Rhinoplasty for Nasal Deformity due to Birth Trauma: A Case Report

The incidence of head and neck traumas during birth is around 1%(2). These traumas include cephalohematoma, skull fractures, skin lacerations, clavicular fractures, facial, phrenic, laryngeal nerve injuries, brachial plexus damage, vocal cord paralysis, and nasal traumas(2). High birth weight, vaginal delivery, primiparity, the use of forceps and vacuum during delivery, and male fetus are predisposing factors that increase the risk of birth trauma(2).

In nasal traumas caused by birth, asymmetry and airway obstruction in the nose usually occur due to the dislocation of the cartilaginous septum from the maxilla. Nasal bone fractures, often resulting from lateral impacts, are the most common type of facial fracture, while septal deviations due to birth trauma were first described by Metzenbaum in 1929(4,5). Septal deformities are classified as anterior deformities involving only the cartilaginous septum and combined nasal deformities involving the nasal bones. The extent of damage varies depending on the intensity of pressure the fetus is exposed to during pregnancy or birth.

The nose is a triangular pyramid consisting of skin, muscle, mucosa, nerve, and vascular structures supported by external nasal cartilage and bone. The nose has different characteristics during childhood and adulthood (3,4,6). In infancy, the nose has less anterior projection, is predominantly cartilaginous, and contains multiple growth centers. The cartilaginous septum acts as the main growth center for the midface. The increased cartilage area in the nose during infancy enhances its compressibility, thereby better absorbing impacts to the face (4). In cases of nasal obstruction during infancy or childhood, the mouth remains open for extended periods, buccal muscles apply extra lateral force to the alveolar processes, pushing the anterior part of the alveolar arch forward, resulting in an elliptical shape of the alveolar arch and elevation and pathologies of the hard palate and midface (5). Although the patient in the case report does not have significant airway obstruction, the history indicates intermittent breathing difficulties over a long period.

Septal extension grafts (SEG), defined as grafts placed between the upper lateral cartilages and the caudal or dorsal septum either unilaterally or bilaterally, were first described by Bryd in 1997 (7). SEGs are very beneficial in controlling nasal tip rotation, projection, shape, and overall nasal length (8). They are particularly advantageous in thick-skinned noses where the medial crura of the lower lateral cartilages have been weakened by impact or are congenitally short and weak, providing superior projection (3). The literature suggests that SEGs are more successful in preventing long-term rotation and projection losses compared to the columellar strut technique (3). Three types of SEGs have been described in the literature, all of which require a robust septum for support. In the case described, an open technique was chosen to improve intraoperative visibility, and a unilateral type 3 SEG was used parallel to the caudal septum for enhancing nasal tip projection and correcting the nasal axis. This adjustment significantly increased the rotation and projection of the nose as desired (3, 9).