Keywords
rhinoplasty - dorsal nose skin necrosis - tretinoin
Introduction
Rhinoplasty is one of the most commonly performed procedures by plastic surgeons worldwide.[1]. Rhinoplasty complications can arise even for experienced surgeons, with complication
rates ranging between 4 and 18.8%.[2] Complications following rhinoplasty can be classified as hemorrhagic, infection,
traumatic, functional, and aesthetic. While the majority of these do not pose as a
life-threatening condition, major life-threatening complications such as rhinorrhea,
pneumothorax, and subarachnoid hemorrhage are rarely encountered.[3] Dorsal nasal skin necrosis postrhinoplasty is reported in less than 1% cases.[4] In this report, we discuss two patients who experienced dorsal nasal skin necrosis
following aesthetic rhinoplasty.
Patient 1: The first patient is a 32-year-old woman on topical tretinoin 0.05% for facial acne
treatment for 7 months. She underwent open rhinoplasty with cephalic trimming, minimal
defatting of the bulbous tip, and bilateral alar base reduction. Tip augmentation
was performed using a columella cartilage strut harvested from the nasal septum. Bilateral
lateral nasal bone osteotomies were performed, and diced cartilage was placed over
the nasal dorsum using a syringe. Steri-Strips were applied on the dorsal nose and
an aluminum Denver splint was safely applied. Upon removing the splint 1 week postoperatively,
full-thickness skin loss over the dorsal nose was observed, measuring 3 × 1 cm2.
Gentle debridement of the necrotic skin was performed, and local tissue advancement
was performed to downsize the wound surface. The wound was managed conservatively
with dressing changes. Six months after the wound healing, she received two sessions
of dermal hyaluronic acid filler injections to correct residual deformities, and an
aesthetically acceptable result was eventually obtained ([Fig. 1]).
Fig. 1 (A) Patient preoperative picture. (B) At 1 week postoperatively. (C) Local tissue advancement to minimize wound surface. (D) At 1 year postoperatively. The patient after complete wound healing and two sessions
of dermal fillers to correct residual deformities.
Patient 2: A 34-year-old woman presented with a crooked nose following rhinoplasty 2 years ago.
She had been using topical 0.05% tretinoin for acne for 6 months. We performed a secondary
open rhinoplasty with bilateral lateral osteotomies, spreader grafts, and a columellar
strut using a septal cartilage graft. Diced cartilage placement over the nasal dorsum
was done, and an aluminum Denver splint applied postoperatively. One week later, she
developed partial-thickness dorsal skin necrosis, which was managed nonsurgically
with dressing changes. Six months after the wound had healed, she underwent facial
carbon dioxide laser resurfacing and a touch-up session with hyaluronic acid fillers
([Fig. 2]).
Fig. 2 (A) Pre-op. (B) At 1 week post-op. (C) At the 1-year follow-up.
Discussion
Complications postrhinoplasty are very stressful for both the patient and the surgeon.
Although rarely reported, skin necrosis postrhinoplasty can present as superficial
or full-thickness skin loss. Typically, superficial necrosis occurs due to overly
tight bandaging or dressing. These cases are usually managed conservatively, and if
necessary, revision procedures can be performed after the scar has matured. Full-thickness
skin necrosis, on the other hand, typically necessitates secondary surgery and is
associated with much less satisfactory outcomes. Smoking is a known risk factor for
skin necrosis postsurgery,[5] but none of our patients were smokers. Both our patients reported were on topical
0.05% tretinoin for acne treatment and we queried if this had a role in the complications.
Since the U.S. Food and Drug Administration (FDA) approved tretinoin in 1971, retinoids
alone or combined with other agents have become the mainstay of acne treatment.[6] Isotretinoin, an oral retinoid, is also commonly used to treat inflammatory skin
conditions, genodermatoses, skin cancer, and other skin disorders. This is due to
its anti-inflammatory, immunomodulatory, and antineoplastic properties.[7] Low-dose isotretinoin has been safely utilized as an adjunct in rhinoplasty to enhance
skin thinning and improve outcomes. Yahyavi et al demonstrated that oral isotretinoin
20 mg daily given for 2 weeks before surgery and up to 2 months following the surgery
was safe and associated with better aesthetic outcomes.[8] Additionally, Blough et al reported starting oral isotretinoin, 20 mg daily, as
early as 1 week to 2 months before surgery.[9] However, the use of isotretinoin before rhinoplasty surgery still has many controversies[9] as there are no universal criteria regarding the duration or dosage. Currently,
there are limited data on the safety of topical retinoids prior to rhinoplasty. In
patient 1, bilateral alar base reduction and open rhinoplasty were performed. In both
patients, nasal dorsal dissection was performed in a loose areolar tissue plane on
the cartilaginous vault and the subperiosteal plane on the bony vault with minimal
trimming of the fibrofatty tissues performed.
The senior author has performed simultaneous alar base reductions and open rhinoplasty
over the years with no such complications; however, we still queried if this combination
was a contributing factor in patient 1. Simultaneous alar base reduction and open
rhinoplasty have been proven to be safe over the years.[10]
Although dealing with these complications postrhinoplasty can be very frustrating
to both the patient and the surgeon, it is crucial to refrain from being surgically
aggressive in the early healing phase. Multiple surgeries might worsen the outcome
or create a more distorted anatomy. Nonsurgical options such as dermal fillers and
laser therapy can be safely utilized to achieve aesthetically pleasing results. However,
we recommend utilizing these modalities at least 6 months after the external wounds
have resolved.
While we are unable to provide definite recommendations, we believe this report raises
important considerations that merit further investigation. There may be a need to
study the long-term use of topical retinoids prior to rhinoplasty. Alternatively,
enhanced precautionary measures should be considered for patients undergoing rhinoplasty
while on long-term topical retinoid therapy.
Based on this experience, we routinely advise patients to discontinue topical retinoid
use for at least 6 weeks before rhinoplasty. Additionally, it is crucial to thoroughly
review a patient's current topical regimens to exclude retinoids, as this was discovered
later in the cases reported above. However, we acknowledge the need for further studies
with larger patient populations or multicenter studies to evaluate the safety of topical
retinoids in rhinoplasty and draw more reliable conclusions.
Nonsurgical aesthetic techniques, such as dermal fillers, and lasers serve as valuable
adjuncts in the management of postrhinoplasty complications and whenever suitable
should be considered as an alternative approach without additional surgery.
