Rhinoplasty - Postoperative Care & Complications

👃 Rhinoplasty - Postoperative Care & Complications

📝 Pre operative Counselling

The patient should be told during pre operative counselling what to expect after surgery, so that unnecessary anxiety is avoided.

The patient may experience:

• Slight oozing of blood stained secretions from the nasal pack
• Middle ear discomfort
• Dryness of the mouth, due to mouth breathing with the nasal pack in place
• Swelling of the eyes and face
• Discomfort in the nose, but no pain

What preoperative assessment should be carried out prior to Rhinoplasty procedure?

🏥 Postoperative Care of Rhinoplasty

1- Position

👉 Propped up position

What is the reason behind keeping patient in propped up position in the postoperative period after Rhinoplasty?

2- Cold Compresses

Ice cold compresses or ice packs over the eyelids for at least the first day.

⚠️ Use small ice packs, so that the plaster of Paris cast does not get soaked.

What problem does the cold compress help with in the immediate postoperative period after Rhinoplasty?

3- Diet

• Liquids, followed by a soft diet for 2 to 3 days
• Regular diet afterwards

Why is liquid diet advised in the immediate postoperative period after Rhinoplasty?

4- Medications

• Anti-inflammatory drugs (NSAIDs or enzymes), to reduce postoperative swelling
• Prophylactic antibiotics for at least one week
• Analgesics, especially on the first day

5- Sleeping Position

👉 The patient should sleep on the back, as sleeping on the side may press the splint.

6- Care of Nasal Packs and Splints

Nasal bolster - A gauze piece placed beneath the columella. It is changed whenever soaked, without disturbing the splint or the columella.

When is nasal pack removed after Rhinoplasty and Septorhinoplasty?

When is nasal splint removed after Rhinoplasty?

👉 After splint removal, the patient is called for check-up at 1, 3 and 6 months.

7- Instructions After Pack Removal

• Avoid nose blowing for at least 2 weeks
• Nasal drops, to prevent crust formation
• Avoid trauma to the nose for a few weeks
• Avoid strenuous physical activity for a month
• Avoid unnecessary palpation of the nose

8- Points to Explain to the Patient

• After removal of the splint and tapes, the nose may appear stiff, numb and somewhat swollen
• Eyeglasses cannot be worn until the swelling on the bridge of the nose subsides. If essential, they must be modified so that no pressure falls on the nasal bridge

What are the expected postoperative changes & timeline following Rhinoplasty surgery?

⭐ A proper evaluation of a post-rhinoplasty case must be done only after 6 months, when the soft tissues have settled and reformed in their corrected state.

📋 Classification of Complications of Rhinoplasty

1️⃣ Intraoperative complications

2️⃣ Postoperative complications

• Early postoperative
• Late postoperative

🚨 Intraoperative Complications

1- Bleeding / Hemorrhage

⭐ The most common complication of any surgery. Bleeding obstructs the surgical field.

Causes

• Inadequate vasoconstriction when packing the nose
• Injury to vessels such as the anterior ethmoidal artery or septal vessels
• Hypertension
• Coagulopathy or bleeding disorders

How would you manage Hemorrhage in a postoperative case of Rhinoplasty?

What measures can you take to prevent Hemorrhage in a postoperative case of Rhinoplasty?

2- Mucosal Tears

Causes

• Wrong plane of dissection while raising the mucoperichondrial flap
• Poor visualization of the surgical field due to bleeding
• Scar tissue in revision cases

How does a mucosal tear lead to septal perforation?

How would you treat a case of Septal perforation in a postoperative case of Rhinoplasty?

Prevention

• Meticulous flap elevation
• Gentle handling of tissues

3- Septal Injury

Causes

• Opposing (bilateral) mucosal tears at the same site
• Excessive cartilage removal during septoplasty
• Septal hematoma

Which part of septum is at the highest risk of injury during Rhinoplasty?

What are the different causes behind Septal perforation developing in a postoperative case of Rhinoplasty?

What measures can you take to prevent Septal injury during the surgery?

Treatment

• Close one side of the tear with absorbable sutures
• Interpose a free mucosal graft if both sides are torn at the same level

4- Osteotomy Complications (Uncontrolled Fracture)

Causes

• Incorrectly placed osteotomy cut
• Use of excessive force

Effects

• Asymmetry
• Rocker formation
• Instability of the region

Treatment

• Reposition the fragment immediately and hold it with an external splint
• A bone graft or implant may be needed as a secondary procedure in a comminuted fracture

What measures can you take to prevent the complications from osteotomy?

What are the different types of osteotomies performed in rhinoplasty?

5- Cartilage Over Resection

Excessive resection of the upper or lower lateral cartilage leads to deformity, such as a pinched tip deformity.

Treatment

• Cartilage graft reconstruction

How can you prevent pinched tip deformity in Rhinoplasty case?

6- Button Holing of the Skin

A breach in the skin envelope over the nasal dorsum or tip.

Causes

• Very thin skin, especially in revision cases with scarring
• Dissection plane too superficial

Treatment

• Primary closure with a fine monofilament

What is the importance of looking at skin quality during the pre operative assessment for rhinoplasty?

How will you prevent button holing of skin in a postoperative case of Rhinoplasty?

7- CSF Leak / Skull Base Injury

⭐ Very rare.

Cause

During osteotomy or rasping of the bone, going too superiorly through the cribriform plate, especially with a high lateral osteotomy.

How will you manage a case of CSF leak in a postoperative case of Rhinoplasty?

How can you prevent CSF leak from developing in a postoperative case of Rhinoplasty?

8- Anaesthetic Complications

• Hypotension from the adrenaline in the local anaesthetic
• Drug allergy
• Cardiac arrest

Management

Handled by the anaesthetist intraoperatively.

Prevention

Good pre-operative assessment.

⏳ Early Postoperative Complications

1- Hemorrhage (Reactionary)

⭐ The most common complication of rhinoplasty. Occurs within a few hours of surgery.

Causes

• Inadequate hemostasis
• Postoperative hypertension
• Dislodged clot

What are the sites of Reactionary Hemorrhage in Rhinoplasty?

How will you manage a case of reactionary hemorrhage in a postoperative case of Rhinoplasty?

Prevention

• Meticulous hemostasis
• Blood pressure control, with hypotensive anaesthesia where appropriate

2- Hematoma

Causes

• Reactionary bleed into the dead space beneath the skin envelope or under the mucoperichondrial flaps
• Hematoma over the bridge of the nose occurs due to inadequate fixation, and can be drained at the canthal area

What does an untreated hematoma lead to?

How will you manage hematoma in a postoperative case of Rhinoplasty?

Prevention

• Meticulous hemostasis during the operation
• Proper splint and pack postoperatively

3- Infection

Causes

• Infected hematoma
• Contamination from skin flora or nasal mucosa
• Use of implants

What is the most common organism involved in infection in a postoperative case of Rhinoplasty?

Treatment

• Antibiotics
• Removal of the implant in implant-related infection that does not settle
• Drainage of a localized abscess by needle aspiration or a small incision

What measures can be taken to prevent infection in the postoperative period of Rhinoplasty?

4- Edema & Ecchymosis

Cause

Soft tissue trauma from manipulation and handling around the external nose and periorbital region.

Treatment

• Propped up position with head end elevated
• Cold compresses over the periorbital region in the first one to two days

⭐ This settles by itself.

5- Skin Necrosis

⭐ Rare. Loss of skin viability, especially over the nasal dorsum.

Causes

• Excessive pressure from the splint over a large implant or graft
• Injury to the subdermal plexus during over-aggressive defatting of the nasal tip skin

How will you manage skin necrosis in a postoperative case of Rhinoplasty?

What measures can be taken to prevent skin necrosis in the postoperative period of Rhinoplasty?

6- Airway Obstruction

What are the causes of Airway obstruction in a postoperative case of Rhinoplasty?

Treatment

• Nasal dilators
• Revision with spreader grafts, if persistent

Prevention

• Pre-operative assessment of the internal nasal valve area and its angle

7- Olfactory Disturbances

⭐ Reduced smell sensation is possible in the first few weeks after rhinoplasty, and usually resolves on its own within a few months.

What is hyposmia?

What is anosmia?

8- Numbness / Paresthesia

Numbness of the nose is experienced right after removal of the splint.

⭐ Always temporary. The nose may feel stiff and heavy for a few days, resolving within days to weeks.

⭐ The patient should be counselled about this beforehand, to avoid anxiety.

🕰️ Late Postoperative Complications

1- Nasal Synechiae

Fibrous bands formed between two opposing raw surfaces on the medial and lateral nasal walls.

How will you manage Nasal Synechiae in a postoperative case of Rhinoplasty?

What measures can be taken to prevent Nasal Synechiae in the postoperative period of Rhinoplasty?

2- Persistent Nasal Obstruction

What are the causes of Persistent Nasal Obstruction in a postoperative case of Rhinoplasty?

Treatment

• Identify the cause and correct it surgically

3- Saddle Nose Deformity

Loss of support of the nasal vault with subsequent collapse, producing a dip in the nasal dorsum.

What are the causes of Saddle nose deformity in a postoperative case of Rhinoplasty?

How can you prevent Saddle nose deformity in the postoperative period of Rhinoplasty?

Treatment

• Augmentation rhinoplasty with an autologous cartilage graft, preferably septal or auricular cartilage

What is Augmentation rhinoplasty?

4- Polly Beak Deformity

Excessive fullness in the supratip area, making the nose resemble a parrot's beak.

What are the causes of Polly Beak Deformity in a postoperative case of Rhinoplasty?

Treatment

• Revision rhinoplasty with reduction of the cartilaginous dorsum and the septal angle cartilage
• Excision of soft tissue scar
• Correction of the columellar strut

How can you prevent Polly Beak Deformity in the postoperative period of Rhinoplasty?

5- Pinched Tip Deformity

An overly narrow, constricted nasal tip.

Cause

Excessive alar cartilage resection

Treatment

• Cartilage grafting

Prevention

• Conservative tip surgery, avoiding over-resection

6- Nasal Valve Collapse

Dynamic or static collapse of the internal or external nasal valve, causing nasal obstruction.

What are the boundaries of Internal nasal valve?

What are the boundaries of External nasal valve?

What are the causes of Nasal Valve Collapse in a postoperative case of Rhinoplasty?

Treatment

• Spreader grafts
• Alar batten grafts

Prevention

• Knowledge of valve anatomy and preservation of structural support in that area

7- Hypertrophic Scar

May develop as a hypertrophic scar or keloid at the transcolumellar or alar incision site.

Cause

Poor wound tension alignment

Treatment

• Intralesional triamcinolone injections
• Scar revision, if needed

Prevention

• Precise apposition of skin edges with everting sutures
• Gentle tissue handling

8- Retention Cyst

A cyst-like structure over the nasal dorsum, forming especially at the lateral osteotomy site around retained bone dust or chips when a saw has been used.

How can you prevent Retention Cyst in the postoperative period of Rhinoplasty?

9- Psychological Dissatisfaction

Causes

• Unrealistic expectations from the surgery
• Underlying body dysmorphic disorder

⭐ The patient remains unhappy even when the result is objectively good.

Treatment

• Psychiatric referral
• Counselling and CBT
• Avoid revision surgery where body dysmorphic disorder is suspected

What are the things you should look out for during case selection during psychological assessment of the patient for Rhinoplasty?

⭐ Exam Pearls

• Patient is nursed in a propped up position
• Nose blowing avoided for 2 weeks, strenuous activity for a month
• Final evaluation of a rhinoplasty case only after 6 months
• Most common complication → Hemorrhage
• Bilateral mucosal tears at the same site → Septal perforation
• Incorrect medial osteotomy → Rocker formation
• Internal nasal valve angle less than 15 degrees → Airway obstruction
• Excessive dorsal hump reduction → Saddle nose deformity
• Excessive fullness in the supratip area → Polly beak deformity
• Excessive alar cartilage resection → Pinched tip deformity
• Nasal valve collapse treated with spreader grafts or alar batten grafts
• Retention cyst forms around bone dust at the lateral osteotomy site

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