Fig. 55.8 Removed bone–cartilage hump

a

b

Fig. 55.9 (a) The beginning of a nasal surgery. (b) The end of a nasal surgery

of the alar cartilage and do necessary corrections on them through transcartilaginous incision.

After finishing the modeling of the nasal pyramid, triangular and quadrangular cartilages are sutured separately. It is preferable to fix caudal end of the septum for the spina nasalis anterior inferior. All the incisions are closed with separate sutures (Fig. 55.9).

It is necessary to put nasal packing in the nasal cavity to prevent hematomas of the nasal septum, and at the same time to stabilize the parts of nasal bones. The nasal pyramid is immobilized.

55.5 Complications

Rettinger [8] states that rhinoplasty is considered a surgery of a high risk, primarily for limited possibilities of influencing its final aesthetic outcome. A good indirect postsurgical result can be a bad one after a year. This is usually the consequence of tissue healing. Several different kinds of tissue heal after a rhinoplastic surgery (bone, cartilage, muscles, skin, fat tissue, etc.) The complications are the consequences of individual reactions and the healing process and surgeons are not responsible for them.

Certain complications occur due to a poor preoperative planning and analysis as well as the selection of the surgical technique [9].

The incidence of complications ranges, according to literature data, from 4% to 18.8%. The percentage of complications is smaller in relation to the occurrence of resurgical procedures undergone by patients [10]. Surgeons are often unaware about the number of procedures their patients undergo due to their discontent with postsurgical results, so they make an appointment and plan another surgery with another surgeon.

The number of resurgical procedures depends on the patients’ mental state. Two percent of the patients who undergo aesthetic surgeries have a personality disorder. Borges found a personality disorder in 20% presurgical patients [7]. These patients are prone to exaggerating when it comes to their problems; they are constantly unsatisfied and they need to consult a psychiatrist.

The analysis of clinical material has proven that there were no patients with personality disorders. However, most patients willing to undergo an aesthetic surgery without functional problems do have a disordered idea of whom and what they are and they mostly see themselves as the best at everything.

According to the time of their occurrence, all complications can be divided into:

ss Intrasurgical

ss Immediate postoperative ss Early postoperative

ss Late postoperative

55.5.1 Intrasurgical Complications

Intrasurgical complications cover: excessive bleeding, tearing of mucoperichondrial flaps, nasal dorsum emerging, nasal pyramid bones collapsing, open nasal roof, excessive resection as well as insufficient resection.

Excessive bleeding is quite a rare complication. If hemostatic mechanism disorders are ruled out prior to the surgery, bleeding occurs in less than 1% of the cases. Bleeding occurs due to an Alvania angularis injury or injury of some of the bigger branches of sphenopalatine artery.

Mucoperichondrial flap tearing occurs in cases of careless nasal suprastructure lifting. This complication needs to be diagnosed and taken care of.

Nasal pyramid bones collapsing usually occur in cases of earlier nasal bone or bone septum parts fracture. However, as this condition is recognized, an adequate bone fragment reposition has not been achieved.

“Open roof” occurs in cases of kyphotic nose correction where both-sided osteotomies is performed. It could occur when a surgeon cannot entirely cover the nose roof, although both-sided lateral osteotomy has been performed. The reason could be inadequate fractured segment adjusting as well as more firmly tamponading. “Open roof” can occur in cases of lesser kyphosis when a surgeon tries to remove the existing deformity by filing without performing lateral osteotomy, most often in female patients for their nose bones are more fragile. A good prevention of the insufficiently covered nose roof with both-sided lateral osteotomy is recovering nose dorsum infrastructure with crashed cartilage.

In cases of “open roof” (Fig. 55.10), nasal mucous membrane grows together with nasal suprastructure in the process of postsurgical healing, causing the change of nose color when the patients have a cold; defect in the bone part of the pyramid can be felt by touching and, can also been seen during examination.

Excessive resections occur due to a poor presurgical planning. They can cause a lordotic nose, stenosis at the level of nose valve, or lowering of the nose tip, when the cartilage part is overly recessed.

Insufficient resections occur due to a poor presurgical planning as well. They are more frequent in inexperienced surgeons who, due to suprastructure nose swelling, cannot estimate the degree of resection. It is usually manifested when the hump is not sufficiently recessed in kyphotic noses or when the hump is to lag in the cartilage part.

Fig. 55.10 The “open roof”

55.5.2Immediate Postoperative Complications

These disorders are mainly linked to the use of particular anesthetics. They can occur in the form of anaphylactic reaction, laryngospasm, or visual disturbances.

Anaphylactic reaction is the consequence of the use of local anesthetics or presurgical antibiotic administration in prophylactic purposes.

Respiratory tract obstruction (postextubation laryngospasm) occurs in cases of total anesthesia when laryngospasm occurs after patient extubation and reintubation cannot be implemented because the patient cannot breathe spontaneously. It can be avoided if anesthesia is correctly supervised and when coughing and swallowing reflexes are regained with the help of extubation.

Visual disturbances occur when local anesthetics are administered. They can be transient due to the eye muscle reaction to local anesthetics or permanent that is the consequence of the use of vasoconstrictor leading to eye blood circulation disorders and ischemia [11].

55.5.3 Early Postoperative Complications

Early postoperative complications involve: bleeding, nasal septum hematoma, infections, dehiscence of the wound,

toxic shock syndrome, permanent soft tissue edema, skin necrosis, osteomyelitis, cerebrospinal fluid rhinorrhea, olfactory disorder, nose breathing difficulties, contact dermatitis, and the onset of mental disorders.

Bleeding is rare in early postsurgical complications. Nose packing as well as immobilization of nasal bones provides a good pressure that disables bleeding from lesser blood vessels. Bleeding is more frequent after packing. It is necessary to do repacking and protect the patient with antibiotics.

Septal hematoma is the consequence of blood depositing between nasal septum cartilage and mucoperichondrial flaps. As soon as it is noticed, it is necessary to start hematoma draining, repacking, and antibiotics. If not noticed on time, septum abscess can develop along with septal cartilage necrosis which can cause further complications. The worst case scenario is thrombosis of sinus cavernosus or brain abscess.

Infections are quite rare in nasal surgeries. The incidence of the infection of the wound itself, surrounding structures, or septicemia is less than 1%. The operating area is rich in gram-positive bacterial flora with

Staphylococcus aureus prevailing [12–15].

Toxic shock syndrome is the consequence of the staphylococcus endotoxin effect. It occurs rarely, only in 16 per 1,000 of the total number of surgeries performed [16]. It occurs after nose tamponading. The symptoms occur 2 days after the surgery and tamponading and they include postsurgical fever, vomiting, diarrhea, hypotension and erythematous rash, and the state of shock might occur as well [14, 17–19]. It is necessary to take the tampons out of the nose and give high doses of antibiotics and corticosteroids.

Dehiscence of the wound occurs scarcely. It occurs more frequently in outer approach than in endonasal approach.

Long lasting soft tissue edema occurs rarely. It occurs in patients whose surgeries lasted longer, in more abundant tamponading, in cases of soft tissue infections, but also in people who are prone to more tissue swelling during injuries [20]. Soft tissue swelling lasts longer in cases of open approach and it can last for a couple of months.

Skin necrosis occurs more frequently in cases of careless suprastructure lifting when suprastructure is thinned and consequently necrosis occurs.

Osteomyelitis occurs in cases of infections when smaller bone particles become infected. It is necessary to administer aggressive antibiotic therapy and to perform a revision surgical procedure if needed.

Cerebrospinal fluid rhinorrhea is a rare complication [21]. It occurs most frequently in the area of cribriform plate. It is diagnosed on the basis of finding E2-transferrina or E-trace protein (prostaglandin D-syntethase) in the collected nasal liquid [22]. It can be diagnosed if 5% fluorescein is injected intrathecally. This method is very useful because it is possible to close cerebrospinal fluid rhinorrhea area endoscopically at the same time.

Olfactory disorder is expected in early postsurgical period. It is the consequence of mucous membrane swelling. Anosmia occurs in 1% of the patients in early postsurgical period [23].

Breathing nose difficulties in early postsurgical period can be the consequence of transient nasal mucous membrane swelling. Nasal mucous membrane swelling is the consequence of surgical procedure trauma. Breathing difficulties can also occur in patients who don’t have allergic rhinitis.

Contact dermatitis occurs as a reaction to taping material used to immobilize nasal pyramid (Fig. 55.11). This is not a significant complication, although it can

Fig. 55.11 Allergic reaction of the skin to tape

be quite unpleasant. Antihistamines and skin corticosteroids are to be administered.

Early psychological complications are usually manifested as transient periods of tension or depression [24].

55.5.4 Late Postoperative Complications

Late postoperative complications include intranasal synechiae, nasal septum perforations, nasal valvula insufficiency, nasal stenosis, dorsal cyst, nasal pyramid deformities, and persistent mental disorders.

Intranasal synechiae (Fig. 55.12) occur on the spots where mucous membrane of nasal septum and lateral side of the nose are damaged, most frequently lower and medium nasal turbinate. They can lead to nasal septum moving to one side, breathing difficulties, and even nasal pyramid deformation. They are solved by cutting and placing stents to enable reepithelialization of the mucous membrane with no contact.

Nasal septum perforation (Fig. 55.13) is a serious complication that is difficult to solve. It occurs in 3–25% of surgical patients. Perforations are usually asymptomatic. In less serious cases whistling can occur while breathing. If a perforation is bigger due to irregular air flow through nasal cavity, depositing and drying of secretion can occur. Lesser perforations are

Fig. 55.12 Intranasal synechiae

Fig. 55.13 Nasal septal perforation

possible to close with mucosal flaps by placing cartilage grafts while some bigger ones are really difficult to close. There are several techniques for closing perforations of nasal septum [25]. If it persists, it is possible to place a silicone button that would reduce or remove unwanted effects of perforation [26].

Nasal valvula collapse occurs in cases of greater resections of alar cartilage. It is solved by placing spreader cartilage grafts in cases of internal collapse of valvula or alar batten grafts in cases of external valvula collapse.

Nose stenosis is a very serious complication that is difficult to solve. It occurs in the area of nose vestibulum most frequently, in cases when hemi or transfixion incision is linked with intracartilaginous or transcartilaginous during surgery. The patient has breathing difficulties on that side of the nose. It is possible to try “Z” plasty in the area of stenosis. Very good results can be achieved by expanding the stenotic area with long-term dilatation.

Recurrent meningitis occurs in patients with cerebrospinal fluid rhinorrhea. It is necessary to administer antibiotic therapy, diagnose the fistulous area endoscopically with 5% fluorescein, and close the existing defect of duramater cerebri.

Dorsal cyst (Fig. 55.14) occurs in cases when nasal mucosa is transplanted into subcutaneous tissue during surgery. This disorder is quite easy to remove.

Nasal pyramid deformations usually occur due to a mistake in estimation and presurgical analysis of the patient. It is necessary to highlight that rhinoplasty belongs to the group of surgeries of highest risk when it comes to unfavorable postsurgical results. The occurrence of nasal pyramid deformity after a rhinoplastic surgery can be the consequence of the fact that nasal septum deviation has not been done completely or an error in cartilage and nose bone skeleton deformity. The deformities can be the following:

ssNose scoliosis (Fig. 55.15) – usually occurs due to nose pathology that has not been completely dealt

with or in cases when nasal bones have not been equally modeled.

ss“Open roof” – occurs when nasal hump is removed without lateral osteotomies, or in cases when nose tamponading has been too firm leading to nasal bones separation.

ss Bone or cartilage fragment leftovers after resection – it is manifested with the existence of greater or lesser prominence below skin. They can be spotted only after the withdrawal of nasal soft tissue swelling.

ssExcessive nasal resection – this deformity usually leads to lordosis, empty columella (Fig. 55.16), sagging of the cartilaginous dorsum.

ssColumella retraction – occurrence of cranial withdrawal of the columella.

Fig. 55.16 Empty columella

ssCartilage hump (Fig. 55.17) – occurs in cases when a surgeon has not done a complete resection of the bone–cartilage hump causing another cartilage hump in the lower third of the nose (surgical hump).

ssNostril asymmetry – can occur due to a mistake in modeling of alar cartilages or due to uneven nasal bone resection. In the latter case, nasal pyramid is leant on one side.

Persistent psychological disorder occurs only in cases of poor presurgical mental estimation of the patient’s