Atlas of Asian Rhinoplasty (Volume 1) – Tác giả chưa rõ – Hướng Dẫn Giải Phẫu & Phẫu Thuật Mũi (file pdf)

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a
e
b
f
g
h
c
d
Fig. 16.78 Contracted short-nose correction with
septal extension graft. (a–d) This patient developed
contracted-nose deformity after multiple rhinoplasty
and infection. She underwent septal extension graft
(IHCC), alar rim graft on right side (conchal cartilage),
and dermofat graft on the dorsum. (e–h) Postoperative
photographs at 7 years
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Derotation Graft
The derotation graft is a conchal cartilage that is interposed between the dorsal septum-upper cartilages and the lower lateral
cartilages, to cephalically position the nasal tip (Fig. 16.79). The operative steps are discussed in Chaps. 9 and 12.
The major advantage of derotation graft is that it allows the nasal tip to remain supple and mobile even after lengthening.
Additionally, the technique is independent of the septum and can be performed even if the condition of septum is not ideal.
Compared to septal extension graft, the derotation graft is less stressful to the surgeon. A portion of surgeons doubt whether
a soft and pliable conchal cartilage can lengthen a contracted short nose, but the graft can yield satisfactory outcome with
adequate release of lower lateral cartilages and soft-tissue envelope (Fig. 16.80).
Fig. 16.79 Derotation graft
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Fig. 16.80 Contracted short-nose correction with
derotation graft. (a–d) This patient with short contracted
nose and upturned tip underwent derotation graft
(conchal cartilage) and conchal cartilage graft on lower
dorsal depression. (e–h) Postoperative photographs at
5 months
a
b
f
g
c
h
d
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Contracted Columella
A large proportion of contracted short nose is accompanied by contracted (retracted) columella. Mild columella contracture
can be corrected by adequate release of membranous septal scarring and use of columella strut graft and derotation graft.
However, severe columella retraction is difficult to address and will require the use of septal extension graft. Severe wound
tension may preclude adequate correction of columella retraction, in which case the operation should be performed to the
extent possible and the columella revisited during a subsequent staged operation. Another method of overcoming severe
wound tension is the active recruitment of local flap and composite graft. This is because wound tension leads to wound
dehiscence and wound infection, with subsequent loss and resorption of the graft.
For severe columella shortening, forehead flap can be considered, but a composite graft from the ear auricle is probably
more acceptable.
Manipulation of Released Capsule/Scar Tissue
Through the dual-plane dissection, the capsule/scar tissue is released and isolated from overlying skin envelope. This flap
should be preserved and used as a kind of soft-tissue layer, unless the capsule is irregular, hypertrophic, sclerotic, infectious
granulomatous, or calcified (Fig. 16.81).
Capsule/scar tissue is stretched laterally after being cut longitudinally along the midline of the posterior capsule and used
to cover the new implant or reinforce the dorsal skin (Fig. 16.82).
a
b
Fig. 16.81 A thick sclerotic capsule should be removed
Contracted Short Nose

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a
b
c
Fig. 16.82 Capsular flap. A thin smooth capsule is turned into a flap by first dividing the posterior layer along the midline. The open capsule is
then stretched laterally and used to cover the new implant or reinforce the dorsal skin
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Mid-Vault Revisional Surgery
Inverted-V Deformity
Inverted-V deformity is an inverted-V-shaped indentation between the caudal end of nasal bones and the upper lateral carti-
lages (Fig. 16.83). This deformity can result from removal of dorsal hump, if the upper lateral cartilages collapse inferomedi-
ally against the septum. The deformity interrupts dorsal aesthetic line (Fig. 16.84) and may also cause respiratory dysfunction.
Fig. 16.83 Inverted-V deformity
a
b
Fig. 16.84 Dorsal aesthetic line. (a) Normal dorsal aesthetic line. (b) Interrupted dorsal aesthetic line due to inverted-V deformity
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Causes of Inverted-V Deformity
The deformity occurs following a hump removal surgery for the following situations:
1. During hump resection of nasal bone and upper lateral cartilages, the upper lateral cartilage is mobilized medially to a
greater degree than the nasal bone (Fig. 16.85).
2. Even if the composite resection is performed after separating the upper lateral cartilage from dorsal septal hump, the
resection can still result in this deformity by removing the lateral wing of dorsal septum in the septal hump (e.g., removal
of thick dorsal septum) or by narrowing of nasal bone (Fig. 16.86).
After a properly performed component resection of large hump, an osteotomy may be required to close the open roof or
to narrow the wide bony base. This can result in the medial mobilization of the upper lateral cartilage. This does not always
induce the inverted-V-shaped indentation between the nasal bone and upper lateral cartilage. However, medial mobilization
of the upper lateral cartilages can decrease the width of internal valve. Even if the lateral wing is preserved through the com-
ponent resection, the operator should have low threshold for employing the spreader graft to counter any medialization of the
upper lateral cartilage.
The inverted-V deformity is masked by edema and is difficult to appreciate in the early postoperative period for this rea-
son. With resolution of the edema, the deformity may appear from weeks to years after an operation. If the operator is not
sure, it would be safer to make error on the side of performing the spreader graft.
Fig. 16.85 Composite
resection of hump
a
b
Fig. 16.86 Component resection of hump. (a) During component resection, the lateral wing of dorsal septum may end up being incorporated into
dorsal hump resection, which will decrease the dorsal width and result in inverted-V deformity. (b) The correct component resection preserves the
lateral wing of dorsal septum with the upper lateral cartilages
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Tests for the Internal Valve Insufficiency
Inverted-V deformity can be accompanied by internal valve insufficiency.
Two maneuvers can help determine the incompetency of internal valve. The first is Cottle maneuver. This is performed by
lateral traction of the cheek soft tissue. If the maneuver improves the nasal inflow, the test indicates narrowing of the internal
valve (refer to Chap. 1). However, the Cottle maneuver cannot distinguish internal valve insufficiency from external valve
insufficiency, septal deviation, or hypertrophy of inferior turbinate. A more specific test for internal valve insufficiency is the
modified Cottle maneuver, which is performed by using a cotton swab to lift the upper lateral cartilage from within the nasal
cavity. If the maneuver alleviates nasal obstruction, the test is positive for internal valve insufficiency.
Correction Technique
Spreader Graft
The spreader graft is used to correct the inverted-V deformity and internal valve collapse by widening internal space between
septal cartilage and upper lateral cartilages. The graft is a long, thin piece of cartilage and is inserted between the dorsal
septum and upper lateral cartilages. It acts as a spacer to push the upper lateral cartilages outward and to widen the angle
between the upper lateral cartilage and septum (Figs. 16.87 and 16.88). The ideal source for the graft is the septal cartilage.
It can also be prepared from auricular cartilage or costal cartilage. The prepared graft is 3 mm in height, 1–2 cm in length,
and 1–3 mm in width.
a
b
c
d
Fig. 16.87 Spreader graft for correction of inverted-V deformity. (a, b) Inverted-V deformity. (c, d) Bilateral spreader grafts were inserted
between the dorsal septum and upper lateral cartilages
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After the separation of upper lateral cartilages from dorsal septum, bilateral spreader grafts are inserted between the dor-
sal septum and upper lateral cartilages. The grafts span from the nasal bone to the caudal margin of upper lateral cartilages.
If the upper lateral cartilage collapse is uneven, the width of spreader grafts is varied to make up for the difference between
the sides.
Grafts are fixed with a double-horizontal-mattress suture using 5-0 PDS. Costal or auricular cartilage can be used in case
the septa cartilage is not available.
a
b
Fig. 16.88 Correction of inverted-V deformity using bilateral spreader graft. (a) Preoperative photograph. (b) Postoperative photograph at
3 months
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Camouflage
With thin nasal skin, the spreader graft may solve the problem of internal valve insufficiency but will not address the visible
inverted-V depression between the nasal bone and upper lateral cartilage. Anatomically, the depression is caused by an over-
lap between cephalic margin of upper lateral cartilages and caudal margin of nasal bone (Fig. 16.89). In a patient without
prior history of rhinoplasty nor functional problems, some patients have visible inverted-V depression through the thin dorsal
skin, and they request that this indentation be corrected. In such patients, the spreader graft cannot solve the issue, but carti-
lage graft along the depressed line can be helpful in camouflaging the appearance (Figs. 16.90 and 16.91).
Also, the inverted-V line can appear after long time after a spreader graft, which can be addressed by camouflage tech-
nique (Fig. 16.92). As such, patients must first understand that the correction of inverted-V deformity may require a revision.
In patients with thin skin, the camouflage technique should be used along with spreader graft (Fig. 16.93).
Fig. 16.89 Anatomically, the caudal margin of nasal bone overlaps the
cephalic margin of upper lateral cartilages
Fig. 16.90 Camouflage technique for inverted-V indentation
a
b
Fig. 16.91 Correction of conspicuous
inverted-V indentation. (a) The
inverted-V indentation is noticeable in
this preoperative photograph, which
was camouflaged using dermal
allograft. (b) Postoperative photograph
at 2 years
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Fig. 16.92 Correction of inverted-V deformity. (a–c) This patient with a history of hump reduction and tip plasty presented with an inverted-V
deformity, dorsal irregularity, pollybeak deformity, and tip drooping. She underwent spreader graft (septal cartilage), dorsal hump reduction, and
tip-revisional surgery (columellar strut graft with septal cartilage). (d–f) Four years after the operation, the patient presented with recurrent but
mild inverted-V deformity, which was addressed with camouflage technique (conchal cartilage onlay graft along the depression). (g–i) Photographs
at 6 years after camouflage operation
a
b
c
d
g
e
h
f
i
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a
b
c
d
Fig. 16.93 Combination of spreader graft and onlay graft. (a) This patient with a congenital inverted-V indentation wanted an operation for purely
aesthetic reasons. (b) Upper lateral cartilages are detached from dorsal septum. (c) Bilateral spreader graft (conchal cartilage). (d) Conchal carti-
lage graft along the indentation line
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Splay Graft
The splay graft is prepared from conchal cartilage and is used for severe collapse of lower lateral cartilages (Fig. 16.94).
From the underside of both upper lateral cartilages, the mucoperichondrium is dissected and elevated. The graft is inserted
between the undersurface of upper lateral cartilage and mucoperichondrium. If there is a preexisting collapse or deficiency
in the dorsal septum, the deficient area is augmented using the thickness of splay graft. If the dorsal septum is not low, the
splay graft can cause a dorsal hump. As such, the septum should be lowered prior to placement of the splay graft.
The splay graft is placed deep to the left and right upper lateral cartilages, and the intrinsic spring effect of the graft lifts
the upper lateral cartilages, which corrects the middle vault collapse and widens the internal valve. The powerful splay effect,
however, can result in excessive widening of caudal portion of dorsum.
Fig. 16.94 Splay graft
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Dorsal Irregularities
Dorsal irregularities have a wide spectrum of causes, including residual hump and focal dorsal depression after hump reduc-
tion, visible groove between medial and lateral bony segment after medial osteotomy, visible dorsal cartilage graft, and
irregularity from calcification on implant surface.
Residual Dorsal Hump
During dorsal hump reduction, the intraoperative edema can often mask residual hump and irregularities. Because of this, the
reduced hump should not be evaluated purely based on sight but should also be palpated several times after redraping the
dorsal skin envelope. Despite this precaution, resolution of edema can often reveal a residual hump.
A small residual hump without inverted-V deformity can be addressed by rasping with a file, which can be accomplished
by closed approach. Compared to inframarginal incision, the intercartilaginous incision is close to residual hump and allows
greater visualization of the hump area. After incision, the soft tissue and periosteum are elevated from the underlying carti-
lage and bony framework. The scar tissue from prior operation makes this a difficult step that requires a meticulous and
tenacious approach from the operator. Application of excessive force through the elevator can result in penetration injury to
the underlying bone or cartilage. In addition, incompletely elevated soft tissue on the framework will be eliminated by the
rasping action. This decrease in soft-tissue thickness can worsen the dorsal irregularity.
A bony hump can be managed by rasping, but a cartilaginous hump will require excision using No. 15 blade under direct
vision.
Large residual hump will require osteotomy to close the post-humpectomy roof and correct the widened dorsum. Large
cartilaginous hump will require a composite resection, which can induce inverted-V deformity. Because of this, the dorsal
septal hump should be removed after the upper lateral cartilages have been separated first (component resection). Both the
osteotomy and component resection are easier through an open approach. Spreader graft may be required for post-osteotomy
inverted-V deformity and for filling the large open roof in narrow nasal bone in which osteotomy cannot be performed.
Depressed Dorsum
Dorsal depression due to excessive hump removal is addressed by filling up the depression with cartilage graft.
For small defects, a piece of crushed conchal or septal cartilage with tapered margin can be adequate, but a diced cartilage
wrapped with temporal fascia will be required for large defect. Cartilage graft can be placed via a closed approach and does
not need to be fixated to the underlying structure (Fig. 16.95). A compression paper tape stabilizes the graft well. If neces-
sary, the graft can be secured using a pullout suture.
In patients with thin skin, cartilage graft on the dorsum can often be visible beneath the dorsal skin. To prevent this, it is
important to carve the graft to match the depressed contour and to taper the graft margin to a beveled edge. The depression
can also be filled using a dermal graft or dermal allograft. However, this will require overcorrection to compensate for resorp-
tion, and this will be less predictable than cartilage graft. Gryskiewicz reported that resorption is higher by 20–30% for
dermal allograft on the bony dorsum. Dermal allograft is believed to undergo a significant degree of resorption in thin dorsal
skin, and it is not rare to observe greater than 50% of resorption.
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a
c
b
Fig. 16.95 Correction of dorsal irregularity. (a) Focal point of dorsal irregularity after hump reduction. (b) Crushed septal cartilage. (c)
Photographs at 3 months after operation (rasping of bony hump and crushed cartilage graft on the depressed lower dorsum)
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Saddle-Nose Deformity
Saddle nose is an extremely familiar clinical entity for a rhinoplasty surgeon that is very challenging to address. The defor-
mity refers to sunken nasal dorsum from loss of septal support and/or nasal bone height loss (Fig. 16.96). It is characterized
by mid-vault collapse and involves cartilaginous component and/or bony component of the dorsum. The deformity has vari-
ous pathologic features:
1. Mid-vault depression due to loss of cartilaginous and bony support of middorsum: This is the most fundamental deformity
and induces the other features of saddle nose.
2. Tip de-projection.
3. Shortening of nasal tip (cephalic rotation of the tip).
4. Columellar retrusion and acute nasolabial angle.
5. Broad nasal tip and wide alar base.
The collapse in upper and lower lateral cartilages can lead to nasal obstruction.
a
b
Fig. 16.96 Development of saddle nose after submucosal resection (SMR)
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Causes
Saddle nose can be caused by prior septal surgery, septal hematoma, septal infection leading to abscess, severe external
trauma to the nose, recurrent polychondritis, Wegener’s granulomatosis, sarcoidosis, congenital syphilis, leprosy, and cocaine
abuse. The most common cause is nasal trauma.
From the perspective of rhinoplasty surgeon, the most important cause of mid-vault collapse is insufficient L-strut from a
prior septal operation. The usual recommendation is to leave a strut with 10–12 mm of width. However, the dorsal strut may
need to be up to 12–15 mm wide, depending on the thickness of septal cartilage. An L-strut of inadequate width may appear
to be normal during the operation, but can result in dorsal collapse over several years due to contracture of scar tissue and
aging process (Fig. 16.97). In addition, minor trauma to L-strut can result in acute saddle deformity. Because of this, there is
a significant limitation in how much of the septal cartilage that can be harvested, while leaving an L-strut of ample width, in
Asian patients. L-strut collapse is accompanied by collapse of the upper lateral cartilages, which leads to mid- and lower
dorsal sinking, tip lowering and shortening, and columella retrusion.
Fig. 16.97 Without a robust
L-strut, the dorsal septum will
gradually collapse with the
contracture of scar tissue and
aging process
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Classification
The etiology and classification of saddle-nose deformity have been discussed by a number of authors, including Tardy et al.,
Daniel and Brenner, and YJ Jang et al. The classification based on septal condition and tip and columella deformity is impor-
tant for correlating the severity of deformity and treatment modality. Daniel and Brenner classified the deformity according
to the severity, with treatment modality for each classification.
Each classification has its own advantage, but the classified types can be ambiguous with inflexible treatment modality.
As such, the author uses the following modified classification for Asian saddle nose (Fig. 16.98):
Fig. 16.98 Classification for saddle-nose deformity. Type I: mild supratip depression with/without slight columellar retraction, while tip projec-
tion is not affected. Deformity is stable and not progressive. Type IIa: mild supratip depression and columellar retraction (like in type I deformity)
but with supratip depression with manual pressure with progressive deformity. The manual palpation to evaluate for depression is very important
in determining the treatment method (Fig. 16.100). Type IIb: advanced deformity with mild loss of tip projection and columella retraction. Type
III: total loss of cartilage vault integrity, flattening of the nasal lobule, and severely retracted columella. Type IV: type III and loss of bony vault
integrity
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a
b
Fig. 16.99 An example of type IIa saddle nose. The saddle is not readily visible but becomes apparent with gentle pressure on the dorsum
Type I: mild supratip depression with/without slight columellar retraction, while tip projection is not affected. Deformity is
stable and not progressive.
Type IIa: mild supratip depression and columellar retraction (like in type I deformity) but supratip depression becomes worse
with manual pressure and the deformity is progressive recently. The manual palpation to evaluate for depression is very
important in determining the treatment method (Fig. 16.99).
Type IIb: advanced deformity with mild loss of tip projection and columella retraction.
Type III: total loss of cartilage vault integrity, flattening of the nasal lobule, and severely retracted columella.
Type IV: type III and loss of bony vault integrity.
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Correction
As mentioned above, the saddle nose exists in a wide spectrum from minimal depression to severe collapse. Depending on
the severity, the treatment option can range from simple camouflage technique to structural reconstruction.
According to Daniel, one important question to be answered is whether the reconstructive surgeon’s obligation lies with
the provision of rigid support or that of a simple cosmetic camouflage. He believes that the surgeon should provide a strong
structure to the nose using autogenous tissue which will last the patient’s life.
The author believes that camouflage technique can be very useful in mild instances of saddle nose. For the camouflage
technique to be lasting, the most important prerequisite is for the septal support compromise to be static, without any pro-
gressive loss of support nor functional problem. To evaluate the stability of septum, the patient must confirm a complete lack
of progression in supratip sinking. A more important factor is total lack of compression with manual palpation of nasal sub-
units, which supplies extremely important information regarding stability of supratip and tip support. Cotton swab palpation
and rhinoscopy can provide supplemental information.
Camouflage Technique for Static Saddle Nose
Type I saddle nose (mild supratip depression and columella retraction, without tip projection problem with static dorsal sep-
tal cartilage) can be camouflaged using cartilage dorsal onlay graft (Fig. 16.100). For the camouflage technique to be valid,
the surgeon must palpate the mid-vault to confirm that the dorsal septum is stable. One or multiple layers of auricular carti-
lage or rib cartilage can be used for this purpose (Fig. 16.101). The graft can be inserted through the intercartilaginous inci-
sion into the sunken area. Unlike with soft-tissue grafts, cartilage grafts do not undergo significant resorption, and
overcorrection is unnecessary. Camouflage graft for columellar retrusion can be placed through transfixion incision. Diced
cartilage can also be used but is not as predictable as solid cartilage grafts due to resorption.
The camouflage technique can be performed with alloplastic implant (Fig. 16.102). Dermis or dermofat graft is less pre-
dictable due to resorption and is not recommended for this purpose.
Fig. 16.100 Camouflage technique (cartilage onlay graft) for type
I saddle nose
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a
b
Fig. 16.101 Correction of type I saddle nose using cartilage onlay graft. (a) Preoperative photograph. (b) Postoperative photograph at 7 months
For a saddle nose with stable septum, camouflage technique provides a relatively easy method of correcting the depres-
sion while allowing for a soft movable tip. However, patients should understand that it is not without recurrent sunken defor-
mity (Fig. 16.103).
Camouflage technique should be performed only after a sufficient amount of time has passed for a saddle nose to have
stabilized. Also, this technique should not be used where a wide dissection is required for additional procedures, in order to
minimize the effect of scar contracture. In Asian patients with thick skin, scar contracture can rarely lead to sudden worsen-
ing of saddle nose.
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a
b
c
Fig. 16.102 Saddle-nose correction using an e-PTFE implant. (a) In this
patient with a history of submucosal resection, an episode of nasal trauma
onto the weakened septum was the cause of saddle-nose deformity, which
was addressed with dorsal augmentation (e-PTFE implant) and tip plasty
(columellar strut graft using conchal cartilage). (b) Postoperative photo-
graph after 1 year. (c) At 3 years after the operation, the patient returned
to the clinic after an episode of trauma to the nasal dorsum. No deformity
is appreciated except for the minor soft-tissue trauma
a
b
Fig. 16.103 Recurrent supratip depression. (a) In this patient, the
supratip depression was corrected with conchal cartilage onlay graft.
(b) The depression returned within 5 months of operation, albeit to a
milder degree
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Anatomical Structural Correction
Type IIb and severe saddle nose type III require mid-vault (L-strut) reconstruction using spreader grafts and a septal strut
(costal cartilage) (Fig. 16.104). Cantilever graft has the disadvantages of bony dorsum height change and screw fixation in
the radix. To avoid these problems, the author prefers septal L-strut reconstruction, which can be performed as a single block
or in two units (spreader grafts and septal strut).
The harvested costal cartilage is prepared into thin lengthwise slices and allowed to warp in an antibiotic solution. A sym-
metric pair of warped pieces are carved into long spreader grafts and inserted on both sides of the cephalic dorsal septal
stump.
The proximal end of costal cartilage grafts is extended cephalically under the nasal bone and fixed to the remaining septal
cartilage. Alternatively, the caudal border of the nasal bone is excised in a wedge shape, and the proximal end of grafts is
secured to the wedge. If the septal stump is unstable, the cephalic end of rib cartilage is placed under the nasal bone and fix-
ated with a suture through a hole drilled in the nasal bone (Fig. 16.105). Extended spreader grafts enhance the function of
internal valve.
Shorter straight slices of costal cartilage are placed between the two distal ends of septal extension grafts. This is the fixed
type of columellar strut graft, which should be wide enough (10–15 mm) and designed to push down the columellar labial
angle and project the tip. The septal strut is sutured to or in front of the anterior nasal spine. Firm fixation of the premaxilla
area is very important for stable L-strut reconstruction. The fixation suture may be easier to place through the upper gingival
incision. Anterior end and caudal margin of the columellar strut graft are positioned more anteriorly and caudally respec-
tively to the caudal end of spreader graft to project the tip and columella (Fig. 16.106). Upper lateral cartilages are suspended
and sutured to the costal cartilage. Reinforcement of the septal L-strut forms the basis of stable and proper tip and columellar
projection. Additional tip projection can be achieved by cartilage onlay or shield grafts.
Fig. 16.107 is an example of structural septal L-strut reconstruction with the techniques mentioned above.
A longer rib cartilage (from seventh or eighth ribs) can obviate the need for a tongue-in-groove type of graft and allow a
single-block technique (Fig. 16.108). This method provides a single-block graft that supports both the dorsum and nasal tip.
The specifics of this procedure differ according to the state of mid-vault integrity, condition of the remaining septal strut, tip
and columella integrity, and status of harvested costal cartilage.
The operator must fight the temptation to manage a type IIa deformity with a camouflage technique. However, this solu-
tion will result in progression of the saddle-nose deformity over a long term. The author recommends anatomical structural
reconstruction for type IIa, whenever possible (Fig. 16.109).
At times, a rhinoplasty surgeon will have to make the difficult choice between a simple dorsal onlay graft for camouflage
and reconstruction of dorsal strut using rib graft. A simple dorsal onlay graft is associated with short operation time with
quick recovery. However, the camouflage technique does not resolve any underlying structural weakness and can result in
progressive dorsal collapse, which will require another revisional operation.
Strong reconstruction with rib cartilage requires a longer operation with delayed recovery. Its shortcomings are donor-site
morbidity, warping, and very rigid nasal tip. For a soft and mobile tip when performing L-strut reconstruction with costal
cartilage, the strut graft (costal cartilage) supporting the caudal end of spreader graft can be placed in a more cephalic posi-
tion without contacting the lower lateral cartilages, while the columella strut and derotation grafts (conchal cartilage) are
placed more caudally for the tip projection.
Collapsed vestibular and nostril valves require insertion of alar rim support grafts.
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Fig. 16.104 L-strut
reconstruction using spreader
grafts and a septal strut
Fig. 16.105 Cephalic end of
the graft can be fixed to the
nasal bone after drilling the
holes on the nasal bone
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a
b
c
d
e
Fig. 16.106 L-strut reconstruction using the costal cartilage. (a) Sliced layers of costal cartilage. (b) Upper lateral cartilages are detached from
the dorsal septum. (c, d) The dorsal midline is reconstructed using bilateral extended spreader type of septal extension graft and columellar strut
graft. Anterior end and caudal margin of the columellar strut graft are positioned more anteriorly and caudally respectively to the caudal end of
spreader graft. (e) Lower lateral cartilages are fixed to the strut graft
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a
b
c
d
e
f
Fig. 16.107 Correction of saddle
nose with L-strut reconstruction. (a–c)
This patient with type III saddle and
short nose underwent L-strut
reconstruction using extended spreader
graft and columellar strut graft (costal
cartilage), osteotomy, and dorsal
augmentation (dermofat graft). (d–f)
Postoperative photographs
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a
b
c
Fig. 16.108 L-strut reconstruction using single-piece costal cartilage grafts. (a, b) Each of the bilateral grafts is prepared from a single piece of
costal cartilage slice. The grafts are placed as spreader graft without the need for the tongue-in-groove-type technique necessary for multiple-piece
grafts. (c) Upper and lower lateral cartilages are fixed to the costal cartilage grafts
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Fig. 16.109 Correction of saddle nose
with deviation. (a, b) This patient with
saddle nose and deviation underwent
L-strut reconstruction and osteotomy.
(c) L-strut reconstruction using costal
cartilage. (d, e) Postoperative
photographs show straightened nasal
axis and correction of saddle-nose
deformity
a
c
b
d
e
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Dorsal Augmentation
In patients with low dorsum, dorsal augmentation is necessary in addition to mid-vault reconstruction. The stability of L-strut
and tip position is established using the techniques mentioned above. The dorsal augmentation is performed as the last step
because strong stable L-strut and firm tip posture are fundamental to dorsal augmentation.
Dorsal augmentation is performed through additional graft or implant placement. Options for augmentation material
include block cartilage from rib, diced cartilage wrapped in temporal fascia, dermofat, fascia, IHCC, and various implants.
Autogenous tissue is ideal for correction of saddle nose. Among various autogenous tissues, solid costal cartilage graft is
preferred for major dorsal augmentation (Fig. 16.110). The author considers silicone or e-PTFE implants to be acceptable.
Fig. 16.110 Block costal cartilage graft for saddle nose. (a–d) Type III saddle nose. (e) Exploration reveals the majority of the sepal support to be
lost. (f) This L-strut was reconstructed with costal cartilage. (g) Lower lateral cartilages are sutured to the L-strut. The tip onlay graft is placed atop the
domes. (h) This three-piece costal cartilage graft is ready for dorsal augmentation. (i–l) Postoperative photographs after 1 month
a
c
b
f
g
h
i
j
k
l
d
e
16 Secondary Rhinoplasty

869
Correction of Type IV Saddle Nose
Type IV saddle nose represents the end stage of septal collapse. This degree of septal collapse is not only accompanied by
total loss of cartilage vault integrity but also suffers from disruption of bony vault and severe contracture of nasal lining. It is
characterized by flatness of whole nasal dorsum, short upturned tip with loss of projection, columellar shortening, and val-
vular problem. Reconstructing this type of severe saddle nose usually requires a cantilever dorsal graft with columellar strut
graft.
The author prepares a seventh rib cartilage into a solid block dorsal graft (seventh rib cartilage) and a columellar strut graft
in a tongue-in-groove formation (Fig. 16.111). The seventh rib provides a cartilage block that is the most straight and the
longest. The dorsal graft is inserted into a dorsal bed and fixed using a percutaneous K-wire, which is removed after 7 days.
In summary, correction of saddle nose requires a graduated stepwise approach. Reconstruction and stabilization of L-strut
is a key to saddle-nose correction and provides the foundation necessary for tip and columellar repositioning. In turn, firm
and stable mid-vault and correct tip positioning are fundamental to dorsal augmentation. Stepwise progressive reconstruction
of these structures provides stable long-standing aesthetic contour and counteracts the contractile forces of scar tissue.
Despite the stepwise reconstruction, a slight mid-vault collapse can occur due to structural instability, aging process, and
contractile forces. The first method to reduce the potential for this complication is to apply firm fixation of cephalic portion
of the graft and secure premaxilla fixation of the fixed-type columellar strut graft. If the fixation of proximal portion of the
graft cannot be assured, the nasal bone should be drilled and the graft fixated with a wire. An alternative to this is to perform
the graft as a cantilever. The second method to reduce the mid-vault collapse is to minimize all forms of scarring. The force
of scar contracture is extremely high, and the effort to minimize scarring is very important. For this, the operation must be
performed at an optimal time, with gentle and minimal dissection, prevention of infection, and postoperative medication to
minimize the risk of contracture.
The surgeon and patient should understand the complexities of saddle-nose correction and the unexpected problem of
nasal frame weakness caused by aging and scar contracture. Both parties must acknowledge that revisional surgery may be
needed down the road, and the need for revision should not be regarded as failure of previous operation but as a consequence
of unpredictability in the complex healing process.
Mid-Vault Revisional Surgery

870
Fig. 16.111 Correction of type IV
saddle nose. (a–c) This patient
suffered a significant midface injury
during a motor vehicle collision. The
patient presented with saddle nose,
collapsed nasal bone, and upturned
nasal tip. (d, e) The lower lateral
cartilages are released from scar
tissue and rotated caudally. Septal
support is lost. (f) A costal cartilage
has been harvested. (g, h) Two-layer
carved costal cartilage is ready for
dorsal augmentation of about 10 mm.
(i, j) To lengthen the upturned nasal
tip, a small piece of costal cartilage is
attached to the caudal end of dorsal
graft in the tongue-in-groove pattern.
(k) Graft is placed in position. (l, m)
Lower lateral cartilages are sutured to
the end of graft. (n–p) Postoperative
photographs at 2 years after
reconstruction
a
b
c
d
e
f
g
h
16 Secondary Rhinoplasty

871
i
j
k
l
m
n
o
p
Fig. 16.111 (continued)
Mid-Vault Revisional Surgery

872
IHCC (Cadaveric Cartilage) in the Saddle Nose
For correction of severe saddle nose, the most optimal graft source for L-strut reconstruction is autogenous costal cartilage.
In contrast, the unpredictable resorption rate of irradiated homologous costal cartilage (IHCC) is a significant disadvantage,
as well as the potential for fracture and infection. A patient with saddle-nose deformity has already suffered greatly, consider-
ing the amount of psychosocial stress of the deformity and the multiple operations endured. As such, the operator must come
as close as possible to perfection when it comes to corrective surgery of saddle nose. In this context, IHCC should not be used
for major reconstruction of saddle nose, except for the extenuating circumstance of severely calcified or ossified costal
cartilage.
According to Daniel, cadaveric cartilage will undergo complete resorption within 15 years of implantation. Per Toriumi,
the use of IHCC is reasonable to nonstructural grafts such as dorsal graft and radix grafts. If the IHCC is used for structural
grafts (e.g., columellar strut or caudal septal extension graft), resorption may compromise nasal tip position, nasal tip con-
tour, or nasal function. However, the author believes that the disadvantages of IHCC graft can be mitigated significantly by
graft quality and operator technique (Fig. 16.112). On rare occasions, IHCC use cannot be avoided because the autogenous
costal cartilage is not available.
The following advice is used to minimize the resorption rate of IHCC. First, selection of the dense outer area of IHCC is
important. Within a single block of IHCC, the density of cartilage varies, with outer area being more solid. Chance of degen-
eration is higher for the more brittle, inner portion of IHCC, which should be discarded. Second, it is important to thoroughly
cleanse the graft after carving in order to reduce the innate immune response. Carving of the IHCC can destroy the lacuna,
leading to exposure of chondrocytes and presentation of extracellular cell debris such as DNA, RNA, lipids, and carbohy-
drates, which can induce the innate immune response. Cleansing the graft would reduce the immune response that may
contribute to resorption. Third, during the graft fixation, care should be taken to minimize exposing too much of the cut
surface of IHCC graft, particularly for a septal extension graft. Exposure could lead to an immunogenic reaction to the graft
chondrocytes. A few penetrations on the graft would not present a major problem, as any immune reactions would be con-
fined to the cut surface of the hole. However, too many penetrations from a cutting needle might induce structural weakness,
followed by graft fracture. Multiple fractures may lead to the graft instability or total resorption. Therefore, it is prudent to
employ the absolute minimal number of sutures required to fixate the graft, using a round needle. The tip portion of IHCC
graft should not be sutured directly to avoid avulsion fracture. Wraparound suture technique is recommended. It is also pref-
erable to use toothless forceps to avoid microtrauma to the surface of graft.
16 Secondary Rhinoplasty

873
a
b
d
e
c
f
Fig. 16.112 Correction of saddle nose
using IHCC. (a–c) In this patient with
severe saddle-nose deformity, the costal
cartilage was too calcified to be used as
a graft. Instead, the L-strut was
reconstructed using IHCC. (d–f)
Postoperative photographs
Mid-Vault Revisional Surgery

874
Further Reading
1. Guyuron B, Michelow BJ, Englebardt C. Upper lateral splay graft. Plast Reconstr Surg. 1998;102(6):2169–77.
2. Becker DG. My personal philosophy of revision rhinoplasty. In: Becker DG, Park SS, editors. Revision rhinoplasty. New York: Thieme; 2007.
3. Bjornsson AS, Didie ER, Phillips KA. Body dysmorphic disorder. Dialogues Clin Neurosci. 2010;12(2):221–32.
4. Son D, Kwak M, Yun S, et al. Large auricular chondrocutaneous composite graft for nasal alar and columellar reconstruction. Arch Plast Surg.
2012;39(4):323–8.
5. Russo de la Torre F. Retroauricular revolving door island flap. Actas Dermosifiliogr. 2012;103(8):737–8.
6. Daniel RK, Brenner KA. Saddle nose deformity: a new classification and treatment. Facial Plast Surg Clin North Am. 2006;14(4):301–12.
7. Durbec M, Disant F. Saddle nose: classification and therapeutic management. Eur Ann Otorhinolaryngol Head Neck Dis. 2014;131(2):99–106.
8. Byrne PJ, Walsh WE, Hilger PA.  The use of “inside-out” lateral osteotomies to improve outcome in rhinoplasty. Arch Fac Plast Surg.
2003;5:251–5.
9. Sciuto S, Bianco N. Surgical correction of “rhinoplastic look”. Acta Otorhinolaryngol Ital. 2013;33(3):177–82.
10. Gunter JP, Rohrich RJ. Correction of the pinched nasal tip with alar spreader grafts. Plast Reconstr Surg. 1992;90(5):821–9.
11. Clark JM, Cook TA. The ‘butterfly’ graft in functional secondary rhinoplasty. Laryngoscope. 2002;112(11):1917–25.
12. Jung DH, Kim BR, Choi JY, et al. Gross and pathologic analysis of long-term silicone implants inserted into the human body for augmentation
rhinoplasty: 221 revision cases. Plast Reconstr Surg. 2007;120(7):1997–2003.
13. Honda Y, Tanizaki H, Otsuka A, et al. Calcinosis cutis long after rhinoplasty with silicone. Case Rep Dermatol. 2014;6(3):288–90.
14. Kim SK, Kim JC, Lee KC, et al. Correction of the supratip deformity of the nose. Aesthet Surg J. 2012;32(8):943–55.
15. Hanasono MM, Kridel RW, Pastorek NJ, Glasgold MJ, Koch RJ. Correction of the soft tissue pollybeak using triamcinolone injection. Arch
Facial Plast Surg. 2002;4:26–30. discussion 31
16. Guyuron B, DeLuca L, Lash R. Supratip deformity: a closer look. Plast Reconstr Surg. 2000;105:1140–51. discussion 1152-1153
17. Tosun F, Arslan HH, Hidir Y, et al. Subcutaneous approximation suture for preventing soft tissue pollybeak deformity. Am J Rhinol Allergy.
2012;26(4):e111–4.
18. Hyun SM, Jang YJ. Treatment outcomes of saddle nose correction. JAMA Facial Plast Surg. 2013;15(4):280–6.
19. Young K, Rowe-Jones J. Current approaches to septal saddle nose reconstruction using autografts. Curr Opin Otolaryngol Head Neck Surg.
2011;19(4):276–82.
20. Ahmed A, Imani P, Vuyk HD. Reconstruction of significant saddle nose deformity using autogenous costal cartilage graft with incorporated
mirror image spreader grafts. Laryngoscope. 2010;120(3):491–4.
21. Bilen BT, Kilinc H. Reconstruction of saddle nose deformity with three-dimensional costal cartilage graft. J Craniofac Surg. 2007;18(3):511–5.
22. Tardy ME Jr, Schwartz M, Parras G. Saddle nose deformity: autogenous graft repair. Facial Plast Surg. 1989;6(2):121–34.
23. Pribitkin EA, Ezzat WH. Classification and treatment of the saddle nose deformity. Otolaryngol Clin N Am. 2009;42(3):437–61.
24. Suh MK, Lee KH, Harijan A, Kim HG, Jeong EC. Augmentation rhinoplasty with silicone implant covered with acellular dermal matrix. J
Craniofac Surg. 2017;28(2):445–8.
25. Won TB, Jin HR. Immediate reconstruction with autologous cartilage after removal of infected alloplast in revision rhinoplasty. Otolaryngol
Head Neck Surg. 2012;147(6):1054–9.
26. Lo S, Sinrachtanant C. Immediate autologous fat graft augmentation rhinoplasty after removal of extruding or infected silicone implant. Clin
Otolaryngol. 2012;37(4):333–4.
27. Raghavan U, Jones NS, Romo T III. Immediate autogenous cartilage grafts in rhinoplasty after alloplastic implant rejection. Arch Facial Plast
Surg. 2004;6:192–6.
28. Peled ZM, Warren AG, Johnston P, Yaremchuk MJ. The use of alloplastic materials in rhinoplasty surgery: a meta-analysis. Plast Reconstr
Surg. 2008;121:85e–92e.
29. Lam SM, Kim YK. Augmentation rhinoplasty of the Asian nose with the “bird” silicone implant. Ann Plast Surg. 2003;51:249–56.
30. Sheen JH, Sheen AP. Problems in secondary rhinoplasty: alloplastics. In: Sheen JH, Sheen AP, editors. Aesthetic rhinoplasty. St. Louis, MO:
CV Mosby; 1987. p. 1365–440.
31. Clark JM, Cook TA. Immediate reconstruction of extruded alloplastic nasal implants with irradiated homograft costal cartilage. Laryngoscope.
2002;112:968–74.
32. Suh MK, Ahn ES, Kim HR, et al. A 2-year follow-up of irradiated homologous costal cartilage used as a septal extension graft for the correc-
tion of contracted nose in Asians. Ann Plast Surg. 2013;71:45–9.
33. Robitschek J, Hilger P. The saddle deformity: camouflage and reconstruction. Facial Plast Surg Clin North Am. 2017;25(2):239–50.
34. Garcia AM, Villa MV, Escudero ME, Gomez P, et al. Use of nasal mupirocin for staphylococcus auresus: effect on nasal carriers and nosoco-
mial infectinos. Biomedica. 2003;23(2):173–9.
35. Inanli S, Sari M, Baylancicek S. The use of expanded polytetrafluoroethylene (gore-Tex) in rhinoplasty. Aesthet Plast Surg. 2007;31(4):345–8.
36. Gryskiewicz JM. Waste not, want not: the use of AlloDerm in secondary rhinoplasty. Plast Reconstr Surg. 2005;116(7):1999–2004.
37. Gryskiewicz JM, Rohrich RJ, Reagan BJ.  The use of alloderm for the correction of nasal contour deformities. Plast Reconstr Surg.
2001;107(2):561–70. discussion 571
38. Jackson IT, Yavuzer R. AlloDerm for dorsal nasal irregularities. Plast Reconstr Surg. 2001;107(2):553–8. discussion 559-60
39. Suh MK, Lee SJ, Kim YJ. Use of irradiated homologous costal cartilage in rhinoplasty: complications in relation to graft location. J Craniofac
Surg. 2018 Mar 8. Doi: 10.1097/SCS.0000000000004440. [Epub ahead of print].
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© Springer Nature Singapore Pte Ltd. 2018
M. K. SUH, Atlas of Asian Rhinoplasty,
Complications of the Rhinoplasty
17
This chapter discusses several possible complications of rhinoplasty.
Intraoperative Hemorrhage
Severe hemorrhage not only interferes with the operation itself but also leads to postoperative ecchymosis and swelling,
which delays recovery. This is associated with worse outcomes following rhinoplasty, especially after tip plasty. In Asians,
excessive bleeding and edema in bulbous tip correction can cause significant scar tissue formation and ill- defined shape. For
these reasons, the importance of intraoperative hemostasis cannot be emphasized enough.
Abrupt and brisk bleeding mainly occurs with manipulation of the septum. If such bleeding occurs, the ruptured vessel is
identified under suction and coagulated. If the vessel cannot be found due to profuse bleeding, a gauze soaked with saline
solution with 1:40,000 epinephrine can be useful in temporarily controlling the bleed source to allow for exploration. It can
be helpful to decrease blood pressure by communicating with the anesthesiologist.
Among osteotomies, lateral osteotomy is most commonly associated with bleeding. If possible, the bleeding vessel should
be visualized and coagulated through the osteotomy incision. However, the bleeding vessels cannot be visualized in most
cases but cease to bleed with intranasal packing and external compression. Intravenous infusion of desmopressin (DDAVP)
can be a very helpful addition.
Desmopressin is also helpful for patients with intrinsic coagulopathy, coagulopathy due to aspirin, NSAIDs, herb medica-
tion, and bleeding without clear cause for coagulation issues. Guyuron et al. reported the use of desmopressin for maxillofa-
cial surgery and treatment of epistaxis, which was a significant contribution to the field. The recommended dose is 0.3 μg/
kg, with a delay of 20 min prior to the onset of hemostatic effect. They also reported that unremitting postoperative epistaxis
following outpatient nasal surgery can be successfully controlled by intravenous injection of 0.3 μg/kg of intravenous des-
mopressin over 30 min without the need for alternative maneuvers. The group of authors have been using intravenous des-
mopressin as an effective, alternative treatment for patients who have had intraoperative bleeding with no response to surgical
maneuvers traditionally used to control bleeding.
Commonly, higher-than-expected rate of bleeding vessels should lead an operator to suspect high blood pressure. Despite
with antihypertensive medication, patients can often have elevated intraoperative blood pressure from epinephrine injection,
operative stress, and/or pain. Also, patients with undiagnosed hypertension are highly sensitive to epinephrine exposure and
painful stimuli, with increased difficulty in hemostatic control. For this reason, the role of anesthesiologist is crucial for
managing the blood pressure in minimizing intraoperative bleeding.

876
Hemorrhage in the Immediate Postoperative Setting
In the immediate postoperative setting, most cases of epistaxis following rhinoplasty are due to elevated blood pressure from
postoperative pain. As such, management of postoperative pain is an important component of maintaining a normal blood
pressure. Nausea due to IV sedation is another common cause of increased blood pressure and bleeding, and patients with
nausea should be made comfortable with antiemetic medication. Any patient experiencing nausea should be evaluated for
adequate hydration, which is important in renal clearance of anesthetic agents. The author usually administers 10 mg of IV
metoclopramide for nausea that continues despite adequate hydration. For more severe nausea or for patients who vomit, a
bolus of IV ondansetron is injected, and the patient is kept on a continuous infusion while in recovery.
Oral intake of antibiotic or pain medication on an empty stomach is another cause for nausea, and patients should be
instructed to take the medications after a meal.
For light nasal bleeding, the patient should keep the head elevated. Before any maneuver that can potentially be discom-
forting or painful, the patient should be given intravenous desmopressin infusion prior to each procedure. Most potential
bleeding can be controlled by desmopressin infusion. Guyuron et al. reported that postoperative bleeding following septorhi-
noplasty or turbinectomy has been effectively controlled with the use of intravenous desmopressin without the need for
invasive maneuvers, such as nasal packing or cauterization.
If desmopressin infusion is ineffective in controlling a bleed, the source of bleeding must be identified. If the bleeding
originates from the septum, additional packing should be used for 10–20 min of compression. If the bleeding originates from
lateral osteotomy site, compressive dressing should be applied both internally and externally to lateral ala/nasal bony base.
If the bleeding does not stop, packing and splint are removed. The blood clot is carefully suctioned, and the bleeding focus
is identified. Bleeding from septal mucosa or turbinate mucosa should be cauterized and packed. If the bleeding originates
not from mucosa but from within the operative field, the patient should be taken back to the operating room for exploration.
If necessary, the patient may require endoscopic ligation of the sphenopalatine artery and anterior and posterior ethmoidal
arteries. When all measures have failed in controlling the bleeding, an interventional radiologist should be consulted for
emergency angiographic embolization.
17 Complications of the Rhinoplasty

877
Delayed Postoperative Hematoma
Postoperative hematoma can significantly worsen the outcome of an operation (Fig. 17.1). Hematoma in the nasal tip can
lead to fibrosis, which changes the form and shape of nasal tip. It is imperative that all hematoma is removed in its entirety.
Hematoma that is confined to the dorsum will liquefy after a week and can be aspirated. However, accompanying tip
hematoma will need to be removed by reopening a small portion of the intranasal incision. A drain will need to be inserted.
A septal hematoma can cause septal perforation, septal fibrosis, nasal obstruction, and septal abscess (Figs. 17.2 and
17.3). All instances of septal hematoma should be aspirated with an 18-gauge needle as soon as they are discovered. The
aspirated septum should be compressed with splint or packing material. If the hematoma cannot be aspirated easily, a small
incision can be made in the caudal portion of septal mucosa to access and remove the hematoma, after which the area is
compressed.
Bilateral septal hematoma is especially dangerous and requires immediate and complete removal. Bilateral hematoma
compromises the nutrient provided to the cartilage by the diffusion from perichondrium, and can cause necrosis of septal
cartilage with resultant saddle nose. Avascular cartilage is known to undergo rapid absorption after 3 days.
Fig. 17.1 Hematoma after rhinoplasty
Delayed Postoperative Hematoma

878
Fig. 17.3 Septal infection
Fig. 17.2 Septal hematoma
17 Complications of the Rhinoplasty

879
Acute Injury to the Keystone Area (L-Strut Fracture)
The intersection between septal cartilage and perpendicular plate is vulnerable to injury. During submucosal resection (SMR)
or septal cartilage harvest, over-resection of cartilage or excessive pressure to this area can lead to dorsal collapse (Fig. 17.4).
Any injury to the keystone area should be repaired immediately. Otherwise, dorsal collapse will become worse with time.
Direct suture repair is not difficult if the fracture is located in the dorsal septal cartilage and readily accessible. The repair
will also incorporate a spreader graft. A fracture at the cartilage-bony junction can also be repaired, given adequate exposure.
A hole can be made in the bony septum to allow direct suture repair with 5-0 nylon and a spreader graft. In many cases, a
23-gauge needle is all an operator needs to create the hole in the bony septum. If fixation to dorsal bony septum is not easy,
a hole can be drilled in the nasal bone, and the dislocated keystone portion can be secured to the nasal bone using 5-0 nylon.
Fracture in the cephalic portion of high bony septum is reduced using a percutaneous K-wire, which is driven through
nasal bone and high bony septum caudal to fracture site. The wire is maintained for 3–4 weeks.
If the dorsal septum is not fractured but still unstable, the spreader graft is used to stabilize the dorsal septum to the upper
lateral cartilages. This is because the upper lateral cartilages are firm structures attached to the nasal bone.
L-strut of
septal cartilage
Fig. 17.4 L-strut fracture
Acute Injury to the Keystone Area (L-Strut Fracture)

880
Nasal Bone Collapse During Osteotomy
From humpectomy or osteotomy, it is important to avoid instability and collapse of the nasal bone. If the nasal bone does
collapse, re-approximation of the upper lateral cartilages to the dorsal septum can place traction and stabilize the nasal bone.
At this point, a long spreader graft should be placed beneath the bone. The intranasal space under the nasal bone should be
packed for 1–2 weeks.
If fixation of the upper lateral cartilage does not stabilize the bony collapse, or if a septum is also collapsed, a K-wire
should be used to fixate the collapsed sections for 2–3 weeks.
17 Complications of the Rhinoplasty

881
Infection
Generally, infection is very rare after a rhinoplasty. In Asian rhinoplasty, implant-related infection has been reported at rates
up to 5.3%, but there is a significant variation across operators.
A post-rhinoplasty infection, when it does occur, not only represents a local infection but can also develop into toxic
shock syndrome, endocarditis, meningitis, and spinal osteomyelitis. As such, active measures to prevent and treat post-
rhinoplasty infection cannot be emphasized enough.
Initial symptoms and signs of infection are pain, swelling, redness, heating sensation, and tenderness (Fig. 17.5).
A patient with an infection should be treated immediately with broad-spectrum IV antibiotics, and the internal splint is
removed. Local infection limited to soft tissue (e.g., cellulitis) can be treated with systemic antibiotics administration.
However, the abscess formation will require surgical drainage. Implant-related infection requires implant removal.
Management of such an infection without implant removal (pocket irrigation and antibiotics) not only is ineffective but also
prolongs the treatment duration, which increases the chance of secondary complications such as fistula, scar tissue forma-
tion, and contracture. As with any infection, it is imperative to obtain a culture from any available source, in order to deter-
mine the antibiotic sensitivity. Upon implant removal, the implant pocket should be irrigated vigorously using a Betadine
solution mixed with antibiotics. Any surrounding granulomatous tissue should be removed with a curette. The implant cap-
sule should be removed if it appears infected and granulomatous.
The results of sensitivity test should dictate the antibiotic regimen. However, a culture may not identify a pathogen if the
patient was already on antibiotic prior to the tissue samples being taken. If the culture returns a null result and the clinical
picture does not significantly improve over a week, the antibiotic should be switched to cover for gram-negative bacteria and
Pseudomonas.
In Asian rhinoplasty, a wide variety of implants and allograft materials are used, with patients often having a history of
multiple operations. Many patients do not know or are often wrong about what kind of implant was used in prior operations.
Therefore, unaccounted foreign material should be suspected in a patient with a prolonged infection that cannot be controlled
with standard treatment.
Fig. 17.5 Post-rhinoplasty infection
Infection

882
Nasal Tip Numbness
Sensory change in the tip and upper columella is not rare after open rhinoplasty. Thompson reported that 65.3% of patients
experienced some degree of nasal tip numbness after rhinoplasty. Among those, the numbness resolves in 2/3 by 3 months
after operation. Jaberoo et al. reported that 26.2% experience persistent nasal tip numbness beyond the first 6 months after
operation.
Sensation to the nasal tip and upper columella is supplied by the external nasal branch of the anterior ethmoidal nerve, and
sensation to the lower columella and ala is conducted by the labial branch of infraorbital nerve (see Fig. 1.22 in Chap. 1).
External nasal branch may be injured during the open rhinoplasty dissection. Most cases of nasal tip numbness resolve
after the first year, which is suspected to be due to regeneration of external nasal branch or collateral sprouting of peripheral
nerve branches. Patients should always be warned against the potential for nasal tip numbness prior to an operation.
Nasal Obstruction
Nasal obstruction is relatively common in the early recovery period following rhinoplasty, most of which is due to mucosal
edema and crusting. The obstruction will improve with resolution of edema. In most instances, the nasal obstruction does not
require a specific treatment, outside of patient reassurance. If the patient complains of great distress, nasal decongestant can
be helpful. However, topical spray should not be used for more than 7 days because of rebound effect.
However, nasal obstruction that persists even after the resolution of edema may require surgical intervention. Despite the
necessity, the intervention will have to be delayed for a year after an operation—after maturation of the scar tissues.
With preexisting allergic rhinitis and vasomotor rhinitis, patients may experience worsening of rhinorrhea after a rhino-
plasty operation.
Nasal obstructions that require operative intervention are septal deviation after septal extension graft, excessive nasal
bone narrowing, turbinate medialization by osteotomy, internal valve collapse, internal valve scarring, and external valve
stenosis.
During the respiratory cycle, the passage of air against the intranasal mucosa provides the sensory feedback for normal
breathing. However, surgical scars can impair this sensation, and patients will complain of nasal obstruction despite there
being no anatomic reason for obstruction. In these patients, operations to widen the airway (e.g., turbinate reduction) do not
improve and can even aggravate the symptoms.
17 Complications of the Rhinoplasty

883
Mucosal Synechiae
Synechiae are bands of scar tissue between the septum and turbinates, which contribute to nasal obstruction (Fig. 17.6).
Synechiae represent a minor complication of septal surgery, turbinate surgery, sinus surgery, nasal packing, or trauma (such
as nose-picking). These can also be observed in systemic diseases, such as tuberculosis, lupus, and sarcoidosis.
A synechia is treated by resection using surgical scissors, electrocautery, or microdebrider (Fig. 17.7). Electrocautery
should be applied close to the turbinate to avoid potential risk of septal perforation due to thermal damage. Thin silicone
sheet is interposed between two opposing raw surfaces to keep the layers from coming into contacting with each other.
Silicone sheet should be maintained for 1–3 weeks until healing is confirmed and it should be changed regularly to prevent
infection.
Bleeding and infections are possible complications of synechia surgery. After synechia resection, nasal cavity must be
examined for purulent discharge. Streptococcus and Staphylococcus species are part of the normal nasal cavity flora.
Introducing a sheet into the nasal cavity can lead to an increase in these bacterial species, which can subsequently increase
the risk of toxic shock syndrome. The sheet should be replaced every 3–4 days, and the patient should be taking oral antibi-
otic. Patients should be warned of signs of systemic infection such as fever, dizziness, headache, vomiting, diarrhea, and
rash.
Fig. 17.6 Mucosal synechia between septum and inferior turbinate
Fig. 17.7 One month after correction of mucosal synechia
Mucosal Synechiae

884
Septal Perforation
Intraoperative management of septal tearing is discussed in Chap. 15. This section deals with management of old septal
perforation due to a prior operation. Symptoms of septal perforation are crusting, whistling sound, bleeding, and nasal
obstruction. Occasionally, there are patients who are not aware of the fact that they have septal perforation.
Perforations Less Than 2 Cm
Guyuron introduced the following manner:
An incision is made in the membranous septum, and a pocket is created beyond the perforation site by separating the
mucoperichondrium on either side. A straight piece of septal or conchal cartilage is then advanced in position, and simple
stents are applied to either side to maintain the cartilage in position and aid re-epithelialization.
Larger Perforations
Large perforation (Fig. 17.8) requires mucosal flap and interpositional cartilage graft. However, this solution does not have
a high success rate, and failed operation can result in an even larger perforation. As such, this problem should be solved by
the most experienced of surgeons.
a
b
Fig. 17.8 Large septal perforation
17 Complications of the Rhinoplasty

885
Empty Nose Syndrome
Empty nose syndrome is an iatrogenic disorder featured by paradoxical nasal obstruction despite an objectively wide, patent
nasal airway. This is a late complication of reduction or resection of the inferior and/or middle turbinate. The respiratory
difficulty is accompanied by nasal dryness and mucosal crusting. The exact incidence of this syndrome after turbinate sur-
gery is not known, but true empty nose syndrome is very rare.
The terms “atrophic rhinitis” and “empty nose syndrome” are often used interchangeably. However, empty nose syndrome
refers to the atrophic rhinitis secondary to turbinate surgery, whereas primary atrophic rhinitis is caused by endocrine and
nutritional abnormalities, chronic inflammation or irritation, and infection.
Pathophysiology
The pathophysiology of this syndrome is poorly understood. The debate has been whether it should be considered solely
rhinologic in nature, or whether it may have neurological or psychological aspects. The following hypothesis provides per-
suasive arguments.
Normally, turbinates act as “air-conditioning” (nasal humidification, temperature control). The turbinates warm up and
humidify the inspired air, and the incoming air cools the turbinate mucosa. It is speculated that the sensation of nasal patency
is largely dependent on this mucosal cooling. Normal stimulation of trigeminal thermoreceptor in the mucosa produces the
sensation of nasal patency and the perception of adequate airflow as a response to mucosal cooling. After turbinate resection,
the decreased nasal surface area leads to decreased humidification and warming up, and thus disruption of mucosal cooling
and subsequent neurosensory feedback.
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Diagnosis
There is no specific physical sign for empty nose syndrome. On endoscopy or X-ray, the turbinates are either absent or small.
The mucosa is pale and dry. Outside of the subjective symptoms from the patient, there is no objective evidence for airway
obstruction. In addition to nasal obstruction, patients complain of airway dryness, crusting, and/or foul smell. Associated
symptoms include pharyngeal dryness, pharyngeal pain, headache, depression, and anxiety. Empty nose syndrome is a diag-
nosis of exclusion and can only be diagnosed after a complete patient history, endoscopic examination, and X-ray (Fig. 17.9).
Fig. 17.9 Empty nose syndrome (X-ray)
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Treatment
Empty nose syndrome is difficult to manage, and prevention of this serious complication through turbinate-sparing tech-
niques is essential.
The symptoms of nasal obstruction are managed with conservative treatment, with surgical therapy reserved for failed
conservative treatment. If turbinate reduction is necessary, the mucosa (which contains the receptors responsible for sensa-
tion of airflow) should be preserved as much as possible.
Medical Treatment
The medical treatment of empty nose syndrome is identical to that used for atrophic rhinitis, consisting of mucosal moistur-
ization, irrigations, and emollients. However, treatment is less effective for empty nose syndrome, compared to atrophic
rhinitis.
Surgical Treatment
All patients should be following a strict regimen of medical treatment, prior to any surgical solution.
Surgical therapy should be reserved for refractory cases and may involve turbinate reconstruction, most commonly using
implantable biomaterials. The operative solution should be delayed for a year, to allow for recovery of sensory nerve
endings.
Operative methods include the placement of autograft (cartilage, temporal fascia), silicone implant, allograft dermis,
hydroxyapatite cement, and/or hyaluronic acid into submucoperichondrial plane of the septum or floor of the nose adjacent
to the location of the former turbinate, lateral nasal wall, or submucosal plane of the residual turbinate.
Post-rhinoplasty Rhinitis
After a rhinoplasty operation, the nasal discharge may temporarily increase due to the edema. With time, the post- rhinoplasty
rhinitis resolves spontaneously. If the symptoms are severe, however, conservative treatments can be useful, such as oral
decongestants or topical spray.
In certain cases, patients may experience clear watery nasal discharge on cold days or while eating a bowl of hot soup.
This can be a variant of vasomotor rhinitis caused by abnormal parasympathetic tone. This can be addressed by topical cor-
ticosteroid spray and topical anticholinergic spray. Oral antihistamines are not effective in treating vasomotor rhinitis. If
medical treatment is ineffective in a patient with a history of septal surgery, cerebrospinal fluid should be considered as a
source of the rhinorrhea.
Impairment of Olfaction (Respiratory Hyposmia or Anosmia)
Post-rhinoplasty olfactory dysfunction can be caused by the following reasons:
1. Transient olfactory impairment can be caused by mucosa edema, increased rhinorrhea, and crusting, even after removal
of packing and splint.
2. Synechiae between septum and middle turbinate that prevent the air from reaching the olfactory cleft.
3. Deficient aeration to olfactory groove by turbinate deformity (out-fracture, atrophy).
4. Injury to olfactory neuroepithelium or cribriform plate.
5. Psychogenic etiology.
6. Unknown origin.
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Treatment
Most olfactory impairment spontaneously resolves between 6 and 18 months. It is important to reassure the patient and wait
for olfaction to improve. Oral steroid can be helpful. Steroid can decrease the inflammation within the nasal cavity and is also
known to directly affect olfactory epithelial cells, though the mechanism is unknown. Surgical management is needed for the
presence of synechiae in the cephalic area of nasal cavity.
Cacosmia
If a patient complains of persistent foul odor after rhinoplasty, the following potential causes should be evaluated:
1. Transient cacosmia: In the few months following rhinoplasty, the increase in rhinorrhea and crust formation can lead to
foul odor, which resolves spontaneously with time.
2. Abnormal airflow: A nasolabial angle between 90 and 110° allows for the most ideal airflow. This angle alters the direc-
tion of airflow. A narrower angle causes the airflow in cephalic direction, with wider angle causing airflow towards naso-
pharynx. Abnormal airflow induces accumulation of mucosal secretion in specific areas within the nasal cavity, which can
become a source of foul odor and infection.
3. Narrow spaces within the nasal cavity can allow accumulation of secretion and subsequent cacosmia.
4. Septal perforation can induce crust formation with foul odor.
5. Recurrent or aggravation of underlying disease process (e.g., sinusitis, rhinitis).
Post-rhinoplasty Fibrosis Syndrome
Despite a trouble-free nasal tip plasty operation, severe and persistent edema can lead to eventual fibrosis of the nasal tip,
with the nasal tip becoming larger than its preoperative state and having poor definition. This is post-rhinoplasty fibrosis
syndrome.
A nose with thick skin is more prone to post-rhinoplasty fibrosis syndrome, especially when the skin has an abundance of
sebaceous skin. If the postoperative swelling does not resolve, the prolonged lymphedema will trigger fibrosis and increase
the skin thickness. Post-rhinoplasty fibrosis in thick skin turns all of the operative labor into a waste, and the tip bulbousness
becomes a cause for significant complaint on the part of the patient.
It is difficult to predict which patient will suffer from this syndrome, but it is observed more frequently for a patient with
thick sebaceous skin, darker skin, and keloid history. Acne, allergic rhinitis, smoking, vigorous exercise, sunburn, and exor-
bitant salt take can be aggravating factors, which should be avoided or minimized as much as possible.
For prevention, any postoperative edema should be minimized by the use of taping and administration of systemic and
intralesional steroid. In a patient with excessive edema, the steroid should be injected as early as clinically possible.
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