Risks and complications in rhinoplasty.

Abstract

Rhinoplasty is regarded to be associated with many risks as the expectations of patient and physician are not always corresponding. Besides of postoperative deformities many other risks and complications have to be considered. Reduction-rhinoplasty e.g. can cause breathing disturbances which are reported in 70% of all revision-rhinoplasty-patients. One has to be aware however that scars and loss of mucosal-sensation can also give the feeling of a "blocked nose". The main risks of autogenous transplants are dislocation and resorption, while alloplasts can cause infection and extrusion. In this respect silicone implants can have a complication rate between 5-20%. Less complications are reported with other materials like Gore-Tex. Complications of skin and soft tissues can be atrophy, fibrosis, numbness, cysts originating from displaced mucosa or subcutaneous granulomas caused by ointment material. Postoperative swelling depends mainly on the osteotomy technique. Percutaneous osteotomies cause less trauma, but may result in visible scars. Infections are rare but sometimes life-threatening (toxic-shock-syndrome). The risk is higher, when sinus surgery and rhinoplasty are combined. Osteotomies can also cause injuries of the orbital region. Necrosis of eye-lids by infections and blindness by central artery occlusion are known. There are reports on various other risks like rhinoliquorrhea, brain damage, fistulas between sinus-cavernosus and carotid artery, aneurysms and thrombosis of the cavernous sinus. Discoloration of incisors are possible by damage of vessels and nerves. Rhinoplasty can also become a court-case in dissatisfied patients, a situation that may be called a "typical complication of rhinoplasty". It can be avoided by proper patient selection and consideration of psychological disturbances. Postoperative deformities are considered as main risks of rhinoplasty, causing revision surgery in 5% to 15% of the cases. The analysis of postoperative deformities allowes the identification of specific risks. The most frequent postoperative deformity is the "pollybeak" when a deep naso-frontal angle, cartilaginous hump and reduced tip projection are present preoperatively. The pollybeak is the indication in about 50% of all revision rhinoplasties. Other frequent postoperative deformities are a pendant and wide nasal tip, retractions of the columella base or irregularities of the nasal dorsum. These deformities are very often combined and caused by a loss of septal support. This is why the stability of the caudal septum in septorhinoplasty is the key for a predictable result. Maintaining the position of the tip and the columella is one of the main issues to avoid typical postoperative deformities. The risks for rhinoplasty-complications can be reduced with increasing experience. A prerequisite is continuing education and an earnest distinction between complication and mistake.