Complications of Rhinoplasty - Page 14

Deviated Nose

Persisting deviation after rhinoplasty may occur at the upper third, middle third, or tip of the nose, or may occur postop­eratively in a previously straight nose. Preoperative anatom­ ical diagnosis is a critical component of successful treatment. Persisting deviation of the nasal bones may occur due to greenstick fractures or other problems with osteotomies. Inherent deviations in the cartilage of the middle nasal vault may prove especially challenging. Also, hump removal may uncover asymmetries that result in postoperative deviation where none existed previously. Tip asymmetry may be over-looked preoperatively, or it may be due to asymmetrical exci­sion of lateral crura, asymmetrical placement of a columellar strut, or placement of an overlong columellar strut, as well as other causes. A number of surgical maneuvers are available to address the deviated nose.

UPPER THIRD OF THE NOSE
Specific Complications

Rocker Deformity
If osteotomies are taken too high (into the thick frontal bone) the superior aspect of the osteotomized nasal bone may pro­ject or "rock" laterally when the bone is infractured. This is a "rocker" deformity. A 2-mm osteotome may be employed percutaneously to create a more appropriate superior frac­ture line and thus correct the rocker deformity.

Dorsal Irregularities
After creation of an "open roof" by hump removal, the bony margins should be smoothed with a rasp. Any bony frag­ments should be removed, with care taken to ensure that all obvious particles are removed from under the skin/soft tissue envelope. Failure to remove all fragments may lead to a visible and/or palpable dorsal irregularity.

Bony dorsal irregularities are a well-recognized compli­ cation of rhinoplasty. In the search for an approach that could reliably assure a smoother contour without sharp edges, irregularities, or asymmetries, surgeons have reported on the use of various onlay grafts, including homograft sclera,' gelatin film, temporoparietal fascia," and superficial musculo-aponeurotic system (SMAS). Becker et al have described the use of a powered drill or rasp, which they thought might decrease the incidence of dorsal irregularities. The multiple proposals in the literature on this subject may suggest the lack of a completely satisfactory solution.

"Open-Roof" Deformity
After hump removal, the free edges of the nasal bones are palpable beneath the skin/soft tissue envelope. Failure to per -form lateral osteotomy, or inadequate osteotomy, results in an open-roof deformity. Lateral osteotomies are typically undertaken to "close" the open roof.

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