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- Managing the Nasal Tip
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- Complications in Rhinoplasty
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- Injury After Rhinoplasty
Complications in Rhinoplasty
Complications in rhinoplasty may arise because of several reasons. One of the most important factors responsible for the success of surgery is the surgeon. The surgeon needs to have complete knowledge of how the surgery has to be performed. Rhinoplasty is demanding and requires physical strength, an artistic sense, attention to detail, and patience. A rhinoplasty surgeon must therefore be selected carefully only after checking all credentials and experience. Dr. Sam Rizk is a board-certified facial plastic surgeon who has met all of the ABFPRS standards. Click here to learn more about Dr. Rizk’s board certification.
Complications can be defined as any unforeseen occurrence during or after the surgery. It is important to have an understanding of how to deal with complications so that the surgery can be called a success. The complications that can occur during or after rhinoplasty can be divided into four categories:
- Intra operative complications are the ones that occur during the surgery. For example, these can occur due to a reaction to some medication or due to the local or general anesthesia given.
- Immediate post operative complications are the ones that occur immediately after the surgery when the patient is in the initial recovery stage and may include bleeding or a medication reaction and can be corrected immediately. These complications need to be handled immediately by the surgeon who performed the operation.
- Early post operative complications in rhinoplasty are the ones that occur once the patient has been discharged. These appear almost immediately after the person returns to normal routine. It can include bleeding or a medication reaction, and can be corrected by contacting the doctor immediately. For these complications, the patient needs to contact the surgeon who performed the surgery.
- Late post operative complications associated with rhinoplasty are the ones that occur when the patient fails to take proper care after the surgery. They may also be due to the nose not healing well independent of a successful operation. These complications show affect after the patient has almost recovered from the surgery. The patient needs to consult the surgeon almost immediately to treat these complications.
Most of the complications are minor and can be corrected easily. However, there may be a few of these that can lead to severe problems with the patient’s nose structure and functionality. These complications may be due to improper surgical procedures or IMPROPER HEALING on the patient's part. To avoid all these complications, the patient needs to discuss the case with the selected surgeon. Dr. Rizk strongly suggests that the patient have some knowledge about the surgical process and must follow post surgery care instructions for complete recovery as early as possible.
In case the surgery has not been done in a proper manner or the complications are not treated by the surgeon successfully, a variation of rhinoplasty called revision rhinoplasty can be opted for by the patient.
The following is a list of specific complications that can occur with rhinoplasty, some are cosmetic and some are functional breathing issues. Realize that this list is comprehensive but generally these complications are rare, although can occur even in the best of hands as the healing process and many other factors play a role in a successful rhinoplasty.
1. INADEQUATE PROJECTION OF TIP: The most common complication after rhinoplasty is inadequate tip projection. The problem may result if the tip is not supported with a cartilage graft in a patient who had a large dorsum or hump reduced. Sometimes this hump is supporting the tip and when the hump is reduced, the tip needs some other form of support to prevent it from becoming underprojected or droopy. A simple reduction rhinoplasty will accomplish adequate dorsal hump reduction, but it will not produce adequate tip projection. Furthermore, after sculpturing the lower lateral cartilages, the surgeon can expect further loss of tip projection. All rhinoplasties cannot be simple reductions. The surgery usually requires reduction, augmentation, or both. Prevention of inadequate tip projection begins with correct preoperative assessment. Dr. Sam Rizk, a New York City facial plastic surgeon and rhinoplasty expert, recommends evaluating the extent of tip projection as well as septal support in the preoperative assessment. Nasal tip projection is assessed as adequate, inadequate, or excessive. Septal support is determined by simple palpation of the nasal tip. If the nasal tip is well supported by septal cartilage, the surgeon can conclude that the nose has adequate septal support. Once nasal tip projection and septal support are determined, the surgeon can decide on the appropriate surgical course. The treatment of a patient with inadequate tip projection depends on the adequacy of septal support. A patient with inadequate tip projection and good septal support may only require onlay cartilage grafts to the nasal tip. The same patient with inadequate septal support will require columellar struts or umbrella graft. (DR. RIZK HAS EXAMPLES OF THIS DEFORMITY IN HIS PHOTO GALLERY WHICH HE CORRECTED)
2. SADDLE NOSE DEFORMITY
Saddle nose deformity where the nasal dorsum is too low in the cartilaginous portion, the bony portion or both can result from many reasons such as surgery, trauma, nasal fractures, or a septal perforation. The most common cause of saddle nose deformity is surgery, especially overaggressive surgery. When the deformity is the result of rhinoplasty, it is caused by over-reduction of the dorsal septal cartilage, nasal bone, or both. Another cause of saddle nose deformity is the dislocation of the dorsal strut at the osseo-cartilaginous junction following septal surgery. Surgically produced nasal deformities can be prevented through good surgical technique. For example, the reduction of the nasal bones should always be done with a rasp rather than an osteotome. The rasp offers much better control and reduces the nasal bones more evenly. Dr. Sam Rizk has further introduced a new technology to rhinoplasty surgery using 3d high definition telescopes to visualize the nasal dorsum better during the surgery and precisely change it, thereby, reducing the risk of a saddle nose deformity. If saddle nose deformity occurs, it can be corrected by augmenting the nasal dorsum with autogenous cartilage or bone grafts or the use of rib cartilage grafts or the use of alloplastic implants such as medpor. Dr. Rizk custom sculpts the medpor implant to fit your nose during your procedure, It is not a one size fit all implant. Dr. Rizk has introduced new technology to better sculpt cartilage grafts and make their edges smoother and nonpalpable on the nasal dorsum. (PLEASE SEE OTHER SECTIONS AND PHOTO GALLERY TO SEE EXAMPLES OF PATIENTS THAT DR RIZK CORRECTED WITH SADDLE NOSE DEFORMITY)
3. THE HANGING COLUMELLA
Another common problem in primary and secondary rhinoplasty is the hanging columella. This problem can occur from excess caudal septum or occasionally from excessive medial crural footplate. It can also occur from excessive or lack of reduction of the membraneous septum in the rhinoplasty. Prevention of this problem is simple and requires adequate reduction of the caudal septum and evaluating the medial crural footplates to see it they cause the hanging columella. Dr. Rizk also believes the membraneous septum is important to reduce in order to prevent this complication. Surgical treatment of the hanging columella involves shortening the caudal end of the septal cartilage and trimming the anterior nasal spine if necessary or reducing the membraneous septum. In shortening the posterior end of the caudal septum, the surgeon should attempt to produce a 90 degree nasolabial angle in men and 100 degree angle in women.
4. SUPRATIP DEFORMITY (POLLYBEAK DEFORMITY)
The supratip, or pollybeak deformity is characterized by a high supratip septum or fullness in the supratip region from thick skin. This usually coexists with inadequate tip support and may be a relative visual drop of the tip that is causing the pollybeak, rather than a true pollybeak, or it may be both a true pollybeak and a tip drop. To avoid this complication, Dr. Sam Rizk recommends lowering the supratip dorsal septum adequately and correcting inadequate tip projection. If necessary, in thick skinned ethnic patients, the supratip thick skin needs to be debulked as well. Treatment of this deformity involves reducing the dorsal septum combined with possible debulking of the thick skin in the supratip region. Restoring tip support and projection may also be necessary with various grafting techniques.
5. THE BROAD NASAL TIPThe complication of a broad nasal tip may result from the inability to refine and narrow the nasal tip during the rhinoplasty. After a basic rhinoplasty, the surgeon may find the nasal tip remains too wide or broad. An untreated broad nasal tip will yield an unsatisfactory aesthetic result.
To prevent a broad nasal tip from occurring, Dr. Sam Rizk recommends first diagnosing the problem preoperatively and knowing how to correct it intraoperatively. This is one of the most common reasons patients seek Dr. Rizk from around the globe for revision rhinoplasty. Dr. Rizk has specialized techniques he has developed which enable better tip definition and involve a combination of suture and cartilage grafting techniques. Dr. Rizk also has pioneered high definition 3d -sculpting and debulking techniques for thick skinned ethnic nasal tips. (See Dr Rizk's published articles on these techniques in media section of website)
6. THE LONG NOSE
The long nose is excessively long from the glabella to the nasal tip. This problem results from inappropriate shortening of the caudal septum. The long nose is treated by reduction rhinoplasty and by shortening the posterior portion of the caudal septum. In decreasing the long nose, Dr. Rizk recommends decreasing the distance from the root of the nose to the nasal tip by shortening the caudal end of the septum. It usually involves rotating the nasal tip as well. Dr. Rizk believes sometimes a nose can look unnaturally long after a rhinoplasty because the area between the eyes (nasofrontal angle) rises and is filled with scar tissue or a raised procerus muscle. This can make the nasofrontal angle shallow or ill-defined and is seen very commonly after rhinoplasty if the surgeon did not remove the procerus muscle in the original operation. This is easily correctable. Dr. Rizk has innovated endoscopic precise reduction with high defintion 3d telescopes of the procerus muscle in the initial operation. The muscle usually becomes more pronounced after a reduction of the nasal hump and needs to be addressed to avoid this complication. This muscle is not discussed or addressed much in rhinoplasty meetings but Dr. Rizk believes this look of a shallow nasofrontal angle and a long nose is not aesthetically pleasing.
7. THE SHORT NOSE (pig nose)
A short nose is inappropriately short from the glabella to the nasal tip. This problem can result after rhinoplasty from excessive shortening of the posterior portion of the caudal septum and improper tip rotation. A short nose can be prevented by proper reduction during rhinoplasty. There are many relations that need to be taken into account in shortening a nose which include the distance between the nose and lips, the cheeks, the chin, the length of the face, the height of the person and the sex (male nasolabial angles should ideally be 90 degrees and female nasolabial angles should be 100-105 degrees). A short nose can be prevented by proper reduction done conservatively during rhinoplasty. The correction involves nasal reconstruction with autogenous cartilage grafts placed either to extend the caudal septum or grafts placed in the infratip lobule in the columella.
8. OPEN ROOF DEFORMITY
The open roof deformity after rhinoplasty results in a wide nasal dorsum and bridge and is due to improper sculpting and positioning of the nasal bones after a rhinoplasty. THIS IS PROBABLY THE SECOND REASON PATIENTS SEEK DR SAM RIZK FOR REVISION RHINOPLASTY. DR RIZK HAS A SPECIAL TECHNIQUE TO NARROW THE NASAL DORSUM OR BRIDGE IN VERY WIDE NOSES. This is correctable and involves properly infracturing of the nasal bones or correcting a wide dorsal septum or a dorsal deviated septum preventing the nasal bones from coming in. The proper infracture technique of the nasal bones and correction of a high deviated septum assure adequate narrowing and correction of an open roof deformity.
9. ALAR RIM DEFORMITIES
Alar rim deformities consist of a wide alar base and notching, or total collapse of the alar rim. The most common alar rim deformity is a wide alar base. It is caused by flaring of the rims, a wide floor, or both. The treatment consists of reduction of the alar base using the Weir technique (see page on Nostril Reduction on this website).
10. CARTILAGE GRAFT COMPLICATIONS: VISIBLE POINTY GRAFTS, GRAFT MOVEMENT OR INFECTION
Complications of grafts to the nasal tip are not uncommon. Infections or extrusions are rare with autogenous cartilage grafts but may occur with synthetic grafts such as silicone. The most common complications of nasal grafts are the visualization of the edge of the cartilage graft through the skin, especially through thin skin. In patients with thick, sebaceous skin, the cartilage graft is almost never a problem. Dr. Sam Rizk has innovated new techniques for smoothing out graft edges with a micro-powered sanding tool rather than the older techniques with a knife in order to reduce this complication. (see rhinoplasty articles published in Plastic Surgery Practice Journal in Media section of this website) Additionally, Dr. Sam Rizk may use Alloderm matrix, an acellular collagen matrix which help thicken the skin and camouflage graft edges. Dr. Sam Rizk may also use autogenous tissue from the temporalis muscle facia to smooth out graft edges. Dr. Rizk may also use autogenous fat to camouflage a graft edge in thin skinned patients.
11. BREATHING PROBLEMS AFTER RHINOPLASTY
An uncommon complication after rhinoplasty but may occur from development of scar tissue in the nose, not correcting a deviated septum in the original operation, or collapse or inward movement of the nasal skin due lack of adequate support after a primary rhinoplasty. If any of these reasons are the culprit, they are usually fixable with a revision which may include removing scar tissue, providing additional support using a cartilage graft, or repairing a deviated septum, or a combination of the above. Dr. Rizk's patients rarely experience this problem but it does occur in some patients and may be corrected.