Skin Necrosis Following Rhinoplasty: A Review and Proposed Strategy on Identifying High-Risk Patients

Abstract

Vascular compromise leading to cutaneous loss following surgical rhinoplasty is a devastating complication. The objective of this review is to identify all reported cases in literature published in English and summarize the current evidence to identify the patients at risk of this complication following surgery. A comprehensive literature review using Medline and Embase databases was performed to capture all reported cases of cutaneous vascular compromise following rhinoplasty from database inception through September 2020. Nonsurgical rhinoplasty cases were excluded. We identified eight studies that featured vascular cutaneous compromise following surgical rhinoplasty. A total of 18 patients were included in the analysis. The majority of the patients were females with a mean age of 30.9. Risk factors included smoking in 23.5% patients and revision setting. Extensive tip thinning, tight splinting and taping with dorsal onlay grafting, or combining extended alar base excision with revision open rhinoplasty were among surgical techniques associated with vascular compromise. The most commonly affected aesthetic nasal subunit in our review was the dorsum followed by the nasal tip. Conservative management primarily was utilized in 72.2% of patients, allowing the defect to heal by secondary intention. Studies reporting on cutaneous vascular compromise following surgical rhinoplasty are of low level of evidence. This review is the largest summary reporting on this complication to date, aiming to caution surgeons about associated techniques and management options. We also share an expert opinion on preoperative assessment of nasal skin to guide surgeons to potentially avoid rhinoplasty surgery in this subset of patients.

Functional Nasal Surgery in a Compromised Soft Tissue Envelope

“…But, it poses the greatest risk in the setting of a compromised soft tissue envelope. 7 Flap ischemia reported in those settings can be avoided with meticulous sub-SMAS dissection. In these cases the tissue planes are obliterated with scar leading the surgeon into the dangerous subcutaneous plane.…”

“…Severe contracture must be addressed first, whether with composite cartilage grafts, mucosal grafts, or even flaps to expand the internal lining (►Fig. 7).…”

“…Early signs of vascular compromise are well studied and include findings such as delayed capillary refill (>2 s), mottled, pale or violaceous skin color, tense or edematous STE, poor bleeding, or dark blood color with pinprick. 7 These signs of skin compromise can be seen as early as the closing of the columellar incision. Increased tension at the time of skin closure can disrupt the blood flow and result in signs of ischemia.…”