Postoperative bleeding is one of the most common complications after nasal surgery. Prevention of postoperative bleeding depends on identifying patients at risk, and those patients with a personal or family history of bleeding disorders should be investigated using specific tests. The use of anticoagulant drugs, aspirin, and NSAIDs should be interrupted at least 2 weeks before surgery in all patients.
Epistaxis is most frequently mild but may be severe. The most common causes of mild epistaxis are bleeding from the incision sites and traumatized mucosa. Fortunately, mild postoperative bleeding can generally be controlled with 60-degree head elevation, gentle nostril pressure for 15 minutes, and application of topical decongestant nasal sprays.
If bleeding persists, the septal splints should be removed, and the nasal passages should be gently suctioned to remove blood clots and crusts. Focal areas of bleeding may be cauterized with silver nitrate, or a light hemostatic packing made of methylcellulose may be placed over the bleeding surface. Newer topical hemostatic sealants containing thrombin may alleviate diffuse mucosal bleeding. Continued bleeding may require a formal nasal pack, either in the form of gauze or a commercially available nasal tampon. Bleeding that persists despite anterior packing may signify a posterior bleed from a branch of the sphenopalatine artery, and a posterior pack may be required. Patients should be observed for airway compromise while a posterior pack is in place. Antibiotics should be administered while packing is in place to reduce the risk of toxic shock syndrome.
Serious bleeding occurs in less than 1% of patients and warrants operative exploration when conservative measures fail. Persistent bleeding may require endoscopic ligation of the sphenopalatine artery, internal maxillary artery, or anterior and posterior ethmoidal arteries. Alternatively, bleeding that is refractory to all of these measures can be addressed with angiographic embolization.
A septal hematoma is a potentially serious complication of rhinoplasty. Patients may present with symptoms of nasal obstruction, pain, rhinorrhea, or fever. The typical finding on physical examination is an ecchymotic nasal septal mass. An untreated septal hematoma can have serious implications, as it may lead to cartilage necrosis with subsequent loss of dorsal support and a saddle-nose deformity. Proper management consists of early recognition with prompt evacuation of the hematoma, either via needle aspiration or incision and drainage. Antimicrobial therapy should be initiated if a secondary nasal septal abscess is suspected.
In spite of the fact that rhinoplasty is a “non-sterile operation”, infections happen in less than 1% of all interventions. Postoperative infections following rhinoplasty can range in severity from mild cellulitis of the soft tissue envelope to life-threatening systemic illness resulting from cavernous sinus thrombosis or toxic shock syndrome. The rhinoplasty surgeon should be diligent in examining his or her patient for signs of infection and initiating treatment early.
Local wound infections, such as cellulitis, can be treated with systemic antibiotics and close observation; however, any suspected abscess requires prompt surgical drainage in addition to antibiotic therapy. Common sites of abscess formation following rhinoplasty include the nasal dorsum, nasal tip, and septum.
A septal abscess usually arises in the setting of an infected septal hematoma that has gone unrecognized or inadequately treated. Treatment of a septal abscess begins with incision and drainage. Packing the abscess site with gauze may aid in local wound debridement and a means of egress for residual infection. Generally, patients should be administered intravenous antibiotics until the infection is under control. Cavernous sinus thrombosis, meningitis, or a brain abscess may result without adequate treatment.
Toxic shock syndrome, an acute, multisystem disease, has been described after nasal surgery with the use of both nasal packing and intranasal splints. Toxic shock syndrome is usually caused by the release of an exotoxin, toxic shock syndrome toxin-1, created by Staphylococcus aureus. The exotoxin acts as a superantigen that causes leukocytes to release massive amounts of proinflammatory cytokines. Symptoms occur early and can include nausea or vomiting, rash, fever, tachycardia, and hypotension. Treatment requires the immediate removal of the offending object, intensive care unit admission, intravenous antibiotics, and supportive care.
When harvesting septal cartilage, most authors recommend preserving a 1-cm-wide septal L-strut that should remain attached to the perpendicular plate of the ethmoid and the nasal spine– maxillary crest area. When L-strut fractures occur, they should be repaired immediately to prevent significant deformity because the cartilaginous septal segment tends to rock posteriorly, resulting in a loss of dorsal support and a saddle-nose deformity.
For fractures of the midportion of the dorsal septal L-strut, the fracture can be stabilized with suture techniques and spreader grafts. When the fracture occurs cephalad to the nasal bone edges, the fractured L-strut can be rigidly fixated using percutaneous Kirschner wires that are placed through the nasal bones and the fractured dorsal septum caudal to the fracture site. For fractures that occur near or at the nasal bone edges (keystone area), a combination of spreader grafts and Kirschner wires is required because suture placement above this area is precluded by the tight anatomic relationships. By placing the Kirschner wires through the nasal bones as opposed to the upper lateral cartilages, the fractured segment can be rigidly fixated. The Kirschner wires are left in place for 3-4 weeks, when they are removed in the office setting with a wire twister.
Intracranial Injury and Cerebrospinal Fluid Leak
Intracranial injury and cerebrospinal fluid leaks are a major complication after rhinoplasty. Violation of the cribiform plate by surgical instruments can result in a cerebrospinal fluid leak and potential intracranial injury or infection. A fractured cribiform plate can also result from excessive bony septum manipulation.
Symptoms of a cerebrospinal fluid leak include clear rhinorrhea and positional headache. The diagnosis may be confirmed by testing the fluid for the presence of 2-transferrin, a protein highly specific for cerebrospinal fluid. A cerebrospinal fluid leak necessitates hospitalization, bed rest, and prompt otolaryngologic and neurosurgical evaluations with potential placement of a lumbar drain. Surgical repair via endoscopic techniques may be required for patients who continue to leak despite conservative measures.
Epiphora after rhinoplasty most commonly occurs due to compression of the lacrimal system by the characteristic soft-tissue edema. Fortunately, this normally resolves after 1-2 weeks. Bleeding epiphora and lacrimal sac injury have been reported during straight-line or saw nasal osteotomies after subperiosteal tunneling. Treatment of these injuries may require early silicone intubation of the lacrimal system or dacryocystorhinostomy.
Septal perforations are most often caused by opposing tears in the elevated septal mucoperichondrial flaps with no intervening septal cartilage. However, perforations may also result from significant interruption of blood flow to the septal mucoperichonidral flaps from an unrecognized septal hematoma or tissue necrosis from septal stitches. Symptoms of a nasal septal perforation include crusting, bleeding, whistling, and nasal airway obstruction due to disruption of the normal laminar airflow through the nasal passages. These symptoms are often dictated by the size and location of the perforation, with anterior or caudal septal perforations being more problematic.
Symptom severity should guide the decisions for treatment. Conservative measures include local hygiene with nasal saline irrigation or obturation with a Silastic septal button. For small perforations, local advancement flaps with an interposed connective tissue autograft or an allograft can be used to close the perforation. Larger perforations are more challenging and may require more extensive exposure and tissue for successful closure.
Synechiae are intranasal adhesions that result from cicatrical healing of opposed, abraded mucosal surfaces. Patients may present with nasal obstruction. Intranasal examination will reveal a “bridge” of mucosa from the septum to the inferior turbinate, middle turbinate, or lateral nasal wall. Treatment requires division and placement of a barrier between the incised surfaces, such as a Silastic splint, until the surfaces undergo complete re-epithelialization.
Postoperative Septal Deviation
Septal deviation, whether new or uncorrected, following septorhinoplasty is a source of frustration for both the patient and the surgeon. Residual deviation of the septum may result from inadequate surgical techniques or from insufficient septal stabilization during the immediate postoperative period. New septal deviation can result from overresection of the septum and from unpredicted forces of healing. Any significant septal deviation that persists and causes cosmetic or functional impairment should invite the discussion of revision surgery.
There has been considerable debate over the need and optimal means of internal splinting of the septum. While most surgeons do not routinely pack the nose, Guyuron found that patients in whom nasal packs were used were less likely to develop recurrent or residual septal deviation and synechiae compared with patients in whom no packing was used. He later demonstrated that septal splints provided patients with improvements in nasal airway obstruction similar to those seen in patients treated with packing. Conversely, several studies have demonstrated that paired silicone splints may not prevent adhesions and can add to postoperative discomfort.
Nevertheless, intranasal splints are routinely used to help maintain septal stability and prevent intranasal adhesions following septorhinoplasty. The general consensus is that when placed bilaterally, these septal splints help stabilize the septum as the mucoperichondrium re-adheres; they may also aid in preventing the formation of a septal hematoma.
Overresection of intranasal structures such as the middle or inferior turbinate can lead to atrophy of the nasal mucosa, referred to as atrophic rhinitis. Patients may present with subsequent symptoms of dryness, crusting, and nasal obstruction. Nasal saline may provide symptomatic relief.
More commonly, patients may report a spontaneous clear watery nasal discharge. This phenomenon most likely represents a variant of vasomotor rhinitis caused by abnormal parasympathetic tone to the intranasal mucosa. Topical anticholinergic preparations act locally and are effective in decreasing watery rhinorrhea. The recommended dosing regimen is two sprays in each nostril two to three times a day as needed. Continued symptoms of watery nasal discharge despite appropriate topical therapy should raise the concern for an occult cerebrospinal fluid leak.
Supratip (“Pollybeak”) Deformity
Postrhinoplasty Nasal Cysts
Postrhinoplasty nasal cysts are a rare complication of rhinoplasty. Several forms of nasal cysts have been described. Lipogranulomas or “paraffinomas” are foreign-body inclusion cysts that are thought to arise from the use of petroleum-based ointments in conjunction with nasal packing. Mucous cysts are a second type of nasal cyst that can arise after rhinoplasty. The most common site of occurrence for both types of cysts is the nasal dorsum, and they are thought to arise from ectopic or displaced mucosa and ointment extravasation into osteotomy sites. Mucous cysts and lipogranulomas may require complete excision, often in the setting of a secondary rhinoplasty via an open approach to allow for adequate exposure. Meticulous closure of intranasal incisions and judi cious use of nonpetroleum-based antibiotic creams should be used to help decrease the chance of lipogranuloma formation.
Contact Dermatitis and Skin Necrosis
Contact dermatitis may result from irritation of the skin by the topical adhesives, tape, or dorsal splint. The treatment of contact dermatitis includes removal of the offending agent and application of topical and potentially systemic steroids, depending on the severity of the reaction. Fortunately, contact dermatitis usually resolves without any permanent sequelae.
Superficial skin necrosis or epidermolysis can occur secondary to excessive compression of the skin by the taping and dressing. Even more problematic, however, is partial-thickness or full-thickness skin necrosis, which occurs when the blood supply of the soft-tissue envelope is more severely embarrassed. This may occur due to erroneous dissection of the skin flap, injury to the lateral nasal arteries, aggressive debulking of the subcutaneous tissue of the tip or prolonged compression of the skin by the taping and dressing.
The treatment of minor skin necrosis should initially be conservative. Daily wound care and protection from the sun should be diligently exercised until the wound closes by secondary intention. After maturation of the scar, dermabrasion, filler substances, skin care, and laser treatment may be helpful. In selected patients, a skin or composite graft may be utilized to improve the contour of the affected aesthetic unit. Fortunately, major skin necrosis is extremely rare. In these cases, reconstruction should be performed using local or regional flaps.
Telangiectasias are small superficial vessels of the skin visible to the human eye and usually measure 0.1 to 1.0 mm in diameter. While telangiectasias of the nose have been reported to result from rhinoplasty, their incidence following surgery is unknown. Telangiectasias following rhinoplasty may result from a failure to dissect in a subperiosteal plane on the nasal dorsum. Other causes of nasal telangiectasias include significant dorsal augmentation in patients with contracted soft-tissue envelopes or following alloplastic augmentation with Silastic or expanded polytetrafluoroethylene.
Whether new or exacerbated, telangiectasias of the nasal skin following rhinoplasty are a frustrating problem for both the patient and the surgeon. Argon and pulsed dye lasers have proven to be an effective means of treatment. While the argon laser carries a risk of scarring and a relatively high risk of posttreatment pigmentary changes, the pulsed dye laser (585 and 577 nm) has been shown to be a safe and highly effective means of combating telangiectasias. It has a short pulse duration (0.45 msec) that reduces the risk of severe long-term adverse effects.
When wearing glasses, it’s important that no pressure or weight from the eyewear rests on your nose. If your glasses are somewhat heavy, they may put indentations in the sides of the nasal bones while they heal, causing the bones to heal incorrectly (crooked nose, horse saddle nose). It is highly recommended that Doctor CO eyewear be used during times like these, as to not cause any more problems that can hinder the recovery process of your nose.