Continuing Education Activity

Rhinoplasty is one of the most popular surgeries worldwide. In the United States alone, more than 200.000 were performed in 2018, rendering it the third most conducted plastic surgery in the country. This surgical procedure is considered one of the most complex in plastic surgery. This activity describes the anatomical structures and the technique of closed rhinoplasty and highlights the role of the interprofessional team to improve surgical outcomes.

Objectives:

• Identify the anatomical structures of the nose.
• Summarize indication and contraindications for rhinoplasty surgery.
• Explain the surgical technique of closed rhinoplasty and possible complications.
• Outline the importance of an interprofessional team for improving surgical outcomes with rhinoplasty.

Introduction

Rhinoplasty is one of the most popular surgeries worldwide. In the United States alone, more than 200.000 were performed in 2018, rendering it the third most conducted plastic surgery in the country. 

The procedure has significantly changed over the years since the first aesthetic procedure described by John Roe in 1887.[1] This long evolutive process was not only technical but also and more critically, philosophical. In pursuance of better and more consistent results, the reduction-only concept in nasal surgery was progressively substituted with a more proportional approach, using a combination of careful reduction and grafting. Such advancements were possible mainly due to a better understanding of the anatomical structures and by the works of great surgeons like Joseph and Sheen. They described a number of techniques that we still use today.

Despite this shifting of the paradigm, rhinoplasty remains presently one of the most complex surgical procedures in Plastic Surgery. As a central landmark of the face, nasal proportions and symmetry are directly linked to facial beauty.[2] Technical difficulties, the wide range of different techniques described, and the struggle to achieve consistent results can be challenging even for very experienced surgeons.

The anatomical variations of inner structures and different thicknesses of soft tissue envelopes contribute to the difficulty of making “the same nose in every patient.” Furthermore, there’s no such thing as an “ideal nose” since a nasal configuration that may suit one patient’s face might be very different for another. 

Rhinoplasty is not exclusively a cosmetic procedure. The surgery also aims to maintain nasal function or improve it if the patient has reduced airflow due to an obstructive process. This adds to the complexity of the operation as internal nasal structures have to be modified in order to correct functional issues. 

All of these factors combined can explain why rhinoplasty is also such a rewarding surgery, which can provide highly favorable outcomes.

A correct selection of surgical patients, along with thoughtful preoperative analysis and planning, are critical steps for enhancing rhinoplasty results and also preventing secondary procedures.

In this chapter, we will review many relevant aspects of aesthetic nose surgery, focusing on closed rhinoplasty, so that the reader can have a general understanding of the subject and develop a logical and insightful approach to it.

Anatomy and Physiology

A deep understanding of nasal anatomy is the cornerstone of a good rhinoplasty. A slight change in one nasal structure can have an impact on the rest and dramatically modify the facial configuration.

The external nose consists of a bony and cartilaginous framework, covered by muscles, soft tissue, and skin. 

• Nasal Bones and Cartilages: The upper third of the nose is defined by the paired nasal bones and the frontal process of the maxilla, which constitute the bony pyramid. Nasal bones are in an intimate relationship with the perpendicular plate of the ethmoid bone. The middle third is formed by the upper lateral cartilages, which attach to the nasal bones cranially. Nasal bones overlap the upper lateral cartilages for 4 - 5 mm, constituting the “Keystone area.” This anatomical landmark is important for the aesthetics of the dorsal contour and should be treated carefully during surgery. Upper lateral cartilages also attach to the septum dorsally, forming an angle of 10 - 15 degrees approximately. This narrow zone of air resistance is called the internal nasal valve and has clinical importance. During surgical maneuvers, it is important to maintain this angle in order to guarantee a patent airflow. The lower lateral cartilages define the lower third with its medial, middle, and lateral crura. The anatomical configuration of these cartilages will determine the shape and size of the nasal tip area. They also set the framework for the external nasal valves.

• Muscles: The main mimetic muscles of the nose are the nasalis, levator labii aleque nasi, and depressor septii. These muscles are enclosed and interconnected by a fibrous fascia called the nasal superficial musculoaponeurotic system (SMAS). The importance of nasal muscles may sometimes be underestimated, but they are important for keeping a patent airway. A proof of this is patients with facial paralysis, where a collapse of the external nasal valve can be observed.

• Skin and Soft Tissue Envelope (SSTE): When divided into upper, medial, and lower thirds of the nose, the tissue covering the Rhinion zone is the thinnest, followed by the upper and then lower third which is the thickest. Based on multiple characteristics like sex, age, ethnicity, and others, SSTE can be thinner or thicker. This plays a significant role in surgical planning. When dealing with patients with very thin SSTE, small changes in nasal cartilage and bony structures will have a significant impact on the shape, and small irregularities of grafts utilized can be very noticeable. Contrarily, in patients with very thick SSTE, a more aggressive approach is often needed so that the changes can be perceptible, and small irregularities won’t have such an impact on the aesthetics of the nose after surgery. 

The internal nose is constituted of the septum and the turbinates, all of which are covered by mucosa.

• Septum: The nasal septum is a rigid, quadrangular-shaped structure covered by mucosa that is located in the midline of the nasal cavity. It separates the two nostrils, and it constitutes the principal support for the nose. In the junction between the dorsal and caudal septum lies the anterior septal angle, which helps to determine nasal projection. It also helps to define other parts of the nasal anatomy like the dorsal and columellar areas. Through the internal nasal valve, it has a very important role in maintaining a patent airway. The septum is composed of cartilaginous and bony components, the latter being the maxillary crest, the vomer, and the perpendicular plate of the ethmoid bone. The thick cartilaginous portion is extensive and is one of the main sources for cartilage harvesting in nasal surgery.

• Turbinates: Turbinates are bony outgrowths covered by mucosa. These structures form pathways where the air flows and is warmed and humidified. They also help in removing particles from the inspired air and additionally assist in regulating the airflow by contracting and expanding. They are divided into superior, middle, and inferior turbinates. Most of the airflow passes through the middle and inferior turbinates. Some causes like rhinitis or septal deviation can induce turbinate hypertrophy, which can obstruct the air canal to variable extents. If an obstruction is found, it must be addressed during surgery in order to improve nasal function.

Blood Supply: The nose has a rich vascular network. This allows for wide-undermining without compromising tissue irrigation.

The main nasal arteries are the supratrochlear and the facial artery (branches of the internal and external carotid, respectively). Both these arteries, together with branches of the ascending columellar arteries, will widely anastomose, forming a network. 

Blood to the nasal septum is supplied by the anterior and posterior ethmoid arteries, originating from the ophthalmic branch, the sphenopalatine artery (branch of the external carotid), and the septal branch of the superior labial artery. All these branches end up anastomosing in a network known as Kiesselbach's Plexus, which is the most common site for nosebleeds. 

Venous drainage is primarily through vessels anastomosing to the facial vein.

Indications

Rhinoplasty can be performed for functional issues, aesthetic issues, or both. It is important to emphasize that patients initially seeking functional improvement solely, often raise complaints about the aesthetics of the nose during the interview, and, postoperatively, they give more importance to the aesthetic results than to their ability to breathe properly.[3] This is one of the reasons why interviewing the rhinoplasty patient thoroughly plays such an important role. 

Although much has been written about the difficulty of finding the ideal candidate for surgery, there is no proven way of accurately detecting the high-risk patients that will probably be unhappy regardless of the outcome. In consequence, the surgeon must evaluate other non-visible aspects of the patients and use his/her instinct to try to determine whether the surgery will be beneficial or not.

In the first consults, interrogation is paramount to know if the patient’s expectations are achievable, as patient satisfaction postoperatively is determinant for the success of the surgery.[4]. By making open questions about the patient's life and his/her context (family composition, social relationships, etc.), the physician can listen and also interpret non-verbal characteristics that can be useful to picture the overall image of the individual.

The acronym SIMON (single, immature, male, over-expectant, narcissistic) is commonly used to describe patients that should be considered as being unsuited for surgery, and SYLVIA (secure, young, listens, verbal, intelligent, attractive) has been used to describe the ideal candidate.

After a global analysis, it is important to discuss the specific features they dislike about their nose (dorsal hump, nasal deviation, tip issues, etc.) and explain step by step what can be improved and how. This can be done by employing computer simulation. This is a helpful tool that helps to identify patients with unrealistic expectations by using real images of the person and simulate an approximate surgical result.[5] It started gaining popularity among surgeons in the last years, and in a survey conducted in 2017, 63% of them reported using it in rhinoplasty consultations.[6] Both 2-D and 3-D simulation tools are available. 

The functional analysis includes anterior rhinoscopy to search for common causes of obstruction like turbinate hypertrophy and septal deviations. In patients with airway obstruction with no visible cause, a nasal endoscopy might be helpful to diagnose other causes of obstruction like polyps. Nasal valves can be studied using the Cottle maneuver, which consists of gently pulling off the cheek laterally by using two fingers in order to open the ipsilateral valve. If the airflow improves, there might be a valve collapse that is impairing the nasal function.

Breathing problems in the past, history of sinusitis, obstructive sleep apnea, previous hospital admissions, use of medications or cocaine, and history of mental illness should also be recorded.

Preoperative photos have to be taken for previous analysis and planning and for medico-legal purposes. Frontal, both profiles, and a basal view are the minimum requirements. They should be taken using a dark background with good lighting settings.

Informed consent, as in every surgical procedure, has to be discussed in a serious manner with the patient in order that he/she fully understands every step of the operation with its risks and benefits, alternatives, and possible outcomes.

Agewise, this surgery is usually performed when nasal structures have developed completely, and nasal form will not continue to change greatly. This is approximately 15 years old for females and 17 years old for males.

Contraindications

Common contraindications for rhinoplasty include patients with an unstable mental state at the time of consult or surgery, patients with body dysmorphic disorder (BDD) or unrealistic expectations, obstructive sleep apnea, active cocaine users, and patients with comorbidities that contraindicate surgical procedures. 

• Body Dysmorphic Disorder (BDD): This psychiatric disorder is characterized by excessive preoccupation with an imagined or barely noticeable defect in appearance.[7] These cause patients to have difficulties in socializing, poor quality of life, and they are more prone to depression and have higher suicidal rates.[8] It is very important for surgeons to recognize this type of patient in an early manner because symptoms may worsen postoperatively if not diagnosed, and the patient won’t be satisfied with the results. To date, there is no validated questionnaire to adequately diagnose these patients. If clinical suspicion arises, referral for psychiatric evaluation is imperative. 

• Obstructive Sleep Apnea: This high prevalence disease is characterized by repeated episodes of airway obstructions during sleep. Patients with this condition have a higher risk of perioperative complications. Diagnosis can be suspected by the patient’s symptoms, although it can be asymptomatic. Screening questionnaires can be used, but with limited accuracy. The gold standard for diagnosis is polysomnography. Although it’s not an absolute contraindication, patients with this disease should be advised of the risks, and preoperative measures like the use of a continuous positive airway pressure device (CPAP) could be implemented in order to reduce complication rates. 

• Cocaine Abuse: Patients who abuse cocaine constitute a special group of patients. Inhaled cocaine induces intense vasoconstriction and chronic mucosal inflammation due to numerous contaminating additives.[9] Rhinoscopy findings can vary from mild inflammation to severe septal perforations. These patients are also more likely to have postoperative complications like septal collapse or impaired healing of the septal mucosa, and they should be advised not to have nasal surgery.

• Tobacco Smoking: Although it appears that tobacco smoking does not affect septoplasty outcomes, patients should be encouraged to quit prior to the procedure because of other harmful effects.[10]

• Bleeding Disorders: Impaired coagulation may cause postoperative complications. Patients should be asked about a history of excessive bruising or bleeding, consumption of drugs, supplements, or vitamins that alter coagulation cascade, or history of thrombotic events in the past. Any drug, vitamins, or supplement that impairs coagulation might have to be suspended preoperatively.

As a general rule, patients that had a previous rhinoplasty and are unhappy with the results should wait at least one year before any evaluation on the definite result or secondary procedure can be performed.

Technique or Treatment

Anesthesia: Closed rhinoplasty can be performed either with general anesthesia or local anesthesia and sedation, both with similar results in experienced hands.The patient is placed in the supine position, with a slight reverse Trendelenburg, to minimize bleeding. 

Whether using general anesthesia or sedation, infiltration anesthesia is the first step of the procedure, and it has to be done in a very meticulous way in order to produce not only numbness in the nasal region but also a bloodless operative field. Prior to the injection, a local vasoconstrictor like oxymetazoline can be applied to the nasal mucosa.

For the anesthetic solution, 1% lidocaine with epinephrine in a dilution of 1:100,000 is preferred. About 5 ml to 10 ml of the solution should suffice to infiltrate the nasal area and septal mucosa if needed.

Infiltration may start in the nasal root and descend to the lateral nasal walls, the columellar region, and the maxillary arch in order to constrict the main vessels and nerves without much distortion of the nose. Mucosal infiltration can be performed in the incision areas. If septal reconstruction or cartilage harvesting is planned, infiltration in the septal mucosa helps to prevent bleeding when elevating the flaps and produces hydraulic dissection.

Posterior to infiltration, nasal vibrissae are shaved, and a povidone-iodine solution is applied to the nasal mucosa, the whole face is then prepped and draped. If ear cartilage harvesting is planned, ears should be included in the surgical field.

Incisions and Exposure: A retractor is placed holding the alar rim superiorly, and slight pressure is performed in order to evert the mucosa and visualize the intercartilaginous groove. Depending on the surgical planning, an approach to the tip area could be done via delivery or non-delivery of the lower lateral cartilages. Non-delivery approach can be done by performing a trans-cartilaginous (incising through the lower lateral cartilage) or intercartilaginous incision (in the junction of the upper and lower lateral cartilages), connected to a transfixion incision running through the membranous septum. 

The trans-cartilaginous incision is usually performed in the context of a patient with a bulbous or boxy tip, and the cephalic trim of the lower lateral cartilages is planned. After the incision, with the use of a hook, eversion of the nasal mucosa is performed, and excess cartilage is detached using scissors. At least a 5 mm rim strip should be maintained in order to avoid a pinched tip or an external valve collapse. 

The delivery technique is used when more complex tip modifications are planned. It allows for better visualization as an open approach would provide. It is performed by making a marginal incision from lateral crus to medial crus and an intercartilaginous incision bilaterally, which connect in the midline and can continue to a hemitransfixion incision. The soft tissue between the marginal and the intercartilaginous incision is dissected so that the lower lateral cartilages can be “delivered out” of the incisions in order to modify them. These modifications can include trimming of the cephalic portion of upper lateral cartilages, inter or intradomal sutures, tip grafts, and controlled weakening of the cartilages.After this step, using a periosteal elevator, soft tissues are separated from the cartilaginous and bony dorsum in a subperichondrial and subperiosteal plane.

Treatment of the Dorsum: If a dorsal hump exists, an objective evaluation should be made in order to differentiate whether there is a cartilaginous hump, osseous, or combined. These patients will generally require dorsal reduction techniques. In other patients, there is a need for augmentation of the dorsum rather than for reduction. 

The reduction of the bony dorsum can be performed by using a rasp, an osteotome, or an ultrasonic device, according to the surgeon’s preference. When finished, the dorsum should feel smooth and straight, or there might be asymmetries afterward.

Cartilaginous dorsum can be trimmed with scissors or scalpel, either detaching the superior lateral cartilages from the septum or not. The surgeon should be extremely careful in this step to avoid over resection and the possible collapse of the middle vault. Trimming of thin strips of cartilage and reassessment after each trim is the author’s recommendation in order to prevent these complications.

Augmentation of the Dorsum is usually performed to strengthen this area and improve contour imperfections. It’s especially important in the context of a secondary rhinoplasty with loss of dorsal support and other structural deficiencies produced by congenital or traumatic etiologies. There are many techniques described, the most popular being the use of homologous or autologous tissue like bone or cartilage. Synthetic implants are also an option, and they can be made from different materials like silicone and Gore-Tex. The use of these implants is controversial when autologous tissue is available, as there have been reports of implant extrusion, skin loss, and infection.[11]

Lateral Osteotomies: If the patient has a wide bony vault or if the surgeon needs to correct the open roof deformity created by surgical maneuvers or a deviated nose, unilateral or bilateral lateral osteotomies are necessary in order to maintain aesthetic dorsal lines. Osteotomies can be internal through the nasal mucosa or external by incising the skin and inserting a thin osteotome from the outside. Some authors favor the external approach because it minimizes edema and hemorrhage, and permits a more controlled fracture pattern.[12]

Depending on the level of the osteotomy, they can be classified as low-to-high, low-to-low, or double level. Lateral osteotomies are carried out generally in the junction between the frontal process of the maxilla and the nasal bone, where the bone is thinner. Once the osteotomy pattern is completed, gentle pressure is applied to perform a greenstick fracture and reposition of the nasal bones. Relative contraindications for lateral osteotomies are mostly patients with very thin or short nasal bones.

Septoplasty: In favor of correcting a septal deviation or if cartilage harvesting is needed, septoplasty might be performed. The technique involves elevating bilateral mucoperichondrial flaps to expose the septum. Once the anterior septal angle is identified, an incision on the cartilage is performed to reveal the subperichondrial plane, which should be not hard to recognize because of its white-blueish color. Once into the plane, a Cottle elevator is used to separate the mucoperichondrial flaps off the septal cartilage. Cartilage can be harvested by using a scalpel and a Ballenger swivel knife. Care should be taken to leave at least a 1 cm segment of the dorsal and caudal septal cartilage strut (L strut) in order to prevent septal collapse. Depending on the type of septal deviation encountered, techniques to correct it involves either scoring of the cartilage, resecting the deviated portion, or in the case of a septal tilt, remotion of the postero-caudal part of the septum, which can be later reattached or not (swinging door technique). 

If there is impairment of the internal nasal valve, spreader grafts may be needed. These grafts, described by Sheen,[13] are used to increase the valve angle by creating more space between the septum and the upper lateral cartilages. They also improve aesthetic dorsal lines, as seen in patients with middle vault collapse. When spreader grafts are planned, the previous design of a septal “tunnel” can be made with a Cottle elevator, leaving undissected septum below and above to aim to maintain the grafts into place. This should be a precise maneuver as the graft should be placed in the right place. A high placing could produce contour irregularities, and a low placing might not open the angle as much as needed to improve nasal function. After septoplasty is finished, mattress sutures can be performed in order to close dead space.

Tip Modifications: The nasal tip approach requires careful planning and execution. Tip projection, definition, symmetry, and morphology may be altered and can be corrected by the use of different techniques. Treatment of the tip area has evolved over time from destructive and sometimes irreversible to a less aggressive strategy, using cartilage shaping procedures and better placement of grafts.[14]

• Tip Projection: It refers to the distance that the nose protrudes from the face. A tip can be over projected or under projected. Techniques for decreasing projection usually involve shortening the length of the lateral and/or medial crura. This is regularly done by cartilage overlapping. Some of these techniques may also modify the tip rotation. The methods described for increasing tip projection are many, and the one to use depends mainly on the amount of projection needed. Placement of a columellar strut will increase projection slightly by enhancing the medial crura. It involves dissection of a pocket between the medial crura and placement of a rectangular piece of cartilage fashioned from septal cartilage, which is held in place by using sutures. The use of a septal extension graft is a powerful way of increasing tip projection and can also have an enormous impact on rotation. It is performed by fixing a cartilage graft to the dorsal or caudal septum, extending between the lower lateral cartilages. The distal portion of the graft enhances the supratip area and can be fixed at the desired angle. Ideally, the graft should be made from septal cartilage. If unavailable, other options like ear or rib cartilage must be considered. When compared to the columellar strut, the septal extension graft has proven to be more favorable in maintaining tip projection.[15] Tip grafts can also be used to increase projection. Many types of grafts for the tip area were described with different forms and placement, but their application should be reserved for when the previous techniques won’t achieve the required effect as grafts could produce asymmetries or angulations, especially on patients presenting with thin skin. In these patients, morselized or crushed cartilage may be used to “soften” the graft.

• Tip rotation: The position of the nasal tip is an important aesthetic factor for patients. During rhinoplasty consultations, many of them are unhappy with their nasolabial angle and wish to modify it. There are many methods of achieving cephalic rotation of the tip, and the technique to use depends on the amount of rotation needed. An excessive amount of rotation will result in an exaggerated nostril show, while an insufficient rotation will produce a droopy tip. Understanding the anatomy and the dynamics of nasal surgery is paramount to realize why some maneuvers have an influence over tip rotation. Cephalic trim of the lower lateral cartilages is an example. When resecting the cartilage, space is created between the lower and upper lateral cartilages, and it facilitates passive rotation of the tip. Septal caudal trim is another tactic that can be used for the rotation of the tip. By altering the position of the ASA, the nasolabial angle will change because of its relations with other tip-defining structures. This must be done carefully, as this also can reduce tip projection. The tongue-in-groove technique was described in 1999 by Kridel.[16] The procedure relies on establishing a strong connection between the medial crura and the septum. This is achieved by the use of multiple sutures. The surgeon can immediately assess the changes by tightening or loosing of the sutures. It is a reliable, easy to perform, and reversible method. This and the fact that it preserves the integrity of nasal structures make it a very seductive technique. It may also be used in the correction of a columellar show and to control tip projection.

• Transdomal Suture: Variations in nasal dome angles and their convexity can produce different tip shapes and deformities. Bulbous and boxy tips are examples of this. Transdomal sutures are used to narrow these angles, bringing the domal and lobular segments closer to each other while pulling the lateral crura medially. This projects the nasal tip while narrowing it.The technique involves the placement of a horizontal mattress suture, which is tied up medially, between the domes, tightening it gradually until the desired effect is achieved. Care must be taken to place the sutures superficial to the vestibular lining. 

• Interdomal Suture: This is a simple suture that is placed between the domes of the middle crura of each lower lateral cartilage. It is used to narrow tip width, enhance the infratip region, and increase projection. As with the previous technique, gradually tightening of the suture is advisable in order to achieve the expected results. Too much tightening may end up in a pinched tip. This maneuver was classically performed via the delivery of the lower lateral cartilages. In 2016, Harel described an interdomal suture technique through a non-delivery approach.[17] This technique uses a PDS 4/0 with a straight needle to perform a suture in a way that the final knot ends up buried in the interdomal space. This method is the author’s preference for its simplicity, versatility, and speed, as no delivery is needed. 

Turbinectomy: Inferior turbinate hypertrophy is a common finding that can produce varying amounts of airway obstruction. Its treatment will depend on the extent of the obstruction. Conventional methods include submucous turbinectomy, turbinoplasty, radiofrequency, and laser. If valvular issues and/or septal deviations have been addressed, turbinate outfracture alone may be satisfactory to provide an adequate airway size.

Closure and Dressing: After mucosal incisions are closed with resorbable sutures, Silastic splints are placed and sutured to each side of the septum in order to provide septal support and enhance mucosal healing.[18] Several strips of paper tape are distributed over the dorsum and cast over it, which is removed 7 days postoperatively.

Complications

As stated earlier, rhinoplasty is one of the most challenging surgical procedures, and one of the main reasons for this is its limited predictability. An immediate good result postoperatively may not be so one year later. This can be attributed mainly to the many variables involved in the healing process. The individual reactions of the different nasal tissues are not always anticipated, and therefore, unfavorable results can occur. 

Although the risk for major complications is low,[19] functional and, mainly, aesthetic complications can cause social and psychological issues and may result in legal problems for the surgeon.

Surgical complications can be defined as hemorrhagic, infectious, traumatic, functional, and aesthetic.[20] 

Hemorrhagic Complications

• Epistaxis: Postoperative bleeds are a common complication in rhinoplasty. They tend to be mild and usually resolve by head elevation, nasal decongestants, and compression. If bleeding continues, an anterior tamponage should be performed, and the patient reassessed. If bleeding persists in spite of the anterior tamponage, posterior bleeding should be suspected, and a posterior tampon will be required. Although severe bleeds are rare, sometimes an endoscopic approach or angiographic embolization could be needed.
• Septal Hematoma: It represents an early complication that can lead to serious injury if not treated promptly. Septal hematoma appears as a postoperative tender mass in the septal area. It is usually painful, and the patient can also present with fever, anosmia, and airflow obstruction. If suspected, septal hematomas should be drained in an early manner in order to prevent infection and loss of septal cartilage. After drainage, anterior tamponage should be placed, and the patient reassessed in 24 hours. If a septal abscess is suspected, antibiotic therapy must be started immediately.

The use of anti-fibrinolytic drugs in plastic surgery has been investigated in the last years to diminish hemorrhagic complications. The number one drug in this family is tranexamic acid (TXA) and can be administered intravenously in a 10 mg/kg concentration previous to anesthetic induction. Studies have shown that TXA decreases the intraoperative bleeding rate, eyelid edema, and periorbital ecchymosis.[21] 

Infectious Complications: Infections after rhinoplasty can range from mild cellulitis to severe systemic infectious processes. Cellulitis may be seen after rhinoplasty as an early complication. It usually presents a favorable response to cephalosporins, but close observation is necessary for preventing progression. Septal abscesses can be a complication of a non-treated hematoma, and surgical drainage followed by antibiotics is the treatment of choice. They can appear in the septal region, tip, or dorsum. Severe infectious processes are very rare. They occur in less than 1% of the cases.[22] Early readmission, intravenous antibiotic treatment, and prompt tissue debridement are important in order to prevent complications like tissue necrosis or toxic shock syndrome.[23] There have been many studies regarding the use of antibiotics during and after the surgery, but still, there is no consensus about it. There is supporting evidence that prophylactic antibiotics play a beneficial role in preventing postoperative infections.[24] Regarding the use of antibiotics posterior to the surgical intervention, the WHO does not recommend their use for more than 24 hours after surgery due to low infection risk.[25]

Traumatic Complications: These include septal deformities or collapse due to injury to the L-strut, intracranial injuries, and injury to the lacrimal system. In the case of an unnoticed septal injury, deformities are usually seen as a late complication, as the soft tissue envelope contracts over the nasal framework. These often require secondary procedures in order to correct them. If a septal injury is noticed during surgery, it must be repaired before closure. 

Intracranial injury is a rare complication and can produce a cerebrospinal fluid leak, which manifests as rhinorrhea and headaches. This complication requires hospital admission and neurosurgical evaluation. 

Injury to the Lacrimal Ducts: This can produce epiphora that can present with bleeding. It may be caused by lateral osteotomies, and its treatment sometimes will require duct intubation. It is important to know that epiphora can be present in the first few weeks after the procedure due to edema compressing the lacrimal ducts, which typically resolves spontaneously. 

Functional Complications: 

• Septal Perforation: Defined as continuity defects, they can be produced by tears in the manipulation of mucoperichondrial flaps or an unnoticed septal hematoma. The importance of preventing tears or repairing them if found is important for their prevention. Once the perforation occurs postoperatively, it can range from a small perforation producing whistling while breathing to large perforations, causing epistaxis and rhinitis due to turbulent airflow. If symptoms are mild due to a small perforation, treatment may not be needed. Larger perforations will require surgical treatments using flaps, with a high recurrence rate.

• Nasal adhesions: The presence of synechiae can occur between abraded mucosal surfaces. They can be prevented with the use of a Silastic splint during septoplasty. If found postoperatively, they should be divided surgically.

• Rhinitis: This is often a temporary complication, especially when an obstructed airway has been improved. It may produce nasal discharge, dryness, and breathing issues. It is usually treated with topical agents. If rhinorrhea persists after a few weeks, a cerebrospinal fluid leak must be suspected. 

Aesthetic Complications: These usually appear as late complications and may develop in different nasal regions. In the tip area, asymmetries and tip deformities due to grafting are sometimes encountered. This is dependent on many aspects like the thickness of the skin, the number of grafts used, and ways of fixation. Their resolution should be deferred at least one year after the first surgery. In the dorsal area, under-resection or over-resection of the septal cartilage can manifest as a residual hump, a middle vault collapse, or a pollybeak deformity. The latter is characterized by a convex formation over the supratip area, which originates tip ptosis. It can be produced, paradoxically, by over-resection of the cartilaginous dorsum. This produces scar tissue formation in the dead space area. This soft tissue pollybeak deformity may be treated with injected Triamcinolone and taping[26] with acceptable results in the majority of cases. If not successfully treated, surgical correction should be performed. If scar tissue is not generated in the dead space area, the soft tissue envelope can keep contracting, gradually collapsing the nasal vault, a condition known as saddle nose deformity. The usual findings are a depressed middle vault, tip projection, and overrotation, columellar retraction, and alar base widening. It can also produce breathing issues.[27] Its treatment usually requires grafting for restoring septal integrity and provide dorsal support. This can be accomplished in most cases by the use of autologous material. In some cases, rib grafts will be required. 

Clinical Significance

Either for improving the nasal appearance or in order to correct functional issues, rhinoplasty can provide excellent results in experienced hands.

A good understanding of nasal function, form, and anatomy, and the use of a surgical technique that respects critical structures are vital features that the rhinoplasty surgeon must possess. 

As previously mentioned, an important step is a careful selection of surgical candidates to achieve high patient satisfaction rates. It is also necessary that the patient complies with postoperative indications responsibly and communicate with the surgical team in an early manner if alarm signs or symptoms appear.

Satisfaction with rhinoplasty results can improve the patient's quality of life, measured by an improvement in the ROE scale and other scales after surgical procedure, as demonstrated by many authors over the years.

Enhancing Healthcare Team Outcomes

The many variables interacting in the difficulty of the rhinoplasty procedure have been previously stated. In addition to achieving aesthetic goals, the surgeon must keep a patent airway or improve it in the case of impairment. 

Surgical team satisfaction with the postoperative results, although important, is not determinant for the success of the surgery as patient satisfaction is. Between the tools for measuring patient satisfaction and surgical outcomes, the Rhinoplasty Outcome Evaluation (ROE), designed by Alsarraf et al., is one of the most used. This validated questionnaire consists of six questions evaluating social, emotional, and psychological variables. Although the ROE focuses more on the aesthetic aspects,[28] meeting these expectations seems to be more important than functional ones for achieving patient satisfaction.

An interprofessional care team is always necessary for every surgical procedure in order to obtain the best results. In preoperative visits, it is important to screen for unsuitable candidates for surgery. As previously discussed, patients with dysmorphophobia or unreal expectations are high-risk individuals that most likely won’t be satisfied with the postoperative results. A psychiatric evaluation can be beneficial at this stage for determining appropriate treatment.

In patients presenting with previous medical conditions, preoperative consults with specialists in those diseases are advised to discuss the suspension of some medications prior to the procedure and reinforce care standards.

When general anesthesia is required, a preoperative consult with an anesthesiologist will determine if the patient is fit for receiving anesthetic drugs.

Nurses also play a very important role. They can monitor the patients in the postoperative period in order to detect early complications, manage their pain, and educate them for home care when they are discharged.

Communication between team members, evidence-based medicine, and patient-based care must always exist in order to achieve good postoperative results, with both patient and surgical team satisfaction.