Alar base reduction
Rhinoplasty surgery is difficult so it is not surprising that problems arise from time to time. It has been said that a surgeon needs to have performed one hundred such operations in order to get good at it.
The commonest problem is the unexpected result. It may be a technically satisfactory result but not what the patient requested. Perhaps the nose ended up much smaller than intended. The answer to this is unhurried pre-operative consultations where photographs are viewed followed by accurate surgery (eg. template rhinoplasty).
The result may be less than satisfactory but not technically bad. The drooping tip is a common example of this. As discussed above, the answer to this problem involves the lateral alar ligament as in the template rhinoplasty.
Another example of a less than satisfactory but not technically bad result is supra-tip swelling. This is seen in cases where the nose has been greatly reduced in size. The skin and muscle layers are too big for the smaller skeleton so the tissue bunches up. The answer to this problem is adequate redistribution of the skin and muscle by more than the usual freeing of tissues. The redistributed tissue can be taken up at the junction of nose and cheeks if the nasal pyramid is adequately narrowed.
Partial blockage of the nasal airway is another problem that is certainly not rare. The conventional procedure used to shorten a long nose produces slackness in the soft outer walls of the nose so they suck inwards on inspiration, blocking the airway. The majority opinion is that the obstruction is at the internal nasal valve, defined as the lower edge of the upper lateral cartilages. Spreader grafts that push the upper lateral cartilages outwards are commonly recommended. Paul O'Keeffe disagrees with this idea preferring to believe that the obstruction is due to slackness of the lateral alar ligament and a tightening of the ligament is recommended.
Internal mucosal adhesions between the side wall of the nose and the septum are not uncommon. They would be prevented by placement of silicone splints in the nose for about one week after surgery but they are uncomfortable and difficult to breathe through. It is more comfortable to have no packs or light packs for one or two days only so that is what most patients have. If adhesions occur they are easily dealt with by a minor office procedure.
Empty nose is the result of overly aggressive resection of turbinates. The nose allows an excessive airflow through the nasal passages which impedes the airconditioning function of the nose.
Post-operative bruising especially around the eyes is not uncommon after rhinoplasty when the nasal pyramid was narrowed. This problem is greatly reduced by the use of a large external splint (not too large!) and eye pads for four hours followed by cold compresses to the eyes.
Post-operative bleeding, also called epistaxis, can occur during the first two or three days. Strangely, a blood clot in the nose often promotes bleeding. Removal of the clot, sitting upright and placing a cold compress on the forehead is often effective. Persistent bleeding may require placement of a pack in the nose or even treatment in a casualty or admission to hospital. Bleeding that commences four or more days after surgery may be caused by infection so an antibiotic should be beneficial.
Infection is a rare complication in
rhinoplasty but it can happen if there is haematoma (blood clot)
within the tissues or if foreign material (grafts, implants or
permanent sutures) has been placed into the tissues. It may be
wise to use prophylactic antibiotics for these cases but that is
a controversial topic.
Lack of definition at the root of the nose (radix or nasion) might be seen if too much change was intended there. The depth of the skeleton where it is covered by a thick muscle (procerus) is the problem. Changes to the skeleton are not fully reflected in the skin. The situation can be improved if the muscle is lengthened by a procerusplasty.
Bumps on the bridge of the nose are occasionally seen. The thin cartilage that adheres to the under surface of the nasal bones can be difficult to trim because it bends down away from the cutting implement. It can spring back up again during the healing process. Retained cartilage fragments may be present or the bone may have broken in an unfavorable way during the operation. A revision operation is required if the problem persists.
The nasal bones are sometimes overly reduced producing the appearance of a narrow ridge-like bridge. This is caused by the surgeon blindly rasping away the tissues in a narrow pocket and not realising that the bone is being removed while the springy cartilage remains. It is preferable to expose the area more and do the reduction under direct vision, a more time-consuming exercise.
In the past, the alar cartilages were greatly reduced with view to making the tip more pointed and the long nose shorter. In the 1970's very eminent surgeons even recommended complete removal of the alar cartilages. The inadvertent long-term effect was the "Miss Piggy" nose where the nostril rims retract exposing the nostril openings. It is obviously better to have a more conservative approach to surgery.
Sometimes the septal cartilage is overly reduced. If the bottom edge of the cartilage is trimmed too much support is lost for the columella and it retracts while the nose tip retrudes adding to the problem of supra-tip swelling. If too much tissue is removed while trying to correct a severely deviated septum a saddle nose can develop.
Numbness of the nose tip occurs occasionally. There are three nerves on each side of the nose that can supply the tip. If the main nerve is the one coming from the cheek then it is unlikely to be affected. If the main nerve is the one coming from beneath the nasal bone then it will be affected by rhinoplasty. If the nerve coming from the septum is the main one it could be affected if a septoplasty is done. Luckily, numbness persisting longer than one year is uncommon.
A particularly painful complication is ulceration of the cornea that can occur if the eye is sensitive or allergic to the skin prep used to clean the skin before surgery. Ulcers can also occur if the eye is accidentally rubbed during the operation. For this reason the eyes are taped shut for surgery. This painful condition is associated with photophobia and it usually improves significantly next day. Full recovery is expected.
Finally, psychological problems may be present that do not respond to cosmetic surgery. Of particular concern is Body Dysmorphic Disorder characterised by a preoccupation with an imagined defect in appearance, or if a slight physical anomaly is present, markedly excessive concern. This condition should be treated by general practitioners, psychologists and psychiatrists, not plastic surgeons.
There needs to be a cooling off period of at least 10 days between consultation and surgery so all the above can be properly considered.