Complications of Rhinoplasty

1
Complications of Rhinoplasty

• Review of Literature
• Paul Foster, M.D.
• Discussant
• Robert L. Simons, M.D., F.A.C.S.

2
Goals

• Basics
• Anatomy
• Support mechanisms
• Discussion of complications
• Etiology
• Prevention
• Treatment

3
Tip Support

• Major
• Length and strength of medial and lateral crus
• Attachment of medial crura to septum
• Scroll
• Interdomal ligmentous sling

• Minor
• Septum
• Membranous septum
• Anterior nasal spine
• S-STE
• Lateral crural attachment to piriform aperature

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Overview

• Infection
• Trauma
• Necrosis
• Functional
• Iatrogenic
• Tip ptosis, Bossae
• Alar retraction
• Pollybeak
• Inverted V
• Nasofrontal angle
• Saddle nose

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Infection

• Surprising rate less than 3
• Perioperative Abx?
• Mild cellulitis to septicemia, cavernous sinus
  thrombosis, brain abscess.

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Antibiotics(as per Holt, Garner, McLarey)

• Active infection in the operative site
• Furuncle, sinusitis
• Nasal packing gt 24 hours
• Risk of packing, blockage of ostia
• Hematoma
• Alloplastic implants
• Abx soaks
• Graft infection risk

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Trauma

• Instability of nose after osteotomies and septal
  resections
• Splaying, lateral displacement, shard formation,
  septal dislocation, hematoma formation
• Long term bone formation from fibrous union, not
  osteoneogenesis
• Spouse, children, patient

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Necrosis

• Septal perf, saddle nose, skin necrosis,
  cartilage lysis.
• Increased risk with vascular compromise
• Grafts and skin necrosis
• Red, edematous skin blanching
• Change in casting/taping technique?

9
Functional

• Failure to address underlying cause of nasal
  obstruction
• Septal deflection, hematoma
• Valve
• Septal perforation
• Conservative treatment?
• Ozena

10
Iatrogenic Principles

• Simons sins of commission and omission
• Ortook off too much, didnt take enough off, or
  didnt do it symmetrically
• Secondary Rhinoplasty - 15 vs. True
  complications 10
• Patient dissatisfaction mostly from failure of
  understanding between the patient and surgeon

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Iatrogenic

• Minor Deformities
• Bossae
• Hanging columella
• Wide base
• Irregular dorsum
• Implant adjustment
• Acute nasolabial angle

• Major deformities
• Saddling
• Midnasal asymmetry
• Pollybeak
• Retracted ala
• Retracted columella

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Tip Ptosis

• inadequate rotation of the nasal tip or loss of
  tip projection. Quatela and Wayne, 2000
• Weakness of tip through standard techniques
• Transfixion
• Cartilage delivery
• Excessive excision of lateral crura
• Inter-cartilaginous incision

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Fix it

• Anticipation Avoidance
• Leave adequate LLC, avoid transfixion, place
  struts and tip grafts at initial surgery
• Correction restore symmetry, projection, and
  strength
• Strut
• Graft
• Tongue in groove
• Re-approximate LLCs
• Cartilage reinforcement to cephalic rim

15
Tip Bossae

• Etiology proposed factors
• Thin skin with show of tip alterations
• Interrupted strip techniques
• Malposition of alar cartilages
• Excessive horizontal cartilage excision
• Unrecognized asymmetry of lobular cartilages
• VDD without suture reconstitution
• Thin skin/firm cartilage/ intra-lobular bifidity
• Retrograde or cartilage splitting approaches

Gillman et al, 1999
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Bossae Quatela Wayne

• Thin skin - reveals any alterations
• Irregular cartilage alterations
• Contracture forces
• Alterations
• Dome division
• Overresection of lateral crura - buckling

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Gillman, Simons, Lee 1999

• 875 pts with 4.2 bossae rate
• Factors
• Females
• Primary rhinoplasty
• Lobular bifidity
• Thin skin
• Younger patients (12-22 yo)
• VDD 3.5 times less likely to result in bossa
  formation (when used with sutures) than an intact
  caudal strip procedure

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Fixing the Bossae

• Smooth contours with carving
• Onlay graft
• Reinforce LLC to prevent buckling
• Transdomal suturing

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Alar Retraction

• Irregular healing from aggressive resection of
  LLC
• Must differentiate from hanging columella

20
Repair

• Cartilage graft
• V-Y advancement
• Composite graft
• Reposition LLC
• Size relevance?

21
Polly Beak

• Hard
• Under-resection of cartilagenous dorsum
• Over-resection of upper third bony drosum
• Loss of tip projection
• Overridding LLC
• Soft
• Fibrous scar

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Polly Beak Pitfalls

• Temporary intraoperative false tip projection
• Overinjection of local anesthetic
• Edema and hemorrhage
• Delivery techinques
• Excessive traumatic tip surgery (?)
• Bunching columellar sutures falsely projecting tip

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Avoiding the Polly Beak

• Preserve tip support, dont over-resect
• Section of the depressor septi
• Regularly squeeze edema from S-STE
• Minimal Local injections

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Polly Beak Fix

• Grafting to bony dorsum
• Resect cartilage as needed
• Tip support
• Steroid injections
• Skin resections
• Taping?

25
Inverted V Deformity

• Pinched Middle Third
• Significant resection of dorsum with ULC
• Internal nasal valve collapse
• Correction
• spreader grafts
• Parks flaring stitch
• Paneillo suspension to orbital rim

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Saddle Nose Deformity

• Exessive dorsal septal resection
• Hematoma/infection
• Others
• Wegeners
• Syphillis
• Leprosy
• Neoplasm
• Lethal midline granuloma

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• Group I minimal saddle nose deformity (minor
  destruction of support, with persistence of both
  cartilage and bony support)
• Group II intermediate deformity (destruction of
  cartilage or bony support, with persistence of
  cartilage or bony support)
• Group III major saddle nose (major destruction
  of both bony and cartilaginous support, giving a
  bird-like appearance).