Once you have chosen a surgeon, a patient should have a candid discussion with the surgeon regarding the goals and expectations of surgery. A discussion of the potential complications is critical, so that you understand the risks of a complication and the types of complications that can occur.
Although most complications are relatively minor and correctable, more serious and debilitating complications do occur. Despite the best efforts of talented surgeons, unanticipated technical problems can and do occur during surgery that can lead to a complication. Surgery is not an exact science, and results cannot always be anticipated. Despite careful pre-operative analysis and meticulous attention to surgical detail, unacceptable results may still occur.
No surgical procedure should be taken lightly; a slight but real risk is involved in all surgery. Cosmetic surgical procedures have been repeated successfully countless times and are dependable when executed by skillful, experienced surgeons. Plastic surgery is a combination of art and science, and as such can be subject to unpredictables – usually (but not always) minor in nature.
One of the ways a surgeon can decrease the risk of complications is by carefully studying and understanding the types of complications that can occur, and how to avoid them. Dr. Becker was asked to write the important chapter entitled "Complications in Rhinoplasty" in the Medical Textbook, Facial Plastic and Reconstructive Surgery. Dr. Becker was asked to share his knowledge of rhinoplasty, to help other surgeons understand some of the types of complications that can occur, so that they could possibly minimize the risk of complications in their own practice. To read this chapter, continue below.
Complications of Rhinoplasty – Page 1
Daniel G. Becker
The nose plays a functional role in nasal breathing, as well as an aesthetic role as it represents the most prominent and central facial feature. That the nose has enormous psychological, emotional, social, and symbolic importance is indisputable. ) Most studies suggest that the great majority of rhinoplasty patients benefit psychologically from the operation. ‘ While rhinoplasty can be a satisfying procedure for both patient and surgeon, the literature reports an incidence of postoperative rhinoplasty complications ranging from 8% to 15%. 2-1 The rhinoplasty surgeon must take great care to minimize the incidence of both functional and cosmetic complications.
How is a "complication" defined? In most cases with an unacceptable result, the patient and surgeon recognize an unac ceptable result, and a corrective plan is agreed upon. At times, the surgeon may notice a relatively subtle abnormality that is amenable to correction, but the patient is not concerned by it. It should be a rare situation that the surgeon is proud of the outcome while the patient is displeased. 5
A candid discussion with the patient regarding the goals and expectations of surgery is an essential aspect of preoperative planning. A discussion of the potential com plications is critical, so that the patient understands the risks of a complication. Although most complications are relatively minor and correctable, more serious and debilitating complications do occur. All complications must be addressed with forth-right recognition, close attention to the patient, and appropriately timed corrective measures.
Careful preoperative anatomical diagnosis and a conservative approach guided by an understanding of the postoperative changes that occur during healing are critical in minimizing complications. Failure to recognize the precise anatomical cause of a nasal feature may result in failure to effect the desired change. Problems with technical execution is another potential cause. Despite careful preoperative analysis and meticulous attention to surgical detail, less than ideal aesthetic results may still occur.
Complications in rhinoplasty may be categorized as func tional or aesthetic in nature; often, there are elements of both. In considering this subject, it may also be helpful to organize aesthetic complications by the specific nasal subunit affected.
Problems after rhinoplasty commonly relate to issues of underresection, overresection, and/or asymmetry. In general, it is easier to address a problem relating to underresection because the surgeon needs only to "take a little more."
Problems relating to overresection can be difficult, and are often complicated by scarring, need for graft material, and other issues.
Anatomical diagnosis is helpful in the prevention of com plications and is also critical in the proper evaluation and treat ment of complications when they occur. In this chapter we will address many of the more commonly described surgical com plications with special attention to their cause and treatment. Emphasis is placed on the anatomical basis of each complica tion, as this approach provides a guide to correction. Although complications have been generally arranged by anatomical location, there are some topics that cross categories.
In the nasal tip, overreduction may violate critical tip sup-port mechanisms (Table 391) which can lead to complications such as tip ptosis and inadequate tip projection (see below).
TABLE 391 Tip Support Mechanisms
Major tip support mechanisms
- Size, shape, and strength of lower lateral cartilages
- Medial crural footplate attachment to caudal septum
- Attachment of caudal border of upper lateral cartilages to cephalic border of lower lateral cartilages
[Nasal septum is also considered a major support mechanism of the nose.]
Minor tip support mechanisms
- Ligamentous sling spanning the domes of the lower lateral cartilages (i.e., interdomal ligament)
- Cartilaginous dorsal septum
- Sesamoid complex of lower lateral cartilages
- Attachment of lower lateral cartilages to overlying skin/soft tissue envelope
- Nasal spine
- Membranous septum
Alternatively, overresection of the caudal septum can result in overrotation of the nasal tip with excessive shortening of the nose. Overresection may also contribute to other complications, such as bossae, alar retraction, and alar collapse.
Underreduction may simply be due to overcaution but may also be due to a failure to correctly assess preoperatively the anatomical situation. For example, failure to recognize an overprojected nose or to diagnose the steps required based on the patient’s anatomy to adequately address this can lead to a persistent overprojected state. Failure to adequately resect cartilaginous dorsum may result in a pollybeak deformity.
Asymmetry of the nasal tip may be due to unequal reduction of the lower lateral cartilages or to asymmetrical application of dome-binding sutures. ‘ It may also be caused by unequal scarring that can occur during the natural healing process and may not be evident for months or even years after surgery. Asymmetry is often present preoperatively and should be recognized and pointed out to the patient prior to surgery.
A critical principle in avoiding undesired changes of the nasolabial angle is assessment of tip anatomy and tip sup-port, followed by maneuvers that maintain or augment tip support and restore the nose to a more natural appearance. However, as mentioned above, maneuvers that result in loss of tip support may lead to a droopy tip (tip ptosis with an overly acute nasolabial angle). The normal nasolabial angle (angle defined by columellar pointtosubnasale line intercepting with subnasaletolabrale superius line) is 90 to 120 degrees. 12 Within this range, a more obtuse angle is more favorable in females, a more acute angle in males. Loss of tip support can lead to a ptotic, underprojected, drooping nose.
Management of complications relating to a ptotic nose relies on restoration of tip support and tip projection. When faced with an operative complication such as a droopy, ptotic tip, appropriate diagnosis will guide correction. ‘ There are numerous rhinoplasty maneuvers to increase tip support, reproject the nose, and rotate the nose (Table 392).
Conversely, one may face a patient with a nose that has been overrotated, with an overly obtuse angle. Overresection of the caudal septum is a common cause of overrotation of the tip. Overrotation of the nose creates an unsightly, overshortened appearance.
Careful preoperative assessment can identify those patients in whom operative rotation should be avoided. Man agement of complications relating to a short, overrotated nose relies on maneuvers that lengthen and counterrotate the nose.’ There are specific rhinoplasty maneuvers to lengthen and counterrotate the nose (Table 392).
A bossa is a knuckling of the lower lateral cartilage at the nasal tip due to contractural healing forces acting on weak ened cartilages. Patients with thin skin, strong cartilages, and nasal tip bifidity are especially at risk. Excessive resection of lateral crus and failure to eliminate excessive interdomal width may play some role in bossa formation. Bossae are felt to be the result of scar contracture on an overly narrowed complete rim strip, causing a bulge during postoperative healing. Some investigators have described an association between cartilage splitting techniques and bossa formation. ‘ However, others maintain that vertical dome division tech niques are reliable when performed correctly and do not con -tribute to these difficulties.
As an isolated deformity, bossae are typically treated through a small marginal incision with minimal undermining over the offending site followed by trimming or excising the offending cartilage. In some cases, the area is covered with a thin wafer of cartilage, fascia, or other material to further smooth and mask the area.
TABLE 392 Operative Maneuvers
Lateral crural steal
Transdomal suture that recruits lateral crura medially Base-up resection of caudal septum (variable effect) Cephalic resection (variable effect) Lateral crural overlay
Columellar strut (variable effect) Plumping grafts (variable effect)
Illusions of rotationincreased double break,
plumping grafts (blunting nasolabial angle)
Decrease rotation (counterrotate)
Double-layer tip graft
Shorten medial crura
Caudal extension graft
Reconstructed L strut, as in rib graft reconstruction (integrated dorsal graft/columellar strut) of saddle nose
Lateral crural steal (increased projection, increased rotation)
Septocolumellar sutures (buried) Columellar strut (variable effect) Caudal extension graft
High partial- or full-transfixion incision
Lateral crural overlay (decreased projection, increased rotation)
Nasal spine reduction
Vertical dome division with excision of excess medial crura, with suture reattachment
Caudal extension graft Radix graft
Double-layer tip graft Reconstructed L strut
See increased rotation
Also, deepen nasofrontal angle
Cephalic resection of the lateral crus of the lower lateral carti lage is commonly undertaken to effect refinement of the nasal tip. If inadequate cartilage is left, then the contractile forces of healing over time will cause the ala to retract (Fig. 39 1). This is a commonly seen sequela of overresection of the lateral crus. The surgical rule of thumb is to preserve at least 6 to 9 mm of complete strip. Nevertheless, an anatomical study of the alar base recognized that in a normal patient population 20% of patients have a thin alar rim. This anatomical variation must be recognized, as these patients may require even more conservative approaches to avoid the risk of alar retraction and/or external nasal valve collapse . Also, vestibular mucosa should be preserved, as excision of vestibular mucosa contributes to scar contracture with alar retraction.
Alar retraction may be treated by cartilage grafts in more minor cases. The area of retraction is marked prior to injection, and a small marginal incision allows dissection of a precise pocket. A contoured cartilage graft (commonly of auricular or septal cartilage) may be inserted into the precise pocket; it should extend inferiorly to the sesamoids and be wide enough to simulate the normal shape of the lateral crus at the dome.
Auricular composite grafts are commonly used in more severe cases. The cymba concha of the opposite ear (e.g., left ala, right ear) provides the best contour. An incision several millimeters from the nostril rim is followed by careful dissection with freeing of adhesions, creating a defect and displacing the alar rim inferiorly. The fashioned composite graft is carefully sutured into place.
Alarcolumellar disproportions can be areas of significant patient concern. The range of normal columellar show is generally considered to be 2 to 4 mm. The complexities of the alarcolumellar relationship have been categorized by Gunter and colleagues, who describes the position of the ala and the columella in relationship to a line drawn through the long axis of the nostril. All patients have a hanging, normal, or retracted ala and a hanging, normal, or retracted columella. Thus, there are nine possible anatomical combinations making up the alarcolumellar relationship (Fig. 392).
Alarcolumellar disproportion may exist in the unoperated nose; also, it may be caused by surgical misadventure (Fig. 391). A protruding or hanging columella may be due to a persisting uncorrected deformity, such as an overly wide medial crura or an overly long caudal septum.’ The deformity may be increased columellar show secondary to retraction of the alar margins rather than an actual protrusion of columella. A deficient or retracted columella may be due to a preexisting uncorrected deformity, or it may be due to exces sive resection of soft tissue, cartilage, or nasal spine. The sur geon should avoid excessive resection of the caudal septum, and should avoid resection of the nasal spine.
Management of a protruding or hanging columella may include resecting full-thickness tissue from the membranous columella, including skin, soft tissue, and perhaps a portion of the caudal end of the septum itself. If the medial crura is excessively wide, management may include a conservative excision of the caudal margin of the medial crura.
Retracted columella may be improved with plumping grafts inserted at the base of the columella to address an acute nasolabial angle; columellar struts may also be helpful for minor deformities. A cartilage graft may be used to lengthen the overshortened nose. The use of composite grafts has also been described.
Figure 392 The alarcolumellar relationship can be described with nine possible anatomical combinations. (From Toriumi DM, Becker DG. Rhinoplasty Dissection Manual. Philadelphia : Lippincott Williams & Wilkins; 1999. With permission.)
A pollybeak refers to postoperative fullness of the supratip region, with an abnormal tipsupratip relationship (Fig. 393). This may have several causes, including failure to maintain adequate tip support (postoperative loss of tip projection), inadequate cartilaginous hump (anterior septal angle) removal, and/or supratip dead space/scar formation.
Management of the pollybeak deformity depends on the anatomical cause. If the cartilaginous hump was underresected, then the surgeon should resect additional dorsal sep tum. Adequate tip support must be ensured; maneuvers such as placement of a columellar strut may be of benefit. If the bony hump was overresected, a graft to augment the bony dorsum may be beneficial. If pollybeak is the result of excessive scar formation, Kenalog injection or skin taping in the early postoperative period should be undertaken prior to any consideration of surgical revision.
The external rhinoplasty approach includes a columellar incision. Great care must be taken when making this incision not to bevel it but rather to ensure that the incision is perpendicular to the skin, thereby avoiding the complication of a trapdoor deformity. Great care must be taken in closing the incision to avoid notching at the margins or other deformity (Fig. 394).
A single subcutaneous 6-0 polydioxanone (PDS) suture can be positioned in the dermal tissues to enhance skin edge eversion and take tension off of the closure. This suture should provide skin edge alignment and slight eversion. Excessive eversion will create a deformity that may require many months to resolve. The level of the skin edges must be precisely aligned with this suture; otherwise an unsightly scar may result. if there is no tension on the closure, a subcu taneous suture may not be needed.
To close the skin, five 7-0 nylon vertical mattress sutures are used. The first suture lines up the apex of the inverted V. The next two sutures are angled from medial on the lower flap to lateral on the upper flap to properly align the closure. A 6-0 chromic suture is used to line up the vestibular skin at the corner of the columellar flap. This corner suture is impor tant because aberrant healing of this corner can result in a visible notch defect.
Figure 39-3 Patient with overresected bony dorsum and underresected cartilaginous dorsum. Her pollybeak deformity was due to persistent cartilaginous dorsum and was therefore corrected by additional excision of cartilaginous dorsum. Her overresected upper nasal third was augmented to create a more balanced profile. (A) Preoperative lateral view. (B) Postoperative lateral view.
Figure 39-4 Special attention should be given to the columellar incision, and to its closure, when undertaking external rhinoplasty. Great care should be taken to perform these maneuvers properly (see text) to avoid a visible deformity. (From Toriumi DM, Becker DG. Rhinoplastp Dissection Manual. Philadelphia : Lippincott Williams & D Wilkins; 1999. With permission.)