--- title: "Rhinoplasty - Postoperative Care & Complications" description: "ENT notes on postoperative care and complications of Rhinoplasty." source: "The ENT Resident" author: "Dr. Mausumi Das" canonical_url: "https://www.theentresident.com/ent-notes-lectures/rhinoplasty-complications-postoperative-care" categories: ["Rhinology", "Surgery"] video: "https://www.youtube.com/watch?v=0PS1zKfWe-Q" image: "https://media.theentresident.com/og-images/rhinoplasty-complications-postoperative-care.jpg" --- # Rhinoplasty - Postoperative Care & Complications ENT notes on postoperative care and complications of Rhinoplasty. Watch the full video lecture on YouTube: https://www.youtube.com/watch?v=0PS1zKfWe-Q ## 👃 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](https://www.theentresident.com/ent-notes-lectures/preoperative-assessment-rhinoplasty.md) 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](https://www.theentresident.com/ent-notes-lectures/rhinoplasty-osteotomies-types-complications.md)? #### 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 --- ## About This Note This free ENT note on Rhinoplasty - Postoperative Care & Complications was written by Dr. Mausumi Das and is paired with a corresponding video lecture. 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