Appendix G - Selected Complications of Rhinoplasty

Bossae: A knuckling of lower lateral cartilage at the nasal tip caused by contractural heal­ing forces acting on weakened cartilages. Patients with thin skin, strong cartilages, and nasal-tip bifidity are especially at risk. Excessive resection of lateral crux and failure to eliminate excessive interdomal width may play some role in bossae formation.

Polly beak: Postoperative fullness of the supratip, with an abnormal tip-supratip relation. This has several etiologies: Failure to maintain adequate tip support (postoperative loss of tip projection), inadequate cartilaginous hump (anterior septal angle) removal, and/or supratip dead space/scar formation.

Trea"ent depends on anatomic cause. If the cartilaginous hump was underresected, then resect additional dorsal septum. One also must ensure adequate tip support. Ma­ neuvers such as placement of a columellar strut may be of benefit. If the bony hump was overresected, consider a graft to augment the bony dorsum. If a polly-beak is from ex­cessive scar formation, consider triamcinolone (Kenalog) injection or skin taping in the early postoperative period, before any consideration of surgical revision.

Inverted V deformity: Inadequate support of the upper lateral cartilages after dorsal-hump removal can lead to inferomedial collapse of the upper lateral cartilages and an "inverted V deformity." In this deformity, the caudal edges of the nasal bones are visible in broad relief. Inadequate infracture of the nasal bones is also a frequent cause. When executing hump excision, it is helpful to preserve the underlying nasal mucoperichondrium (extra­mucosal dissection), which provides significant support to the upper lateral cartilages and helps decrease the risk of inferomedial collapse of the upper lateral cartilages after hump excision. When undertaking osteotomies after hump excision, appropriate infrac­ture and narrowing of the bony vault must be achieved.

Rocker deformity: If osteotomies are taken too high, into the thick frontal bone, the supe­ rior aspect of the osteotomized nasal bone may project or "rock" laterally when the bone is infractured. This is a "rocker" deformity. A 2-mm osteotome may be used percuta­neously to create a more appropriate superior fracture line and correct the rocker defor­mity.

Dorsal irregularities: After creation of an "open roof" by hump removal, the bony mar-gins should be smoothed with a rasp. Any bony fragments should be removed, making sure that all obvious particles are removed from under the skin/soft-tissue envelope. Fail ­ure to remove all fragments may lead to a visible and/or palpable dorsal irregularity.

Nasal valve collapse: The surgeon should recognize the existence of the internal and ex­ternal nasal valve. The internal nasal valve area is bounded by the caudal margin of the upper lateral cartilage, septum, and floor of the nose. The external nasal valve refers to the area delineated by the cutaneous and skeletal support of the mobile alar wall. Exces­ sive narrowness in either of these locations may cause nasal obstruction. Weakness at ei ­ther of these locations may result in collapse with the negative pressure of inspiration, resulting in nasal airway obstruction. Nasal valve collapse is seen most often as a sequela of overresection of lateral crura or middle vault collapse. Overaggressive resection of the lateral crura and the subsequent postoperative soft-tissue contraction frequently leads to nasal valve compromise.

REFERENCES

1. Simons RL, Gallo IF. Rhinoplasty complications. Facial Plast Surg Clirr North Am 1994:2:521-529.
2. Kamer FM, Pieper PG. Revision rhinoplasty. In: Bailey B, ed. Head and Neck Surgery Otolaryngology. Philadelphia : Lippincott, 1998:2663-2676.
3. Tardy ME, Kron TK, Younger RY, Key M. The cartilaginous pollybeak: etiology, prevention, and trea"ent. Facial Plast Surg 1989:6:113-120.
4. Larrabee WF Jr. Open rhinoplasty and the upper third of the nose. Facial Mast Surg C/in North Am 1993;1: 23-38.
5. Toriumi DM. Management of the middle nasal vault. Opel- Tech Plast Recoostr Surg 1995;2:16-30.
6. Becker DG, Toriumi DM, Gross CW, Tardy ME. Powered instrumentation for dorsal nasal reduction. Facial Plast Surg 1997;13:291-297.

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