Advertisement

Complications of Rhinoplasty

      Keywords

      Key points

      • Meticulous history, physical examination, and standardized photographic documentation are central to preoperative evaluation and surgical planning for rhinoplasty.
      • Photographic documentation is very useful to help illustrate preexisting preoperative asymmetries, and the surgeon must document these in the physical examination and discuss them with the patient.
      • As with any surgery, any complications should be openly discussed with the patient.
      • Appropriate preoperative counseling regarding all risks, benefits, and alternatives is critical.
      • The surgeon must have a comprehensive understanding of nasal anatomy and effects of surgical maneuvers to help avoid complications.

      Overview

      Rhinoplasty is a very common surgical procedure among facial and general plastic surgeons. It may be performed for functional and aesthetic reasons. It is a highly technically challenging procedure, because the surgeon must pay careful attention to both form and function. An aesthetically pleasing nose without the ability to breathe is a surgical failure. Some complications may occur intraoperatively, whereas others may occur postoperatively during wound healing and contracture. Therefore, some complications may not become evident until months to years after surgery.

      Asymmetries

      Asymmetries of the bony pyramid can occur for multiple reasons, including discrepancies in osteotomies between sides, asymmetric dorsal reduction, and persistence of preoperative asymmetries. A greenstick fracture, with failure to fully osteotomize, may result in either failure to fully mobilize the nasal bone or the nasal bone lateralizing from memory.
      Asymmetries of the middle third are also often multifactorial. A septal deviation that was not causing asymmetry before dorsal reduction may become “unmasked” after dorsal reduction, and thereby cause asymmetries of the middle vault. Asymmetric dorsal reduction of the middle third can also occur. Palpation of the dorsum with moistened gloves allows careful assessment of the underlying anatomy after dorsal reduction.
      Establishing symmetry at the tip is highly dynamic and requires an understanding of all major and minor tip support elements, as shown in Table 1.
      • Tardy Jr., M.E.
      • Kron T.K.
      • Younger R.
      • et al.
      The cartilaginous pollybeak: etiology, prevention, and treatment.
      Careful attention to tip suture technique and proper suture placement will help minimize tip asymmetries. Preexisting asymmetries of the medial and lateral crura may not be evident until other tip dynamics are altered. Similar to the middle third, a septal deviation that was not causing any asymmetry preoperatively may become “unmasked” as a result of surgical maneuvers, with resultant tip asymmetry or deviation. Contracture of the skin soft tissue envelope can also result in asymmetry of the tip over time.
      Table 1Complications of rhinoplasty
      ComplicationCauseAvoidanceCorrection
      Asymmetry of the bony vaultAsymmetric osteotomiesMeticulous attention to osteotomiesPercutaneous osteotomies
      Asymmetry of the middle vaultUnmasked dorsal septal deviation after dorsal reductionRecognition of septal deviationCrushed cartilage camouflage grafts
      Tip asymmetryAsymmetric tip suturesMeticulous attention to suture techniqueRevision
      Unmasked caudal septal deviationMeticulous inspectionPossible placement of septal extension graft

      Possible repositioning of caudal septum with swinging door, secure to nasal spine with suture
      Overresection of nasal bonesOveraggressive resectionJudicious bony dorsal reductionPlacement of dorsal onlay graft
      Open roof deformityBony dorsal reductionJudicious bony dorsal reduction when no osteotomies are planned, but unavoidable when narrowing of the bony base is plannedLateral osteotomies to close open roof
      Rocker deformityContinuation of osteotomies into frontal boneMeticulous planning of osteotomies and continuous palpation/inspectionPercutaneous osteotomies
      Stair step deformityImproper placement of lateral osteotomy anterior to the ascending process of the maxillaMeticulous planning of osteotomies and continuous palpation/inspectionPercutaneous osteotomies
      Pollybeak deformityOverresection of nasal bonesMeticulous planning of dorsal reduction, both bony and cartilaginous dorsumDorsal onlay camouflage graft
      Underresection of dorsal septum (anterior septal angle)Appropriately match cartilaginous dorsal reduction to that of bony dorsal reduction

      May require revision
      Postoperative soft tissue scar formationAvoid overaggressive dorsal reduction in thick-skinned patientsKenalog injections postoperatively
      Inverted V deformityUpper lateral cartilages drop inferior and posterior, causing show of the nasal bones and dorsal septum

      This results from failure to repair the upper laterals to the dorsal septum after dorsal reduction
      Repair upper lateral cartilages to dorsal septum after dorsal reduction

      Use of spreader grafts or autospreader grafts
      Revision with use of spreader grafts (if upper lateral cartilage present), possible onlay crushed cartilage camouflage grafts, consider osteotomies to narrow the bony base if this is a contributing factor
      Saddle nose deformityOveraggressive dorsal reduction with septoplasty, resulting in a dorsal strut that is inadequate to support cartilaginous dorsumMaintain 1.5-cm dorsal strutRevision with dorsal onlay camouflage graft (minor cosmetic deformity) and rib cartilage graft reconstruction (severe cases)
      BossaeOveraggressive cephalic trim of lateral cruraNote predisposing factors for bossae formation (see below), avoid overaggressive resectionRevision with structural grafting of lateral crura (strut grafts), crushed cartilage, and/or temporalis fascia camouflage grafts
      Visible graftsThin skinNote thin skin preoperatively and place temporalis fascia overlay grafts to camouflageRevision with possible graft removal and/or placement of temporalis fascia for contour smoothing and camouflage
      Pinched tipOverresection of lateral crura during cephalic trimSpare 6- to 7-mm rim stripLateral crural strut grafts, possible crushed cartilage grafts for camouflage
      Malpositioning of lateral cruraEnsure appropriate orientation and positioning of lateral cruraRemoval/revision of any offending tip sutures, possible lateral crural strut grafting, possible repositioning of lateral crura
      Contracture from wound healingUnavoidable, must preoperatively counsel patient about this risk and document having done soRevision surgery with one or more of the above maneuvers
      Poorly defined tipOveraggressive tip deprojection in thick-skinned patientAvoid overaggressive deprojectionJudicious superficial nasalis aponeurotic system (SNAS) excision intraoperatively, Kenalog injections postoperatively
      Nostril asymmetryAltered caudal septum, medial, intermediate, and lateral crura dynamics from intraoperative suture technique or alterationMeticulous attention to symmetric placement of sutures, such as tip and tongue in groove suturesRevision, with correction of underlying offending cause
      Alar retractionOverly tight closure of marginal incisionRemove/revise offending sutures
      Overresection of lateral crura during cephalic trimLateral crural strut grafts, possible alar rim grafts (minor cases), auricular composite grafts (severe cases)
      Malpositioning of the lateral cruraRepositioning of the lateral crura, lateral crural strut grafts, possible alar rime grafts (minor cases), auricular composite grafts (severe cases)
      Overly tight lateral crural spanning suturesRemoval/revision of any offending tip sutures
      Contracture from wound healingRevision surgery with one or more of the above maneuvers
      Columellar retractionOverresection of the caudal septumAvoid overresectionCaudal septal extension graft, columellar strut graft, columellar plumping graft
      Excessive setback of the medial crura during tongue-in-grooveAvoid excessive setbackRevise tongue-in-groove, consider columellar plumping graft

      Septocolumellar suture can be used to help prevent contracture during wound healing
      Columellar and alar base scar formationWound healingMeticulous wound closureKenalog injections with revision reserved for severe cases
      Nasal obstructionExternal nasal valve collapseMaintain integrity and appropriate position of lateral crura, avoid overaggressive narrowing of the alar baseLateral crural strut grafts, possible alar rim grafts
      Internal nasal valve collapseAvoid overaggressive narrowing of the bony base, use spreader grafts or autospreader grafts to maintain patencySpreader or autospreader grafts
      Septal deviationAppropriately address any septal deviationSeptoplasty
      Intranasal synechiaCareful soft tissue handling and fastidious wound closureLysis of synechia
      Recurvature of the lateral cruraRecognize contribution to the patency of the nasal airwayLateral crural strut grafts
      Septal perforationOpposing mucoperichondrial lacerationsMeticulous elevation of mucoperichondrial flaps to prevent opposing lacerationsPlace fascia or crushed cartilage graft interposed between lacerations
      Septal hematomaPlacement of septal whip sutures and use of removable soft silastic intranasal splints, prophylactic mucoperichondrial flap incision to allow drainage of any accumulated bloodIncision and drainage
      Costal cartilage (autograft and homograft) warpingIntrinsic property of cartilageConcentric carvingRevision
      Pneumothorax after costal cartilage harvestInjury to the pleuraHarvest cartilage in subperichondrial planeClose wound under water seal with positive pressure ventilation
      Edema of the soft tissue envelope can make asymmetries and irregularities difficult to discern intraoperatively. Thus, careful marking before injection is paramount. Asymmetries can be minimized through judicious inspection from the top of the patient’s head and through careful palpation using sterile saline-moistened gloves.

      The bony pyramid

      Overresection of the Nasal Bones

      Overresection of the nasal bones can be avoided through judicious dorsal reduction, as seen in Fig. 1. Notice that this patient also has a pollybeak deformity, which is discussed later. More bone may easily be removed, whereas replacement after overresection presents a more challenging scenario.
      Figure thumbnail gr1
      Fig. 1Overresected nasal bones after prior rhinoplasty. Also note prominent pollybeak.

      Open Roof Deformity

      An open roof is a normal consequence of dorsal reduction. Failure to close an open roof with appropriate osteotomies will result in a “flat top” appearance to the bony pyramid, as seen in Fig. 2. Edema of the soft tissue envelope can mask an open roof deformity on visual inspection. Again, careful palpation will make this readily apparent to the surgeon. Medial and lateral osteotomies are used to close an open roof deformity, narrowing the bony pyramid.
      Figure thumbnail gr2
      Fig. 2Open roof deformity after prior rhinoplasty from failure to close with osteotomies.

      Rocker Deformity

      Rocker deformity results from carrying osteotomies too far superiorly up into the frontal bone without appropriate back fracture. On medialization of the nasal bones, the superior portion is cantilevered, or “rocked,” laterally, as shown in Fig. 3.
      • Toriumi D.M.
      • Hecht D.A.
      Skeletal modifications in rhinoplasty.
      This deformity can be avoided through careful planning of one’s osteotomies. When performing an endonasal lateral osteotomy, the guarded portion of the osteotome is oriented laterally and the surgeon continually palpates during the osteotomization process. Should this complication be encountered, transverse percutaneous osteotomies may be performed to create the appropriate controlled back fracture.
      Figure thumbnail gr3
      Fig. 3Rocker deformity with osteotomies continuing into frontal gone. Note superior aspect “rocking” laterally when bony base is medialized.
      (From Toriumi DM, Hecht DA. Skeletal modifications in rhinoplasty. Facial Plast Surg Clin North Am 2000;8(4):424; with permission.)

      Stair Step Deformity

      Stair step deformity is caused by placement of the lateral osteotomy anterior to the ascending process of the maxilla, resulting in a palpable step-off. The lateral osteotomy should be placed along the ascending process (also known as the frontal process) of the maxilla in the standard high-low-high fashion, which is illustrated Fig. 4.
      • Toriumi D.M.
      • Hecht D.A.
      Skeletal modifications in rhinoplasty.
      Careful planning of the lateral osteotomies will help the surgeon avoid this complication. The guarded portion of the osteotome is oriented laterally, and the surgeon continually palpates during the osteotomization process. In addition to careful palpation, the surgeon must listen for the distinct sound made when the osteotomy is being placed in the correct location along the ascending process of the maxilla. Percutaneous perforating lateral osteotomies also lend a degree of safety. This problem is difficult to correct, and therefore stair step deformity must be avoided.
      Figure thumbnail gr4
      Fig. 4Appropriate placement of osteotomies is demonstrated. Note lateral osteotomy in high-low-high fashion, fading medial osteotomy, with controlled back-fracture connecting medial and lateral osteotomies.
      (From Toriumi DM, Hecht DA. Skeletal modifications in rhinoplasty. Facial Plast Surg Clin North Am 2000;8(4):422; with permission.)

      The middle third

      Pollybeak Deformity

      Pollybeak deformity results when the lower third of the dorsum is more projected than the tip. This is seen in Fig. 1. Overresection of the bony pyramid, underresection of the cartilaginous middle third (specifically the anterior septal angle), and supratip fibrosis deep to the soft tissue envelope can all result in pollybeak.
      • Tardy Jr., M.E.
      • Kron T.K.
      • Younger R.
      • et al.
      The cartilaginous pollybeak: etiology, prevention, and treatment.
      The first 2 are preventable, whereas the third occurs postoperatively in the setting of wound healing. Additionally, loss of tip support with subsequent tip ptosis can result in a relative pollybeak. Palpation allows the surgeon to assess the dorsum and to determine if additional resection is necessary. Soft tissue pollybeak can be addressed with Kenalog injections to the affected area. The senior author prefers to use a very conservative Kenalog 10 mixed 1:10 or 1:5 with 1% lidocaine with 1:100,000 epinephrine. It is critical that all Kenalog be injected deep to the dermis to avoid dermal thinning. Overaggressive injection can itself cause divots from dermal or cartilaginous injury.

      Inverted V Deformity

      The inverted V deformity results from accentuated visibility of the caudal margins of the nasal bones after dorsal reduction, as seen in Fig. 5. As illustrated in Fig. 6, dorsal reduction causes narrowing of the cartilaginous dorsal width.
      • Toriumi D.M.
      Management of the middle nasal vault in rhinoplasty.
      As a result, the upper lateral cartilages become displaced inferiorly and posteriorly, thereby accentuating the caudal margin of the nasal bones.
      • Constantian M.B.
      The incompetent external nasal valve: pathophysiology and treatment in primary and secondary rhinoplasty.
      • Rohrich R.J.
      • Hollier L.H.
      Use of spreader grafts in the external approach to rhinoplasty.
      • Sheen J.H.
      Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty.
      This deformity is further exaggerated if the bony base is not appropriately narrowed after dorsal reduction. Repair of the upper lateral cartilages to the dorsal septum and use of spreader grafts will help prevent this.
      • Sheen J.H.
      Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty.
      The senior author routinely uses the autospreader upper lateral turn-in flaps, which are shown in Fig. 7.
      • Yoo S.
      • Most S.P.
      Nasal airway preservation using the autospreader technique: analysis of outcomes using a disease-specific quality-of-life instrument.
      Figure thumbnail gr5
      Fig. 5Inverted V deformity is noted with prominence of the bony base and narrowing of the middle third.
      Figure thumbnail gr6
      Fig. 6Noted dorsal narrowing after cartilaginous dorsal reduction.
      (From Toriumi DM. Management of the middle nasal vault in rhinoplasty. Facial Plast Surg Clin North Am 1995;2(1):18; with permission.)
      Figure thumbnail gr7
      Fig. 7Autospreader technique is shown. Upper lateral cartilage is scored (A), subsequently folded on itself and suture repaired to the dorsal septum (B).
      (From Yoo S, Most SP. Nasal airway preservation using the autospreader technique: analysis of outcomes using a disease-specific quality-of-life instrument. Arch Facial Plast Surg 2011;13(4):232; with permission.)

      Saddle Nose Deformity

      The saddle nose deformity may be the result of overresection of the quadrangular cartilage with insufficient dorsal strut. A postoperative saddle deformity is seen in Fig. 8. Inadvertent disarticulation of the keystone area, in which the quadrangular cartilage fuses superiorly with the perpendicular plate of the ethmoid, may also result in saddling. The keystone is shown in Fig. 9.
      • Tardy Jr., M.E.
      • Toriumi D.M.
      • Hecht D.A.
      Functional and aesthetic surgery of the nose.
      Extracorporeal septoplasty is particularly prone to this and can be avoided using the anterior septal reconstruction technique.
      • Most S.P.
      Anterior septal reconstruction: outcomes after a modified extracorporeal septoplasty technique.
      Figure thumbnail gr8
      Fig. 8Saddle nose deformity after prior rhinoplasty.
      Figure thumbnail gr9
      Fig. 9The keystone area is highlighted in red.
      (From Tardy ME, Toriumi DM Jr, Hecht DA. Functional and aesthetic surgery of the nose. In: Papel ID, editor. Facial plastic and reconstructive surgery. 2nd edition. Thieme; New York: 2002. p. 370; with permission.)
      Saddle nose deformity can be difficult to correct and is best avoided. A mild saddle deformity may be corrected with crushed cartilage camouflage dorsal onlay grafting. If disarticulation of the keystone is noted intraoperatively, rib cartilage graft may be used for reconstruction, provided the patient has previously consented.

      Tip and ala

      Bossae

      Bossae, as illustrated in Fig. 10, are the result of visible flexing and buckling of the alar cartilage. These deformities tend to become evident months to years postoperatively.
      • Kridel R.
      • Yoon P.
      • Koch R.
      Prevention and correction of nasal tip bossae in rhinoplasty.
      Patients at risk for tip bossae are those with thin skin, strong alar cartilages, and tip bifidity.
      • Kridel R.
      • Yoon P.
      • Koch R.
      Prevention and correction of nasal tip bossae in rhinoplasty.
      • Gillman G.
      • Simons R.
      • Lee D.
      Nasal tip bossae in rhinoplasty. Etiology, predisposing factors, and management techniques.
      Bossae can be avoided through maintaining the strength and integrity of the alar cartilage, using structural grafting when necessary, and symmetric reconstitution of the domal subunit with tip sutures.
      • Brenner M.
      • Hilger P.
      Thin skin rhinoplasty: aesthetic considerations and surgical approach.
      Temporalis fascia or crushed cartilage may also be used in thin-skinned patients to help camouflage any irregularities.
      Figure thumbnail gr10
      Fig. 10Bossae are seen after prior rhinoplasty.

      Visible Grafts

      In thin-skinned individuals, tip grafts can become visible over time as the skin soft tissue envelope contracts and thins. Therefore, avoiding tip grafts in very thin-skinned individuals is preferable, because this complication is often noted at a later date, after edema has decreased and the skin soft tissue envelope has begun contracting, and must be addressed with formal revision. The authors often use temporalis fascia as a camouflage graft in thin-skinned patients if grafts must be used.

      Pinched Tip

      A pinched tip may result from overaggressive cephalic resection of the lateral crura, which results in weakening of the remaining rim strip (Fig. 11).
      • Paun S.
      • Trenite G.
      Correction of the pinched nasal tip deformity.
      Care must be taken to avoid overresection during cephalic trim. The senior author preserves at least a 7-mm rim strip to avoid overresection during cephalic trim. Malpositioning of the lateral crura, with the caudal border placed significantly inferior to the cephalic border, may similarly result in a pinched tip, as described by Toriumi and Checcone
      • Toriumi D.M.
      New concepts in nasal tip contouring.
      • Toriumi D.M.
      • Checcone M.A.
      New concepts in nasal tip contouring.
      and illustrated in Fig. 12. Lateral crural repositioning and lateral crural strut grafts may be used to facilitate appropriate orientation of the lateral crura.
      • Toriumi D.M.
      New concepts in nasal tip contouring.
      • Toriumi D.M.
      • Checcone M.A.
      New concepts in nasal tip contouring.
      • Gunter J.P.
      • Friedman R.M.
      Lateral crural strut graft: technique and clinical applications in rhinoplasty.
      Figure thumbnail gr11
      Fig. 11Pinched tip after prior rhinoplasty.
      Figure thumbnail gr12
      Fig. 12Pinched tip may result from malpositioned lateral crura, with caudal margin positioned significantly inferior to cephalic margin.
      (From Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 2006;8(3):162; with permission.)

      Poorly Defined Tip

      The poorly defined or amorphous tip can occur in thick-skinned individuals after tip deprojection and suture modification. Recognizing thick skin preoperatively and avoiding overaggressive deprojection in thick-skinned individuals is key. Judicious SNAS excision may be performed to help improve tip definition.

      Nostril Asymmetries

      Nostril asymmetries can occur from an unmasked septal deviation after caudal septal resection, placement of a septal extension graft, or asymmetric tip modifications. It is important to recognize any preoperative nostril asymmetries and counsel patients appropriately in this regard. The authors routinely perform a nostril check before final closure to ensure appropriate symmetry.

      Alar-Columellar Disproportion

      Gunter and Friedman
      • Gunter J.P.
      • Friedman R.M.
      Lateral crural strut graft: technique and clinical applications in rhinoplasty.
      previously described the alar-columellar relationship and classification of related deformities. This article focuses on alar retraction, columellar retraction, and hanging columella. Fig. 13 shows both alar retraction and a hanging columella.
      Figure thumbnail gr13
      Fig. 13Patient with both alar retraction and hanging columella after previous rhinoplasty.
      Alar retraction may result from overly tight closure of marginal incisions, especially as one approaches the nasal facets. Careful attention to closure of the marginal incisions can help avoid Alar retraction. Overaggressive resection during cephalic trim can result in contracture of the lateral crura superiorly with time and wound healing, thereby causing alar retraction.
      • Kridel R.W.
      • Chiu
      The management of alar columellar disproportion in revision rhinoplasty.
      Lateral crural spanning sutures placed too tightly may result in alar retraction.
      • Baker S.
      Suture contouring of the nasal tip.
      The orientation of the lateral crura is also of importance. As described by Toriumi and Checcone,
      • Toriumi D.M.
      • Checcone M.A.
      New concepts in nasal tip contouring.
      the caudal margin of the lateral crura should lie in a plane almost horizontal and oriented just inferior to the cephalic margin. This technique prevents cephalic positioning of the lateral crura and helps support the alar rim. Alar retraction may be corrected with the use of alar rim grafts in minor cases (Fig. 14), with placement of ear composite grafts in more severe cases (Fig. 15).
      • Kridel R.W.
      • Chiu
      The management of alar columellar disproportion in revision rhinoplasty.
      Figure thumbnail gr14
      Fig. 14Placement of alar rim grafts.
      (From Kridel RW, Chiu RJ. The management of alar columellar disproportion in revision rhinoplasty. Facial Plast Surg Clin North Am 2006;14(4):326; with permission.)
      Figure thumbnail gr15
      Fig. 15Auricular composite grafts may be used to address alar retraction. These grafts may be placed at the level of the scroll (A) or at the caudal margin of the lateral crura (B).
      (From Kridel RW, Chiu RJ. The management of alar columellar disproportion in revision rhinoplasty. Facial Plast Surg Clin North Am 2006;14(4):319; with permission.)
      Columellar retraction may result from overaggressive resection of the caudal septum, medial crura, or excessive setback of the medial crura after placement of a tongue-in-groove suture.
      • Kridel R.W.
      • Chiu
      The management of alar columellar disproportion in revision rhinoplasty.
      An overly resected caudal septum may be addressed with a caudal septal extension graft with or without tongue-in-groove repair of the medial crural footplates. Excessive setback after tongue-in-groove suture is best addressed through revision of the tongue-in-groove until the desired effect is achieved. Columellar struts or plumping grafts may also be helpful adjunctive measures in certain cases.
      A hanging columella may result from placement of an overly large columellar strut graft, septal extension graft, or tip graft.
      • Kridel R.W.
      • Chiu
      The management of alar columellar disproportion in revision rhinoplasty.
      Contributing anatomy includes the caudal septum, medial crura, intermediate crura, and membranous septum. Tip deprojection and decreased rotation may also contribute.
      • Kridel R.W.
      • Chiu
      The management of alar columellar disproportion in revision rhinoplasty.
      Depending on the origin, a hanging columella can be addressed by selective resection of the caudal septum and tongue-in-groove suture technique.

      Columella and alar base

      Scar Formation

      Patients should be counseled about the potential for scar formation from the columellar incision in external rhinoplasty and with all alar base excisions. Unsightly columellar scars, hypertrophic scars, and keloids are very uncommon. Alar base excisions put the patient at risk for visible scar formation. The columellar incision is performed using an inverted V, so as to prevent scar formation.
      • Davis R.E.
      Proper execution of the transcolumellar incision in external rhinoplasty.
      Meticulous attention to closure will help prevent columellar and alar base scar formation.

      Airway

      Nasal obstruction can occur as a result of external nasal valve collapse, internal nasal valve collapse, septal deviation, and intranasal synechia formation. Weak lateral crura can be reinforced with lateral crural strut grafts.
      • Gunter J.P.
      • Friedman R.M.
      Lateral crural strut graft: technique and clinical applications in rhinoplasty.
      Spreader grafts may be used to widen the patency of the internal nasal valve.
      • Rohrich R.J.
      • Hollier L.H.
      Use of spreader grafts in the external approach to rhinoplasty.
      • Sheen J.H.
      Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty.
      • Most S.P.
      Trends in functional rhinoplasty.
      • Most S.P.
      Analysis of outcomes after functional rhinoplasty using a disease-specific quality-of-life instrument.
      The senior author routinely uses autospreaders, as previously noted and illustrated in Fig. 7.
      • Yoo S.
      • Most S.P.
      Nasal airway preservation using the autospreader technique: analysis of outcomes using a disease-specific quality-of-life instrument.
      Meticulous inspection of nostril symmetry, position of the caudal septum, and an understanding of the dynamics of the internal nasal valve will help minimize postoperative nasal obstruction. Recurvature of the lateral crura may also result in nasal airway obstruction, especially after maneuvers that narrow the nasal base, such as alar base excisions. Lateral crural strut grafts can be used to mitigate recurvature.

      Septum

      Septal Perforation

      Septal perforation is a known risk of any septal surgery and patients should be counseled in this regard. Prior septoplasty places the patient at a higher risk. Meticulous dissection of the mucoperichondrial flaps, with avoidance of lacerating the mucosa on both sides directly opposing one another will help minimize the risk of perforation. If bilateral opposing perforations occur intraoperatively, a crushed cartilage graft may be placed to allow mucosal healing.

      Septal Hematoma

      A septal hematoma is a risk of any septal surgery. These complications result when blood accumulates within any dead space between the elevated mucoperichondrial flaps. Septal hematomas predispose patients to infection and septal perforation. Use of transseptal whip sutures, placement of inferiorly based drainage incisions, and use of soft silastic removable intranasal splints will help minimize hematoma formation. Once a hematoma develops, it should be drained immediately.

      Costal cartilage grafts

      Costal cartilage grafts, including autologous and homologous, may become visible from warping over time. This deformity occurs from the intrinsic properties of cartilage. Concentric carving can mitigate this to some degree, but it is important to counsel patients regarding the risk of cartilage warping and subsequent irregularities or visibility of the graft.
      Pneumothorax is a rare complication from autologous cartilage harvest. The risk of this is roughly 1% and can usually be managed without a chest tube. Should the surgeon encounter a pneumothorax, the injury is usually confined to the parietal pleura.
      • Marin V.P.
      • Landecker A.
      • Gunter J.P.
      Harvesting rib cartilage grafts for secondary rhinoplasty.
      Management consists of inserting a sterile red rubber catheter into the wound, placing the distal end of the catheter into sterile saline (as a water seal). Anesthesia then administers positive pressure ventilation and the wound is closed as the catheter is removed. Patients should receive a postoperative chest radiograph and be admitted for observation, with a repeat chest radiograph on the morning of postoperative day one.
      Homograft costal cartilage has a theoretical risk of resorption over time. Kridel and colleagues
      • Kridel R.W.
      • Ashoori F.
      • Liu E.S.
      • et al.
      Long-term use and follow-up of irradiated homologous costal cartilage grafts in the nose.
      found no significant difference between autologous and homologous cartilage with regard to resorption or infection. The senior author has been using homologous costal cartilage with good results in patients who are not candidates for autologous grafts because of age (ossification), severity of obstructive sleep apnea, other comorbidities, or patient preference. It is important to counsel patients regarding the theoretical risk of resorption, although this does not seem to manifest clinically.

      Summary

      The dynamics of nasal aesthetics and function are very complex, and therefore the potential for complications are myriad. A thorough understanding of nasal anatomy and how various surgical maneuvers affect both form and function is imperative. Certain complications are within the surgeon’s control, such as those related to technique, whereas those related to patient wound healing are out of the surgeon’s control. Careful patient selection, history, physical examination, photo documentation, and patient counseling about appropriate expectations are important aspects of the surgery and should not be underestimated.

      References

        • Tardy Jr., M.E.
        • Kron T.K.
        • Younger R.
        • et al.
        The cartilaginous pollybeak: etiology, prevention, and treatment.
        Facial Plast Surg. 1989; 6: 113-120
        • Toriumi D.M.
        • Hecht D.A.
        Skeletal modifications in rhinoplasty.
        Facial Plast Surg Clin North Am. 2000; 8: 413-430
        • Toriumi D.M.
        Management of the middle nasal vault in rhinoplasty.
        Facial Plast Surg Clin North Am. 1995; 2: 18
        • Constantian M.B.
        The incompetent external nasal valve: pathophysiology and treatment in primary and secondary rhinoplasty.
        Plast Reconstr Surg. 1994; 93 ([discussion: 932–3]): 919-931
        • Rohrich R.J.
        • Hollier L.H.
        Use of spreader grafts in the external approach to rhinoplasty.
        Clin Plast Surg. 1996; 23: 255-262
        • Sheen J.H.
        Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty.
        Plast Reconstr Surg. 1984; 73: 230-239
        • Yoo S.
        • Most S.P.
        Nasal airway preservation using the autospreader technique: analysis of outcomes using a disease-specific quality-of-life instrument.
        Arch Facial Plast Surg. 2011; 13: 231-233
        • Tardy Jr., M.E.
        • Toriumi D.M.
        • Hecht D.A.
        Functional and aesthetic surgery of the nose.
        in: Papel I.D. Facial plastic and reconstructive surgery. 2nd edition. Thieme, New York2002: 370
        • Most S.P.
        Anterior septal reconstruction: outcomes after a modified extracorporeal septoplasty technique.
        Arch Facial Plast Surg. 2006; 8: 202-207
        • Kridel R.
        • Yoon P.
        • Koch R.
        Prevention and correction of nasal tip bossae in rhinoplasty.
        Arch Facial Plast Surg. 2003; 5: 416-422
        • Gillman G.
        • Simons R.
        • Lee D.
        Nasal tip bossae in rhinoplasty. Etiology, predisposing factors, and management techniques.
        Arch Facial Plast Surg. 1999; 1: 83-89
        • Brenner M.
        • Hilger P.
        Thin skin rhinoplasty: aesthetic considerations and surgical approach.
        in: Azizzadeh B. Murphy M.R. Johnson C.M. Master techniques in rhinoplasty. Elsevier, Philadelphia2011: 331-334
        • Paun S.
        • Trenite G.
        Correction of the pinched nasal tip deformity.
        in: Azizzadeh B. Murphy M.R. Johnson C.M. Master techniques in rhinoplasty. Elsevier, Philadelphia2011: 235-244
        • Toriumi D.M.
        New concepts in nasal tip contouring.
        Arch Facial Plast Surg. 2006; 8: 156-185
        • Toriumi D.M.
        • Checcone M.A.
        New concepts in nasal tip contouring.
        Facial Plast Surg Clin North Am. 2009; 17 (vi): 55-90
        • Gunter J.P.
        • Friedman R.M.
        Lateral crural strut graft: technique and clinical applications in rhinoplasty.
        Plast Reconstr Surg. 1997; 99 ([discussion: 953–5]): 943-952
        • Kridel R.W.
        • Chiu
        The management of alar columellar disproportion in revision rhinoplasty.
        Facial Plast Surg Clin North Am. 2006; 14 (vi): 313-329
        • Baker S.
        Suture contouring of the nasal tip.
        Arch Facial Plast Surg. 2000; 2: 34-42
        • Davis R.E.
        Proper execution of the transcolumellar incision in external rhinoplasty.
        Ear Nose Throat J. 2004; 83: 232-233
        • Most S.P.
        Trends in functional rhinoplasty.
        Arch Facial Plast Surg. 2008; 10: 410-413
        • Most S.P.
        Analysis of outcomes after functional rhinoplasty using a disease-specific quality-of-life instrument.
        Arch Facial Plast Surg. 2006; 8: 306-309
        • Marin V.P.
        • Landecker A.
        • Gunter J.P.
        Harvesting rib cartilage grafts for secondary rhinoplasty.
        Plast Reconstr Surg. 2008; 121: 1442-1448
        • Kridel R.W.
        • Ashoori F.
        • Liu E.S.
        • et al.
        Long-term use and follow-up of irradiated homologous costal cartilage grafts in the nose.
        Arch Facial Plast Surg. 2009; 11: 378-394