Chapter 20 Prevention and Management of Rhinoplasty Complications
Pearls
• The intraoperative complications of rhinoplasty include excessive bleeding, loss of dorsal support due to fracture of the L frame, unstable nasal bones and septal perforation.
• The short-term postoperative complications of rhinoplasty include infection, epistaxis, airway occlusion, hematoma, and dehiscence.
• The most common reason for intraoperative bleeding is hypertension which should be corrected by the anesthesiologist.
• Von Willebrand disease type I and type IIa, which are the most common subtypes and represent the majority of patients with this condition, respond favorably to the infusion of DDAVP (desmopressin).
• Patients who are vegetarian or those who have been taking antibiotics for a long time could be deficient in vitamin K and may need replacement. This can be accomplished with 10 mg of vitamin K orally or intramuscularly starting the day before surgery.
• If the patient initially forms clots appropriately during the surgery but the clots are unstable, a process of fibrinolysis should be suspected and can be treated with diffusion of aminocaproic acid.
• At one time the most common reason for intraoperative bleeding used to be the preoperative consumption of aspirin and aspirin-type nonsteroidal anti-inflammatory drugs (NSAIDs). With vigorous patient education, this condition has been reduced.
• Patients who are suspected to have consumed NSAIDS can also be treated successfully with DDAVP in most incidences.
• While most rhinoplasty authorities recommend leaving a 10 mm wide dorsal portion of the L strut, the author strongly recommends leaving at least a 15 mm dorsal strut to minimize the potential for postoperative loss of support.
• Unstable nasal bones that shift medially and posteriorly can be suspended from the septum by using the upper lateral cartilages or by passing sutures through the bone, and in rare incidences, by using K wires.
• Patients who have von Willebrand disease and receive intraoperative DDAVP with a presumptive diagnosis of this condition frequently have an episode of epistaxis 7–8 days after the surgery, which can be successfully treated with another infusion of DDAVP.
• Postoperative treatment of epistaxis includes control of hypertension, nose sprays with vasoconstrictive agents such as neosynephrine spray, and if it cannot be controlled, treatment with DDAVP.
• The incidence of revision rhinoplasty ranges from a minimum of 2% up to 25–30%, depending on the level of perfectionism of the surgeon and patient.
• In a recent study by the author’s group, while minor flaws were noted by the author in 17% of patients, only 3% of patients underwent revision surgery, leaving 14% who chose not to have revision surgery.
• The most common presentation of nose infection following surgery is minor bleeding or bloody secretions, especially in the morning, which is an indication of infectious rhinitis; usually the culture will grow staphylococcal aureus.
• Use of PDS rather than permanent sutures, when feasible, can reduce the incidence of suture-related infection.
• Infections of the nasal cavity can often be successfully treated with topical application of Bactroban ointment.
• Commonly, very small perforations are symptomatic and cause whistling and larger perforations may result in crusting or bleeding, leading to the growth of bacteria.
• While the internal valve dysfunction will be associated with an inverted V deformity, the external valve collapse is commonly associated with a cloverleaf deformity.
• The majority of techniques utilized to redefine the nose, which are reductive in nature, will also result in reduction in the airway. These include nasal bone osteotomy with medialization of upper lateral cartilages, transdomal sutures, interdomal sutures, lateral crura spanning sutures, and convexity control sutures.
• Spreader grafts, turbinectomy, septoplasty, insertion of alar rim graft, tip rotation cephalically, and lateral crura strut can all result in improvement in the airway.
Complications of rhinoplasty, other than the flaws requiring revision surgery, are rare and very few articles have covered this topic.1–3 The complications can occur intraoperatively, in the short term or in the long term postoperatively. Intraoperative complications are listed in Box 20.1. Short-term postoperative complications are those that occur within 1 week of surgery (Box 20.2) and long-term postoperative complications are experienced beyond the first week (Box 20.3).
Intraoperative Complications
Excessive Intraoperative Bleeding
The most common reason for intraoperative bleeding is hypertension. It is therefore prudent to seek information on this from the anesthesiologist immediately when excessive bleeding is encountered. Hypertension is most commonly induced by the sudden systemic absorption of the vasoactive agents contained in the local anesthetic or the nasal packing, both of which are intended to cause vasoconstriction in the nose, septum, and turbinates. The level of anesthesia also plays a significant role in controlling hypertension. Inadequate depth of anesthesia at the beginning of the surgery, during the operation, or at the time of emergence from anesthesia, along with any painful stimulus, can result in a sudden rise of blood pressure and thus excessive bleeding. This type of abnormal bleeding should not occur often and can be readily controlled if the anesthesia is provided by an experienced attendant and certain measures are implemented by the surgical team. Injection of the turbinates, placement of gauze saturated with vasoactive agent in the nose, and subsequent injection of the nasal soft tissues must be done gently and in a systematic manner. Throughout the process, there should be constant communication between the anesthesiologist and the surgeon. The injections should be titrated to prevent a sudden rise in blood pressure. Additionally, the double injection technique described in Chapter 4 minimizes the systemic effect of injected vasoactive agents. Furthermore, the injection must be targeted to cause thorough vasoconstriction in all the surrounding superficial and deeper vessels on the exterior and interior surfaces of the nose. The rate of infusion and the content of the intravenous fluid should also be watched closely. If a patient, especially an older patient, receives too much salt-containing solution, the result will be an uncontrollable rise in blood pressure, which may persist postoperatively. Such excessive fluid administration may also result in dilution of coagulation factors, disturbance of the clotting cascade, and exaggerated postoperative swelling.
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