Question: What kinds of complications can occur in rhinoplasty?
Answer: Complications in rhinoplasty may be categorized as functional (related to breathing) or aesthetic (related to appearance); often, there are elements of both. Problems after rhinoplasty commonly are due to under-resection (not enough taken off), over-resection (too much taken off), and/or asymmetry. Also, sometimes abnormal scarring is a problem after rhinoplasty.
In general, it is easier to fix problems relating to under-resection, because they can be fixed by going back and "taking a little more." Problems caused by over-resection can be a little more complicated because material needs to be added, and technical factors arising from the need to add tissue must be considered. Asymmetries can usually be improved and at times can be completely fixed.
Question: If you need to use grafting material to rebuild my nose, what kind of materials are used in revision rhinoplasty?
Answer: Whatever material is used, you should expect that you and your surgeon will discuss exactly what is to be used in your case.
Various materials are used. Most commonly, cartilage is taken from inside your nose (specifically the nasal septum) or from your ear. Less commonly, rib cartilage is used. This may be your own rib,or it may be specially treated, irradiated rib taken from a donor. Examples of each may be seen in the Photo Album.
Question: My skin is very thin. Do you take any special measures in my revision rhinoplasty?
Answer: In patients with very thin skin, even the slightest irregularity may be felt or even seen. In these cases, we consider the use of Alloderm. Of course, if this is a consideration for a patient, Dr. Becker discusses this with him/her in advance of surgery.
Alloderm is a non-cellular human dermis taken from an organ donor and treated with a patented, FDA-approved treatment. Alloderm is used in a number of facial cosmetic applications, including lip augmentation, scar revision, and rhinoplasty. In revision rhinoplasty in patients with extremely thin skin, Alloderm may be placed between the skin and the graft to thicken the skin and thereby provide additional camouflage for the graft.
This patient had a reconstructive rhinoplasty in which Alloderm was used due to his thin nasal skin.
Question: Why don’t you use artificial implants?
Answer: Some surgeons use artificial implants such as gortex in the nose, but we do NOT advocate them. We feel that artificial materials carry the risk of becoming infected and extruding at any time. If these artificial implants come out through the nasal skin, this can cause irreversible damage to the nasal appearance.
The medical literature contains multiple reports describing this problem. Some surgeons who use this material have stated that they discuss this risk with the patient and make sure he/she understands the risks. We believe there are better options, and so we are not willing to take this risk when fixing your nose.
Question: If you need to take ear cartilage, how will that affect my ear?
Answer: The good news is that if you need ear cartilage for your revision rhinoplasty, taking that cartilage should not alter your ear’s shape or function.
The septum is usually our first choice for grafting material. However, if you have already had a septoplasty or septorhinoplasty, then this source of grafting material may have already been used, in which case we turn to your ear.
The incision is usually placed behind your ear where it cannot be seen. Sometimes, though, for instance if you wear a hearing aid (the incision behind the ear can be irritated by your hearing aid during the healing process), we prefer to make the incision on the front side of your ear in a location where it is well-camouflaged and difficult to see.
The cartilage taken from your ear works well in rebuilding your nose. The good news is — when performed properly, removing this cartilage should not change the shape of your ear! Occasionally, we see a patient who has had both ear cartilages used already, and they still need revision rhinoplasty. In these cases, we are sometimes able to find that there is still enough of the patient’s own cartilage in the ear and septum, but we also consider the use of either the patient’s or irradiated rib from a tissue bank.
Question: What about breathing and other functional complications?
Answer: Airway complications merit a website in itself; in brief, the surgeon must take a careful history and physical examination to identify which of the many causes of nasal breathing problems is affecting you. It is critical that during rhinoplasty, every effort is directed toward maintaining or improving the nasal airway. Failure to preserve nasal airway function can be crippling. The cause of nasal airway obstruction must be identified and addressed.
At the Penn Rhinoplasty Course, Dr. Becker gives a lecture entitled "Functional Considerations in Rhinoplasty." In this lecture, he emphasizes the importance of thoroughly evaluating the patient for nasal obstruction.
Question: I have problems with the tip of my nose. What kinds of complications occur at the nasal tip,
Answer: Over-reduction, under-reduction, and asymmetry.
In the nasal tip, over-reduction can lead to droopy tip (ptotic tip). Over-resection can result in excessive shortening of the nose, with a "pig snout" appearance. Over-resection may also contribute to other complications such as bossae (unsightly points), alar retraction (unsightly lifting of the nasal sidewall), and nasal collapse.
Under-resection may cause a problem to persist. Also, if under-resection is uneven, more significant abnormalities can result. For instance, if not enough of the lower portion of the nasal bridge is reduced, but all other parts of the operation are completed successfully, a "pollybeak" or parrot’s beak deformity can occur.
Asymmetries of the nasal tip may be present preoperatively and may have been overlooked by both the patient and the surgeon. Since rhinoplasty in some ways is like "two operations" ( a left and a right side), the surgery must be performed with great attention to symmetry. Asymmetries can also be caused surgically, for example by unequal treatment of the lower tip cartilages. It may also be caused by unequal scarring that can occur during the natural healing process and may not be evident for months or even years after surgery.
Question: Please discuss specific complications in the nasal tip.
Answer: OK, let’s talk about every problem mentioned above:
Question: What about a droopy or ptotic tip?
Answer: Loss of tip support can lead to a ptotic, under-projected, drooping nose. The normal angle at the nose-lip junction is 90-120 degrees. Within this range, a larger angle is more favorable in females, a smaller angle in males. The nasal tip must be supported and even strengthened during rhinoplasty to avoid the complication of a droopy tip.
Treatment of the droopy nose relies on restoration of strength, support and "lift." There are numerous rhinoplasty maneuvers that a surgeon can use to increase tip support, re-project the nose, and rotate the nose. These are outlined for surgeons in numerous sources, including Dr. Becker’s textbook. See the before and after results:
Question: How do you treat a short or "over-rotated" tip?
Answer: The opposite of a droopy nose is an overshortened nose. This can also be caused by overresection. Over-resection of the front end of the septum (the "caudal" septum) is a common cause of over-rotation of the tip. Over-rotation of the nose creates an unsightly, over-shortened appearance.
There are specific rhinoplasty maneuvers to lengthen and counter-rotate the nose. . These are outlined for surgeons in numerous sources, including Dr. Becker’s textbook. Shown here is a patient with a saddle nose and an over-shortened nose. Dr. Becker restored both the nasal profile and nasal length:
Question: How can overresection cause a droopy nose in some cases and an overshortened nose in others?
Answer: It depends on what exactly is overresected that determines whether a nose is droopy or short. If the support structures of the tip are weakened or overresected, the tip can fall down or droop. If other structures, such as the front part of the septum, are overresected, then the tip can fall backwards and become too short.
Question: I have little pointy knobs on my nasal tip. What are they, and can they be fixed?
Answer: Surgeons call these little knobs "bossae" (pronounced one of two ways: boss-ah or boss-eye). A bossae is a knuckling of the lower lateral cartilage at the nasal tip due to contractural healing forces acting on overly weakened cartilages. Certain types of patients, especially those with thin skin and strong tip cartilages that are widely placed, are especially at risk. In these patients, special techniques in surgery minimize the risk of bossae. Your surgeon should be able to tell you if you are at high risk for bossae formation.
If a bossae is your only problem, it can typically be treated with a limited revision procedure through a small endonasal (inside the nose) incision. The skin and soft tissue are lifted over the bossae and it is trimmed or excised. In these cases, the area is sometimes covered with a thin wafer of cartilage, fascia or other material to further smooth and mask the area.
Question: What if bossae are not my only problem?
Answer: If there are more complex problems, a larger revision may be necessary.
Shown below is a patient with bossae. He had other problems as well and underwent revision rhinoplasty as seen here:
Question: The insides of my nostrils show too much now, and it looks unattractive. What caused this, and can you fix it?
Answer: The contractile forces of healing over time may cause the side walls of the nostrils to retract upward if too much cartilage is resected from this area. This results in a situation in which the inside of the nostril shows too much. This is due to upward scarring of the nasal sidewall, known by surgeons as alar retraction. Shown here is an example of this problem.
Alar retraction may be treated by cartilage grafts in minor to moderate cases (1-2 mm). The area of retraction is marked, and a small incision inside the nose allows dissection of a precise pocket. A contoured cartilage graft (commonly of ear cartilage or septal cartilage) may be inserted into the precise pocket. The grafts restore support to the side wall of the nose.
Composite grafts made of cartilage and skin are commonly used in more severe cases. Ear cartilage is used in this situation. An incision several millimeters from the nostril rim is followed by careful dissection with freeing of the scar, displacing the side wall of the nostril downward, where it belongs. The fashioned composite graft is carefully sutured into place.
Question: What is a pollybeak?
Answer: A pollybeak refers to fullness of the region above the nasal tip, giving the nose the appearance of a "parrot’s beak" or "pollybeak." An example is shown here.
Pollybeak may have several causes. Your surgeon will examine you to determine the exact cause of pollybeak in your situation, and will suggest treatment based upon this.
Treatment of the pollybeak deformity depends upon the cause. If the cartilaginous hump was under-resected, then the surgeon can resect additional tissue here. Adequate tip support must be ensured or a pollybeak can occur. If a pollybeak is from excessive scar formation, Kenalog injection or skin taping in the early post-operative period may be undertaken prior to any consideration of surgical revision. If this doesn’t work, the surgeon may excise some scar tissue, followed by skin taping and possible Kenalog injection.
Question: What kinds of problems can occur in the middle and upper nasal thirds?
Answer: Over-reduction, under-reduction, and asymmetry
Question: What kind of problems result from over-resection of the middle and upper thirds?
Answer: Over-reduction of the upper portion of the profile results in a flattened appearance. If extreme overreduction occurs then the patient may have an overly concave, operated appearance. Over-reduction may lead to iatrogenic saddle nose deformity (also known as "boxer’s nose.") When undertaking profile reduction, great care must be taken to preserve support of the middle nasal vault – failure to do so can lead to complications such as nasal valve collapse and inverted-V deformity.
Question: What kind of problems result from under-reduction of the middle and upper third?
Answer: Under-reduction leads to a persistent deformity. Under-reduction may not only leave a persistent dorsal hump but may also create a pollybeak deformity, or alternatively an unsightly prominence at the upper nasal third. Nevertheless, this deformity is preferable to over- reduction because it is easier to correct the under-reduction secondarily when indicated.
Asymmetric resection may lead to unsightly appearance. Correction of this deformity is challenging. This may be treated with onlay grafts, either through a precise pocket placement or via an external rhinoplasty approach.
Question: What is a saddle nose deformity?
Answer: Saddle nose or "boxer’s nose" refers to the appearance of the nose after loss of support of the nasal vault with collapse. This deformity has been described after over-resection. Other causes of saddle nose deformity include septal hematoma, septal abscess, and severe nasal trauma.
Mild to moderate saddle nose deformity may be treated by onlay grafting to effectively camouflage and restore the nasal profile, or alternatively in experienced hands by conservative profile reduction. Severe saddle nose deformity may require major reconstruction with cantilevered cartilage or bone grafts. For examples of saddle nose deformity, please refer to the Photo Album.
Question: What is an inverted V deformity?
Answer: In this deformity, the lower edge of the nasal bones are visible to the naked eye. This edge or line forms an upside-down or "inverted" V. Feel your own nose and recognize the inverted V – this is just at the lower edge of your nasal bones. Inadequate support of the middle portion of the nose after removal of the nasal "bump" can lead to collapse of the middle portion of the nose (specifically, the upper lateral cartialges) and the "inverted V" may be visible to the naked eye, causing the "inverted V deformity." Inadequate infracture of the nasal bones is another significant cause of inverted V deformity.
This patient has an inverted V deformity. The middle portion of her nose has collapsed, and you can see a line on either side of the nose that joins in the middle to form the inverted V. Please go to the Photo Album to see this patient’s before and after photos.
Question: What is nasal valve collapse?
Answer: There are two "nasal valves" that are narrow areas of the nose that have a unique potential to limit nasal airflow. The internal nasal valve is said to be the narrowest part of the nasal passageway and as such is the "rate limiting step" in nasal breathing. The internal nasal valve is bounded by the free edge of the upper lateral cartilage and the septum. The external nasal valve refers to the area delineated by the nostril. Excessive narrowness or flaccidity in either of these locations may cause nasal obstruction.
Weakness at either 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 due to over-resection.
Treatment of internal nasal valve collapse may include the use of spreader grafts, and also relies on nasal sidewall grafts to resupport a weakened area. Nasal sidewall grafts (known by surgeons as alar batten grafts) may be placed in such a way as to correct internal or external nasal valve collapse. To see pictures of patients treated for nasal valve collapse, go to the Photo Album.
Question: What about persistent deviation of the nose?
Answer: Persisting deviation after rhinoplasty may occur at the upper third, middle third, or tip of the nose, or may occur postoperatively in a previously straight nose. Pre-operative anatomic diagnosis is a critical component of successful treatment. This is the subject of a separate chapter unto itself. A number of surgical maneuvers are available to address the deviated nose. A deviated nose can often be improved, but this can be one of the more difficult problems in primary and revision rhinoplasty. Deviation or twisting of the nose may persist despite the best efforts of a skillful surgeon.
Question: I have small irregular bumps on my nose since my rhinoplasty. What are they, and can you fix them?
Answer: These are small irregularities in the bone or cartilage that were not smoothed perfectly. In Dr. Becker’s experience, these can usually be fixed. If they are cartilage they can be shaved off, and if they are bony they may be rasped or "filed.’ We use a special "powered" rasp that is especially precise for these kinds of problems.
Question: I can feel two bony edges on my nasal bridge. What is this, and can it be fixed?
Answer: After your bony profile is lowered, the surgeon performs osteotomies (cutting or "breaking" of the nasal bones) and shifts the bones inward to make the nose a little narrower. This "closes the open roof" created by taking off the top of the nasal bridge. If the nasal bones are not completely closed, then you may feel the free edges of the nasal bones. This is called an "open roof" deformity and may be corrected by repeating the osteotomies (ie cutting the nasal bones).
As part of the office consultation, computer imaging can be done. In the senior author’s practice, the office computer network provides for imaging in each examination room. The patient’s photos are uploaded onto the computer screen in the examination room, and computer imaging is undertaken.
The senior author explains to the patient that computer imaging is just a "video game"dthat it is a way to communicate a shared surgical goal. This is not an "after" picture, it is not a guarantee, and it should not be taken to offer the slightest implication of a guarantee. It is simply a way to communicate the shared surgical goal. The senior author does not provide the patient with printouts of the computer imaging. The senior author explains to the patient that the preoperative photo and shared surgical goal photo routinely are printed out and taped to the wall in the operating room during surgery so that the pictures can be referred to as surgery progresses.
Typically, the surgeon and patient are able to reach a shared surgical goal. If so, the surgeon should reiterate his or her impression that the goals are reasonable and realistic. Technical details are discussed further. The potential benefits and potential risks of surgery are reviewed. After the surgeon and patient have concluded their discussion, the patient should be introduced to the office manager to discuss logistical and financial details.