the cartilage which parallels the dorsum or bridge of the nose. We do leave about 1.5 centimeters of cartilage along this strip of septum as well. It turns out that you only really a strut of cartilage of about 1 to 1.5 centimeters along the bridge and along the front of the nose. This L-shaped cartilage then supports the nose and maintains its normal position. The remaining cartilage and bone can be removed if needed and this is what we're doing now with the bony portion being deviated as well towards the back of the nose. I don't always do this but in this patient's case i'm replacing a portion of the removed cartilage because we've straightened that aspect and then am replacing it back in the pocket. Once that is back in place we'll then close our incisions. I'll play this portion a little bit faster than in real time just for brevity. These sutures are dissolvable and will come out on their own within a few weeks. I'll put just a few interrupted sutures along the initial Killian incision that I made to start the procedure. Once we do the last sutures for this incision then we must reappose the skin flaps that we had separated. This prevents blood and fluid from collecting there. And this is the only dressing that we'll need for the septoplasty. I don't pack the nose after a septoplasty. Occasionally I'll use a septal splint but I don't' need one in this case. So now we are doing this quilting stitch. This is a different type of dissolvable suture. It takes about a month for it to disintegrate and come out of the nose on its own. It comes on a straight needle and we bring it back and forth and back and forth many times throughout the areas that we've dissected and again this prevents fluid and blood from collecting between the skin lining. It allows the skin lining to heal back to itself more normally. Once we're near completion we bring it back out toward where we initially brought in into the nose. We tie it to itself there in the front. That's what we're doing now. Cutting the end and tying the suture in the front. This is just behind where the incision line was so it's even harder to see this area.
And now we'll move onto the broken nose. This patient broke her nose about a week and a half ago. We use a device to reduce the fracture. Her left nasal bone is what is misplaced. It's a depressed nasal bone fracture. So it's pretty straight forward where we just insert this elevator to mobilize the bone and set it back into place. The right nasal bone is actually not out of place so we're really just focusing on that left side. Once I'm happy how the bone is situated we then work on our dressings. This is a telfa. This is a type of non-stick dressing. You'd probably recognize it as being the white part of a bandaid so this is the same type of material. Next I'm gong to do an internal splint for the nose. This is based off of the nasal fracture reduction. I don't always put these in the nose when I reset a broken nose but I'm afraid that the bone doesn't want to stay mobilized outward, where it tends to want to fall back in again I'll put this inside the nose. It looks like silk but it is actually a dissolvable type of material. It will come out and dissolve on its own. It's really acting as an internal splint and just supports that bone and keeps it into position until it set in place on its own. The nasal bones will be fully set within about 6 weeks from this procedure. So until then you do have to be careful about trauma to the nose. For the first week she'll have this cast on and dressing as you'll see me put on now. This is just some skin adhesive that allows us to place the steri-strip dressing on top of the telfa. This helps keep down the nasal swelling as well. I like to do this zig zag pattern as you can see just to give different lengths to the steri-strips. We'll work our way from the bottom towards the top using the different lengths. I do a few layers. And this dressing isn't really any different otherwise from what I would use during a rhinoplasty. If I do controlled bone fractures, or osteotomies, during rhinoplasty I will also use a hard plastic Aquaplast cast which I'll now put on top as well on this patient. That's the main step whenever there is nasal bone fractures that you need to heal. I'm just trimming the steri-strips right now to make sure that they are in the proper orientation and I want to make sure that they look good -- that's the only part of the dressing in the procedure itself that you see. Now I'm trimming and customizing the Aquaplast, or thermasplint. It is heat activated so it's hard plastic at first and then once it's put in hot water, which I'll do in a minute, it becomes soft and flexible and we can mold it to the person's nose. I'm just checking the sizing and putting it in the hot water right now. Letting it seep a bit like a tea bag and after waiting several seconds I'll take it out of the hot water. You can see that it's turning clear -- that's how you can tell that it's at the right level of flexibility. And now we mold it over the nose. As it cools, it only takes a few seconds, it starts cooling down and hardening and turning white again. And as that occurs I mold it into the proper shape where I want it. I don't want to press too hard because I don't want to press the nasal bone back in that I've just reset. So you do want to be careful when you're molding this outer cast. And that's the conclusion of the procedure. We'll now wake the patient up and she'll head to the recovery area before going home."