Keywords: Trauma, Nasal tip, Avulsion, rhinoplasty
Authors: Nicolai Lassen Frid, MD, Johan Hindkjær Therchilsen, MD, Jakob Gerlach Christensen, MD Institution: Department of Otorhinolaryngology and Maxillofacial Surgery, Zealand University Hospital, Køge, Denmark
Abstract
Traumatic partial avulsion of the nasal tip is a rare condition that can present both functional and aesthetic challenges. This case reports a 58-year-old woman with a partial nasal tip avulsion after a fall onto a metal crate. Examination revealed injury to the lower lateral cartilages with loose cartilaginous fragments. Surgical repair focused on restoration of the structural tip support, using end-to-end sutures for approximation of the cartilage and interdomal suturing. This case focuses on rhinoplasty-based principles in acute management of nasal trauma to preserve projection, symmetry, and long-term stability of the nose.
Patient medical history
A 58-year-old woman presented to the emergency department with a traumatic partial avulsion of the nasal tip sustained after slipping on ice and striking her face against a metal crate. The patient reported neck soreness but exhibited no signs of concussion and no other facial injuries or neck injuries. She had no prior history of nasal trauma. Her medical history included well-controlled hypertension and chronic back pain.
Before and After
Patient examination
Examination of the external nose revealed a large laceration involving the nasal tip, with partial avulsion on the right side. The lower lateral cartilages were injured, with transection of the right lateral crus, a loose fragment of the right intermediate crus, and bilateral fractures of the medial crura with loose cartilaginous fragments. The skin was intact over the columellar and the left alar surface. The wound edges were well defined and with no tissue loss. Sensation was absent in the lacerated tip, but with preserved capillary refill.
Anterior rhinoscopy showed a midline septum without hematoma or mucosal injury. There were no epistaxis and no fractures of the nasal bones. Sensation in all three branches of the trigeminal nerve was intact. A minor mucosal laceration in the midline of the lower lip and a fissure of the upper lip, without dental injury or malocclusion.
Due to the extent of the laceration and the cartilaginous injury, surgical repair under general anaesthesia was indicated.
Pre-operative considerations
The nasal tip is supported by three major support mechanisms: The ligamentous attachments from the medial crura of the lower lateral cartilages to the caudal portion of the septum, the inherent strength of the lower lateral cartilages, and the interdigitation of upper and lower lateral cartilages at scroll region(1-2). In this case, the disruption of the medial crura directly compromised:
-tTip projection
-tColumellar support
-tDome symmetry
-tInterdomal relationship
Failure to restore these structures risks:
-tLoss of projection
-tDroopy tip
-tAlar retraction
-tLong-term asymmetry
Given preserved vascularity and absence of tissue loss, a primary structural repair was indicated.
Exposure of the cartilage
After induction of general aesthesia, infiltration with local anaesthetic with adrenalin was administered in the nasal mucosa to reduce bleeding and facilitate dissection.
The lower lateral cartilages were partially exposed bilaterally through the existing laceration. Devitalized tissue was conservatively debrided to preserve vascular supply.
Cartilage reconstruction
The bilateral medial crus and right intermediate crus fractures were identified and anatomically realigned. End-to-end sutures were performed using 5-0 PDS to restore columellar support. Particular attention was paid to equal medial crural length, symmetrical dome positioning, and preservation of the curvature.
Intraoperative photograph with markings highlighting the lower lateral cartilages and fractures:
-tRight lateral crus (blue)
-tRight intermediate crus fragment (yellow)
-tRight medial crus fragment (purple)
-tLeft medial crus fragment (green)
-tLeft lateral crus (orange)
Restoration of tip definition
An interdomal suture, 5-0 PDS, was placed to re-establish dome symmetry and tip projection.
Skin and mucosa closure
The skin over the nasal tip was adapted and closed with 6-0 nylon sutures, 11 sutures in total
A small fissure of the upper lip was closed with 6-0 nylon sutures, and the mucosal laceration in the lower lip was sutured with 3-0 polyfilament resorbable sutures.
Pearls
-tAccurate realignment of the medial crura is essential to maintain tip support(3).
-tInterdomal suturing helps restore tip projection, contour, and symmetry(4).
-tPreserve cartilage length whenever possible.
-tLayered closure is critical for structural stability.
Pitfalls
-tFailure to adapt the medial crus fractures may lead to long-term tip deformity and instability(5).
-tInadequate cartilage alignment can result in alar retraction, asymmetry, and nasal stenosis(5).
-tInfection risk must be considered in injuries occurring within the facial ‘danger triangle’.
Post-operative plan
Due to wound contamination, the patient received prophylactic antibiotics and a tetanus vaccination. Sutures were removed after 5 days. Postoperatively, the patient was informed to use saline nasal rinse. Strenuous physical activities, including sports and household chores, were discouraged until suture removal.
5 weeks follow-up:
The patient reported no symptoms of nasal obstruction. Tip support and projection were preserved, with no asymmetry. Sensation in the tip remained absent. (Photos after surgery)
References
1. Stephan, S., u0026 Wang, T. D. (2012). Asymmetric nasal tip. Facial Plastic Surgery, 28(2), 177–186. https://doi.org/10.1055/s-0032-1309297
2. Nathan, J. M., u0026 Ettinger, K. S. (2021). Management of Nasal Trauma. In Oral and Maxillofacial Surgery Clinics of North America (Vol. 33, Issue 3, pp. 329–341). W.B. Saunders. https://doi.org/10.1016/j.coms.2021.04.002
3. Patel, K. B., Mendonca, D. A., Skolnick, G., u0026 Woo, A. S. (2013). Anatomical study of the medial crura and the effect on nasal tip projection in open rhinoplasty. Plastic and Reconstructive Surgery, 132(4), 787–793. https://doi.org/10.1097/PRS.0b013e3182a0137a
4. Malone, C. H., Hays, J. P., Tausend, W. E., u0026 Wagner, R. F. (2017). Interdomal sutures for nasal tip refinement and reduced wound size. Journal of the American Academy of Dermatology, 77(4), e107–e108. https://doi.org/10.1016/j.jaad.2017.04.1115
5. Locketz, G. D., Franco, A., u0026 Miller, P. J. (2022). Correction of the Nasal Ala. Facial Plastic Surgery, 38(01), 070–073. https://doi.org/10.1055/a-1724-3656