Complications of Rhinoplasty

Joshua B. Surowitz, MD*, Sam P. Most, MDKEYWORDS

Rhinoplasty Septorhinoplasty Complications

KEY POINTS

Meticulous history, physical examination, and standardized photographic documentation are cen-tral to preoperative evaluation and surgical planning for rhinoplasty.

Photographic documentation is very useful to help illustrate preexisting preoperative asymmetries,and the surgeon must document these in the physical examination and discuss them with thepatient.

As with any surgery, any complications should be openly discussed with the patient. Appropriate preoperative counseling regarding all risks, benefits, and alternatives is critical. The surgeon must have a comprehensive understanding of nasal anatomy and effects of surgicalmaneuvers to help avoid complications.OVERVIEW

Rhinoplasty is a very common surgical procedureamong facial and general plastic surgeons. Itmay be performed for functional and aestheticreasons. It is a highly technically challenging pro-cedure, because the surgeon must pay carefulattention to both form and function. An aestheti-cally pleasing nose without the ability to breatheis a surgical failure. Some complications mayoccur intraoperatively, whereas others may occurpostoperatively during wound healing and con-tracture. Therefore, some complications may notbecome evident until months to years aftersurgery.m

ASYMMETRIES

Asymmetries of the bony pyramid can occurfor multiple reasons, including discrepancies inosteotomies between sides, asymmetric dorsalreduction, and persistence of preoperative asym-metries. A greenstick fracture, with failure to fullyDisclosures: The authors have nothing to disclose.Division of Facial Plastic and Reconstructive Surgery, StanSurgery, 801 Welch Road, Stanford, CA 94305, USA* Corresponding author.E-mail address: jsurowitz@ohns.stanford.edu

Facial Plast Surg Clin N Am 21 (2013) 639651http://dx.doi.org/10.1016/j.fsc.2013.07.0031064-7406/13/$ see front matter 2013 Elsevier Inc. Allosteotomize, may result in either failure to fullymobilize the nasal bone or the nasal bone lateraliz-ing from memory.

Asymmetries of the middle third are also oftenmultifactorial. A septal deviation that was notcausing asymmetry before dorsal reduction maybecome unmasked after dorsal reduction, andthereby cause asymmetries of the middle vault.Asymmetric dorsal reduction of the middle thirdcan also occur. Palpation of the dorsum withmoistened gloves allows careful assessment ofthe underlying anatomy after dorsal reduction.

Establishing symmetry at the tip is highly dy-namic and requires an understanding of all majorand minor tip support elements, as shown inTable 1.1 Careful attention to tip suture tech-nique and proper suture placement will helpminimize tip asymmetries. Preexisting asymme-tries of the medial and lateral crura may not beevident until other tip dynamics are altered.Similar to the middle third, a septal deviationthat was not causing any asymmetry preopera-tively may become unmasked as a result offord Department of Otolaryngology/Head and Neck

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mailto:jsurowitz@ohns.stanford.eduhttp://dx.doi.org/10.1016/j.fsc.2013.07.003http://facialplastic.theclinics.com

Table 1Complications of rhinoplasty

Complication Cause Avoidance Correction

Asymmetry of the bonyvault

Asymmetric osteotomies Meticulous attention to osteotomies Percutaneous osteotomies

Asymmetry of the middlevault

Unmasked dorsal septaldeviation after dorsal reduction

Recognition of septal deviation Crushed cartilage camouflage grafts

Tip asymmetry Asymmetric tip sutures Meticulous attention to suture technique RevisionUnmasked caudal septal deviation Meticulous inspection Possible placement of septal extension

graftPossible repositioning of caudal septumwith swinging door, secure to nasal spinewith suture

Overresection of nasalbones

Overaggressive resection Judicious bony dorsal reduction Placement of dorsal onlay graft

Open roof deformity Bony dorsal reduction Judicious bony dorsal reduction when noosteotomies are planned, butunavoidable when narrowing of thebony base is planned

Lateral osteotomies to close open roof

Rocker deformity Continuation of osteotomiesinto frontal bone

Meticulous planning of osteotomies andcontinuous palpation/inspection

Percutaneous osteotomies

Stair step deformity Improper placement of lateralosteotomy anterior to theascending process of the maxilla

Meticulous planning of osteotomies andcontinuous palpation/inspection

Percutaneous osteotomies

Pollybeak deformity Overresection of nasal bones Meticulous planning of dorsal reduction,both bony and cartilaginous dorsum

Dorsal onlay camouflage graftUnderresection of dorsal septum

(anterior septal angle)Appropriately match cartilaginous dorsalreduction to that of bony dorsalreduction

May require revisionPostoperative soft tissue scar

formationAvoid overaggressive dorsal reduction in

thick-skinned patientsKenalog injections postoperatively

Inverted V deformity Upper lateral cartilages dropinferior and posterior, causingshow of the nasal bones anddorsal septum

This results from failure to repairthe upper laterals to the dorsalseptum after dorsal reduction

Repair upper lateral cartilages to dorsalseptum after dorsal reduction

Use of spreader grafts or autospreadergrafts

Revision with use of spreader grafts (ifupper lateral cartilage present), possibleonlay crushed cartilage camouflagegrafts, consider osteotomies to narrowthe bony base if this is a contributingfactor

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Saddle nose deformity Overaggressive dorsal reductionwith septoplasty, resulting in adorsal strut that is inadequateto support cartilaginous dorsum

Maintain 1.5-cm dorsal strut Revision with dorsal onlay camouflagegraft (minor cosmetic deformity) and ribcartilage graft reconstruction (severecases)

Bossae Overaggressive cephalic trim oflateral crura

Note predisposing factors for bossaeformation (see below), avoidoveraggressive resection

Revision with structural grafting of lateralcrura (strut grafts), crushed cartilage,and/or temporalis fascia camouflagegrafts

Visible grafts Thin skin Note thin skin preoperatively and placetemporalis fascia overlay grafts tocamouflage

Revision with possible graft removal and/orplacement of temporalis fascia forcontour smoothing and camouflage

Pinched tip Overresection of lateral cruraduring cephalic trim

Spare 6- to 7-mm rim strip Lateral crural strut grafts, possible crushedcartilage grafts for camouflage

Malpositioning of lateral crura Ensure appropriate orientation andpositioning of lateral crura

Removal/revision of any offending tipsutures, possible lateral crural strutgrafting, possible repositioning of lateralcrura

Contracture from wound healing Unavoidable, must preoperatively counselpatient about this risk and documenthaving done so

Revision surgery with one or more of theabove maneuvers

Poorly defined tip Overaggressive tip deprojectionin thick-skinned patient

Avoid overaggressive deprojection Judicious superficial nasalis aponeuroticsystem (SNAS) excision intraoperatively,Kenalog injections postoperatively

Nostril asymmetry Altered caudal septum, medial,intermediate, and lateral cruradynamics from intraoperativesuture technique or alteration

Meticulous attention to symmetricplacement of sutures, such as tip andtongue in groove sutures

Revision, with correction of underlyingoffending cause

Alar retraction Overly tight closure of marginalincision

Remove/revise offending sutures

Overresection of lateral cruraduring cephalic trim

Lateral crural strut grafts, possible alar rimgrafts (minor cases), auricular compositegrafts (severe cases)

Malpositioning of the lateral crura Repositioning of the lateral crura, lateralcrural strut grafts, possible alar rimegrafts (minor cases), auricular compositegrafts (severe cases)

Overly tight lateral cruralspanning sutures

Removal/revision of any offending tipsutures

Contracture from wound healing Revision surgery with one or more of theabove maneuvers

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Table 1

(continued)

Complication Cause Avoidance Correction

Columellar retraction Overresection of the caudal septum Avoid overresection Caudal septal extension graft, columellarstrut graft, columellar plumping graft

Excessive setback of themedial crura duringtongue-in-groove

Avoid excessive setback Revise tongue-in-groove, considercolumellar plumping graft

Septocolumellar suture can be used to helpprevent contracture during woundhealing

Columellar and alarbase scar formation

Wound healing Meticulous wound closure Kenalog injections with revision reservedfor severe cases

Nasal obstruction External nasal valve collapse Maintain integrity and appropriateposition of lateral crura, avoidoveraggressive narrowing of the alarbase

Lateral crural strut grafts, possible alar rimgrafts

Internal nasal valve collapse Avoid overaggressive narrowing of thebony base, use spreader grafts orautospreader grafts to maintain patency

Spreader or autospreader grafts

Septal deviation Appropriately address any septal deviation SeptoplastyIntranasal synechia Careful soft tissue handling and fastidious

wound closureLysis of synechia

Recurvature of the lateral crura Recognize contribution to the patency ofthe nasal airway

Lateral crural strut grafts

Septal perforation Opposing mucoperichondriallacerations

Meticulous elevation ofmucoperichondrial flaps to preventopposing lacerations

Place fascia or crushed cartilage graftinterposed between lacerations

Septal hematoma Placement of septal whip sutures and useof removable soft silastic intranasalsplints, prophylactic mucoperichondrialflap incision to allow drainage of anyaccumulated blood

Incision and drainage

Costal cartilage(autograft andhomograft) warping

Intrinsic property of cartilage Concentric carving Revision

Pneumothorax aftercostal cartilage harvest

Injury to the pleura Harvest cartilage in subperichondrial plane Close wound under water seal withpositive pressure ventilation

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Fig. 2. Open roof deformity after prior rhinoplastyfrom failure to close with osteotomies.

Complications of Rhinoplasty 643surgical maneuvers, with resultant tip asymmetryor deviation. Contracture of the skin soft tissueenvelope can also result in asymmetry of thetip over time.

Edema of the soft tissue envelope can makeasymmetries and irregularities difficult to discernintraoperatively. Thus, careful marking before in-jection is paramount. Asymmetries can be mini-mized through judicious inspection from the topof the patients head and through careful palpationusing sterile saline-moistened gloves.

THE BONY PYRAMIDOverresection of the Nasal Bones

Overresection of the nasal bones can be avoidedthrough judicious dorsal reduction, as seen inFig. 1. Notice that this patient also has a pollybeakdeformity, which is discussed later. More bonemay easily be removed, whereas replacementafter overresection presents a more challengingscenario.

Open Roof Deformity

An open roof is a normal consequence of dorsalreduction. Failure to close an open roof withappropriate osteotomies will result in a flat topappearance to the bony pyramid, as seen inFig. 2. Edema of the soft tissue envelope canmask an open roof deformity on visual inspection.Fig. 1. Overresected nasal bones after prior rhino-plasty. Also note prominent pollybeak.

Fig. 3. Rocker deformity with osteotomies continuinginto frontal gone.Note superior aspect rocking later-ally when bony base is medialized. (From Toriumi DM,Hecht DA. Skeletal modifications in rhinoplasty.Facial Plast Surg Clin North Am 2000;8(4):424; withpermission.)

Fig. 4. Appropriate placement of osteotomies isdemonstrated. Note lateral osteotomy in high-low-high fashion, fading medial osteotomy, withcontrolled back-fracture connectingmedial and lateralosteotomies. (From Toriumi DM, Hecht DA. Skeletalmodifications in rhinoplasty. Facial Plast Surg ClinNorth Am 2000;8(4):422; with permission.)

Surowitz & Most644Again, careful palpation will make this readilyapparent to the surgeon. Medial and lateral osteot-omies are used to close an open roof deformity,narrowing the bony pyramid.Fig. 5. Inverted V deformity is noted with prominenceof the bony base and narrowing of the middle third.Rocker Deformity

Rocker deformity results from carrying osteoto-mies too far superiorly up into the frontal bonewithout appropriate back fracture. On medializa-tion of the nasal bones, the superior portion iscantilevered, or rocked, laterally, as shown inFig. 3.2 This deformity can be avoided throughcareful planning of ones osteotomies. When per-forming an endonasal lateral osteotomy, theguarded portion of the osteotome is oriented later-ally and the surgeon continually palpates duringthe osteotomization process. Should this compli-cation be encountered, transverse percutaneousosteotomies may be performed to create theappropriate controlled back fracture.

Stair Step Deformity

Stair step deformity is caused by placement of thelateral osteotomy anterior to the ascending pro-cess of the maxilla, resulting in a palpable step-off. The lateral osteotomy should be placed alongthe ascending process (also known as the frontalprocess) of the maxilla in the standard high-low-high fashion, which is illustrated Fig. 4.2 Carefulplanning of the lateral osteotomies will help thesurgeon avoid this complication. The guardedportion of the osteotome is oriented laterally, andthe surgeon continually palpates during the osteo-tomization process. In addition to careful pal-pation, the surgeon must listen for the distinctsound made when the osteotomy is being placedin the correct location along the ascending pro-cess of the maxilla. Percutaneous perforatinglateral osteotomies also lend a degree of safety.This problem is difficult to correct, and thereforestair step deformity must be avoided.

THE MIDDLE THIRDPollybeak Deformity

Pollybeak deformity results when the lower thirdof the dorsum is more projected than the tip.

Fig. 6. Noted dorsal narrowing after cartilaginous dorsal reduction. (From Toriumi DM. Management of themiddle nasal vault in rhinoplasty. Facial Plast Surg Clin North Am 1995;2(1):18; with permission.)

Complications of Rhinoplasty 645This is seen in Fig. 1. Overresection of the bonypyramid, underresection of the cartilaginous mid-dle third (specifically the anterior septal angle),and supratip fibrosis deep to the soft tissue enve-lope can all result in pollybeak.1 The first 2 arepreventable, whereas the third occurs postopera-tively in the setting of wound healing. Addition-ally, loss of tip support with subsequent tipptosis can result in a relative pollybeak. Palpationallows the surgeon to assess the dorsum and toFig. 7. Autospreader technique is shown. Upper lateral casuture repaired to the dorsal septum (B). (From Yoo S, Mostechnique: analysis of outcomes using a disease-specif2011;13(4):232; with permission.)determine if additional resection is necessary.Soft tissue pollybeak can be addressed with Ke-nalog injections to the affected area. The seniorauthor prefers to use a very conservative Kenalog10 mixed 1:10 or 1:5 with 1% lidocaine with1:100,000 epinephrine. It is critical that all Kena-log be injected deep to the dermis to avoiddermal thinning. Overaggressive injection can it-self cause divots from dermal or cartilaginousinjury.rtilage is scored (A), subsequently folded on itself andt SP. Nasal airway preservation using the autospreaderic quality-of-life instrument. Arch Facial Plast Surg

Surowitz & Most646Inverted V Deformity

The inverted V deformity results from accentuatedvisibility of the caudal margins of the nasal bonesafter dorsal reduction, as seen in Fig. 5. As illus-trated in Fig. 6, dorsal reduction causes narrowingof the cartilaginous dorsal width.3 As a result, theupper lateral cartilages become displaced inferi-orly and posteriorly, thereby accentuating thecaudal margin of the nasal bones.46 This defor-mity is further exaggerated if the bony base isnot appropriately narrowed after dorsal reduction.Repair of the upper lateral cartilages to the dorsalseptum and use of spreader grafts will help pre-vent this.6 The senior author routinely uses the au-tospreader upper lateral turn-in flaps, which areshown in Fig. 7.7Fig. 9. The keystone area is highlighted in red. (FromTardy ME, Toriumi DM Jr, Hecht DA. Functional andaesthetic surgery of the nose. In: Papel ID, editor.Facial plastic and reconstructive surgery. 2nd edition.Thieme; New York: 2002. p. 370; with permission.)Saddle Nose Deformity

The saddle nose deformity may be the result ofoverresection of the quadrangular cartilage withinsufficient dorsal strut. A postoperative saddledeformity is seen in Fig. 8. Inadvertent disarti-culation of the keystone area, in which thequadrangular cartilage fuses superiorly with theperpendicular plate of the ethmoid, may also resultFig. 8. Saddle nose deformity after prior rhinoplasty.in saddling. The keystone is shown in Fig. 9.8

Extracorporeal septoplasty is particularly proneto this and can be avoided using the anterior septalreconstruction technique.9

Saddle nose deformity can be difficult to correctand is best avoided. A mild saddle deformity maybe corrected with crushed cartilage camouflagedorsal onlay grafting. If disarticulation of thekeystone is noted intraoperatively, rib cartilagegraft may be used for reconstruction, providedthe patient has previously consented.TIP AND ALABossae

Bossae, as illustrated in Fig. 10, are the result ofvisible flexing and buckling of the alar cartilage.These deformities tend to become evident monthsto years postoperatively.10 Patients at risk for tipbossae are those with thin skin, strong alar carti-lages, and tip bifidity.10,11 Bossae can be avoidedthrough maintaining the strength and integrity ofthe alar cartilage, using structural grafting whennecessary, and symmetric reconstitution of thedomal subunit with tip sutures.12 Temporalisfascia or crushed cartilage may also be used inthin-skinned patients to help camouflage anyirregularities.

Fig. 10. Bossae are seen after prior rhinoplasty.

Complications of Rhinoplasty 647Visible Grafts

In thin-skinned individuals, tip grafts can becomevisible over time as the skin soft tissue envelopecontracts and thins. Therefore, avoiding tip graftsin very thin-skinned individuals is preferable,because this complication is often noted at a laterdate, after edema has decreased and the skinsoft tissue envelope has begun contracting, andmust be addressed with formal revision. The au-thors often use temporalis fascia as a camouflagegraft in thin-skinned patients if grafts must beused.Fig. 11. Pinched tip after prior rhinoplasty.Pinched Tip

A pinched tip may result from overaggressivecephalic resection of the lateral crura, which re-sults in weakening of the remaining rim strip(Fig. 11).13 Care must be taken to avoid overre-section during cephalic trim. The senior authorpreserves at least a 7-mm rim strip to avoid over-resection during cephalic trim. Malpositioning ofthe lateral crura, with the caudal border placedsignificantly inferior to the cephalic border, maysimilarly result in a pinched tip, as described byToriumi and Checcone14,15 and illustrated inFig. 12. Lateral crural repositioning and lateralcrural strut grafts may be used to facilitate appro-priate orientation of the lateral crura.1416Poorly Defined Tip

The poorly defined or amorphous tip can occur inthick-skinned individuals after tip deprojection andsuture modification. Recognizing thick skin preop-eratively and avoiding overaggressive deprojec-tion in thick-skinned individuals is key. JudiciousSNAS excision may be performed to help improvetip definition.

Nostril Asymmetries

Nostril asymmetries can occur from an unmaskedseptal deviation after caudal septal resection,

Fig. 13. Patient with both alar retraction and hangingcolumella after previous rhinoplasty.

Fig. 12. Pinched tip may result from malpositionedlateral crura, with caudal margin positioned signifi-cantly inferior to cephalic margin. (From ToriumiDM. New concepts in nasal tip contouring. Arch FacialPlast Surg 2006;8(3):162; with permission.)

Surowitz & Most648placement of a septal extension graft, or asym-metric tip modifications. It is important to recog-nize any preoperative nostril asymmetries andcounsel patients appropriately in this regard. Theauthors routinely perform a nostril check beforefinal closure to ensure appropriate symmetry.

Alar-Columellar Disproportion

Gunter and Friedman16 previously described thealar-columellar relationship and classification ofrelated deformities. This article focuses on alarretraction, columellar retraction, and hanging colu-mella. Fig. 13 shows both alar retraction and ahanging columella.Alar retraction may result from overly tight

closure of marginal incisions, especially as one ap-proaches the nasal facets. Careful attention toclosure of the marginal incisions can help avoidAlar retraction. Overaggressive resection duringcephalic trim can result in contracture of the lateralcrura superiorly with time and wound healing,thereby causing alar retraction.17 Lateral cruralspanning sutures placed too tightly may result inalar retraction.18 The orientation of the lateral crurais also of importance. As described by Toriumi andCheccone,15 the caudal margin of the lateral crurashould lie in a plane almost horizontal and orientedjust inferior to the cephalic margin. This techniqueprevents cephalic positioning of the lateral cruraand helps support the alar rim. Alar retractionmay be corrected with the use of alar rim graftsin minor cases (Fig. 14), with placement of earcomposite grafts in more severe cases (Fig. 15).17

Columellar retraction may result from overag-gressive resection of the caudal septum, medialcrura, or excessive setback of the medial crura af-ter placement of a tongue-in-groove suture.17 Anoverly resected caudal septum may be addressedwith a caudal septal extension graft with or withouttongue-in-groove repair of the medial crural foot-plates. Excessive setback after tongue-in-groovesuture is best addressed through revision ofthe tongue-in-groove until the desired effect isachieved. Columellar struts or plumping graftsmay also be helpful adjunctive measures in certaincases.A hanging columella may result from placement

of an overly large columellar strut graft, septalextension graft, or tip graft.17 Contributing anat-omy includes the caudal septum, medial crura, in-termediate crura, and membranous septum. Tipdeprojection and decreased rotation may alsocontribute.17 Depending on the origin, a hangingcolumella can be addressed by selective resectionof the caudal septum and tongue-in-groove suturetechnique.

Fig. 14. Placement of alar rim grafts. (From Kridel RW, Chiu RJ. The management of alar columellar disproportionin revision rhinoplasty. Facial Plast Surg Clin North Am 2006;14(4):326; with permission.)

Complications of Rhinoplasty 649COLUMELLA AND ALAR BASEScar Formation

Patients should be counseled about the potentialfor scar formation from the columellar incision inexternal rhinoplasty and with all alar base ex-cisions. Unsightly columellar scars, hypertrophicscars, and keloids are very uncommon. Alar baseexcisions put the patient at risk for visible scar for-mation. The columellar incision is performed usingan inverted V, so as to prevent scar formation.19Fig. 15. Auricular composite grafts may be used to addressof the scroll (A) or at the caudal margin of the lateral cruracolumellar disproportion in revision rhinoplasty. Facial PlasMeticulous attention to closure will help preventcolumellar and alar base scar formation.

AIRWAY

Nasal obstruction can occur as a result of externalnasal valve collapse, internal nasal valve collapse,septal deviation, and intranasal synechia forma-tion. Weak lateral crura can be reinforced withlateral crural strut grafts.16 Spreader grafts maybe used to widen the patency of the internal nasalalar retraction. These grafts may be placed at the level(B). (From Kridel RW, Chiu RJ. The management of alart Surg Clin North Am 2006;14(4):319; with permission.)

Surowitz & Most650valve.5,6,20,21 The senior author routinely uses au-tospreaders, as previously noted and illustratedin Fig. 7.7 Meticulous inspection of nostril sym-metry, position of the caudal septum, and an un-derstanding of the dynamics of the internal nasalvalve will help minimize postoperative nasalobstruction. Recurvature of the lateral crura mayalso result in nasal airway obstruction, especiallyafter maneuvers that narrow the nasal base, suchas alar base excisions. Lateral crural strut graftscan be used to mitigate recurvature.

SEPTUMSeptal Perforation

Septal perforation is a known risk of any septalsurgery and patients should be counseled in thisregard. Prior septoplasty places the patient at ahigher risk. Meticulous dissection of the mucoper-ichondrial flaps, with avoidance of lacerating themucosa on both sides directly opposing oneanother will help minimize the risk of perforation.If bilateral opposing perforations occur intraopera-tively, a crushed cartilage graft may be placed toallow mucosal healing.

Septal Hematoma

A septal hematoma is a risk of any septal surgery.These complications result when blood accumu-lates within any dead space between the elevatedmucoperichondrial flaps. Septal hematomas pre-dispose patients to infection and septal perfora-tion. Use of transseptal whip sutures, placementof inferiorly based drainage incisions, and use ofsoft silastic removable intranasal splints will helpminimize hematoma formation. Once a hematomadevelops, it should be drained immediately.

COSTAL CARTILAGE GRAFTS

Costal cartilage grafts, including autologous andhomologous, may become visible from warpingover time. This deformity occurs from the intrinsicproperties of cartilage. Concentric carving canmitigate this to some degree, but it is importantto counsel patients regarding the risk of cartilagewarping and subsequent irregularities or visibilityof the graft.Pneumothorax is a rare complication from autol-

ogous cartilage harvest. The risk of this is roughly1% and can usually be managed without a chesttube. Should the surgeon encounter a pneumo-thorax, the injury is usually confined to the parietalpleura.22 Management consists of inserting a ster-ile red rubber catheter into the wound, placing thedistal end of the catheter into sterile saline (as awater seal). Anesthesia then administers positivepressure ventilation and the wound is closed asthe catheter is removed. Patients should receivea postoperative chest radiograph and be admittedfor observation, with a repeat chest radiograph onthe morning of postoperative day one.Homograft costal cartilage has a theoretical risk

of resorption over time. Kridel and colleagues23

found no significant difference between autologousand homologous cartilage with regard to resorptionor infection. The senior author has been usinghomologous costal cartilage with good results inpatients who are not candidates for autologousgrafts because of age (ossification), severity ofobstructive sleep apnea, other comorbidities, orpatient preference. It is important to counsel pa-tients regarding the theoretical risk of resorption,although this does not seem to manifest clinically.SUMMARY

The dynamics of nasal aesthetics and functionare very complex, and therefore the potential forcomplications are myriad. A thorough understand-ing of nasal anatomy and how various surgicalmaneuvers affect both form and function is im-perative. Certain complications are within the sur-geons control, such as those related to technique,whereas those related to patient wound healingare out of the surgeons control. Careful patientselection, history, physical examination, photodocumentation, and patient counseling aboutappropriate expectations are important aspectsof the surgery and should not be underestimated.REFERENCES

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Complications of RhinoplastyKey pointsOverviewAsymmetriesThe bony pyramidOverresection of the Nasal BonesOpen Roof DeformityRocker DeformityStair Step Deformity

The middle thirdPollybeak DeformityInverted V DeformitySaddle Nose Deformity

Tip and alaBossaeVisible GraftsPinched TipPoorly Defined TipNostril AsymmetriesAlar-Columellar Disproportion

Columella and alar baseScar Formation

AirwaySeptumSeptal PerforationSeptal Hematoma

Costal cartilage graftsSummaryReferences