Complications of Rhinoplasty - Page 15

Greenstick Fracture
Incomplete fracture of the nasal bones after osteotomy, also known as greenstick fracture, may lead to the recurrence of a deformity (such as nasal deviation) due to "memory" and "spring" in the nasal bone. While this may be acceptable in certain patients, such as an elderly rhinoplasty patient with thin, brittle bones, greenstick fractures commonly lead to recurrence of a preoperative nasal bony deformity.

SKIN/SOFT TISSUE ENVELOPE
The skin/soft tissue envelope has well-defined tissue planes in which avascular dissection may be undertaken. Operating in more superficial planes not only leads to a bloody surgical field but also risks damage to the vascular supply with potential damage to the skin. Once the skin/soft tissue envelope is damaged, it can never be fully restored. The damaged skin creates an aesthetically displeasing appearance."

Vascular supply and lymphatics are found superficial to the nasal musculature . The soft-tissue layers in the nose are epidermis, dermis, subcutaneous [this plane contains blood vessels and lymphatics, and also a (typically) thin layer of fat], muscle and fascia (musculoaponeurotic) plane, areolar tissue plane, and perichondrium/periosteum. Dissection during rhinoplasty in the proper tissue planes (areolar tissue plane, i.e., submusculoaponeurotic) preserves nasal blood supply and minimizes postoperative edema.

Use of alloplastic implants risks skin complications. The nose fulfills few of the requirements for use of alloplastic materials. If the alloplast extrudes through the skin, the skin-soft tissue envelope is permanently and irreparably damaged.

Infection of the skin/soft tissue envelope is a rare complication of septorhinoplasty. Nevertheless, cellulitis characterized by erythema, edema, and pain is a potential risk that must be identified and treated promptly. If oral antibiotics are not quickly effective, intravenous antibiotics must be used to quickly control this rare but potentially serious complica ­tion. Nasal culture may guide therapy in difficult cases.

FUNCTIONAL
COMPLICATIONS OF SURGERY
The list of possible functional complications can be exhaustive. Note must be made of possibly serious complications. Intracranial complications may occur in association with septal surgery, as the perpendicular plate of the ethmoid has an attachment superiorly in the floor of the cranial cavity. Great care must be taken, particularly in the elderly, to avoid avulsing ethmoid bone and creating a fracture with cerebrospinal fluid leak. Other functional complications of septoplasty and septorhinoplasty include septal perforation, toxic shock syndrome, septal hematoma, and abscess.

Airway complications merit a chapter in themselves. In brief, the surgeon must take a careful history to recognize medical causes of obstruction, such as allergy, sinusitis, or medication misuse (rhinitis medicamentosa).

It is critical that rhinoplasty maintain or improve the nasal airway. Failure to preserve nasal airway function can be crippling. The causes of nasal airway obstruction must be identified and addressed. Conservatism must be empha­sized; for example, overresection of turbinates can lead to atrophic rhinitis, which can be crippling. Overnarrowing of the bony pyramid, with failure to preserve the airway at the nasal valve, can also lead to nasal obstruction. Overresection of the lateral crus can lead to aesthetic complications that are often accompanied by nasal valve collapse and breath­ing problems.

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