Risks & Complications Of Secondary Rhinoplasty

It is possible to develop tiny red marks, "spots" or general redness post-op. This can be the result of blood vessels that may have burst under the skin's surface during the surgery, although this is extremely infrequent it can happen and the "spots" may not ever go away. Scarring is minimal if the incisions are made inside of the nose, however when an "open" technique is used, or if extreme narrowing of the nostrils is desired the scars made on the outside of the nose may be visible for am undetermined amount of time (Usually until maturation). Even when a highly skilled surgeon performs your surgery, sometimes your body may not heal "correctly" or have adverse reactions causing undesired results. If so it is quite possible that additional surgeries may be needed. Some patients will lose their sense of smell, temporarily. Your nose may be swollen and for up to a year - and in some patients over that period. In rare cases, the scar tissue may heal in a way that may cause a "whistling" sound to be heard when you breathe in and out.

As you know, rhinoplasty, in general, has the highest rate of revisions. This surgery is considered to be a type-changing surgery. It seems that some patients, especially mature patients, may not readily accept the new look. Being accustomed to their "old" nose they just can't seem to comfortably make the transition. Although there are a few rhinoplasties that just don't heal right, due to something as serious as human error (the doctor's) or as simple as not having your head elevated enough or sleeping on one side a lot without a proper cast. The nose can "pull" to one side if the cast does not support it properly in the first few weeks. Or quite simply, your body may just heal that way.

Although this next topic is controversial and unproven - it is speculated. One complaint that has been reported by many rhinoplasty patients is the appearance of "hollow eyes". This is where patients complain of a sunken look which is usually due to sub-Orbicularis oculi fat (SOOF) loss. This can happen due to age, genetics, trauma, elective surgery or lipodystrophy disorders. Just be sure to take a pre-operative (before) photo and compare it to an after photo a year later. Notice your eyes and note any changes, Of course realize if you are in your late twenties, SOOF loss is a common unfortunate occurrence.

Loose skin IS a problem however and can be apparent especially with significant refining. This should alleviate itself although it very well may not. Speak with your surgeon further on this to get a general idea of the percentage of cases where this remains permanent.

Depression After Rhinoplasty?
It has been reported that disrupting the sensitive receptors such as the Turbinate structure - 3 flexible spongy "flaps" which moisten and control the temperature of the air which you breathe - in the nose can lead to minor disorientation and depression for several weeks and sometimes months after rhinoplasty or Septoplasty. Unfortunately, there is no sure fire way to know that this is the reason for uneasiness as you could generally be depressed due to being psychologically unable to accept your bruises and discolorations or swelling. As well as disliking the shape of your new nose or experiencing discontent, both bodily and mentally, from your medications.

Depression is possible from the pain medications, anesthesia, antibiotics and even from constipation from the aforementioned variables. Please take this into account and be prepare mentally so that you may recover more easily or so that a loved one may know what to expect. This way they can be certain to prepare and to provide means for you to be "cheered up" or supported. Just remember that many patients go through this.

If anything you must remember that your rhinoplasty takes about 10 months to a year to fully refine although most of the swelling that others may notice will dissipate in a few months. Please be sure to choose your doctors wisely when it comes to rhinoplasty as secondary (revision) surgery is more difficult to perform due to scar tissue and less tissue to work with in general. In other words, it is easier to remove than to replace.

It is possible if you have a Rhinoplasty, Septoplasty or Turbinectomy that the Turbinate structure can be harmed and cause physical ailments as well. Be sure that your doctor advises of you of the risks and complications resulting from rhinoplasty and even though rare, Turbinate damage is possible causing a few of the below problems. Turbinate damage, especially of the medial or middle turbinate (like mine) can occur during the infracture (breaking of the nasal bones to make them thinner), from instruments or just plain 'bad luck'. This can also cause nonallergic rhinorrea (runny nose) for many months (which is normal anyway) but that persists after a year or even permanently. 

You can also experience quite the opposite: nasal dryness and bleeding due to this dryness. Headaches can persist as well as depression but depression is unfortunately a common temporary affliction after surgery. There is just a difference in standard and expected depression as opposed to non-typical persistent, unexplained depression.


Secondary Contraindications
& Complications - Anesthesia 

(This is also included on the anesthesia page, if you have already read the Anesthesia Information page you may skip this section.)

Causes of anesthesia-related death are usually linked to the respiratory system. These include insufficient intubation or proper ventilation which results in hypoxia:

hyp*ox*ia (noun)
[New Latin] First appeared 1941
: a deficiency of oxygen reaching the tissues of the body
-- hyp*ox*ic (adjective)

But this was usually because the older monitors were not very good. Medical Science has progressed very much in that respect. 

Complications are mostly related to General Gaseous-state anesthesia and may include:

  • laryngospasm: la*ryn*go*spasm (noun) : spasmodic closure of the larynx 

  • bronchospasm: bron*cho*spasm (noun) : constriction of the air passages of the lung (as in asthma) by spasmodic contraction of the bronchial muscles 

  • aspiration: as*pi*ra*tion (noun) 3 : the taking of foreign matter into the lungs with the respiratory current 

  • intubation injury: The teeth, lips, pharynx, esophagus, larynx and trachea may be injured by the tube which is placed down your throat.

  • pulmonary edema: pul*mon*ary e*dem*a (noun) : abnormal accumulation of fluid in the lungs

  • respiratory arrest: (noun) Cessation of breathing. the condition of being stopped

Cardiovascular complications:

  • myocardial ischemia/infarction,: of or relating to the myocardium: myo*car*di*um plural -dia  (noun): the middle muscular layer of the heart wall

    • myocardial ischemia (noun) : localized tissue anemia due to obstruction of the inflow of arterial blood (as by the narrowing of arteries by spasm or disease) 

    • myocardial infarction (noun) : infarction of the myocardium that results typically from coronary occlusion

  • cardiac failure: *see heart failure: (noun) 1 : a condition in which the heart is unable to pump blood at an adequate rate or in adequate volume

  • cardiac arrest: (noun) : temporary or permanent cessation of the heartbeat which may be secondary to an underlying respiratory problem.

  • emboli: em*bo*lus (plural -li) (noun) : an abnormal particle (as an air bubble) circulating in the blood

    • possible causes:

      • clots

      • air bubbles

      • orthopedic stimuli

  • hypotension: hy*po*ten*sion (noun) 1 : abnormally low pressure of the blood -- called also low blood pressure...

    • possible causes:

      • hypovolemia: (noun) : decrease in the volume of the circulating blood 

      • massive hemorrhage: massive bleeding

      • anaphylaxis: (noun) 1 : hypersensitivity (as to foreign proteins or drugs) resulting from sensitization following prior contact with the causative agent. Also affects the pulmonary system (lungs)

      • drug overdose

  • malignant hyperthermia: (noun) : a rare inherited condition characterized by a rapid, extreme, and often fatal rise in body temperature following the administration of general anesthesia 

  • machine malfunction

  • liver or kidney injury

  • stroke: (noun) : sudden diminution or loss of consciousness, sensation, and voluntary motion caused by rupture or obstruction (as by a clot) of an artery of the brain

  • ventricular tachycardia (rapid heartbeat of 100-200 bpm)

    • possible causes:

      • hypoxia: (noun) : a deficiency of oxygen reaching the tissues of the body 

      • Increased CO2: increased carbon dioxide

      • Decreased K+ (vitamin K) : (noun) 1 : either of two naturally occurring fat-soluble vitamins that are essential for the clotting of blood because of their role in the production of prothrombin in the liver and that are used in preventing and treating hypoprothrombinemia and hemorrhage: 

      • Digitalis toxicity

      • Acid-base imbalance (see Acidosis): (noun) : a condition of decreased alkalinity of the blood and tissues marked by sickly sweet breath, headache, nausea and vomiting, and visual disturbances and usu. a result of excessive acid production

  • electromechanical dissociation (EMD) ("Clinically, a description of EMD covers a spectrum of bradycardic (relatively slow heart action whether physiological or pathological), to tachycardic (relatively rapid heart action whether physiological (as after exercise) or pathological), arrhythmias associated with pulselessness (excluding V-Tach or V-Fib). 
    *According to new AHA guidelines, EMD is now known as PEA (Pulseless Electrical Activity" J Bergsbaken, University of Wisconsin).

    • possible causes:

      • Hypovolemia

      • Hypoxia: (noun) : a deficiency of oxygen reaching the tissues of the body 

      • Cardiac tamponade: (noun) : mechanical compression of the heart by large amounts of fluid or blood within the pericardial space that limits the normal range of motion and function of the heart 

      • Tension pneumothorax: (noun): pneumothorax resulting from a wound in the chest wall which acts as a valve that permits air to enter the pleural cavity but prevents its escape

      • Pulmonary embolus: a clot that reaches and affects the lungs

      • Acidosis: (noun) : a condition of decreased alkalinity of the blood and tissues marked by sickly sweet breath, headache, nausea and vomiting, and visual disturbances and usu. a result of excessive acid production

      • Hyperkalemia: (noun) : the presence of an abnormally high concentration of potassium in the blood -- called also hyperpotassemia 

      • Hypothermia: (noun) : subnormal temperature of the body. *some surgeons automatically wrap you in thermal or thermal-compression blankets to keep your blood circulating well and your body warm)

Lidocaine Toxicity:
Lidocaine toxicity is something that can occur with way too many injections of Lidocaine. A common procedure requiring vast amounts of Lidocaine is Tumescent and Super-Wet Technique Liposuction.

"Maximum dose of plain lidocaine is 5mg/kg (7mg/kg max dose for lidocaine with epinephrine).  So for a 30-kg patient the maximum is 150 mg total.  A concentration of 1% means 1 gm lidocaine per 100cc which equals 10mg/cc.  Total volume which can be injected is therefore: 15cc.

Lidocaine freely crosses the blood-brain barrier. Early symptoms are CNS-related including headache, tinnitus, restlessness, facial twitching, lightheadedness, metallic taste, numbness of the lips and tongue.  At higher dose levels, one may see: seizures, loss of consciousness, apnea, and CV collapse.  CV manifestations are rarer; these are related to direct myocardial depression through depression of vascular smooth muscle and conducting system.  At very high doses, one will see: hypotension, labile heart rate, and v-fib arrest.

Treatment for seizures: hyperventilate with 100% O2, diazepam (thiopental if symptoms persist).  Treat low blood pressure with fluids, trendelenberg, and pressors if required.  Arrhythmia may be refractory (inadvertant IV marcaine) and require prolonged rescuscitation.

Mechanism of local anesthetics is by blocking nerve conduction.  Anesthetic diffuses passively through cell membrane, becomes charged, blocks Na+ channel, and prevents action potential." Yale Medical University Core Curriculum

Major organ systems

    "- Pre-existing cardiac or pulmonary disease may require reduced dosage because sedative and analgesic medications tend to cause cardiovascular and respiratory depression.

    - Hepatic and renal abnormalities may impair drug metabolism and excretion resulting in longer duration of drug action." Adapted from the American Society of Anesthesiologists
    Guidelines on Sedation and analgesia by Non-Anesthesiologists, source: www.GasNet.org

Smoking Tobacco & Illegal Substances

"- Smoking increases risk of airway irritability, bronchospasm, or cough during sedation. "Adapted from the American Society of Anesthesiologists
Guidelines on Sedation and analgesia by Non-Anesthesiologists, source: www.GasNet.org

Physical Disorders or Attributes

"- Previous problems with anesthesia or sedation

- Stridor, snoring, or sleep apnea

- Dysmorphic facial features (e.g. Pierre-Robin syndrome, trisomy 21)

- Advanced rheumatoid arthritis

- Habitus (extreme obesity)

- Small opening (<3 cm in an adult); edentulous [toothless], protruding incisors; loose or capped teeth; high arched palate; macroglossia; [enlarged tongue] tonsillar  hypertrophy [enlarged tonsils]; nonvisible uvula [: the pendent fleshy lobe in the middle of the posterior border of the soft palate; or in English: the little thing that hangs in the back of your mouth]

- Micrognathia [: abnormal smallness of one or both jaw], retrognathism [: a condition characterized by recession of one or both of the jaws], trismus [: spasm of the muscles of mastication (chewing) resulting from any of various abnormal conditions or diseases (as tetanus) ], significant malocclusion [: improper occlusion (bringing together); esp : abnormality in the coming together of teeth]"

Adapted from the American Society of Anesthesiologists Guidelines on Sedation and analgesia by Non-Anesthesiologists, source: www.GasNet.org

Medication and Supplement Contraindications Regarding Anesthesia

There are some medications and supplements that you simply should not be consuming before and after going under anesthesia, although this may be a partial list please talk this over with your surgeon!

  • Ginseng may cause rapid heartbeat/and or high blood pressure in some individuals.

  • St. John's Wort, Yohimbe, ("The natural ViagraŽ") and Licorice root  have a mild monoamine oxidase (MAO) inhibitory effect and may intensify the effects of anesthesia. (*note some well known and popular anti-depressants are MAO inhibitors, disclose any and all medications you are taking - your life may depend on it!)

  • Melatonin decreases the amount of anesthesia needed for surgery.

  • Echinacea may have a severe impact on the liver when general anesthesia is used. Please advise your surgeon of all medications and supplements and alert him to the possible effects of herbal supplements and remedies, he may not be aware of the contraindications.

Special Medication Alerts

If you are on Anti-depressants, please advise your doctor. Some monoamine oxidase (MAO) inhibitors (also known as MAOI) intensify the effects of the anesthesia - especially General. This could be quite dangerous in the operating room if your doctor is unaware of your medication usage. If you advise your doctor he or she can make adjustments for your anesthesia or at least will watch for the slightest decrease in heart or breathing rate.

These medications may include: Isocarboxazid, Marplan, phenelzine (Nardil, Nardelzine)
tranylcypromine (Parnate, Sicoton), Deprenyl, selegiline hydrochloride, They are used for the treatment of depression, obsessive-compulsive disorder, eating disorders, essential hypertension (pargyline), chronic pain syndromes, and migraine headaches. They work by inhibiting nerve transmissions in brain that may cause depression. Tranylcypromine and phenelzine account for over 90% of all MAO inhibitors currently prescribed. 

It is reported that drug interactions can occur even weeks after discontinued use of an MAOI. Therefore, in patients undergoing General anesthesia, cessation of usage is normally instructed several weeks prior to surgery to avoid possible cardiovascular effects. Although, I know of several patients who never were instructed to cease their medications and were perfectly fine.

"Anesthetic Requirements: Anesthetic requirements are increased, reflecting accumulation of norepinephrine in the CNS." Ref: Stoelting, R.K, Pharmacology & Physiology in Anesthetic Practice, pp. 378-381

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