Rhinoplasty in children

What repeats

Five findings that hold across the literature.

The concern is the septum, and the evidence no longer supports a blanket ban

Nasal surgery in children was avoided because the septal cartilage is a growth centre for the midface. Long-term measurement does not bear out the fear. A cohort of 44 children who had endonasal septoplasty was remeasured a mean of 12.2 years later and matched published normative data on every linear, angular and proportional measure but the nasolabial angle, which was lower in the girls and lower again after extracorporeal septoplasty than after a conservative operation. In a cleft cohort measured in three dimensions at skeletal maturity, 52 operated patients matched 52 controls on nasal height, alar width, dorsal angle, surface area and volume, and a systematic review of primary cleft rhinoplasty found eight of nine growth studies showing no restriction.

Rests on: Tasca and Compadretti, nasal growth after pediatric septoplasty · Seo et al., three-dimensional morphometry · Zelko et al., systematic review · Johnson, pediatric nasal surgery.

Leaving an obstructed nose alone has its own cost

Untreated nasal obstruction in a child drives mouth breathing, snoring, malocclusion and obstructive sleep apnoea, and those in turn shape facial growth. That is the argument for operating rather than waiting, and it is why the functional indication is treated differently from the cosmetic one.

Rests on: Shave et al., pediatric functional rhinoplasty · and nasal airway obstruction.

Technique is conservative: preserve cartilage, avoid the growth zones

The rule across the reviews is to spare cartilage rather than resect it, and to leave the dorsal and caudal strips of the septum alone. Surgery for appearance alone is delayed until growth is finished, which the reviews put at about 18 years of age.

Rests on: Shave et al. · Johnson · House et al., aesthetic rhinoplasty in children · and the septum and the airway.

Surgeons practise differently, and say so

Among American Society of Pediatric Otolaryngology members surveyed, 105 responded. Of those, 87.0% perform septoplasty and 27.9% perform septorhinoplasty, and the ones who do not refer on, 74.7% of them to facial plastic surgery. Reduced quality of life was the commonest reason to operate, at 82.2% for septoplasty. No strict age cutoff was used by 38.9% for septoplasty, 24.1% for septorhinoplasty.

Rests on: Lambert et al., ASPO survey.

The series report satisfaction and a revision rate

A series of children aged 6 to 15 who had a dorsum-preserving extracorporeal septoplasty reports functional and aesthetic satisfaction, no major complications and no revisions, at a mean follow-up of 24 months. A cleft series of 103 patients operated with overcorrection at the first repair reached skeletal maturity with symmetry closer to non-cleft controls than a comparison group of 30. The largest septoplasty cohort, 194 children with a mean age of 14.6 years, found revision more frequent in the under-14s and no difference in complications. In 64 children aged 4 to 17 who had rhinoplasty, 26.6% were dissatisfied with the appearance, 12.5% had trouble breathing afterwards and 9.4% had a revision, and the authors ask for strict selection.

Rests on: Guliyev and Erbek, aesthetic septoplasty in children · Murali et al., long-term outcome · Bishop et al., pediatric septoplasty outcomes · Bae et al., pediatric rhinoplasty outcomes.

By why the child is having surgery

Four different reasons, judged by different rules.

Breathing

Septal deviation that resists medical treatment, with reduced quality of life, is the commonest reason surgeons in the ASPO survey operate. Turbinate reduction is offered for the same complaint on weaker evidence: a review of 11 studies covering 730 cases in children aged 1 to 17 found the outcome measures too varied to compare.

Rests on: Lambert et al. · Leong et al., turbinate reduction in children · and nasal airway obstruction.

Trauma

A broken nose in a child is set early, before the parts knit crooked. The paediatric series that tests that rule found otherwise. Of 56 children operated on for a nasal bone fracture, 48 had closed reduction alone and 8 had a rhinoplastic step added; the time from injury to surgery changed neither the cosmetic result nor the breathing at a median follow-up of 62 months. In adults, rhinoplasty within 14 days of the fracture gave aesthetic results no worse than later surgery, in a series of 41 patients. A septal haematoma is the emergency inside this: undrained, it destroys the cartilage.

Rests on: Lee and Jang, pediatric nasal bone fractures · Liao et al., early post-trauma rhinoplasty · Johnson · and saddle nose deformity.

A cleft lip nose

Cleft care operates on the nose in stages: at the lip repair, again in childhood, again at maturity. A 10-year follow-up of 60 patients found that a septal cartilage rim graft at the primary operation gave a straighter septum and better alar support, with no difference in nasolabial angle or tip projection. A photographic study of 146 patients found nostril asymmetry improving from age 1 through 18.

Rests on: Ueno et al., 10-year follow-up · Huang et al., after facial maturation · McCracken et al., cleft rhinoplasty through development.

Appearance

This is the indication that waits. Nasal growth is not finished until adolescence ends, and the reviews put purely aesthetic surgery after that point. One report describes stress-induced cardiomyopathy in two teenage girls having cosmetic rhinoplasty. A narrative review of social media and minors asks the surgeon to weigh how much of the request comes from comparison, validation-seeking and idealised images before agreeing to operate.

Rests on: House et al. · Glamore et al., teenage rhinoplasty · Gimenez Lynch et al., social media and adolescent pressure · and the psychology of rhinoplasty.

What to ask before nasal surgery in a child

Questions the evidence supports asking.

Is this operation for breathing or for appearance

The answer changes the timing. Breathing problems are treated when they are causing harm. Appearance waits for growth to finish. Ask which one is being proposed, and what happens if it waits.

Rests on: Shave et al. · House et al..

Is anyone screening for body dysmorphic disorder

Of 226 patients seeking rhinoplasty, 33% had at least moderate symptoms of body dysmorphic disorder, and the score tracked how the patient rated the nose rather than how observers rated it. Across 597 facial plastic surgery patients, 9.7% screened positive on a questionnaire while surgeons suspected it in 4.0%, and they identified 2 of the 43 who screened positive. Ask which written screen is used.

Rests on: Picavet et al., body dysmorphic disorder in rhinoplasty · Joseph et al., prevalence and surgeon accuracy · and the psychology of rhinoplasty.

How much cartilage will be removed

Ask specifically about the dorsal and caudal septum, the strips the reviews say to leave intact. Ask whether cartilage will be repositioned rather than resected.

Rests on: Shave et al. · Guliyev and Erbek.

How many of these do you do, and what is measured afterwards

The ASPO survey found the NOSE questionnaire the commonest patient-reported measure. Ask which score is used, at what interval, and how many children the surgeon operates on each year. The guideline asks for appearance and function documented at a minimum of 12 months.

Rests on: Lambert et al. · the clinical practice guideline.

What can go wrong that is specific to a child

Ask about septal perforation. In a paediatric series of 20 perforations the commonest causes were iatrogenic at 40% and button batteries at 20%, and half of those repaired achieved closure.

Rests on: Jennings et al., pediatric nasal septal perforation.

The terms, defined

The words used about nasal surgery in children.

• Septoplasty: straightening the partition inside the nose to open the airway. [42462583]
• Growth zone: the parts of the septum the midface grows around, left undisturbed in a child. [37619608]
• Skeletal maturity: the point at which facial growth is finished, used as the earliest date for purely cosmetic surgery. [32332542]
• Extracorporeal septoplasty: the septum is taken out, straightened and put back, used for a severe deviation. [41145862]
• Septal haematoma: blood collecting between the septal cartilage and its lining after an injury, which destroys the cartilage if it is not drained. [28340652]
• NOSE score: the Nasal Obstruction Symptom Evaluation, the commonest patient-reported measure in this setting. [42462583]
• Body dysmorphic disorder: a preoccupation with a perceived defect in appearance that others do not see, screened for with a written questionnaire before cosmetic surgery. [21788842] [27930752]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology guideline on nasal form and function applies to patients aged 15 and over, and directs counselling to the caregiver when the patient is under 18. A plain language summary carries the same content for patients.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online textbook edited by Daniel G. Becker, carries two chapters on operating on the growing nose.

• Rhinoplasty in Children
• Pediatric Septoplasty

The reference summaries

On the National Library of Medicine's Bookshelf, at no charge.

• Septoplasty in StatPearls, the operation and its indications.
• Nasal Septal Fracture in StatPearls, including septal haematoma.
• Pediatric Facial Fractures in StatPearls, how a child's facial skeleton breaks and heals.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

The trials in progress

• Early Management of Fracture Nose in Pediatric Patients, not yet recruiting, 20 participants.
• Adenoidectomy With or Without Partial Inferior Turbinectomy for Pediatric Nasal Obstruction, completed, 60 participants.

What is not settled

• No randomised trial tests nasal surgery in children against waiting. The growth evidence is retrospective cohorts and cleft series measured at maturity. [36409217] [32332542] [28340652]
• There is no agreed age cutoff. Among surveyed pediatric otolaryngologists, 38.9% use none for septoplasty. [42462583]
• Most of the long-term growth data comes from cleft patients, whose noses differ from an otherwise normal nose with a deviated septum. [41949992] [41101813]
• Turbinate reduction in children rests on eleven small studies with outcome measures that cannot be compared. [19818515]
• No paediatric-specific outcome measure exists. The scores in use were built for adults, and the body dysmorphic disorder prevalence figures come from adult clinics. [42462583] [21788842] [27930752]
• Revision after paediatric rhinoplasty is reported at 9.4% in one centre and more often in the under-14s in another, on retrospective review. [23958392] [34976754]
• See also the journal archive on outcomes and psychology and revision rhinoplasty.