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Rinoplastia - Rhinoplasty
The document discusses the frequency and types of complications associated with rhinoplasty, noting that complication rates can range from 4% to 18.8%. It describes common aesthetic issues and emphasizes the importance of careful surgical techniques and patient management to minimize risks. The study highlights the need for preoperative diagnosis and conservative approaches in rhinoplasty to enhance outcomes.
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Rinoplastia - Rhinoplasty
- 1. RHINOPLASTY Minimizing complications GENERAL CONSIDERATIONS Dr. Samuel Benarroch MD, DDS, MS Oral & Maxillofacial Surgery Assistant Professor Oral & Maxillofacial Surgery Residency Program Woodhull Medical Center. New York Hospital Magallanes de Catia. Caracas www.clinicabenarroch.com 902 11 06 47
- 2. EVERY SURGICAL OPERATIONHAS A TENDENCY TO COMPLICATIONS www.clinicabenarroch.com 902 11 06 47
- 3. NASAL SURGERY COMPLICATIONSFRECUENCY Complication rate for nasal surgery varies from 4 - 18.8 % Skin and associated soft tissue complications occur in up to 10% of cases Severe systemic or life-threatening complications occur in 1.7 – 5 % of rhinoplasty cases Revision rhinoplasty may be required in 5 –15 % of patients “ The true revision rate is much higher ” www.clinicabenarroch.com 902 11 06 47
- 4. RHINOPLASTY ComplicationsINTRAOPERATIVE IMMEDIATE POSTOPERATIVE EARLY POSTOPERATIVE LATE POSTOPERATIVE www.clinicabenarroch.com 902 11 06 47
- 5. DISCUSION clinical manifestations of rhinoplasty complications Functional Infectious Aesthetic Psychological Specific to complication www.clinicabenarroch.com 902 11 06 47
- 6. PURPOSE Determine themost frequent aesthetic complications associated with the nasal surgery and determine the techniques and surgical procedures that apparently gives more predictable results www.clinicabenarroch.com 902 11 06 47
- 7. DESIGN Multicenter Retrospectivestudy Conducted from 1998 to 2005 Same surgical team www.clinicabenarroch.com 902 11 06 47
- 8. PATIENT DISTRIBUTION SEX www.clinicabenarroch.com 902 11 06 47 SEX NUMBER % MALE 149 25.82 FEMALE 428 74.17 TOTAL 577 100
- 9. PATIENT DISTRIBUTION AGEwww.clinicabenarroch.com 902 11 06 47 AGE NUMBER % 15 – 20 147 25.47 21 – 30 379 65.68 31 – 40 45 7.79 41 – 50 4 0.69 > 50 2 0.34 TOTAL 577 100
- 10. POPULATION HYBRIDIZED RACESwww.clinicabenarroch.com 902 11 06 47 RACES NUMBER % CAUCASOID 461 79.89 NEGROID 69 11.95 MONGOLID 11 1.90 OTHER TOTAL 2 577 0.34 100
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- 12. A ESTHETIC SURGERY POSSIBLE OUTCOMES A HAPPY PATIENT AND A HAPPY SURGEON A HAPPY PATIENT AND AN UNHAPPY SURGEON AN UNHAPPY PATIENT AND A HAPPY SURGEON AN UNHAPPY PATIENT AND AN UNHAPPY SURGEON www.clinicabenarroch.com 902 11 06 47
- 13. PATIENT DISTRIBUTION SURGICALPROCEDURE GROUPS www.clinicabenarroch.com 902 11 06 47 GROUPS PROCEDURE NUMBER I Primary R 421 II Secundary R (Others) 94 III Secundary R (us) 62 TOTAL 577
- 14. SURGICAL TECHNIQUES BASICCLOSED RHINOPLASTY OPEN RHINOPLASTY www.clinicabenarroch.com 902 11 06 47
- 15. BASIC CLOSED RHINOPLASTYwww.clinicabenarroch.com 902 11 06 47
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- 31. DISCUSION AESTHETIC MOSTCOMMON COMPLICATION THE LOWER TWO THIRDS OF THE NOSE IS THE MOST COMMON SITE OF POSTOPERATIVE DEFORMITIES SUPRATIP DEFORMITY THE MOST COMMONLY OBSERVED COMPLICATION 56% www.clinicabenarroch.com 902 11 06 47
- 32. DISCUSION ESTHETIC COMPLICATIOS Upper third deformities Deep nasofrontal angle Shallow nasofrontal angle Upper third widening Upper third convexity Upper third overreduction Upper third asymmetry Middle third deformities Middle third widening Middle third convexity Middle third saddling Middle third asymmetry www.clinicabenarroch.com 902 11 06 47
- 33. DISCUSION Aesthetic surgical COMPLICATIONS LOWER THIRD DEFORMITIES Lower third widening or flaring Tip widening or boxy tip Tip narrowing or pinched tip Tip asymmetry Tip projection deformities Wide columella Hanging columella "Hanging" or "veiled" alae Alar notching Alar collapse Nostril asymmetry Retracted nasolabial angle Protracted nasolabial angle www.clinicabenarroch.com 902 11 06 47
- 34. DISCUSION Aesthetic surgical complications Graft/implant migration The disproportionate nose UNDERLYING MAXILLOFACIAL DEFORMITY A rhinoplasty result may be ruined by the unmasking of a previously unnoticed or undiagnosed maxillofacial deformity……… www.clinicabenarroch.com 902 11 06 47
- 35. CONSIDERACIONES GENERALES Cadacomplicación tiene una solución y varias formas de evitarlas SER CONSERVADOR NO ANALIZAR LA NARIZ COMO UNA ESTRUCTURA ANATOMICA AISLADA NARIZ Y MENTON ADVERTIR AL PACIENTE QUE SEGURAMENTE SE TENDRA QUE HACER UNA REVISION DE SU CIRUGIA UTILIZAR LOS MATERIALES DE RELLENO FACIAL PARA CORREGIR PEQUEÑAS IMPERFECCIONES NO REALIZAR REVISIONES ANTES DEL AÑO ESTABILIZAR LOS INJERTOS INJERTOS DE CARTILAGO COSTAL PARA LA CORRECCION DE LA DEFORMIDAD EN SILLA DE MONTAR INJERTOS SEPTALES MEJOR QUE EL DE CONCHA AURICULAR MANTENER LOS ADHESIVOS POR 10 DIAS DEFINICION DE LA PUNTA……RINOPLASTIA ABIERTA RESECAR LA JIBA NASAL CON BISTURI Y CORTE LIMPIO NO UTILIZAR LA RASPA EN LA JIBA CARTILAGINOSA JIBA - FRACTURAS LATERALES MANTENER LA FERULA NASAL POR 7 DIAS Y SOBREPRESIONAR www.clinicabenarroch.com 902 11 06 47
- 36. CONCLUSIONS An overviewof rhinoplasty complications addresses the prevention, diagnosis, and management of common complications of rhinoplasty. Careful preoperative diagnosis and a conservative approach guided by an understanding of the postoperative changes that occur during healing are critical in minimizing complications. www.clinicabenarroch.com 902 11 06 47
- 37. THANK YOU Dr.Samuel Benarroch MD, DDS, MS Oral & Maxillofacial Surgery Assistant Professor Oral & Maxillofacial Surgery Residency Program Woodhull Medical Center. New York Hospital Magallanes de Catia. Caracas www.clinicabenarroch.com 902 11 06 47
Editor's Notes
- #3 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.
- #4 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 causing functional impairment. numerous authors have described appropriate overall rates of revision rhinoplasty ranging from 5-12% (Klabunde, 1964; McKinney, 1981; Sheen, 1998; Swanepoel, 1981), the true revision rate is arguably much higher (Baker, personal communication).
- #5 Complications of rhinoplasty may be divided into 4 basic categories as follows:
- #6 The clinical manifestations of rhinoplasty complications may broadly be classified as follows: Functional Infectious Aesthetic Psychological Specific to complication
- #7 Propósito Determinar las complicaciones mas frecuentes asociadas con la cirugia nasal asi como las tecnicas y procedimientos quirurgicos que proporcionan mayor predictibilidad.
- #8 A multicenter retrospective study were conducted from 1994 to 2005
- #10 The mean age was 23.8 years
- #11 The population studied consisted on Hybridize Race type Every patient was evaluated considering surgical risk factors and underwent a complete medical physical examination
- #12 esthetic is a very complex issue and is beyond the scope of this paper talk about it many studies have been published defining by mathematical analysis what constitutes an harmonic NOSE, everybody is aware that there is a great variability and subjectivity in appreciation of facial beauty and even more difficult is to determine with precision topographic facial references points for those systems A practical approach to aesthetics in the nose begins with an accurate assessment.. Facial analysis IN COSMETIC SURGERY is the combination of the eye of the surgeon with a little help of the points, lines and angles that comes from any facial analysis system 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. The goal of rhinoplasty is to improve the existing harmony without causing functional impairment.
- #13 Aesthetic surgery has 4 possible outcomes: (1) a happy patient and a happy surgeon, (2) a happy patient and an unhappy surgeon, (3) an unhappy patient and a happy surgeon, and (4) an unhappy patient and an unhappy surgeon. While the unhappiness of the surgeon usually relates to self-perfection, the unhappiness of the patient has several reasons, some of which may be genuine. The surgeon must be able to carefully select patients preoperatively. This demands a thorough knowledge of the patient's psychosocial status. Even so, selection mistakes may be made, and the temperaments of the surgeon and staff may be tested. No surgical operation is devoid of complications. It behooves surgeons, particularly those performing appearance-altering surgery, to be aware and to be informed of possible complications, avoidance measures, and associated corrective techniques. Patients must be informed of all possible complications, so they can make the decision to undergo surgery after carefully considering all risks involved. The surgeon minimizes complications by carefully selecting patients (through consideration of their medical and psychosocial deficiencies), by having a thorough understanding of deformities and correction techniques, by developing a sense of empathy, and by recognizing his or her own limitations.
- #14 Se realizaron 3 grupos de estudio Grupo I, Pacientes que fueron intervenidos por Primera vez y no se les realizo otra cirugia (Rinoplastia Primaria) , Grupo II Pacientes que ya habian sido intervenidos por otros especialistas o aquellos pacientes que habian sufrido traumatismo nasal ( Rinoplastia Secundaria) y que no ameritaron otra cirugia y Grupo III Pacientes que fueron reintervenidos provenientes de los grupos I y II. El Grupo II y III nos ayudo a determinar el tipo de complicaciones mas frecuentemente asociados con esta cirugia y el grupo I determinar las tecnicas y consideraciones quirirurgicas que en nuestras manos proporcionaban mayor predictibilidad Group I were performed under oral or IV sedation and group II and III under general anaesthesia
- #15 Las tecnicas quirurgicas utilizadas, las clasificamos segun la modalidad del abordaje Abierta y Cerrada, entre los procedimientos realizados cabe mencionar, injertos oseos (parietal, creta iliaca, tibial), injertos cartilaginosos (septal, auricular, costal), sistema de fijacion del injerto ( no fijacion, suturas, alambres, tornillos), tecnica de weir modificada, suturas interdomal, reseccion cefalica del cartilago alar inferior, reseccion caudal del cartilago alar superior, fractura de los huesos nasales ( externa e interna), remocion de la jiba nasal ( bisturi,cincel).
- #16 The basic close rhinoplasty technique include Tip-sculpting techniques Cephalic trim Alar suturing techniques Nasal tip grafting Nasal dorsal alignment Hump reduction Osteotomies Nasal base surgery
- #21 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.
- #22 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.
- #23 Another typical case
- #24 Another typical case
- #32 Collapse of bony pyramid Collapse of the bony pyramid may occur during removal of a bony hump with an osteotome, particularly when the patient has had previous nasal trauma or if the vomer or ethmoid have been weakened as a result of previous surgery. Rasping may be advisable in these circumstances. Rectification requires careful approximation of the segments and provision of adequate internal and external splint support during healing. Disarticulation of upper lateral cartilage This complication may occur during rasping. Bilateral disarticulation produces an inverted-V deformity, and unilateral disarticulation produces asymmetry in the middle third of the nose. Spreader grafts may improve airway symptoms and aesthetics. Osteotomy complications "Rocker" deformity: This deformity results when the medial osteotomy creates a cephalic fracture higher in the thicker part of the frontonasal junction. Attempted narrowing after the osteotomies results in lateralization of the superior segment of the fractured bones, based on a fulcrum at or about the radix. Repositioning the cephalic fracture lower on the nasal bone rectifies this deformity. "Open roof" deformity: When the lateral segments fail to align with the septal dorsum following osteotomies, a gap, which may be visually and palpably obvious, results. If neglected, the intranasal mucous membrane adheres to the overlying soft tissue and may create a depression at the site. If alignment failure is unilateral, the nose appears asymmetric. Correction involves assuring centralization of the septum and complete medial mobilization of the lateral segments following osteotomy. Usual causes of open roof deformity include the following: Greenstick cephalic fracture during osteotomies (will return to its preoperative position) Failure to adequately mobilize the fractured segments medially Excessive nasal packing Uncorrected deviated perpendicular plate of the ethmoid (may prevent medialization of the lateral segments) "Step" deformity: This deformity may result if a single lateral osteotomy is performed too far medial to the nasofacial groove, with a visible ridge on the side of the nose. Correction involves repeating the osteotomy at the correct level. Contact dermatitis The dressing may contribute to this complication in sensitive individuals. Initial treatment involves removal of the dressing and administration of indicated antihistamines and/or steroids. Scar hypertrophy This may detract from a good result following an external rhinoplasty. Skin loss from infection and necrosis is a disaster. Aim initial attempts at reducing the size of the scar with intralesional steroids. Further treatment could include dermabrasion, lasers, and/or surgical scar revision. Polly beak nasal deformity This deformity is characterized by absence of the supratip dip and may present in degrees. The cause usually lies in undercorrection of the cartilaginous dorsum and the superior septal angle region (hard polly beak), but it may result from excessive accumulation of soft tissue scarring or loss of tip support (soft polly beak). Correction may require reduction of the cartilaginous dorsum and the superior septal-angle cartilage region and/or excision of the soft tissue scarring and fixation of a columellar strut. Oleogranulomas or dorsal cysts occurring in the supratip region may cause a deformity similar to polly beak deformity. In difficult cases, a CT scan may be necessary to confirm the diagnosis. Synechiae formation Synechiae or adhesions follow the creation of opposing raw surfaces. This occurrence may or may not be symptomatic. Stenting may be attempted if this complication is predictable at surgery. Endoscopic excision and subsequent stenting may be used to treat symptomatic synechiae. In one review of 882 cosmetic rhinoplasties (with a 7.1% revision rate), the authors identified their primary deformity to be the polly beak or supratip deformity, followed by general irregularities of the bony dorsum (Stucker, 1975). In another review of 170 revisions, supratip deformity was identified as not only the most common deformity of the middle one third but as contributing to 33% of overall complications, making it their most frequent complication (O'Connor, 1955). In their analysis of postoperative rhinoplasty complications, Kamer and McQuown identified the lower two thirds of the nose as the most common site of their postoperative deformities and supratip deformity as their most commonly observed complication, comprising 56% of their major deformities. In one review of 882 cosmetic rhinoplasties (with a 7.1% revision rate), the authors identified their primary deformity to be the polly beak or supratip deformity, followed by general irregularities of the bony dorsum (Stucker, 1975). In another review of 170 revisions, supratip deformity was identified as not only the most common deformity of the middle one third but as contributing to 33% of overall complications, making it their most frequent complication (O'Connor, 1955). In their analysis of postoperative rhinoplasty complications, Kamer and McQuown identified the lower two thirds of the nose as the most common site of their postoperative deformities and supratip deformity as their most commonly observed complication, comprising 56% of their major deformities.
- #33 Undercorrection or overcorrection of a preexisting deformity leads to either persistence of the deformity or to introduction of a new one. A new deformity may introduce a functional deficit. Some of these deformities are illusory, and correction only follows after an accurate diagnosis is made. Ideally, revision rhinoplasty should not be performed until at least 12 months after the initial operation. These deformities may occur singly or in combination and may relate as an x-axis (width), y-axis (height), or z-axis (depth) deformity/deformities in the various segments. Upper third deformities Deep nasofrontal angle: Correction may be achieved by augmentation. Various graft and implant materials are available. Shallow nasofrontal angle: The angle may be deepened by removal of the procerus muscle. If the problem is bony, osteotome and/or burr removal are possible corrective measures (after establishing the nasal starting point with a 2-mm osteotome). Upper third widening: This may relate to inadequate medialization of the nasal bones after osteotomies. Widening may also be caused by cephalic greenstick fractures returning the bones to their original position or by excessive nasal packing lateralizing the nasal bones. A persisting deviation of the perpendicular plate of the ethmoid bone prevents medialization of the nasal bone, usually unilaterally. The rocker and open roof deformity are discussed in previous portions of this article. Correction involves ensuring an undeflected nasal septum and recreating appropriate osteotomies that are stabilized medially. Upper third convexity: Satisfactory results may be obtained by reduction. Careful rasping is advised at reoperation. Upper third overreduction: Excessive hump removal may cause saddling, which requires augmentation. Loss of the septal buttress contributing to the deformity may require reconstruction. Upper third asymmetry: Unequal nasal bone remnants, asymmetric healing, and deviation of the subjacent septum contribute to this condition. Rectification depends on cause. Middle third deformities Middle third widening: This usually follows upper third widening due to the attachment of the upper lateral cartilages to the nasal bones. Correction of the upper third leads to a middle third correction as well. This deformity may also be illusory in the presence of tip ptosis. Middle third convexity: This is one of the causes of the polly beak deformity. Simple shaving of the excess cartilages or soft tissues corrects this condition. Middle third saddling: Augmentation improves the aesthetic result subsequent to rectification of any septal insufficiency. Middle third asymmetry: Unequal upper lateral cartilage remnants, unilateral dislocation of an upper lateral cartilage, subjacent septal deviation, and asymmetric healing can contribute to this deformity. Again, correction depends on an accurate diagnosis.
- #34 Lower third deformities Lower third widening or flaring: Destructive techniques resulting in loss of available support from the lateral crura of the lower lateral cartilage may cause widening of the alar base. A columellar strut and alar sill resection may provide a corrective answer. The Foman cinching suture is a useful choice in some circumstances. This involves undermining the floor of the nose through an internal Weir incision, inserting a suture through the incision to one alar crease, turning this suture around to the other alar crease, and finally tying it in the incision. A clear nylon 4-0 suture is appropriate and is tightened as desired. Tip widening or boxy tip: This author generally favors domal suture techniques, although other techniques are also available. Tip narrowing or pinched tip: Destructive techniques may be contributory. Bossae formation and nasal valve collapse may coexist. A carefully stabilized tip graft may suffice in simple cases. Airway complaints may need further intervention. Tip asymmetry: Destructive techniques may provoke lower third deformities. Explore causes with appropriate correction. Camouflage grafts may be necessary, and transdomal sutures may aid stabilization. Tip projection deformities: Surgically induced tip ptosis may require domal sutures, projection control sutures between the caudal septum and medial crura, columellar strut graft, and/or tip graft. Excessive tension of the depressor septi muscle may need release. Overprojection of the tip may be illusory and may require dorsal augmentation. In some cases, a transfixion incision and reduction of the cartilaginous septum and/or reduction of the nasal spine may need to be considered. Such surgically induced tip ptosis may lead to flaring of the alae, which may need further aesthetic balancing. Wide columella: This is usually a preexisting abnormality that was not corrected during the initial operation. The excess soft tissue between the medial crura is excised and the medial crura are sutured together. Should medial crural flaring be responsible, crural trimming and relevant antiflare sutures are used. Hanging columella or "columella show": This may be caused by deep medial crura, caudal projection of the septal cartilage, and/or excessive removal of the lateral crural segments and subsequent scarring. Treatment is directed to the cause, and shaving of the medial crura/septum may be recommended. Excised lateral crural segments may need replacement with intranasal composite grafts. "Hanging" or "veiled" alae: True alar overhang may be related to underexcision of the lateral crura in relation to the columella. Attempt direct correction of this deformity only when obvious and gross and when an illusory component has been excluded. A columellar strut and nasolabial plumping grafts may provide some aesthetic relief. Alar notching: Excessive removal of the lateral crura and subsequent scarring can lead to this problem. True alar notching may be amenable to caudal or cephalic mobilization of the remnant crura and to insertion of an intranasal composite graft in the created defect. A columellar strut may correct illusory notching due to alar flare. Alar collapse: Excessive removal of the lateral crura dampens support afforded by these structures, causing alar collapse and airway discordance. Reconstructive techniques with alar battens may be necessary in difficult cases. Nostril asymmetry: This may be related to columellar or alar components, thus treatment is directed accordingly. Caudal subluxation of the septum is often contributory and needs attention. Attendance to the nasal spine and performance of alar base surgery is sometimes indicated. Retracted nasolabial angle: Excessive excision of the septal cartilage in the region of the posterior septal angle may lead to this deformity, which may be corrected by insertion of plumping grafts in the region. A columellar strut and upward tip rotation may introduce an illusory enhancement. Protracted nasolabial angle: This may be illusory with excess upward tip rotation. Otherwise, excess soft tissue or nasal spine may need attention.
- #35 Other Graft/implant migration: Migration may comprise resorption, displacement, or extrusion; it may be provoked by trauma and infection. Allografts have a higher extrusion and infection rate than autografts. An infected implant must be removed if antibiotics do not help. Revise displaced grafts causing aesthetic inconvenience with appropriate stabilization. The disproportionate nose: This nose does not fit the face and is not a credit to the surgeon's artistic skill. Reconstructive rhinoplasty techniques follow the patient's expression of discontent with original results. Underlying maxillofacial deformity: A superb rhinoplasty result may be ruined by the unmasking of a previously unnoticed or undiagnosed maxillofacial deformity. The maxillae and mandible with labial and dental components must be considered preoperatively and the patient must be forewarned. Attendance by a cosmetic dentist and inclusion of chin surgery may be necessary.
- #36 Entre las complicaciones mas frecuentes podemos mencionar; resecion excesiva de dorso, no conformacion de la piramide nasal (dorso en techo abierto), asimetrias en la punta, colapso de la valvula, asimetrias base nasal, irregularidades en la superfcie del dorso, defecto de supratip o remanentes de la jiba cartilaginosa en punta. Entre las consideraciones de gran utilidad podemos mencionar, la indicacion absoluta de la tecnica de rinoplastia abierta en el grupo II, utilizacion del cartilago costal en la reconstruccion del dorso nasal, utilidad del injerto oseo en el caso de la deformidad severa en silla de montar, fijacion de injertos con tornillos o suturas, remocion de la jiba nasal con bisturi, utilizacion del cartilago septal como primera opcion en el caso de modelado de la punta y osteotomias bajas en el caso de fracturas de los huesos nasales.
- #37 An overview of rhinoplasty complications addresses the prevention, diagnosis, and management of common complications of rhinoplasty. Careful preoperative diagnosis and a conservative approach guided by an understanding of the postoperative changes that occur during healing are critical in minimizing complications. These principles are also essential in the treatment of complications when they occur. La aplicacion de las consideraciones recopiladas a partir de este estudio incidiran en la obtencion de resultados mas estables y armonicos, tambien cabe mencionar que el numero de reintervenciones en nuestro equipo quirurgico disminuyo significativamente ( 12.9 % a un 8.4 % ), los resultados obtenidos en este trabajo son similares a los publicados a nivel mundial .
- #38 Ver,fijar,modelar y presionar