Excerpt from Complications of Rhinoplasty

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Rhinoplasty is arguably the most demanding of all facial surgical operations. While some other operations may claim difficult anatomical access, requisition of excessive physical strength, or significant operating time causing surgeon fatigue, the operation of rhinoplasty demands a thorough understanding of an art and science. Each case has its own challenges and requires a careful estimation of the deformity preoperatively, a clear understanding of the techniques available for correction, a proposed plan of action and sequence, and a meticulous, uncompromising execution of the surgical technique.

Every surgical operation has a tendency to complications, and only the surgeon who does not operate has no complications. A knowledge of relevant complications and sequelae is essential to enlighten the patient so that an informed decision can be made, for reducing the incidence of such complications, for minimizing the gravity of an impending complication, and for treating a complication once it has occurred.

Some complications of rhinoplasty relate to anesthesia and do not fall within the bounds of this discussion. Anaphylactic reactions to general and local anesthetics may well tax the knowledge and skill of the anesthesiologist, surgeon, and attending staff.

Complications of rhinoplasty may be divided into 4 basic categories as follows:

• Intraoperative
• Immediate postoperative (in the recovery ward)
• Early postoperative
• Late postoperative

Problem

A complication may be defined as an unexpected occurrence of an adverse medical or surgical condition requiring separate attention during or following an operation. While recognizing obvious medical and surgical complications should present no difficulty, finer aesthetic complications are harder to define and are based on value judgments related to the aesthetic sense of the surgeon and the body-image demands of the patient. A patient's body-image demands may be categorized as follows:

• The physical reality of an individual's appearance: How do others see the patient? Society has agreed on certain definitions of beauty and unattractiveness, thereby imposing standards and feelings on the vulnerable individual.
• The individual's perception of that appearance: How does the patient see himself or herself? Is this perception congruent with reality as perceived by others?
• The degree of importance the individual attaches to appearance: Some individuals may attach little importance to their appearance, while some cosmetic surgery patients may derive a great deal of self-esteem from their appearance.
• The degree of dissatisfaction the individual has with his or her appearance: Displeasure with appearance ranges from minor dissatisfaction, causing mild concern, to body dysmorphic disorder, causing obsessive preoccupation to the point of interfering with normal function. Approximately 2% of cosmetic surgery patients have body dysmorphic disorder and may need psychiatric appraisal.

Aesthetic sense is difficult to define, and it is much harder to agree on results. Aesthetics depend on variables, including the current fashion taste, the media, the public relations industry, and cultural and ethnic differences.

A practical approach to aesthetics in the nose begins with an accurate assessment. Frontal views define x-axis (width) and y-axis (height) deformities, lateral views define z-axis (depth/projection) and y-axis deformities, and basal views define x-axis and z-axis deformities. Based on these views, a 3-dimensional concept of the nose is made available for manipulation. The goal of rhinoplasty is to improve the existing harmony without causing functional impairment.

Frequency

According to the literature, the complication rate for nasal surgery varies from 4-18.8%. In individual hands, this rate generally falls as surgical experience accumulates. Skin and associated soft tissue complications occur in up to 10% of cases. According to estimates, severe systemic or life-threatening complications occur in 1.7-5% of rhinoplasty cases. Intracranial complications are rare.

Clinical

The clinical manifestations of rhinoplasty complications may broadly be classified as follows:

• Functional
• Infectious
• Aesthetic
• Psychological
• Specific to complication

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