Box 2: Complications of rhinoplasty

Bossae
Bossae are caused by a knuckling of lower lateral cartilage at the nasal tip owing to contractural healing forces acting on weakened cartilages. Patients with thin skin, strong cartilages, and nasal tip bifidity are especially at risk. Excessive resection of lateral crus and failure to eliminate excessive interdomal width may play some role in bossae formation.

Pollybeak
Pollybeak refers to postoperative fullness of the supratip, with an abnormal tip-supratip relationship. It has several etiologies, including failure to maintain adequate tip support (postoperative loss of tip projection), inadequate cartilaginous hump (anterior septal angle) removal, or supratip dead space/ scar formation.

Treatment depends on anatomic cause. If the cartilaginous hump was underresected, one should resect additional dorsal septum. Also, one must ensure adequate tip support. Maneuvers such as placement of a columellar strut may be beneficial. If the bony hump was overresected, one should consider a graft to augment the bony dorsum. If a pollybeak is from excessive scar formation, triamcinolone (Kenalog) injection or skin taping should be considered in the early postoperative period, before any consideration of surgical revision.

Inverted V deformity
Inadequate support of the upper lateral cartilages after dorsal hump removal can lead to inferomedial collapse of the upper lateral cartilages and an inverted V deformity. In this deformity, the caudal edge of the nasal bones is visible in broad relief, frequently owing to inadequate infracture of the nasal bones. When executing hump excision, it is helpful to preserve the underlying nasal mucoperichondrium (extramucosal dissection), which provides significant support to the upper lateral cartilages and helps decrease the risk of inferomedial collapse of the upper lateral cartilages after hump excision. When undertaking osteotomies after hump excision, appropriate infracture and narrowing of the bony vault must be achieved.

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 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, ensuring that all obvious particles are removed from under the skin-soft tissue envelope. Failure to remove all fragments may lead to a visible or palpable dorsal irregularity.

Nasal valve collapse
The surgeon should recognize the existence of the internal and external nasal valve. The internal nasal valve is bounded by the caudal margin of the upper lateral cartilage, septum, and floor of the nose. The external nasal valve refers to the area delineated by the cutaneous and skeletal support of the mobile alar wall. Excessive narrowness in either of these locations may cause nasal obstruction. Weakness at either of these locations may result in collapse with the negative pressure of inspiration, resulting in nasal airway obstruction. Nasal valve collapse is seen most often as a sequela of overresection of lateral crura or middle vault collapse. Over aggressive resection of the lateral crura and the subsequent postoperative soft tissue contraction frequently lead to nasal valve compromise.