Avoiding complications in cosmetic rhinoplasty.

Of all the facial cosmetic corrections, rhinoplasty is the most sought treatment. This is one of the most challenging procedures in the midfacial complex. The high degree of expected transformation coupled with the complex loco-regional anatomy renders the procedure a new challenge every time. In spite of the best efforts, a significant percentage of patients, comment their surgical outcome as unfavorable. Most of such unfavorable outcomes are often due to the inability to meet the high expectation and the reality of the perceived defect, surgeon's skill, dexterity and training. Surgeon side errors are often associated with poor judgment, wrong treatment planning, and decision making. The resultant outcome may be anatomically or functionally in the outcome. Unless a drastic error is performed, the functional defects are relatively uncommon. Esthetically unacceptable cosmetic rhinoplasty could be due or perceived as a minor deviation to grotesque ones.[123]

Improper design of intra-nasal incision would because of defects associated with internal value obstruction, especially by the scar formation of the cartilage and tissues. Improper manipulation of the soft tissue over the hard tissues, especially if grafts are placed would severely impede the esthetic component.[1] Hard manipulation will lead to prolonged swelling and inflammation, both detrimental to the esthetical outcome. Insufficient calculation and planning in nasal tip correction would cause the tip to be flat, asymmetry and or rim deformities. Furthermore, the projection geometry would be a three-dimensional mishap.[2] Over reduction, under reduction, lack of smooth transition is some of the defects associated with hump reduction, especially in young adults. In unplanned cases, open roof deformity, inverted V deformity and saddle nose could result. Dorsal and radix deformities are unmistakable and often occur because of oversight. In case patients claim such deformities, preoperatory conversation and estimation of expectation have gone wrong. Also, in patients with underlying septal deformity, a superficial correction may open up the previously masked deviation. In such a situation, correction of the septal defect is also advised.[13]

Nasal osteotomies could result in complication such as narrowing of nasal airway, open roof deformity, inverted V deformity and asymmetry of the bony wall. In such situation, use of grafts, especially autografts, is recommended. Personally, I would always suggest going with an autograft to avoid many later complications. While preparing autografts, holding of the graft with clinch sutures, bolsters, plaster molds and packs need to be used carefully. Also, the issue of warping should be carefully approached. Warping at a later stage could affect the outcome and may necessitate secondary corrective surgery.[34] Unless a surgeon is trained properly to plan and handle cosmetic corrections of the nose, the results would largely vary from the expectation.