Clinical Review & Education

Surgical Pearls

Suspension Technique for Unstable Nasal Bones

Benjamin G. Hunter, MBBS, FRCS(ORL-HNS), EBCFPRS; Abel-Jan Tasman, PD Dr

Nasal fractures are the most common facial fracture1 and are well
known to any nasal surgeon. Although most fractures are easily
treated, more severe injuries with bilaterally unstable nasal bones
can be challenging to treat and
achieve a good long-term
Video outcome.2,3 Management of un-
stable or floating nasal bones
during rhinoplasty can also be an issue if the nasal skeleton is un-
stable following osteotomies.
The aim of the suspension technique is to restore optimum na-
sal form and function by positioning and supporting the nasal bones.
In traumatic cases, the septum is often damaged and needs to be
treated as well. Frequently, it is sufficient to repair the septum and re-
position the nasal bone fragments, thereby reestablishing the nasal
form and maintaining projection. The septum and nasal bones may
need to be supported with endonasal packing, which helps to splint
the septum and nasal bones. Nasal packing in combination with a plas-
ter or external nasal splint may be sufficient to reestablish the nasal
form. The plaster’s adhesive helps to hold the nasal bones in place.
If the nasal bones have multiple comminutions after trauma or
if osteotomies lead to a fully mobile nasal bone, the suspension tech-
nique is required to reliably reposition the nose and achieve ad-
equate nasal projection. This technique allows for endonasal sup-
port of the nasal bones and fixation to an external plaster of Paris
to support the unstable nose.
Surgical Technique
The management of traumatic injury of the septum is not de-
scribed herein; however, the assumption is that the septum has been
repositioned and optimized according to the case. Prior to address-
ing the nasal skeleton, lacerations should be sutured, and the skin
envelope should be treated according to clinical need. The nasal
bones are then manipulated into the ideal position, and stability is
assessed. In comminuted fractures, the nasal bone fragments may
not remain stable after repositioning as would be the case in a simple
nasal fracture.
To hold the nasal bone fragments in place, silicon sheeting is
folded and placed in the nose under each nasal bone (Video). We
use 1-mm-thick silicon sheets. A nonabsorbable suture is placed
through the silicon sheeting and passed through the nasal bone frag-
ments and the skin. This is repeated on the contralateral side so the
nasal bones can be distracted by tensioning the sutures by pulling
on the silicone sheeting.
The nose is then dressed with adhesive tape and a plaster of Paris
is prepared. The plaster of Paris is sized a little larger laterally to al-
low it to rest on the maxilla on either side of the nose. In this way, it
provides a scaffold that can support the nasal bones.
The plaster is perforated 4 times with a broad-gauge needle to
allow the nylon sutures to be passed through the plaster of Paris.
The sutures are secured with a clip to prevent accidental removal.
The plaster is then moistened, formed, and pressed onto the nose
and maxilla, and the nasal fragments are pulled up and out into the
desired position with the use of the sutures while the plaster cast
sets. This is the key moment in stabilizing the unstable nasal skel-
eton.
Once the plaster is set, the sutures can be tied over the plaster,
and the nasal bones are held firmly to the underside of the plaster
by the silicone sheets within the nose. The use of packing is only re-
quired if a septal injury or an associated injury requires it. The plas-
ter and silicone sheeting is then left in situ for approximately 10 days,
until the bone fragments have begun to heal.
The removal of the dressing is simple and can easily be done in
the outpatient setting. The sutures are cut, and the silicone sheet-
ing and nonabsorbable sutures are removed from each side of the
nose. The plaster and adhesive tape can then be removed from the
nose to reveal the final result.
Discussion
The suspension technique is effective in cases of severe nasal trauma
or for management of the floating nasal sidewall. This technique is
successful in restoring the position and projection of the unstable
nasal skeleton.

ARTICLE INFORMATION
Author Affiliations: Hals-Nasen-Ohrenklinik,
Kantonsspital St Gallen, St Gallen, Switzerland.
Corresponding Author: Benjamin G. Hunter,
MBBS, FRCS(ORL-HNS), EBCFPRS,
Hals-Nasen-Ohrenklinik, Kantonsspital St Gallen,
Rorschacher Strasse 95, St Gallen 9007,
Switzerland (benjamin.hunter@kssg.ch).
Published Online: August 1, 2019.
doi:10.1001/jamafacial.2019.0535
Correction: This article was corrected on
September 19, 2019, to fix an error in the first
sentence of the third paragraph of the introduction.
The sentence should read “If the nasal bones have
multiple comminutions after trauma or if
osteotomies lead to a fully mobile nasal bone, the
suspension technique is required to reliably
reposition the nose and achieve adequate nasal
projection.”
Conflict of Interest Disclosures: None reported.
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