Rhinoplasty Safety and Risk
Hi, I am Dr. Paul Nassif. I am a facial plastic surgeon.
What I would like to discuss with you today is what are the risks with rhinoplasty surgery, especially revision rhinoplasty surgery.
Many patients will come in and think that it is a very easy procedure and they can go out and about their way and go back to work immediately and look great in one week. Unfortunately it is not true. Rhinoplasty surgery is the hardest surgery that we perform. It is something that takes a lot of expertise to perform rhinoplasty surgery and my goal is to tell you some of the possible risks and complications associated with surgery.
Obviously I do not expect many of these things to occur, but I want to tell you what can occur so at least you are aware and informed. From bleeding, infection, maybe not getting the exact result that you want to scar formation inside your nose where you can build up scar tissue especially in this region to possibly if you have an open rhinoplasty having the little scar not heal right. That is rare but it can happen. These are a few of the things we want to initially mention in rhinoplasty surgery.
If we are performing a septoplasty there is something that can occur called the septal perforation. A septal perforation is a little hole that is made inside the nasal septum. You cannot see it from the outside. From the inside it can cause nasal obstruction, you can whistle when you breathe in, it can cause crusting or a little bleeding around the nose. Usually if this is going to occur, there is a little slight higher chance of revision rhinoplasty when the patient has already had a previous septoplasty or in a situation where there has been previous trauma to the septum. Usually I can see that there may be a risk of perforation there and I will usually do something at the time of surgery to correct it. Again, these are really rare risks but I still want to explain them to you.
Sometimes when we lift up the skin of the nose we can get little broken blood vessels called telangiectasias on the nose. That is just by elevating the tissue. If that occurs, we can treat that with a laser called a pulsed-dye laser and that is something that can be corrected after surgery.
I could over do your nose or under do your nose. It is rare, but this can happen. It is a risk we take when undergoing surgery. Sometimes if there is a little hump left behind or if I feel that the profile is straight but as time goes on the little area here called the cartilaginous hump can sometimes depress a little bit so you will see like a little hump and then it goes in a little bit right here. That can happen 1% or 2% of the time. Sometimes you can get something called a callus or a little scab along the nose right through here. Now with the scab, this could occur one month, six months, nine months later on and if that happens we usually can remove that little callus or little bump with a small incision inside your nose. It usually takes about 20 minutes and we do it in the operating room. That is called a callus formation. A callus formation can occur up to 2% or 3% of the time.
Prolonged or chronic swelling or edema especially in patients with thick skin. The nose can swell up after surgery and can stay swollen up to a good year. We have had a few patients even though it is extremely rare where they look great for the first six or seven months and the next thing we know the nose got bigger. It is rare but it can happen. It is something that has happened so far in my whole entire practice to two patients where it appeared after six, seven, eight months the nose got a little bit larger in the region of the tip. It can happen. Sometimes it builds up scar tissue but it is extremely rare.
Asymmetries and irregularities. This is something that will happen with the nose. No matter how perfect the nose looks in surgery, with the healing of the nose you will have some asymmetries or irregularities. So your nose will not be perfect and the reason why this occurs is because of three-dimensional healing of the nose and shrink wrappage. With shrink wrappage of the skin of the nose, especially if it has been previously operated on, this will occur. So sometimes we might not get the absolute desired outcome that we want because of this reason. Sometimes the nose will look great for the first three months and then following six months, a year, even five years down the line the nose will keep changing. Sometimes these asymmetries can develop and be seen later on as the nose heals. But at that point, one year, three years, five years the nose may even get smaller and look better with time. So either there can be asymmetries and irregularities versus the nose can look better because the swelling goes down. So if you look at the nose over a period of time, it keeps changing every year.
Nasal obstruction. I can make your breathing worse and that is very, very rare but there is a chance with doing an aggressive rhinoplasty or even a conservative rhinoplasty you can get a little pinching of the nose. With a pinching of the nose, like right through here, it could obstruct your breathing so there is a small possibility that I can make your breathing worse. I doubt it, but again I want to mention this to you.
What is the chance of you needing a revision surgery following my rhinoplasty with you? Well, the national average is about 10% or 12%. If I look at all my numbers, that is about 2% or 3% of the time that I will have to do a touch up. You may need a revision either because of healing issues that we just explained and if this occurs it is really not in my control and I can control some of these things but it is still a revision. Usually if there is a problem in surgery, which is rare, I am usually able to fix those issues in surgery so most of the time it is from a healing problem. But no matter what, I have to take that responsibility and will have to go back and fix your nose.
In many situations if it has to do with the tip, we have to wait a year. If it has to do with something up in the bony area, we can perform a revision in six months. At the same point, a lot of patients will ask me well how does that work financially. In general if it is because of a healing issue there will not be any surgeon fees but there will be a charge for the anesthesia and the operating room.
One of the biggest things with a rhinoplasty is the swelling. Patients will come in and say “When is the swelling going to go down, am I healed yet?” What I will tell patients is that they have to wait at least a good year and even than as I mentioned a few minutes ago, there will still be healing every year but you need a full year to heal after surgery. After three months of healing you will have about 60% to 70% healing but it takes time to heal so you have to be very, very patient.
One of the most important aspects of rhinoplasty surgery is realistic expectations. The patient has to be realistic about their outcomes and I have to make sure I communicate to you what you can expect, especially with computer morphing. It is not a guarantee of surgery but I will make sure I do the best I can. The nose since it does heal not predictably sometimes, there is really no guarantee.
I cannot guarantee you a perfect nose. Your nose as a matter of fact will not be perfect. My goal is to give you a natural, improved, better looking nose that you can breathe out of so it is functional.
Some patients following rhinoplasty usually will be very bruised and will be very swollen after the first week. You will have a cast on and some little stitches, some splints inside your nose. They will all come out at one week most of the time. The second week you are going to have tape on your nose. Sometimes after that second week, we are going to have you tape your nose for a period of time every night, possibly up to two or three months; sometimes as little as six weeks. Sometimes I will give you nasal exercises to do where you are taking your fingers and pushing on your nose very gently through here. Sometimes we will just have to wait until some of your irregularities just resolve. Following surgery you cannot expect perfection. The nose will keep changing every few weeks.
Following surgery you are going to have numerous medications to take that you have to make sure you follow the instructions and you take all the medications. There is treatment such as hypobaric oxygen which is 100% compressed oxygen which may help you heal faster. There are products called platelet gel we can use in surgery to help you heal faster. It is a product from your own blood that delivers growth factors and healing factors that help you heal faster. There is arnica cream. There is pineapple extracts. There are all kinds of things you can do after to help you heal faster; but the most important thing is following our instructions that we will give you.
In general there is not a lot of pain with surgery. Most patients will take Tylenol but we will give the patient pain medication prescription for after surgery if it is needed. You do want to make sure that you do not take too much pain medication because it can also make you constipated. Sometimes we will tell you to take Colace which is an over-the-counter stool softener to help keep things working without you getting constipated.
When it comes to revision rhinoplasty, it is very difficult and it will take a lot longer to heal. One of the reasons why I take a long time in surgery, sometimes four hours for a rhinoplasty, longer for revisions depending on what we are doing, is because I am adding structural grafts in the nose to prevent it from collapsing.
The reason why this happens is because I do so many revision rhinoplasties and I read so many operative reports that are very conservative, I see these noses that come in after a couple years from surgery and I see them collapsed. So, I am going to add certain grafting material in certain situations in the nose whether it is a columella strut right here in your nose to keep it from falling down or spreader grafts which are put right inside here to prevent the nose from collapsing in called an inverted V or other types of cartilage called lateral crural strut grafts or rim grafts to prevent the tip from collapsing in.
I will not do this with every patient, but in many patients I will. I want to make sure that I give you the best job as possible since I am very detail oriented. I will even take my camera inside the room and look at your nose since it gives me the better details of the nose.
Sometimes I will perform a closed rhinoplasty, which is maybe about 15% of my practice for my rhinoplasties and that is making incisions inside the nose. You usually have a little bit less swelling with that as compared to the open rhinoplasty but your visibility is less. So if I am performing a lot of tip work, I will usually go to the open rhinoplasty.
This overall is a good summary of what is involved in rhinoplasty surgery. It is time consuming, it takes a long to heal, you have to make sure you are going to follow my instructions if you undertake this operation and decide to do a rhinoplasty but my goal is to communicate with you and make sure I give you the best job possible.