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What goes wrong, and how often

Serious complications after rhinoplasty are rare: infection runs under 1% in the two largest single-surgeon series, pooled rib harvests record no pneumothorax, and the bleeding series record no thromboembolism. What happens to patients instead is numbness, acne, a lump, a nose they do not like, and another operation. A review that set 117 papers against 24 consent forms found that the two commonest complications in the literature, dissatisfaction and revision, were the two least likely to be named on the form the patient signed.

Where these 129 papers were published

  • 41Aesthetic Plastic SurgeryAesthetic Plast Surg
  • 21Facial Plastic SurgeryFacial Plast Surg
  • 20Aesthetic Surgery JournalAesthet Surg J
  • 18Facial Plastic Surgery and Aesthetic MedicineFacial Plast Surg Aesthet Med
  • 14Plastic and Reconstructive SurgeryPlast Reconstr Surg
  • 6Plastic and Reconstructive Surgery Global OpenPlast Reconstr Surg Glob Open
  • 4JAMA Facial Plastic SurgeryJAMA Facial Plast Surg
  • 3Facial Plastic Surgery Clinics of North AmericaFacial Plast Surg Clin North Am
  • 1Clinics in Plastic SurgeryClin Plast Surg
  • 1Archives of Facial Plastic SurgeryArch Facial Plast Surg

48 further papers on this topic came in through the history rather than the archive query: Kara CO 1999, Kargi E 2003, Rettinger G 2007, Døsen LK 2008 and 44 more. They are counted on the landmark papers, not here.

What repeats

Six findings reported by independent groups in different countries. Each card carries the papers it rests on.

Reviewing 117 studies of at least 100 patients each, the complications reported most often were skin problems such as acne (18.3%), numbness (16.7%), an unplanned hospital revisit (6.5%), revision at the primary surgeon (5.3%) and dissatisfaction (5.0%). Set against 24 rhinoplasty consent forms found online: infection appeared on 100% of them, bleeding and scarring on 95.8%, unsatisfactory result on 83.3% and revision on 75.0%. The two outcomes a patient is most likely to experience are the two least likely to be in front of them when they sign.

Rests on: Heilbronn et al., literature against consent forms.

Infection is rare, and revision is when it happens

Across 2,630 East Asian rhinoplasties by one surgeon over sixteen years, infection occurred in 0.84% overall but 3.63% of revisions against 0.19% of primaries, nineteen times more likely, with autologous rib raising it to 3.39% and simultaneous septal perforation repair to 8.57%. In 3,084 cases from a second surgeon, infection was 0.62% overall and fell further with antibiotic soaking of grafts, most usefully in secondary cases. Same conclusion from two continents: the primary rhinoplasty almost never gets infected, and the operated nose sometimes does.

Rests on: Tran and Jang, 2,630 cases · Toriumi et al., 3,084 cases.

The graft that fails is usually one that was carved, and the implant that fails is usually one placed low

Pooled autologous rib data: warping around 3%, resorption 0.2% to 1.2%, infection 0.6% to 1.5%. Diced cartilage does not warp but shows as visible irregularity in 5.3%. Long-term East Asian follow-up puts resorption of autologous onlays at 50% or more for almost every material at a decade. And for the manufactured alternative, porous high-density polyethylene in 116 patients over ten years, major complications (infection or extrusion) occurred in 5.2%, at an average of 36.9 months, and every one of them was in a graft that extended into the caudal, mobile part of the nose.

Rests on: Chen et al., autologous rib meta-analysis · Li et al., diced cartilage · Lee et al., long-term resorption · Davis et al., porous polyethylene.

Bleeding is controllable and the drugs that control it are argued about

An algorithm built over 43 years (tranexamic acid, then desmopressin, then vitamin K) controlled intraoperative bleeding in all of 103 consecutive patients with no postoperative epistaxis or thromboembolism. Pooled trial data support tranexamic acid for blood loss and, in one meta-analysis of five randomised trials, for swelling and bruising; two other studies found no effect on bruising at all. Desmopressin reduced measured blood loss by 15.22 mL across four randomised trials, statistically clear, clinically small.

Rests on: Guyuron et al., a bleeding algorithm · McGuire et al., tranexamic acid meta-analysis · Cristel et al., negative · Gutierrez et al., desmopressin.

Filler complications are common and mild, except when they are catastrophic

Across 30 studies and 9,657 non-surgical rhinoplasty patients, the overall complication rate was 39.11%, mostly redness and swelling (27.95%), with arterial occlusion in 0.27%. That fraction of a percent is the whole risk profile: skin necrosis, blindness and stroke are all documented. Filler after previous rhinoplasty is a distinct and higher risk: all seven patients in one necrosis series had had a rhinoplasty more than three years earlier, and the systematic review of filler in post-surgical noses records an increased risk of skin necrosis.

Rests on: Song et al., 9,657 patients · Robati et al., necrosis after previous rhinoplasty · Santamaría-Gadea et al., filler after rhinoplasty · Caranti et al., narrative review of filler complications.

Most perioperative choices change the first week and nothing after it

Steroids, tranexamic acid, drains, piezoelectric osteotomes, fat grafting and light therapy all move swelling or bruising in the first days, and all of them converge with their controls by two to four weeks. Packing has been abandoned in routine cases for the same reason, limited benefit, real discomfort. The exceptions that reach further are the ones that change tissue rather than fluid: triamcinolone into a thickening supratip, reviewed across 1,524 patients as safe and used specifically to prevent a revision.

Rests on: Kisel et al., piezo against conventional · Uzunoğlu et al., drains · Demirel et al., drainage cannula · Caimi et al., packing · Khan et al., triamcinolone.

By category

The complications, grouped by what kind of problem they are.

Bleeding and bruising

Intraoperative bleeding obscures the field and worsens postoperative bruising; the published control sequence is tranexamic acid, then desmopressin, then vitamin K, with known bleeding disorders treated before the operation. Postoperative bruising follows a predictable route around the eyes and fades by two weeks. Nothing on file records a thromboembolic event from these drugs in rhinoplasty.

Key papers: Guyuron et al. · McGuire et al. · Vural and Koycu, topical tranexamic acid against dexamethasone.

Infection

Under 1% in primary rhinoplasty; several times higher in revision, with rib grafts and with simultaneous septal perforation repair. Antibiotic soaking of grafts reduced it in one 3,084-case series and made no difference in a 310-patient fresh-frozen rib series. Late implant infection is a separate problem with its own timescale, an average of three years for porous polyethylene.

Key papers: Tran and Jang · Toriumi et al. · Davis et al..

Skin and soft tissue

The nasal skin has a finite blood supply and previous surgery reduces it. Columellar necrosis is prevented by avoiding tension on the closure, advancing the columellar base and using a healing chamber; two complications in 34 reconstructions. Filler injected into a previously operated nose is the other route to necrosis. Prolonged swelling has been proposed to follow facial filler blocking lymphatic drainage, a hypothesis, not a finding.

Key papers: Toriumi, columellar necrosis · Robati et al. · Maamari et al., fillers and lymphatic drainage.

Airway and the septum

A perforated septum crusts, bleeds and whistles, and used to preclude simultaneous rhinoplasty; a bone-and-cartilage scaffold closed 26 of 31 completely, and pedicled mucosal flaps allow repair under a preserved dorsum. Over-resection of the inferior turbinates and narrowing of the bony vault by osteotomies are named pitfalls that create obstruction rather than relieving it.

Key papers: Sazgar et al. · Mariño-Sanchez et al. · and the septum and the airway.

Pain, nausea and the anaesthetic

Pain is moderate and does not need opioids: ibuprofen matched hydrocodone in randomised comparison, and most prescribed tablets go unused. Nausea belongs to the anaesthetic rather than the nose, 12% under general anaesthesia against 7% with sedation and 4% under local across 43 studies, and complication rates otherwise did not differ by modality.

Key papers: Frants et al., randomised · Barone et al., anaesthesia and packing.

Medication and the patient's own risk factors

Preoperative serotonergic antidepressant use was associated with more readmissions, more bleeding and more opioid use in the first 30 days across 4,917 matched pairs, with revision rates equal at a year. Ethnicity-conscious planning halved complication rates in pooled comparative studies (8.7% against 17.4%). Age, smoking and the number of previous operations predict skin compromise.

Key papers: Zontag et al., antidepressants · Hashemipour and Danesh, meta-analysis · and revision rhinoplasty.

Dissatisfaction

The commonest serious complication in the literature and the least tangible. It sits at about 5% in the pooled review, is the reason most revisions are requested, and is predicted better by what the patient brought to the consultation than by anything measurable about the nose afterwards, which is why it belongs on the consent form and in the psychology of rhinoplasty.

Key papers: Heilbronn et al. · Hashemipour and Danesh.

The terms, defined

Every term the papers above use to mean something specific, in plain language.

  • Epistaxis: a nosebleed after surgery. Rare, and absent entirely in the 103-case bleeding-algorithm series. [38589989]
  • Ecchymosis: bruising, mostly around the eyes, from the bone work. Peaks in the first days and resolves within two weeks. [30605219]
  • Hematoma: a collection of blood under the skin or in the septum; a septal hematoma is an emergency because it can destroy the cartilage. [38485786]
  • Warping: a carved cartilage graft bending after implantation. Around 3% for autologous rib. [36071242, 36656674]
  • Resorption: the graft being absorbed over time. Reported at 0.2% to 1.2% in pooled rib data and at 50% or more for autologous dorsal onlays at ten years, depending on material. [36071242, 35077410]
  • Extrusion: an implant working its way out through skin or lining; the specific risk of alloplastic material in the mobile lower nose. [35802490]
  • Porous high-density polyethylene (pHDPE): a manufactured porous implant that tissue grows into. Major complications 5.2% at an average of three years, all in caudally placed grafts. [35802490]
  • Skin compromise and necrosis: the nasal skin losing its blood supply, from tension, dissection, previous surgery or filler in a vessel. [42210784, 29506052]
  • Vascular occlusion: filler entering or compressing an artery. 0.27% of non-surgical rhinoplasty patients; the mechanism behind necrosis, blindness and stroke. [38862661]
  • Tyndall effect: a bluish tint where hyaluronic acid filler sits too superficially. [39747417]
  • Granuloma and biofilm: a chronic inflammatory nodule around filler, and a bacterial community on implanted material; both present late. [39747417]
  • Septal perforation: a hole through the septum, from surgery or from injected material; crusting, bleeding and whistling are its symptoms. [38648541]
  • Synechiae: adhesions between two raw mucosal surfaces inside the nose; what an internal splint is meant to prevent. [41249522]
  • Supratip fullness: swelling or scar above the tip; the commonest late shape complaint and the target of triamcinolone injection. [38519572]
  • Tranexamic acid, desmopressin, vitamin K: the three drugs in the published bleeding-control sequence, given in that order. [38589989, 40456991]
  • Triamcinolone acetonide: the steroid injected postoperatively into a thick supratip, reviewed across 1,524 patients. [38519572]
  • Level of evidence: the rating attached to each paper. Most complication data here is Level III or IV: retrospective, single-surgeon, no control arm. [36071242, 35802490]

The papers this rests on

The 40 papers everything above was written from. Every one links to its abstract, its authors and its DOI.

  1. APS
    2026PMID 41249522Summary
  2. APS
    2026PMID 40906288Summary
  3. APS
    2025PMID 39747417Summary
  4. APS
    2025PMID 38977451Summary
  5. APS
    2025PMID 40456991Summary
  6. FPS
    2025PMID 39532285Summary
  7. FPSAM
    2025PMID 39466798
  8. FPSAM
    2025PMID 39230478Summary
  9. PRS
    2025PMID 38589989Summary
  10. APS
    2024PMID 38519572Summary
  11. APS
    2024PMID 38862661Summary
  12. APS
    2024PMID 38485786Summary
  13. APS
    2024PMID 37783865Summary
  14. APS
    2024PMID 37217605Summary
  15. APS
    2023PMID 36163553Summary
  16. APS
    2023PMID 36071242Summary
  17. PRS
    2022PMID 35511054Summary
  18. FPSAM
    2021PMID 33798400Summary
  19. FPSAM
    2025PMID 40147429Summary
  20. ASJ
    2026PMID 41672725Summary
  21. JAMA FPS
    2019PMID 30605219Summary
  22. ASJ
    2025PMID 40343983Summary
  23. FPSAM
    2022PMID 34166107Summary
  24. FPSAM
    2026PMID 41452163Summary
  25. FPSAM
    2026PMID 42310865Summary
  26. JAMA FPS
    2019PMID 30589927Summary
  27. FPSAM
    2026PMID 40566666Summary
  28. ASJ
    2020PMID 30868159Summary
  29. PRS
    2021PMID 33370050Summary
  30. FPSAM
    2022PMID 34357798Summary
  31. PRS
    2022PMID 35077410Summary
  32. FPSAM
    2022PMID 35802490Summary
  33. ASJ
    2023PMID 36656674Summary
  34. ASJ
    2023PMID 35748855Summary
  35. FPSAM
    2026PMID 42210784Summary
  36. ASJ
    2024PMID 38648541Summary
  37. PRS
    2025PMID 41071182Summary
  38. FPSAM
    2020PMID 32053419Summary
  39. PRS
    2020PMID 32590640Summary
  40. ASJ
    2018PMID 29506052Summary

What is still contested

  • Tranexamic acid reduces blood loss in pooled trials; whether it reduces bruising is contradicted between a five-trial meta-analysis and two later studies that found nothing. [30605219, 34166107]
  • Antibiotic soaking of grafts reduced infection in one 3,084-case series and did nothing in a 310-patient series using fresh frozen rib. Neither is randomised. [33798400]
  • Resorption figures for autologous dorsal onlays span 0.2% in pooled short-term data and 50% or more at a decade in East Asian follow-up. The follow-up length, not the material, explains most of that gap. [36071242, 35077410]
  • There is no agreed definition of "complication" in this literature. The consent-form review found 36 distinct complications across 117 papers, reported inconsistently. [32053419]
  • Filler complication rates come from case series and voluntary reporting; the 0.27% occlusion figure is almost certainly a floor. [38862661, 39747417]
  • Whether facial filler prolongs post-rhinoplasty swelling by blocking lymphatics is a stated hypothesis with no measurement behind it. [39532285]
  • Late complications (implant extrusion at three years, resorption at ten) need follow-up almost nothing on file provides.

Written by rhinoplasty.cc from the PubMed abstracts, 2026-09-09. Not medical advice.

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Every paper, by year

129 papers. The 40 above are not repeated.

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202414 papers · 6 above
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202313 papers · 4 above
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  6. FPS
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  8. PRS-GO
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202214 papers · 5 above
  1. APS
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  4. APS
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20216 papers · 2 above
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202013 papers · 3 above
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  2. APS
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  3. APS
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  4. APS
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  5. APS
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  6. FPS
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  7. FPS
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  8. FPS
    PMID 32191963Summary
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  10. PRS
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20195 papers · 2 above
  1. ASJ
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  2. APS
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  3. PRS-GO
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20188 papers · 1 above
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20173 papers
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20169 papers
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20155 papers
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  3. FPS
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    PMID 26579868
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20142 papers
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20131 papers
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20125 papers
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20112 papers
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