-------------------------------------------------------------------------------- TITLE: AVOIDANCE AND TREATMENT OF RHINOPLASTY COMPLICATIONS SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: 9 March 94 RESIDENT PHYSICIAN: Joseph J. Bradfield, M.D. FACULTY: Karen H. Calhoun, M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. -------------------------------------------------------------------------------- "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." I. General Considerations A. Rhinoplasty may be one of the most difficult of cosmetic surgical procedures: 1. Complicated three dimensional anatomy. 2. Difficult to predict final result due to differences in surgeons skill, patients skin,cartilage and general healing. 3. There is long term metamorphosis of the result - for months and even years. B. Preoperative evaluation is crucial to minimizing postoperative complications. Both the patients physical and emotional evaluation are crucial. C. It is not possible to approach every nose according to a standard cookbook operation. The rhinoplasty surgeon must have multiple operative approaches and techniques at his disposal. D. Even the most experienced surgeon must keep in mind the possible need for revision surgery in a certain percentage of patients. E. Complications may be grouped into four major categories - Intraoperative, early postoperative, and late postoperative complications, as well as aesthetic deformities requiring secondary revision. II. Intraoperative Complications A. Excessive Bleeding 1. Avoidance: a. Careful preoperative evaluation - Ensure patient is not on any medications which might interfere with coagulation - coumarin, aspirin, NSAIDs. Question for history of bleeding diatheses. b. Adequate vasoconstriction - topical cocaine, phenylephrine, or oxymetazoline. Injection with lidocaine with epinephrine - allow at least 10 minutes for maximum vasoconstriction and local anesthesia. c. Surgical position with head slightly elevated. d. Meticulous (atraumatic) surgical technique. 2. Treatment: a. Pack with cotton gauze/oxymetazoline and wait 10 minutes. b. Ensure patient is normotensive. c. Ligate or cauterize specific bleeding point. Endoscope may be useful in this regard. d. Apply microfibrillar collagen. e. If other steps fail, pack firmly and abort procedure. B. Medication toxicity 1. Avoidance - Bear in mind toxic doses of commonly used medications and medication interactions: a. Lidocaine - 4 mg/kg if used without epinephrine (about 25 cc 1% lidocaine), if used with epinephrine 7 mg/kg (about 50 cc 1% lidocaine). Early manifestations of lidocaine toxicity include lightheadedness, drowsiness, euphoria, tingling around the lips, tinnitus and bitter taste. At higher dosages, siezures begin, which are treated with valium. With high drug levels, cardiorespiratory depression and collapse occur. b. Cocaine - most commonly accepted maximum dose is 200 mg, or 5 cc of 4% solution. The dose is not based on any scientific data other than experience with cocaine injection for tonsillectomy. Cocaine should be used with caution in those taking cholinesterase inhibitors or those with cholinesterase deficiency, who do not metabolize as rapidly. Higher blood levels and a more rapid peak has been reported. Toxicity does not apear to be dose related and has been reported with doses as low as 10 mg. Toxicity is primarily demonstrated by CNS symptoms including excitability, headache, nausea, vomiting and tachycardia. Treatment is supportive. c. Halothane increases myocardial irritability to the effects of epinephrine, and may result in cardiac dysrhythymias. d. Tricyclic antidepressants block reuptake of norepinephrine (similar to cocaine) and result in hypertensive crisis. e. Epinephrine injection in patients on beta blockers can result in pure (unopposed) alpha-adrenergic stimulation and hypertensive crisis. 2. Treatment in General: 1. Cease administration of further medications. 2. Administer appropriate narcotic antagonist (naloxone) or benzodiazepine antagonist (flumazenil). 3. Treat dysrhythymias, hypertension, seizures as per ACLS and other supportive measures. 4. Control the airway. C. Restless/Uncomfortable patient: 1. Avoidance: a. Adequate injection, suitable intravenous sedation. b. Comfortable positioning. c. Supplemental oxygen. 2. Treatment: a. Ensure adequate oxygenation. b. Consider and treat drug toxicity. c. More local. d. Additional pain, sedative medication. e. Consider aborting procedure or change to general anesthesia. III. Early postoperative Complications A. Hemorrhage - the most commonly encountered troublesome complication of rhinoplasty. Several large studies place the incidence of troublesome bleeding between 2 - 4%. Epistaxis may occur from immediately post-operatively to several weeks later. If septoplasty or submucous resection has been performed in conjunction with rhinoplasty, the risk of bleeding increases considerably. Bleeding occurs in a bimodal distribution. The first peak occurs during the first 48 hours, and is likely coming from raw intranasal mucosal surfaces, particularly the septal incision area. The second period of time is at about 10 - 14 days post-operatively when eschars begin to separate. 1. Avoidance: a. Careful preoperative evaluation - Ensure patient is not on any medications which might interfere with coagulation - coumarin, aspirin, NSAIDs. Question for history of bleeding diatheses, and look for physical stigmata - . b. Careful closure of septal incision. c. Atraumatic surgical technique. A 2mm osteotome and perforating osteotomies may decrease damage to the nasal mucosa. d. In addition to mucosal injection, the greater palatine foramen may be injected. e. Patient instruction - Do not blow, pick, manipulate the nose. Do not insert q-tips or otherwise instrument the nose. No strenuous activity, stooping or bending. 2. Treatment: a. Control hypertension. b. Vasoconstriction with oxymetazoline or topical cocaine. c. Suction the nose of clots, identify and, coagulate the bleeding point. An endoscope may prove useful. d. Gentle packing with absorbable material such as gelfoam or surgicel which assists in clot formation. e. Severe/uncontrollable hemorrhage may require formal anterior - posterior packing. f. Bleeding that fails to respond may be an indication for arteriography and embolization or vessel ligation. B. Hematoma can cause displacement of cartilages, distortion of the tip, eventual thickening the tip with excessive scar tissue. Septal hematoma may result in cartilage necrosis, abscess, perforation and saddling. 1. Avoidance: a. Prompt recognition and treatment of hemorrhage as above. b. Careful inspection of septal flaps following septoplasty. c. Coapt mucosal flaps with through and through whipstitch or careful packing. d. Careful taping of the dorsum to obliterate any potential dead space. 2. Treatment a. Prompt recognition. b. Drainage. c. Small anterior septal perforations are likely to be symptomatic, and require closure with mucosal flaps. Larger perforations are often asymptomatic and may be treated conservatively, with septal buttons. Kridel advocates use of the open rhinoplasty approach to septal perforations, and has successfully closed even subtotal perforations (up to ~4 cm) via this approach. C. Infection following rhinoplasty is the second most commonly reported complication, although surprisingly uncommon, with rates reported from 0.8 to 2.8%. Infections are usually found in areas of hematoma formation or areas surrounding retained bone dust or bony fragments. Organisms involved include Staph aureus, Strep pneumoniae, H. infuenzae, although pseudomonades and actinomycoses have been reported. Septicemia and bacterial endocarditis have been reported following nasal surgery, as has Toxic Shock Syndrome (TSS). TSS is characterized be fever, rash, hypotension, mucosal hyperemia, vomiting, diarrhea, and laboratory evidence of multisystem failure. The incidence of TSS post nasal surgery is reported to be 16.5 cases per 100,000. TSS has been reported in patients with nasal packing as well as nasal splints only. The causative agent is Staph aureus which produces TSS toxin number one. A most dreaded but fortunately rare complication is cavernous sinus thrombosis (CST). The cavernous sinus communicates with a number of valveless veins in the nasal and facial ares, which can result in direct hematogenous spread to the sinus. Signs and symptoms include chemosis , eyelid edema, ophthalmoplegia, papilledema, and meningitis. Although CST was uniformly fatal in the pre-antibiotic era, survival rates of 80% are now common. However, there is a high rate (77-88%) of neurological sequelae. 1. Avoidance - a. Prevent/recognize hematoma as above. b. Postpone surgery in patients with active infections elsewhere. Look for evidence of active skin or sinus infection. c. Bone dust, spicules and clots should be carefully removed prior to closure. d. The use of prophylactic antibiotics is debated. Neither systemic nor topical antibiotics have been shown to reduce the risk of TSS. Topical antibiotics have been demonstrated to reduce local bacterial counts - especially gram negatives. e. Antistaph antibiotics are recommended in all patients with nasal packing. Packs should be removed within 48 hours to reduce the incidence of sinusitis. 2. Treatment a. Prompt recognition. b. Drainage of abscess. c. Appropriate antibiotic therapy - the most common causative agent is staph aureus. Modify antibiotics based on cultures and response. d. TSS requires removal of nasal packing and splints, beta- lactam antibiotics and aggressive fluid therapy, as well as supportive measures as indicated. e. Cavernous sinus thrombosis requires vigorous broad spectrum antibiotics. Even with optimal treatment, mortality and morbidity is high. D. Periostitis can begin as a low grade infection along fracture lines, and may smolder for weeks or months. Symptoms include swelling, pain, and erythema. Periostitis is more likely to occur when saw osteotomies are made and bone dust or chips are left behind. Comminution of nasal bones can result in sequestra formation. 1. Avoidance a. Avoidance of saw osteotomy. b. Atraumatic technique with sharp osteotome to avoid comminution. c. Removal of bone dust and chips prior to closure. 2. Treatment: a. Antibiotic therapy may control the infection. b. Sequestrectomy may be necessary. E. Edema and Ecchymoses are universal occurrence following rhinoplasty and there is tremendous inter-individual variation in the amount and the time necessary for resolution. In most patients, it may take 6 - 12 months for all residual swelling to subside. Ecchymoses usually resolve in 2 to 4 weeks. 1. Avoidance: a. Atraumatic Technique. b. Peri-operative systemic steroids have been demonstrated to significantly reduce postoperative edema in rhinoplasty patients. c. Elevate head, apply ice packs. 2. Treatment: a. Reassurance. b. Patience. F. Skin problems include minor trouble such as tape reactions, pustules and telangiectasias, as well as more severe problems from actual skin slough. 1. Avoidance: a. Use of paper tape as opposed to adhesive tape will decrease tape reactions. b. Taping over the dorsum should not be too tight. The tape over the tip should allow for the possibility of excessive edema. c. Splints should neither be too tight nor cause pressure points. 2. Treatment: a. Allergic/tape reactions may be treated with topical steroid creams and antihistamines. b. Pustules should be unroofed as they arise. c. Telangiectasias may arise which can be treated with electrodesiccation or laser. G. Lacrimal Apparatus injury is theoretically possible due to the close proximity of the lacrimal apparatus to the lateral osteotomy. However the anterior lacrimal crest serves to protect the sac. Lacrimal sac injury has been demonstrated, but only in cases where subperiosteal tunneling and straight line or saw osteotomy technique were used. Temporary lacrimal obstruction is common - greater then two thirds in one study, it is usually due to postoperative edema. 1. Avoidance: a. The anterior lacrimal crest is protective. b. Use of the low curved osteotomy technique. 2. Treatment: a. Observation. b. The majority of cases of postoperative lacrimal obstruction resolve during the first two postoperative weeks, but my persist up to three months. c. Lacrimal sac injury may necessitate dacrocystorhinotomy. H. Miscellaneous Complications 1. Traumatic arteriovenous malformation is a well documented, but rare complication of nasal surgery. The mechanism of injury includes intravascular injection of local, surgical exposure, and osteotomies. Avoidance requires meticulous technique. Treatment is embolization and excision. 2. Blindness is exceedingly rare, and results from direct trauma to the optic nerve, or from vascular injury. Most reported cases of blindness involve intranasal steroid injections. Cheney reported a case of blindness following rhinoplasty where the presumed mechanism was retrograde flow of local anesthetic after intra-arterial injection. The best treatment is prevention. 3. Numerous intracranial injuries have been reported, including CSF leak, pneumocephalus, and direct damage to the frontal lobes. The most commonly cited requires care in dissecting high in the nose, as well as using scissors or biting forceps on the perpendicular plate. CSF leaks noted at the time of surgery should be closed in the operating room with local flaps or tissue plugs. Leaks diagnosed postoperatively may be treated conservatively with bed rest, possible lumbar drains, possible prophylactic antibiotics. Most cases (70%) close spontaneously. Those that fail to respond after 2 weeks or where complications occur (meningitis) require operative intervention. IV. Late Postoperative Complications A. Nasal Obstruction is common during the first few weeks postoperatively due to edema and crusting. However, patients with vasomotor or allergic rhinitis may suffer an exacerbation of the problems postoperatively. Beekhuis in a study of 1000 consecutive rhinoplasties demonstrated persistent turbinate hypertrophy in 10%. 1. Avoidance - none. 2. Treatment: a. Intranasal steroids. b. Consider turbinoplasty or reduction at the time of rhinoplasty. B. Hyposmia/Anosmia may be present in up to 20% of patients postoperatively, and should resolve within several months. Anosmia should be a rare complication based on the superior location of the olfactory apparatus, but has been reported. 1. Avoidance: a. Question patient preoperatively about disordered smell. b. Avoid dissection high in the nose, and avoid rocking the perpendicular plate which may in turn lead to cribriform fracture. 2. Treatment: a. Most problems resolve with observation. b. None specific for anosmia. C. Callus Formation may occur at the site of hump removal or osteotomy. This usually results from blood clots, bone dust or fragments left behind, and may result in residual hump or irregularities at the osteotomy site. 1. Avoidance: a. Meticulous surgical technique. b. Removal of bone dust and debris prior to closure. 2. Treatment may require repeat osteotomy or rasping of irregularities. V. Deformities Requiring Revision Surgery A. General 1. There are few statistics regarding the need for secondary surgery. In general, it appears between 5 - 10% of patients may require one or more revisions. 2. Secondary surgery is much more difficult than primary surgery, and it is likely that the level of patient satisfaction after secondary surgery is low. Many rhinoplasty surgeons avoid operating on other surgeons revisions due to the high probability of patient dissatisfaction. 3. A significant number of patients seeking revisions are considered neurotic - they may be surgery seekers or have unrealistic expectations. 4. In order to fully evaluate post-rhinoplasty deformities, sufficient time must elapse after the previous surgery to allow edema and tissue reaction to subside. Rees recommends at least 6 months and preferably one year elapse prior to attempting revision. 5. It is most convenient to classify post-rhinoplasty deformity according to the anatomic parts involved - the skin soft tissue envelope (SSTE); osteocartilaginous framework; internal nose; nasal tip; lip and other structures. B. Skin Soft Tissue Envelope 1. Skin redundancy and wrinkling is more common in older patient with less elastic SSTE. In younger patients the SSTE drapes readily to the underlying framework. 2. Thicker skin is more likely to result in prolonged postoperative edema and subsequent fibrosis with polly-beak deformity. 3. Contraction of thin skin over the cartilages can result in buckling of the cartilages and deformity. 4. Careful evaluation of the quality of the SSTE can assist in anticipation and prevention of deformity. C. Osteocartilaginous Framework 1. "Bird beak" deformity results from over resection of a dorsal hump and is more common with saw osteotomy techniques. a. Avoidance: i. Remove bony hump prior to tip work. ii. Remove cartilaginous hump after tip work. iii. Use sharp osteotome or rasp rather than saw. b. Treatment: i. If too much is resected, replace it during the procedure. ii. Autografted cartilage, from septum, concha, or rib may be used as an onlay graft. iii. Silastic and other implants have a high rate of extrusion, although some have reported good results. Kridel has reported the use of irradiated rib cartilage in reconstruction of 122 noses. Although animal studies indicated a high rate of resorption, such was not the case in short term follow up in humans. Longer follow is required to validate the result. Crumley points out that with concerns about infectious disease and resorption, autograft cartilage is probably the best option, and has acceptably low donor site morbidity. 2. "Stairstep deformity" results when osteotomies are place too high on the dorsum, resulting in a visible stepoff. a. Avoidance: i. The osteotomy should be placed low in the nasomaxillary groove. b. Treatment: i. If noted intraoperatively, an osteotomy deeper in the groove may be made. ii. Secondary correction requires either comminuting the bone of the frontal process of the maxilla, or fine rasping of the defect through subperiosteal tunnels. 3. Postoperative widening may result from high septal deviation preventing narrowing, incomplete osteotomy, or very thick bone preventing adequate narrowing. Open roof deformity refers to failure to medialize the nasal bones after hump removal. The rocker deformity results when the osteotomy is carried too high into the thick bone of the nasal root. As the caudal nasal bones are medialized, the wider cephalad portion widens. a. Avoidance i. Appropriate placement of osteotomies. ii. Avoid greenstick osteotomies. iii. Correct septal deviation. iv. Narrow dorsum after hump resection. b. Treatment: i. Completion or repeat osteotomy. ii. Resection of thickened bone medially to allow in- fracture. 4. Displacement of the Pyramid may result from failure to appropriately position the nasal bones after mobilization. Failure to recognize curvature of the nasal bones preoperatively may also result in deformity. a. Avoidance i. Complete osteotomies and accurate positioning. ii. Intermediate osteotomies. b. Treatment: i. Repeat osteotomy and straightening. ii. Rasping . iii. Camouflage milder deformity with cartilage or fascia blanket onlay. 5. Saddle Nose Deformity results from excessive lowering of the dorsum, or from trauma or surgical maneuvers that result in collapse of the osteocartilaginous framework into the nose. Such causes include stripping the periosteum from the nasal bones prior to fracture, comminution of nasal bones during osteotomy, overzealous submucous resection of the septum, septal abscess, etc. a. Avoidance: i. Preserve periosteal attachments. Elevate only enough periosteum to allow placement of the osteotome. ii. Sharp osteotome. iii. Ensure adequate dorsal and caudal septal struts (at least 1 cm) remain after septoplasty. iv. Prevent septal abscess as above. b. Treatment: i. Flying wing technique - the lateral crura of the lower laterals are dissected free and swung medially onto the dorsum. This technique has limited application and should be considered only in the mildest of cases. ii. Autograft cartilage from the auricle, or rib may be used as an onlay graft. Others prefer an "L" shaped graft for reconstructiom. iii. Split calvarial or iliac bone grafts have been used with reported good results. iv. As above, there are drawbacks to the use of irradiated cartilage and synthetic implants. 6. Supratip deformity - also known as "Ram's Tip"and "Polly Beak" a. Etiology i. Persistent supratip edema or subcutaneous fibrosis.. ii. Insufficient lowering of the dorsal septum. iii. Over resection of a hump. iv. Over-dissection or interrupted strip technique on the lateral crura. v. Over-resection of the nasal bridge. b. Avoidance: i. Conservative tip work including reconstitution of complete strip. ii. Perform tip work prior to lowering the septum. iii. Lower dorsum to tip level and the 1-2 mm further. iv. Trim upper laterals level with septum and secure with suture. v. Meticulous taping to avoid supratip dead space. c. Treatment: i. Subcutaneous injection of steroids (triamcinolone) in areas of persistent supratip edema. Avoid superficial injections or higher doses due to risk of dermal atrophy. ii. Excise supratip scar tissue. iii. Septal shortening. iv. Elevation of the columella. v. Dorsal onlay grafting. D. Internal Nose 1. Vestibular scarring results from surgical trauma, and undue sacrifice of lining. a. Avoidance is the best treatment. i. Avoid dissecting in the soft triangle area. ii. Protect and preserve vestibular mucosa. b. Treatment: i. Z-plasty ii. Transposition flaps. iii. Cartilage and composite grafts. iv. Skin grafting. 2. Internal Valve Collapse and Scarring a. Etiology: i. Excessive resection of the upper laterals. ii. Excessive resection of the septum. iii. Excessive sacrifice of vestibular skin. b. Avoidance is based on meticulous surgical technique. i. Minimize surgical insult to the nose, avoid manipulating or disrupting normal tissues. ii. Conservatism is the key. iii. Reconstruct support mechanisms when severed. c. Treatment: i.. Autogenous cartilage grafting (matchstick grafts) ii. Lyse synechiae. iii. Prosthesis E. Tip Defects 1. Boxed/Amorphous tip. a. Etiology: i. Excessive excision of lower laterals. ii. Interrupted strip techniques. iii. Loss of medial support - medial crura resection. iv. Excessive reduction of septum v. Excessive crosshatching of the dome. b. Avoidance i. Conservatism in tip-plasty always! ii. Avoidance of interrupted strip. Maintain 6-7mm intact strip or reconstitute. iii. Symmetrical excision of cartilage. iv. Open rhinoplasty approach provides direct vision and allows precise tip refinement. v. Preserve or reconstitute tip support. c. Treatment i. Tip grafts - Open structure rhinoplasty ideal. ii. Reapproximate dome. iii. Restore tip support mechanisms. 2. Plunging Tip surprisingly usually results from efforts to project and rotate. a. Etiology: i. Over-resection of the dorsum and overshortening of the caudal septum. ii. Gravity. iii. Angulation of the lower lateral cartilages. iv. Scarring and columellar retraction. b. Avoidance i. Careful technique. c. Treatment: i. Advancement of lower laterals on upper laterals. ii. Tongue and groove fixation of the lower laterals on the caudal septum. iii. Division of the nasalis and depressor septi muscles. iv. Autografting to the caudal septum or columella. 3. Pig Snout Deformity - the overshortened nose. a. Etiology: i. Over-resection of caudal septum. ii. Resection of the spine. iii. Over-resection of the upper and lower lateral cartilages. iv. Commonly associated with saddling as well. b. Avoidance: i. Conservative approach to rhinoplasty. c. Treatment is extraordinarily difficult. It is much easier to take out the put back. i. Septal flaps. ii. Composite grafts. iii. Cartilage or bone grafts. 4. Pinched Nose results not only in deformity but obstruction as well. a. Etiology: i. Excessive resection of the lateral component of the LLC. b. Treatment: i. Reconstitute LLC. ii. May require cartilage grafting. 5. Other Deformities: a. Alar rim retraction may result from resection of the vestibular lining, excessive resection of the upper or lower laterals. Correction requires placement of a cartilage graft at the alar rim. b. Excessive columellar show (hanging columella) may result from failure to resect excess convexity of the medial crura of the lower laterals, or from failure to resect excess caudal septum. Care is necessary to avoid confusion with alar retraction which can give a similar appearance. c. Retracted columella is caused by over resection of the caudal septum, unrecognized septal deflection, or scarring. The deformity requires placement of a graft between the medial crura for correction. ------------------------------------------------------------------------------ BIBLIOGRAPHY 1. Calhoun KH: Introduction to Rhinoplasty. In Bailey BJ (Ed) Head and Neck Surgery- Otolaryngology. JB Lippincott, Philadelphia, 1993. 2. DiFazio CA. Local Anesthetics: Action, Metabolism, and Toxicity. Oto Clinics North Amer 14:515-519, 1981. 3. Goldfarb M et al: Perforating Osteotomies in Rhinoplasty. Arch Otolaryngol Head Neck Surg 119: 624-627, 1993. 4. Hoffman DF et al: Steroids and Rhinoplasty. A Double Blind Study. Arch Otolaryngol Head Neck Surg 117:990-993, 1991. 5. Jacobsen JA and Kasworm EM: Toxic Shock Syndrome After Nasal Surgery: Case Reports and Analysis of Risk Factors. Arch Otolaryngol Head Neck Surg 112:329-32, 1986. 6. Johnson CM and Toriumi DM: Open Structure Rhinoplasty. WB Saunders, Philadelphia, 1990. 7. Kridel RWH and Konior RJ: Irradiated Cartilage Grafts in the Nose. 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Tardy ME: Refinement of the Nasal Tip. In Bailey BJ (Ed): Head and Neck Surgery - Otolaryngology. JB Lippincott, Philadelphia, 1993. 17. Teichgraber JF, Russo RC: Treatment of Nasal Surgical Complications. Ann Plas Surg 30:80-88, 1993. 18. Verlander JM, and Johns ME. The Clinical Use of Cocaine. Oto Clinics North Amer 14:521-531, 1981 ---------------------------------END------------------------------------------ AVOIDANCE AND TREATMENT OF RHINOPLASTY COMPLICATIONS Department of Otolaryngology Grand Rounds 9 March 94 J.J. Bradfield, M.D. K.H. Calhoun, M.D.