Complications of rhinoplasty

What repeats

Five findings that hold across the literature.

The reported rate sits near one in eight, and it is mostly contour

A single surgeon reported 594 consecutive primary rhinoplasties with at least a year of follow-up, split by how the dorsum was handled. Complications ran at 12.74% with structural dorsal reduction, 13.37% with partial preservation and 10.57% with total preservation. Reoperation ran at 7.32%, 3.82% and 3.25% across the same three groups. What differed between them was contour irregularity, 9.55% after reduction against 2.44% after total preservation, and recurrence of the hump, 2.54% against 6.50%. An earlier series of 500 consecutive external rhinoplasties, 380 of them primary and 120 secondary, recorded septal flap tears in 2.8% and alar cartilage injury in 1.8% during the operation, then epistaxis in 2%, infection in 2.4%, prolonged oedema in 17% and nasal obstruction in 0.8% afterwards. Satisfaction in that series was 95.6%, and the scar across the columella was unacceptable to 0.8% of patients.

Rests on: Tarragona and Mirra, 594 cases · Foda, 500 external rhinoplasties · and preservation rhinoplasty · and the dorsal hump.

The rates cannot be compared, because the words are not defined

Thirty rhinoplasty studies were read for whether they defined the complications they counted. Nineteen of them defined none. Eleven defined at least one, eight included a severity scale, and where a complication was named as the primary outcome it was defined in 11 of 15 cases. Without shared definitions, pooling complication rates across series is unreliable.

Rests on: Oleck et al., defining our terms.

Infection is uncommon, and revision surgery carries almost all of it

A single surgeon reviewed 2630 consecutive rhinoplasties over sixteen years. Infection occurred in 22 cases, 0.84% of the series, and 18 of those were revisions. The rate was 3.63% in revision surgery against 0.19% in primary surgery. Autologous rib carried 3.39%, and simultaneous repair of a septal perforation carried 8.57%. Infection showed at the tip in 45% of cases and at the caudal septum or columella in 32%, and most cases needed surgical washout. Pooled dorsal preservation series report infection at 1.89%.

Rests on: Tran and Jang, 2630 cases · Tham et al., preservation meta-analysis · and rib cartilage grafts.

Antibiotics beyond a single dose do not lower the infection rate

A Cochrane-protocol meta-analysis found five randomised trials of preventive antibiotics in rhinoplasty, pooling 589 participants. The pooled risk ratio was 0.92, with a confidence interval running from 0.35 to 2.43, meaning no measurable effect. The clinical practice guideline recommends against prescribing antibiotics for longer than 24 hours after surgery.

Rests on: Nuyen et al., antibiotic prophylaxis · the clinical practice guideline.

Who comes back for revision is partly predictable before the first operation

The rate itself comes from 175,842 septorhinoplasty patients tracked through three state databases for at least three years. Revision ran at 3.3% overall, 3.1% after a primary operation and 11.0% after a secondary one. It was higher in younger patients at 5.9%, in women at 3.8%, with a history of anxiety at 3.9% or autoimmune disease at 4.4%, and in surgery done for cosmetic reasons at 7.9% or for a congenital deformity at 8.9%. A database study followed 101,562 patients for at least three years after primary rhinoplasty and tested 115 variables against the risk of revision. Risk was 16.8 times higher with a record of social exclusion or rejection, 5.36 times higher with a personality disorder, 3.45 times higher with previous filler injection, 2.64 times higher with dependence on anxiolytics or sedatives, and 1.38 times higher in men. A separate single-institution cohort found revision in 18% of patients with a psychiatric diagnosis against 12% of those without.

Rests on: Spataro et al., revision rates in 175 842 patients · Garbaccio et al., predictors of revision · Tie et al., psychiatric diagnoses · and revision rhinoplasty · and the psychology of rhinoplasty.

By which complication

Six groups, from the common and temporary to the rare and permanent.

Swelling and bruising

The most studied outcomes in the whole literature. An umbrella review of 14 systematic reviews covering 128 meta-analyses found swelling and bruising the two most investigated complications, and found steroids, tranexamic acid, preserving the periosteum, an external approach to lateral osteotomy and piezoelectric osteotomy each linked to lower rates.

Rests on: Wu et al., umbrella review · and recovery.

Blocked breathing

Surgery on the outside of the nose can narrow the inside of it. The guideline makes preoperative airway evaluation a separate action statement, and requires the surgeon to tell the patient before surgery how the operation might affect nasal breathing. Of 46 consecutive revision operations done because breathing was blocked after an earlier rhinoplasty, 91.3% came down to a deviated septum or a failing nasal valve. Grafts were needed in 89.1%, septoplasty in 76.1%, support for the lateral wall in 47.8% and spreader grafts in 39.1%.

Rests on: the clinical practice guideline · Goudakos et al., revision for blocked breathing · Salehi et al., safety in rhinoplasty · and nasal airway obstruction · and the pinched tip.

Shape faults

Scar, asymmetry, irregularity, collapse, overcorrection and undercorrection are the complication list that reviews of rhinoplasty safety put first. Named deformities have their own pages. Reading the revisions backwards gives the error patterns in the first operation, and the same surgeon's re-revision rate ran at 15.7% in a teaching hospital and 9% in private practice.

Rests on: Salehi et al. · East et al., error patterns in revision surgery · Eytan and Wang, complications in rhinoplasty · and the polly beak · and the inverted-V deformity · and alar retraction · and saddle nose · and the open roof.

Infection

Rare in primary surgery, concentrated in revision cases using cartilage from elsewhere in the body. It shows at the tip or the columella, usually within the first month, and it is treated surgically more often than not.

Rests on: Tran and Jang · and revision rhinoplasty.

Bleeding and septal haematoma

These belong to the septal half of the operation, and the rates come from septoplasty series. In 1,506 consecutive septoplasties by one surgeon, haematoma occurred in 3.7%, bleeding after surgery in 0.4%, septal perforation in 0.6% and saddle nose in 0.3%, and haematoma, abscess and mucosal defect were all more common where both mucosal flaps were raised. Across 5,639 septoplasties at one centre, complications of any kind ran at 3.42%, and excessive bleeding was the most frequent one. Packing prevents none of it. Sixteen studies, eleven of them randomised, show no reduction in bleeding, haematoma, perforation or adhesion from packing after septoplasty, and more infection.

Rests on: Shin and Jang, 1,506 septoplasties · Dabrowska-Bien et al., 5,639 septoplasties · Banglawala et al., packing meta-analysis · and saddle nose.

Skin loss

The worst outcome short of losing the nose. Every case reported in English up to September 2020 was collected and came to 18 patients from eight studies. Smoking was recorded in 23.5%, and revision surgery, aggressive tip thinning, tight taping over a dorsal graft and wide alar base excision in a revision were the associated manoeuvres. Most defects were managed without further surgery, 72.2% healing by secondary intention.

Rests on: Ferzli et al., skin necrosis.

What to ask about complications

Questions the evidence supports asking.

What is your own complication rate, and how do you define it

Published rates use undefined terms, so a rate quoted without a definition means little. Ask what the surgeon counts, over what follow-up period, and how many patients that covers.

Rests on: Oleck et al. · Tarragona and Mirra.

What is your revision rate, and who pays for a revision

Reoperation is the one complication every series records. Ask for the number, ask over what interval it was measured, and ask what the practice charges when a second operation is needed. The population figure to hold it against is 3.3%, from 175,842 patients followed at least three years.

Rests on: Spataro et al. · Tarragona and Mirra · Tham et al. · and what rhinoplasty costs.

Will I get antibiotics, and for how long

The guideline recommends against continuing antibiotics past 24 hours, and pooled trial evidence shows no benefit from preventive antibiotics. Ask what the surgeon does differently when rib cartilage is used or a septal perforation is being repaired at the same time.

Rests on: the clinical practice guideline · Nuyen et al. · Tran and Jang.

Does my skin put me at risk

Thin skin, aggressive tip work, heavy taping over a graft and a revision setting are the recorded associations with skin loss. Ask the surgeon to assess the skin before surgery and to say what the taping and splinting plan is.

Rests on: Ferzli et al. · and recovery.

Do I have to stop smoking

Smoking is a recorded risk factor in the skin loss cases. A review of 1884 open rhinoplasties found the overall revision rate 3.3%, with 3.8% in smokers against 3.3% in non-smokers, and cellulitis needing extra antibiotics in 3.8% of smokers against 1.6% of non-smokers, differences that were not significant. Cessation is still advised.

Rests on: Tugertimur et al., rhinoplasty in smokers · Ferzli et al..

The terms, defined

The words used about what goes wrong.

• Complication: any unwanted outcome of the operation. The rhinoplasty literature rarely defines which events it counts. [36307563]
• Revision rhinoplasty: a second operation to correct a functional or appearance problem left by the first. [41286173]
• Contour irregularity: a visible or palpable ridge or step in the dorsum after healing. [39557639]
• Hump recurrence: return of dorsal convexity after it was reduced or repositioned. [39557639]
• Septal perforation: a hole through the partition between the two sides of the nose. [35511054]
• Septal haematoma: blood collecting between the septal lining and the cartilage, drained when it happens because the cartilage under it can die. [36452993]
• Skin necrosis: death of nasal skin from loss of blood supply. [34082455]
• Antibiotic prophylaxis: antibiotics given to prevent infection rather than to treat one. [30489601]
• Ecchymosis: bruising, the discolouration around the eyes after osteotomy. [34590168]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology guideline covers the two complication-related actions a patient can check: education before surgery about potential complications and the possible need for further nasal surgery, and the recommendations against prolonged antibiotics and routine packing. The plain language summary states the same points for patients.

• The guideline landing page

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapter

Revision Rhinoplasty Textbook, in Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, catalogues the deformities that bring patients back and how each is repaired.

The reference summaries

• Rhinoplasty in StatPearls, with the complication list in full text at no charge.
• Epistaxis in StatPearls, on nosebleeds and how they are controlled.

The societies

• American Society of Plastic Surgeons, patient information on risks. See associations.

The trials in progress

Whether preventive antibiotics do anything is still being tested.

• Antibiotic Prophylaxis in Rhinoplasty, enrolling by invitation, 864 participants.

What is not settled

• There is no agreed definition of a rhinoplasty complication and no agreed severity scale, so published rates are not comparable. [36307563]
• The largest complication series are single-surgeon and retrospective, with one year of follow-up. Faults that appear at five and ten years are not in them. The one cohort big enough to carry a population revision rate reads state administrative databases, which record a return to theatre rather than what was wrong with the nose. [39557639] [35172105] [26967651]
• Infection data come from one East Asian practice using materials that differ from Western practice, which limits how far the rate transfers. [35511054]
• Preventive antibiotics rest on five small trials with a wide confidence interval, so an effect has not been excluded, only not shown. [30489601]
• Revision predictors come from coded database records, which capture a diagnosis rather than the patient's actual state at consultation. [41286173] [40139802]
• Skin necrosis is reported only in case series, 18 patients in total. The denominator is unknown, so no rate can be quoted. [34082455]