Complications of Rhinoplasty - Page 4

Specific Complications in the Nasal Tip

Ptotic Tip
A critical principle in avoiding undesired changes of the nasolabial angle is assessment of tip anatomy and tip sup-port, followed by maneuvers that maintain or augment tip support and restore the nose to a more natural appearance. However, as mentioned above, maneuvers that result in loss of tip support may lead to a droopy tip (tip ptosis with an overly acute nasolabial angle). The normal nasolabial angle (angle defined by columellar pointtosubnasale line intercepting with subnasaletolabrale superius line) is 90 to 120 degrees. 12 Within this range, a more obtuse angle is more favorable in females, a more acute angle in males. Loss of tip support can lead to a ptotic, underprojected, drooping nose.

Management of complications relating to a ptotic nose relies on restoration of tip support and tip projection. When faced with an operative complication such as a droopy, ptotic tip, appropriate diagnosis will guide correction. ' There are numerous rhinoplasty maneuvers to increase tip support, reproject the nose, and rotate the nose (Table 392).

Overrotated Tip
Conversely, one may face a patient with a nose that has been overrotated, with an overly obtuse angle. Overresection of the caudal septum is a common cause of overrotation of the tip. Overrotation of the nose creates an unsightly, overshortened appearance.

Careful preoperative assessment can identify those patients in whom operative rotation should be avoided. Man agement of complications relating to a short, overrotated nose relies on maneuvers that lengthen and counterrotate the nose.' There are specific rhinoplasty maneuvers to lengthen and counterrotate the nose (Table 392).

Bossae
A bossa is a knuckling of the lower lateral cartilage at the nasal tip due to contractural healing forces acting on weak ened cartilages. Patients with thin skin, strong cartilages, and nasal tip bifidity are especially at risk. Excessive resection of lateral crus and failure to eliminate excessive interdomal width may play some role in bossa formation. Bossae are felt to be the result of scar contracture on an overly narrowed complete rim strip, causing a bulge during postoperative healing. Some investigators have described an association between cartilage splitting techniques and bossa formation. ' However, others maintain that vertical dome division tech niques are reliable when performed correctly and do not con -tribute to these difficulties.

As an isolated deformity, bossae are typically treated through a small marginal incision with minimal undermining over the offending site followed by trimming or excising the offending cartilage. In some cases, the area is covered with a thin wafer of cartilage, fascia, or other material to further smooth and mask the area.

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