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Rhinoplasty: risks and pitfalls

Complications of Rhinoplasty
S.Valentine Fernandez

The operation of rhinoplasty demands a thorough understanding of an art and science.Some complications of rhinoplasty relate to anesthesia and do not fall within the bounds of this discussion.

Complications of rhinoplasty may be divided into 4 basic categories as follows: 

• Intraoperative
• Immediate post operative (in the recovery ward)
• Early postoperative
• Late postoperative

While recognizing obvious medical and surgical complications should present no difficulty, finer aesthetic complications are harder to define and are based on value judgments related to the aesthetic sense of the surgeon and the body-image demands of the patient Aesthetic sense is difficult to define, and it is much harder to agree on results. Aesthetics depend on variables, including the current fashion taste, the media, the public relations industry, and cultural and ethnic differences.

A practical approach to aesthetics in the nose begins with an accurate assessment. Frontal views define x-axis (width) and y-axis (height) deformities, lateral views define z-axis (depth/projection) and y-axis deformities, and basal views define x-axis and z-axis deformities. Based on these views, a 3-dimensional concept of the nose is made available for manipulation. The goal of rhinoplasty is to improve the existing harmony without causing functional impairment.

According to the literature, the complication rate for nasal surgery varies from 4-18.8%. In individual hands, this rate generally falls as surgical experience accumulates. Skin and associated soft tissue complications occur in up to 10% of cases. According to estimates, severe systemic or life-threatening complications occur in 1.7-5% of rhinoplasty cases. Intracranial complications are rare.

The clinical manifestation of rhinoplasty complications may broadly be classified as follows:

• Functional
• Infectious
• Aesthetic
• Psychological
• Specific to complication       

Intraoperative complication:

1. Excessive bleeding  2. Tears of mucoperichondrial flaps  3. Buttonholing of skin  4. Cautery burns

5. Collapse of bony pyramid:     

• Collapse of the bony pyramid may occur during removal of a bony hump with an osteotome, particularly when the patient has had previous nasal trauma or if the vomer or ethmoid have been weakened as a result of previous surgery. Rasping may be advisable in these circumstances.
• Rectification requires careful approximation of the segments and provision of adequate internal and external splint support during healing. 

6.  Disarticulation of upper lateral cartilage:  This complication may occur during rasping. Bilateral disarticulation produces an inverted-V deformity, and unilateral disarticulation produces asymmetry in the middle third of the nose. Spreader grafts may improve airway symptoms and aesthetics.

7. Osteotomy complications 

•  "Rocker" deformity: This deformity results when the medial osteotomy creates a cephalic fracture higher in the thicker part of the frontonasal junction. Attempted narrowing after the osteotomies results in lateralization of the superior segment of the fractured bones, based on a fulcrum at or about the radix. Repositioning the cephalic fracture lower on the nasal bone rectifies this deformity.

• "Open roof" deformity: When the lateral segments fail to align with the septal dorsum following osteotomies, a gap, which may be visually and palpably obvious, results. If neglected, the intranasal mucous membrane adheres to the overlying soft tissue and may create a depression at the site. If alignment failure is unilateral, the nose appears asymmetric. Correction involves assuring centralization of the septum and complete medial mobilization of the lateral segments following osteotomy. Usual causes of open roof deformity include the following:  

• Greenstick cephalic fracture during osteotomies (will return to its preoperative position)
• Failure to adequately mobilize the fractured segments medially
• Excessive nasal packing
• Uncorrected deviated perpendicular plate of the ethmoid (may prevent medialization of the lateral segments)

• "Step" deformity: This deformity may result if a single lateral osteotomy is performed too far medial to the nasofacial groove, with a visible ridge on the side of the nose. Correction involves repeating the osteotomy at the correct level. 

8. Perinasal trauma: During osteotomy, particularly in noses that have previously been traumatized, there is a tendency to recreate preexisting fractures. The proximity of the orbit and cranium renders these structures most susceptible to such occurrences. Malfunction can result directly or can manifest subsequent to infection.

Immediate post operative complications: 

1. Airway obstruction 2 Anaphylaxis: This is a distinct possibility when intraoperative antibiotic medication is used. Anaphylactic shock subsequent to bacitracin nasal packing has been reported, and latex anaphylaxis is well document 3. Visual impairment

Early post operative complications:                                                              
1. Hemorrhage: Reported prevalence of hemorrhage varies from 2-4%.   2. Septal hematoma:

3. Infection:  Wound infection, Septicemia, Toxic shock syndrome, subacute bacterial endocarditis, intracranial infections, and acute &/or chronic sinusitis.

4. Dehiscence of incisions: The transcolumellar incision must be attended to immediately, or a scar will form, contributing to a poor result.

5.Persistent edema: Persistent edema and numbness over the nasal tip region may occur following external rhinoplasty and may last several months. This is not a problem if the patient has been forewarned.

6. Skin necrosis: Excessive undermining, injudicious cautery use, and overzealous skin thinning may lead to skin necrosis. This may cause an impaired blood supply and infection. Similarly, a tight dressing may cause vascular impediment and skin necrosis. Debridement and secondary healing is encouraged if necrosis occurs. Later, local steroid injection, dermabrasion, laser modification, and/or flap reconstruction may be necessary to aid scar aesthetics. Skin necrosis may also result from dorsal augmentation, in which case removal of the augmenting material may be necessary.

7. Sequestra formation, 8. Cardiovascular insufficiency 9. Cerebrospinal fluid rhinorrhea 10. Contact dermatitis 11. Nasal blockage 12. Numbness and pain 13. Olfactory disturbance:  Patients with past facial trauma may be predisposed to injury of the olfactory apparatus during osteotomy. 14. Carotid-cavernous fistula 15. Reassurance demand:  A small number of patients need the surgeon to repeatedly express that the nasal blockage will disappear, the smell and taste sensation will return, the teeth anesthesia will subside, and the tip projection and swelling will decrease in time.Early psychological complications: Transient episodes of anxiety or depression are not uncommon and may last up to 6 weeks after the operation

Late postoperative complications

1. Scar hypertrophy: This may detract from a good result following an external rhinoplasty. Skin loss from infection and necrosis is a disaster. Aim initial attempts at reducing the size of the scar with intralesional steroids. Further treatment could include dermabrasion, lasers, and/or surgical scar revision.
2. Polly beak nasal deformity-This deformity is characterized by absence of the supratip dip (ptosis tip)  may present in degree.

3. Synechiae formation  4. Septal perforation: The prevalence of this complication has been described as 3-24.5%.

5. Nasal valve collapse: Aggressive cephalic trim of the lower lateral cartilages may provoke this complication. Collapse may cause airway distress and is a source of patient discontent. Cartilage spreader grafts may prove useful for internal valve collapse. Alar batten grafts improve external valve collapse.

6. Nasal stenosis  This is a disaster when it occurs, and it may be related to circumscribed incisions with excessive lining removal. Stenosis causes airway obstruction and is a source of persistent discomfort. Reconstructive surgery may provide some relief.

7. Bossa formation

• Bossae are protuberances that may arise in the region of the nasal tip. Their postoperative incidence is quoted at 2%.
• While bilateral symmetric occurrences may assume a pleasing appearance, bilateral asymmetric and unilateral bossae demand surgical attention. During operation, ensuring that the remnant lower lateral cartilages are of equal dimensions on both sides is important.
• Bossae usually occur in noses with preoperative asymmetry, use of destructive rhinoplasty techniques, thin skin, and excessive postoperative scarring. The triad of thin skin, strong cartilages, and bifidity also indicate the patient who is prone to the development of bossae. Tip graft movement may also contribute to bossa formation. 

8. Recurrent meningitis, 9. Oleogranuloma  10. Dorsal cyst:

11. Aesthetic surgical misjudgments

• Undercorrection or overcorrection of a preexisting deformity leads to either persistence of the deformity or to introduction of a new one. A new deformity may introduce a functional deficit. Some of these deformities are illusory, and correction only follows after an accurate diagnosis is made. Ideally, revision rhinoplasty should not be performed until at least 12 months after the initial operation.
• These deformities may occur singly or in combination and may relate as an x-axis (width), y-axis (height), or z-axis (depth) deformity/deformities in the various segments.

Upper third deformities 
Deep nasofrontal angle, Shallow nasofrontal angle, Upper third widening, Upper third convexity, Upper third overreduction:,  & Upper third asymmetry.

Middle third deformities 
Middle third widening:, Middle third convexity, Middle third saddling,  & Middle third asymmetry

Lower third deformities
Lower third widening or flaring,  Tip widening or boxy tip, Tip narrowing or pinched tip, Tip asymmetry,   Tip projection deformities, Wide columella, Hanging columella or "columella show", "Hanging" or "veiled" alae , Alar notching, Nostril asymmetry, Retracted nasolabial angle, Protracted nasolabial angle,   &

Alar collapse: Excessive removal of the lateral crura dampens support afforded by these structures, causing alar collapse and airway discordance. Reconstructive techniques with alar battens may be necessary in difficult cases.

Other

• Graft/implant migration: Migration may comprise resorption, displacement, or extrusion; it may be provoked by trauma and infection. Allografts have a higher extrusion and infection rate than autografts. An infected implant must be removed if antibiotics do not help. Revise displaced grafts causing aesthetic inconvenience with appropriate stabilization.

• The disproportionate nose: This nose does not fit the face and is not a credit to the surgeon's artistic skill. Reconstructive rhinoplasty techniques follow the patient's expression of discontent with original results.
• Underlying maxillofacial deformity: A superb rhinoplasty result may be ruined by the unmasking of a previously unnoticed or undiagnosed maxillofacial deformity. The maxillae and mandible with labial and dental components must be considered preoperatively and the patient must be forewarned. Attendance by a cosmetic dentist and inclusion of chin surgery may be necessary.

A revision rhinoplasty may be required in 5-15% of patients. Any attempt at correction must always be accompanied by a rider promising only improvement and warning that a further "touch-up" operation may be necessary.

Persistent psychological complications: Several contradictory studies are available.
Thoracic and thoracolumbar instability, Gustatory rhinorrhea, Human adjuvant disease:, Lacrimal fistula, Enophthalmos and silent sinus syndrome. 

For more detailed analysis see:
http://emedicine.medscape.com/article/843439-overview#showall

Some other complications not mentioned above: Neuropathic pain (temporary or permanent),  Empty Nose Syndrome, Graft warping and resorption and complications from injectable material in the nose. For more info on this subjects check out  my other blog posts. (See labels on right side column of my blog and click on any of the labels.)

See also:
http://www.youtube.com/watch?v=sj4RrAlAwXo
http://yourguidetoplasticsurgery.com/rhinoplasty-risks
http://www.emptynosesyndrome.org/what_is_ens.php
http://www.therhinoplastycenter.com/ComplicationsofRhinoplasty/complications1.html

Refining the nasal tip with Newer VDD techniques.

Vertical Dome Divison Rhinoplasty: 
 Author: John Hilinski, CoAuthors: Anil R. Shah & Kris S Moe

Nasal tip surgery is among the most complex and difficult tasks in rhinoplasty surgery. Vertical dome division (VDD) is one of a variety of techniques that may be used in refining nasal tip appearance. Collectively, vertical dome division (VDD) refers to one of many methods of vertically dividing the lower alar cartilage at or near the dome to modify nasal tip aesthetics. The technique was originally recommended as an alternative in altering tip projection and appearance while minimizing use of implants and the degree of postoperative tip ptosis. Vertical dome division (VDD) targets various nasal deformities, including overprojection or underprojection, suboptimal rotation, disproportionate lobule ratios, and broad or asymmetric tip. The surgeon must strive to achieve an aesthetically pleasing nasal tip that is in balance with the remainder of the nose without compromising nasal airway function.

The typical patient presenting for vertical dome division (VDD) usually has a poorly defined or malpositioned tip with a combination of abnormal projection/rotation, broad or amorphous lobule, asymmetric tip defining points, and/or boxy, trapezoidal base.

Adherents to this principle argue that horizontal excisional techniques rely too heavily on unpredictable and uncontrollable postoperative scarring to produce desired tip results. Proponents of vertical dome division (VDD) believe that vertical incisional and excisional techniques, on the other hand, offer a more definitive and reliable means to achieve desired tip changes.

In principle, the technique of vertical dome division (VDD) separates the medial and lateral crura into 2 independent units. By transecting the dome, the inherent spring within the arch is released and allows realignment of the newly divided medial and lateral segments to reconstruct the nasal tip.

Vertical dome division (VDD) is typically reserved for more complicated cases that require greater changes to effect tip refinement than could be achieved using other techniques. Nearly all variations of vertical dome division (VDD) used today involve some modification of the original Goldman technique

The lobule is defined as the portion of the nasal tip complex that is situated anterior to the nostrils; it extends from the tip defining point to the junction with the columella, as observed on base view. The alar cartilage (lower lateral cartilage) is C-shaped and can be divided into the medial, middle, and lateral crus. The middle (intermediate) crus comprises the domal segment and largely influences the shape of the lobule and, therefore, the form and definition of the nasal tip. The dome is considered the highest arching segment within the nasal vestibule.

The lobule size can be assessed in comparison to the columellar length. If the base view demonstrates a columellar-to-lobule ratio of approximately 2:1, the structural support and configuration of the nasal tip is considered adequate. A long nasal length reflects an acute nasolabial angle; a short length reflects an obtuse nasolabial angle.

The anatomy of the nasal tip is often described using the tripod concept to facilitate understanding of the key structural components and to provide a simple explanation of tip dynamics. According to this analogy, the cartilaginous framework of the lower third of the nose is compared to a tripod that is attached to the facial frontal plane. The 2 individual lateral crura represent 2 legs of the tripod, and the conjoined medial crura and caudal septal attachments correspond to the third leg.

By lengthening or shortening any or all legs of the tripod, the changes that will be effected in tip projection and rotation can be predicted. For instance, techniques that augment or lengthen the medial crural segment enhance projection. Shortening the medial crura or disrupting their septal attachments without reduction of lateral crural length decreases projection and rotation of the nasal tip. Shortening the lateral crura and maintaining or lengthening the medial crural segment would be expected to increase rotation.

Contraindications

Vertical dome division (VDD) is predominantly contraindicated in patients with relatively thin skin. These patients are particularly prone to developing visible cartilage edges along the nasal tip region. This results from contraction of the thin overlying skin and soft tissue envelope around the new and more prominent medial cartilaginous strut. A thick overlying skin and soft tissue envelope is better able to cushion the appearance of prominent cartilaginous structures, such as those in vertical dome division (VDD).

Avoid classic vertical dome division (VDD) in patients who show evidence of already weakened lateral nasal walls. Dividing the domal region without reapproximation of the cartilage segments disrupts the integrity and continuity of the lower lateral cartilage. The lateral nasal wall is more susceptible to structural collapse than the newly reinforced medial footplates. As a result, lateral wall weakening and collapse are further potentiated.

The original technique is highly focused on manipulation and repositioning of only the medial crura, with no attempt made to reconstruct the remaining lateral crural segment and alar rim. Postoperatively, the medial crura and columella are sufficiently stable to resist loss of projection. Some loss of lateral support, which could result in lateral wall collapse and alar retraction, may occur. Vertical dome division (VDD) is also associated with bossae formation. This is most frequently seen in patients with thin skin and firm cartilages. Disruption of the underlying vestibular mucosa and skin, such as in the Goldman technique, also predisposes the patient to possible stenosis.

With use of newer modified techniques (Hockey stick excision, Lipsett, Simons, Adamson, and others) and caution, vertical dome division (VDD) can be used successfully in nasal tip refinement with limited postoperative complications and reliable long-term results. 

Most practitioners using vertical dome division (VDD) today perform some modification of the original Goldman tip procedure.

Adamson reported that approximately 5% of patients required revision surgery for postoperative tip abnormalities and irregularities attributed to use of vertical dome division (VDD).^[10] These abnormalities were primarily nasal bossae and lobule asymmetries. Abnormalities were nearly 3 times as likely to occur in revision cases as in primary rhinoplasty; incidence was lower with use of the incision and overlap method.

 Vertical dome division (VDD) is likely to remain controversial in the future. As knowledge of nasal tip surgery evolves, so too will further modifications of our existing tip techniques to attain more predictable outcomes.
 http://emedicine.medscape.com/article/841313-overview

The Endonasal Approach to Rhinoplasty
Robert L. Simons and Lisa D. Grunebaum Ch.68 Rhinology and Facial Plastic Surgery 

Today's trends in nasal tip surgeries are for improved visualization with preservation of the cartilage as well as better medial stabilization and support. These tenets are inherent in vertical dome division techniques. It is important to remember that VDD is an incisional technique that allows for repositioning of the nasal tissue and should not be combined with excisional techniques. One should always leave behind more than one takes. Preservation of at least 6-8mm of lateral crus will help prevent alar collapse and help stabilize the nasal base as well as allow for a strong natural-appearing tip.VDD allows for narrowing, rotation, and change in tip projection by repositioning rather than excision of any sizable amount of cartilage.

The Effectiveness of modified VDD Technique in reducing nasal tip projection in rhinoplasty

B.Gandomi, M.H. Arzaghi, M. Rafatbakhsh

The employed technique is a new modification of previous techniques. 3-10 The technique employs an open approach in which a strong columellar strut inserted and a portion of crura is removed near the dome (the cornerstone of our new technique of tip surgery). Depending on the deformity, this segment may involve intermediate, middle or lateral crura with or without removal of vestibular skin considering its thickness: thin skins are not resected, but thick skins are usually removed.

Our technique involves the overlapping of the incised edges of the medial and lateral segments, and suture approximation to restore the integrity of the alar cartilage. The technique allows a more stable configuration for the maintenance of nasal tip support. The overlapping and reapproximation of the medial and lateral units ensure the long-term stability of the newly reconstructed nasal tip complex, and reduce the tendency towards postoperative cartilaginous abnormalities that may accompany scar fibrosis and contracture. 

 http://ijms.sums.ac.ir/files/PDFfiles/07-Dr.%20Gandomi.pdf