Rhinoplasty risks

Some bleeding during and immediately after rhinoplasty is expected and normal. Post-operative ooze from the nose in the first 24–48 hours is common and managed with nasal dressings. More significant bleeding may require nasal packing, cauterisation, or, rarely, a return to theatre.

A septal haematoma — a collection of blood between the septal cartilage and its overlying lining — is a specific and serious concern. If not promptly drained, it can cut off the blood supply to the septal cartilage, causing cartilage necrosis and saddle-nose deformity. Patients must be aware of the signs: increasing pain, progressive nasal blockage, and a sensation of pressure or fullness in the nose. Contact Dr Roth immediately if these develop.

Blood-thinning medications and supplements — including aspirin, ibuprofen, fish oil, vitamin E, and certain herbal supplements — must be stopped at least two weeks before surgery.

Infection following rhinoplasty is uncommon — the face and nose have a good blood supply. However, infections can range from superficial wound infections manageable with oral antibiotics to deeper infections involving the nasal cartilage or bone, requiring intravenous antibiotics and surgical drainage.

A septal abscess is rare but serious — left untreated, it can cause rapid destruction of septal cartilage. In cases where rib cartilage grafts have been used, infection risk is somewhat higher as rib cartilage takes longer to integrate into the blood supply.

Signs of infection — increasing redness, warmth, swelling, discharge, fever, or worsening pain — should prompt immediate contact with Dr Roth.

In closed rhinoplasty, all incisions are internal and there are no external scars. In open rhinoplasty, a small incision is placed across the columella, which is generally not visible in everyday social interaction once healed. Potential scar-related outcomes include:

• Hypertrophic scarring — the scar becomes raised and thickened. Uncommon on the columella but more likely in patients with a history of hypertrophic scarring or in darker skin types. Managed with silicone, steroid injections, or laser.
• Widened or visible scar — if the wound heals under tension or is disrupted by complications.
• Columellar notching — an irregular contour from scar contraction, occasionally requiring minor revision.

Internal scarring (fibrosis) within the nose can also occur regardless of technique, affecting both the final shape and nasal airway function.

Changes to nasal breathing after rhinoplasty are one of the most significant functional risks. Nasal obstruction can result from:

• Internal nasal valve compromise — reducing the dorsum without adequately supporting the upper lateral cartilages can narrow the internal valve. Addressed with spreader grafts.
• External nasal valve collapse — weakening of the lower lateral cartilages can cause alar wall collapse on inspiration. Addressed with alar batten or lateral crural strut grafts.
• Septal deviation — if the septum is not adequately addressed or septal support is compromised during graft harvest.
• Swelling and scar tissue — can temporarily or persistently narrow the nasal passages.
• Collapse of the nasal framework — particularly with aggressive reduction without adequate support in patients with thin or weak cartilage.

In some patients, rhinoplasty actually improves nasal breathing — particularly in functional rhinoplasty where septoplasty and turbinate reduction are performed simultaneously. However, any pre-existing nasal breathing problems must be assessed and addressed as part of the surgical plan.

• Numbness of the nasal tip — almost universal after open rhinoplasty. Gradually recovers over three to twelve months in most patients. Occasionally persistent.
• Hypersensitivity — as nerves regenerate, some patients experience increased sensitivity or tingling at the tip. Usually resolves over time.
• Dental numbness — the upper front teeth and gums may feel numb due to proximity to the surgical field. Usually temporary, resolving over weeks to months.
• Persistent pain — most patients find rhinoplasty less painful than expected. Persistent pain around the nose, forehead, or teeth should be reported to Dr Roth for assessment.

Swelling after rhinoplasty is more prolonged than many patients anticipate:

• Early swelling — significant swelling and bruising in the first one to two weeks. Most patients are socially presentable by two to three weeks.
• Intermediate swelling — around 70–80% of swelling resolves by three months. The nose may appear larger or different from the intended result during this phase.
• Residual swelling — the final 20–30% — mostly at the nasal tip — can take twelve to twenty-four months. In patients with thick skin, this may be longer. The final result cannot be evaluated until all swelling has resolved.

A supratip deformity — where the area just above the tip appears full in the first months as tip swelling resolves — is common and expected. This is not a sign that something has gone wrong.

Temporary reduction in the sense of smell after rhinoplasty is common, largely due to post-operative mucosal swelling, crusting, and congestion. As swelling resolves, smell typically recovers fully.

In a small number of patients, smell may be persistently reduced, altered, or, rarely, lost — due to injury to the olfactory epithelium during dissection or from significant scarring. Distorted smell (parosmia) is a less common but recognised complication. These outcomes are rare but may be permanent if the olfactory nerve endings are significantly damaged.

A septal perforation is a hole in the cartilaginous nasal septum. It occurs when the mucosal lining is torn on both sides of the septum at the same level, and the cartilage between the tears loses its blood supply and resorbs.

Small perforations may be asymptomatic. Larger perforations can cause a whistling sound, crusting, recurrent nosebleeds, progressive enlargement, and — in very large perforations — saddle nose deformity. Surgical repair is technically demanding and not always successful. Prevention through careful dissection and prompt repair of tears during surgery is the primary management strategy.

A CSF leak — where fluid surrounding the brain escapes through a skull base defect — is a rare but serious complication. In rhinoplasty it is most relevant when surgery involves the nasal roof. It typically presents as a persistent clear, watery, unilateral nasal discharge that increases when bending forward, possibly with headache.

An unrecognised CSF leak creates a pathway for bacteria to enter the intracranial space, with risk of meningitis. Any clear, persistent, watery nasal discharge after rhinoplasty should be reported to Dr Roth immediately. This is an extremely rare complication of routine rhinoplasty but is mentioned because it represents one of the most serious potential outcomes.

Rhinoplasty is one of the procedures with the highest revision rates of any elective surgery. Even with excellent technique, the outcome is influenced by factors outside the surgeon’s direct control — particularly how the patient’s tissues heal, how much scar tissue forms, and how the skin redrapes over the new framework.

Common reasons for dissatisfaction or revision include: residual deformities not fully corrected, over-correction producing new deformities, asymmetry, tip irregularity, pollybeak deformity, inverted-V deformity, or collapse of nasal structures over time.

Minor imperfections are common and not all require revision. Where revision is indicated, it should not be undertaken until at least twelve months after the primary procedure — and ideally eighteen months — to allow all swelling to fully resolve and scar tissue to mature. Revision rhinoplasty is significantly more complex than primary surgery.