Oral Maxillofacial Surg Clin N Am 15 (2003) 265 – 283
Complications associated with facial cosmetic surgery
G.E. Ghali, DDS, MD, FACS*, Jason H. Lustig, DDS, MD
Division of Oral and Maxillofacial Surgery, Louisiana State University Health Sciences Center, 1501 Kings Highway,
Shreveport, LA 71130-3932, USA
General considerations
Most individuals who seek esthetic facial surgery
are in good health and lack a major systemic physical
ailment. A surgeon’s task is to improve on this natural
state and avoid any major surgical complications. The
only sure way to avoid surgical complication is to
avoid surgery. Many potential complications can be
prevented by careful assessment of the patient pre-
operatively. During the preoperative visit, the
patient’s motives and expectations should be elicited.
As a result, the patient is fully informed as to the
reality of surgery and the possible complications. It is
necessary for the patient to articulate the problem and
for the surgeon to comprehend the patient’s view of
his or her deformity and the reason for having
surgery. Certain behavioral characteristics of the
patient should alert the surgeon:
 Misses or is late for appointments
 Has a long list of written questions
 Has a history of multiple previous esthetic
surgeries
 Has pending litigation
 Is indecisive or focuses on minutiae
 Denigrates past surgeons
 Effusively offers you praise
 Is rude or demanding of the office staff
 Is undergoing recent life change
By selecting only individuals with proper moti-
vations for surgery, most patients with unreasonable
* Corresponding author.
E-mail address: gghali@lsuhsc.edu (G.E. Ghali).
1042-3699/03/$ – see front matter D 2003, Elsevier Inc. All rights reserved.
doi:10.1016/S1042-3699(03)00015-3
expectations are eliminated. Hopefully, the remain-
der of the patients may be educated to expect
reasonable results and be prepared for surgery and
the postoperative course. Well-motivated patients
whose expectations are unrealistic must undergo
educational modification before surgery. When sur-
gical complications do occur, they are best managed
early and in an aggressive fashion. Close super-
vision by the surgeon and direct acknowledgment
of the problem make it less likely for patients to
become unhappy and institute legal action. Frequent
office visits and referrals to appropriate specialists
also help to ensure that problems are identified
early and managed appropriately. The more the
patient knows and is better informed, the greater
the chance that his or her expectations will be
satisfactorily achieved.
Blepharoplasty
Blepharoplasty is one of the most commonly
performed cosmetic facial surgical procedures in the
United States. Complications of blepharoplasty may
be major or minor and temporary or permanent. Most
complications associated with eyelid surgery can be
prevented by careful preoperative examination of
the patient. Before surgery, all prospective patients
should be evaluated for certain ophthalmologic con-
ditions, such as glaucoma, detached retina, corneal
abrasions, epiphora, dry eyes, lid laxity, lid and brow
ptosis, levator function, lid crease asymmetry, and
even visual loss (Fig. 1). Systemic diseases that may
affect the eyes and adnexal structures, such as renal
or thyroid disease, diabetes, cardiovascular prob-
lems, hormonal effects, Sjögren’s disease, or previous
266 G.E. Ghali, J.H. Lustig / Oral Maxillofacial Surg Clin N Am 15 (2003) 265–283

Fig. 1. Preexisting unilateral lid ptosis in a patient with

Saethre-Chotzen syndrome.

trauma, must be ruled out; formal ophthalmologic

examinations may be indicated.

Major complications

Lid malposition
Malposition of the eyelid, the most common
complication of blepharoplasty, can be prevented in
most cases by careful preoperative evaluation and
good surgical technique [1 – 6]. Lid malposition can
range from simple canthal rounding to increased
scleral show to frank ectropion. Mild to moderate
scleral show postoperatively is common and to be Fig. 2. Instructing the patient to look up with the mouth open
expected. On the other hand, persistent lower lid places the lower lid skin on slight tension or stretch, which
ectropion gives an unacceptable result and can lead may help avoid excess skin excision.
to permanent eye damage. The immediate postoper-
ative ectropion caused by periorbital edema and caudal direction. If it takes more than 1 second for the
chemosis is a normal reaction and often self-limiting. lower eyelids to resume their normal position against
The importance of preoperative assessment cannot the globe, significant eyelid laxity also may be present.
be overemphasized relative to the potential for the Ectropion may be graded from I to IV according to
development of lid malpositioning. The primary risk degree of severity. Typically, conservative treatment
factor for the development of ectropion is laxity of the may be instituted for types I through III. On the other
lower eyelid or excessive skin removal from the lower hand, grade IV often requires surgery. Conservative
lid. The latter can be reduced by avoiding overly
aggressive correction and taking into account gravita-
tional changes in the supine position. One technique to
help avoid excessive skin removal is to have the patient
look up with the mouth open before excision (Fig. 2).
Another common cause of ectropion is the unrec-
ognized senile or excessively lax lower eyelid. The
preoperative evaluation is essential and involves two
easily performed tests: the eyelid distraction test
(Fig. 3) and the snap test (Fig. 4). The eyelid distrac-
tion test involves horizontal distraction of the lower
eyelid away from the globe. If the lower eyelid is easily
distracted more than 7 mm away from the globe,
significant eyelid laxity is present. The snap test is
performed by vertically distracting the lower lids in a Fig. 3. The eyelid distraction test.
 G.E. Ghali, J.H. Lustig / Oral Maxillofacial Surg Clin N Am 15 (2003) 265–283
Fig. 4. The snap test.
treatment that lasts several weeks to months resolves
most of the ectropion. Conservative treatment
includes management of potential dry eyes with
lubricants, massage, and taping. The eyes may be
taped shut at night and skin tape used to draw the
lower lid in a superior-lateral direction during the day.
If conservative measures fail or severe ectropion
persists, surgical treatment may be indicated. Lateral
canthal tightening procedures can be combined with
either transcutaneous or transconjunctival blepharo-
plasty to restore proper lid support. Malposition noted
after surgery often responds to massage, lid taping,
and intralesional corticosteroid injections. If these
measures are unsuccessful, scar release may be neces-
sary in addition to a canthal resuspension. If ectropion
is caused by horizontal lid laxity, a wedge tarsectomy
or tarsal strip procedure may be performed. In indi-
viduals in whom the lid is vertically short, however, a
full-thickness graft may be necessary.
Ptosis
Ptosis may be caused by an undiagnosed preexist-
ing condition or result from surgical trauma. History
and documentation of the lid abnormality are helpful in
determining the type of ptosis present and the appro-
priate treatment necessary. Temporary ptosis post-
operatively is not unusual and resolves as edema
resolves. A history of eyelid trauma, inflammation,
recurrent edema, contact lens use, congenital ptosis, or
evidence of acquired senile ptosis should be noted
preoperatively [7,8].
The preoperative examination of the eyelid creases
and thinning of the upper eyelid and degree of ptosis
should be noted. The eyes are examined in primary,
upward, and downward gazes so as to measure the
amount of ptosis. In acquired ptosis, the abnormal
eyelid remains ptotic in all positions of gaze. In
congenital ptosis, the ptotic eyelid is higher than the
normal, opposing lid in downward gaze. Measuring
267
the movement of the upper lid from extreme down-
ward to extreme upward gaze while the brow and
forehead are held in a somewhat neutral position
assesses levator muscle function. The normal eyelid
covers the limbus 1 to 2 mm, mild ptosis would add an
additional 1 to 2 mm, moderate ptosis would add
an additional 3 mm, and severe ptosis would add an
additional 4 mm or more.
Levator muscle function is measured in all
patients with lid ptosis by having the patient look
upward and downward with finger pressure over the
brow to immobilize the frontalis muscle. The distance
the eyelid travels between these two points is mea-
sured in millimeters. Poor function is noted as 4 mm
or less, whereas fair function is noted as 5 to 7 mm.
Good function is typically more than 8 mm. Elderly
patients with a thin upper lid may have levator
muscle disinsertion. If this is confirmed preopera-
tively or if the levator muscle is cut during surgery, it
should be repaired [9,10]. Ptosis also may result from
operative trauma caused by instrumentation or
excessive use of electrocautery. Lid edema or hema-
tomas also can lead to temporary ptosis after surgery.
A delay of 3 to 6 months is recommended for patients
in whom ptosis is noted after surgery to allow for
spontaneous resolution.
Keratoconjunctivitis sicca
Keratoconjunctivitis sicca—or dry eye syn-
drome—is most commonly the result of an undiag-
nosed, preexisting condition that becomes aggravated
by blepharoplasty. As such, a thorough history and
physical examination should be conducted preopera-
tively to assess tear production quantitatively and
qualitatively. A history of symptoms such as burning,
tearing, and a rough gritty feeling in a patient with an
abnormal periocular physical examination is wor-
risome [11]. Postmenopausal patients who take certain
medications, such as tricyclic antidepressants and
other medications that reduce lacrimal and salivary
flow, should be assessed carefully. Most surgeons
advocate a conservative surgical procedure or at least
a modification to the extent of surgery to increase the
chance of a satisfactory result in patients with derma-
tochalasis and dry eye symptoms [12,13].
Glaucoma
Although uncommon, blepharoplasty procedures
may precipitate an attack of acute closed-angle glau-
coma in susceptible patients. A preoperative history
of migraine-like attacks, blurred vision, or halos
around lights should arouse suspicion, and intraocular
pressure should be checked. An immediate ophthal-
268 G.E. Ghali, J.H. Lustig / Oral Maxillofacial Surg Clin N Am 15 (2003) 265–283
mologic consultation is warranted when postopera-
tive complaints of unilateral eye pain, blurred vision,
and dilated pupils are present [14].
Retrobulbar hematoma
A dreaded complication of eyelid surgery, which
may lead to blindness if unrecognized and inappropri-
ately managed, is the retrobulbar hematoma. Retro-
bulbar hemorrhage is believed to result from injury to
small vessels during deep injection into the orbit or
from torn vessels in the stump of excised fat pedicles
deep to the septum orbitale. Over time, blood accu-
mulates within the orbit behind the septum, which
causes an increase in intraorbital and intraocular
pressure. It is recommended that one refrain from
deep orbital injections and only carefully excise fat
pads when necessary under direct vision. Once
excised, the fat pads should be cauterized carefully
with bipolar cautery. The earliest indication of retro-
bulbar hematoma may be unilateral eye pain, which
may progress rapidly to proptosis, chemosis, elevated
intraocular pressure with decreased retinal pulsations,
and eventually blindness. Any sign of unilateral or
asymmetric ocular pain or decreased vision should
necessitate immediate attention by the surgeon.
Management of a retrobulbar hematoma consists
of immediate reopening of the wounds, including the
orbital septum. Radical canthotomy and catholysis
and intravenous mannitol or acetazolamide are sub-
sequent steps, with orbital decompression being the
ultimate goal. High-dose corticosteroids are indicated
in the event of impending visual loss. Most cases of
retrobulbar hematoma are generally innocuous and
resolve promptly with minimal difficulty after proper
identification and conservative management.
Blindness
Visual loss or blindness, the most feared com-
plication of blepharoplasty, is catastrophic but rare,
and it arises from various possible causes. Although
the exact etiology and frequency of occurrence are
not well documented, it is estimated to occur in
approximately 0.04% of all cosmetic eyelid proce-
dures [15 – 22]. Retrobulbar hematoma is the most
commonly accepted cause for blindness that results
from blepharoplasty. In review, retrobulbar hematoma
results in increased intraorbital and intraocular pres-
sure, which results in compromise of the ophthalmic
vessels. Timely management is critical because the
retina can tolerate only approximately 90 minutes of
vascular occlusion before severe visual impairment
results [17]. The definitive management of impending
blindness is similar to the protocol used for retro-
bulbar hematoma management.
If visual acuity is intact and there is no evidence
of any active bleeding, gentle use of ice packs,
frequent orbital checks, and elevation of the head of
bed are sufficient treatments. If active bleeding is
noted, the sutures should be removed and the area
decompressed and explored. Medical decompression
using intravenous diuretic agents may be indicated.
Rarely, surgical intervention, including lateral cantho-
tomy or paracentesis, may be necessary.
Minor complications
Inclusion cysts and tunnels
Inclusion cysts or milia may result from debris
being trapped within the suture line. Small cysts can be
unroofed using a 20 gauge needle or an 11 blade; larger
cysts may require excision. If sutures are left in for
more than 1 week, epithelial ingrowth may incur along
the suture tract forming tunnels. Treatment usually
involves marsupialization via tenotomy scissors.
Infection
Infection in the periorbital region as a result of
blepharoplasty is rare. Orbital cellulitis after blepha-
roplasty is even rarer and can result in blindness [23 –
25]. Orbital cellulitis presents with unilateral lid
swelling, inflammation, proptosis, and impairment
of extraocular movement. The causative organism is
usually Staphylococcus aureus. Antibiotic treatment
alone may control orbital cellulitis successfully. A
true orbital abscess, as diagnosed by CT scanning,
often requires surgical drainage, however.
Hypertrophic scars
Hypertrophic scarring may occur in any indi-
vidual regardless of Fitzpatrick skin type. It is most
common immediately near the medial canthus and
may form a web but could occur anywhere along the
incision line (Fig. 5). The use of intralesional steroid
injections is the treatment of choice. Rarely, a Z- or
W-plasty may be necessary to eliminate excessive
hypertrophic scarring.
Lagophthalmus
After an upper lid blepharoplasty, a gap of approx-
imately 1 to 2 mm should exist between the upper and
lower lids. The inability to close the lids (lagophthal-
mus) occurs normally in the immediate postoperative
period and usually resolves in a short period of time as
the lid skin stretches. Individuals with significant
lagophthalmus postoperatively should be treated with
 G.E. Ghali, J.H. Lustig / Oral Maxillofacial Surg Clin N Am 15 (2003) 265–283
Fig. 5. Rare example of hypertrophic scarring after upper lid blepharoplasties.
lubricating drops or ointment, manual lid massage
(beginning 10 days postoperatively), and light taping
of the eyelid closed at night. If lagophthalmus does not
resolve, it may be necessary to reconstruct the lid with
a full-thickness skin graft. Some surgeons bank
excised lid tissue to use as a full-thickness skin graft
in the event of this occurrence. Additional donor sites
include the contralateral upper lid and the retroauric-
ular, preauricular, or postauricular skin. It is best to
avoid this complication by leaving a little excess skin
versus using overaggressive excision.
Miscellaneous
Spontaneous loss of the eyelashes is a rare occur-
rence. When it does occur, the eyelashes generally
regrow without treatment. Excessive tearing or epiph-
ora is common after blepharoplasty and is most often
caused by edema that distorts or blocks the lacrimal
collection system. A long-standing epiphora may
occur from ectropion of the punctum or the entire
lower lid. Occasionally, surgical trauma to the collect-
ing system may cause stenosis or obstruction. Light
sensitivity or photophobia is a common finding after
blepharoplastic procedures. The photophobia is gen-
erally short-lived, lasts 1 to 2 weeks, and resolving
spontaneously. During this time period, protection of
the eyes with appropriate UV blocking sunglasses is
recommended. Photophobia may exacerbate epiphora.
Intraoperative trauma may result in corneal abra-
sions or ulcerations. The cornea may be injured as a
269
result of injudicious cauterization either directly on
the cornea or as a result of conduction through blood
or liquid onto the cornea. With this in mind, one
should use only bipolar cautery when operating about
the globe. Additional sources of corneal injury
include instrumentation and surgical sponges and
prolonged exposure. Avoidance of corneal injuries
is achieved by protecting the cornea with lubricants,
shields, and taping in the postoperative period, if
necessary. Pain in the eye may indicate a corneal
abrasion and should be investigated with fluorescein
and a slit lamp. Appropriate measures may include
oral analgesic agents, topical antibiotic medications,
or patching of the eyes.
Minor degrees of lid asymmetry may occur during
the postoperative course. Most of these conditions
eventually resolve and become symmetric over time.
Patients should be counseled preoperatively regarding
any preexisting asymmetry of the lids. This should be
taken into account when resecting muscle or skin. A
partial compensation can be accomplished at the time
of surgery in cases of significant asymmetry.
Rhinoplasty
Major complications
Often considered the most difficult of facial cos-
metic procedures, rhinoplasty is highly complex
because of the many components involved in achiev-
270 G.E. Ghali, J.H. Lustig / Oral Maxillofacial Surg Clin N Am 15 (2003) 265–283
ing an adequate esthetic and functional outcome. It is
incumbent upon the surgeon to be aware of the
problem and its solution as the patient perceives it.
Intracranial communication
Intracranial injuries are rare complications of
traumatic etiology that may be associated with rhi-
noplastic procedures. Often, these rare intracranial
complications are the result of inappropriate manip-
ulation near the anterior skull base during nasal or
sinus surgery [26 – 28]. When deviated segments of
the perpendicular plate of the ethmoid bone or vomer
are removed during a rhinoplastic procedure, one first
should create the desired horizontal plate fracture as
to avoid fracture of the entire ethmoid bone. If the
entire ethmoid is fractured, a separation at the crib-
riform plate may occur and lead to cerebrospinal fluid
leak or a frank intracranial abscess. Most cerebrospi-
nal fluid leaks noted postoperatively resolve sponta-
neously in approximately 2 to 3 weeks if the patient is
managed with bed rest and head of bed elevation.
Few cases require lumbar drainage or surgical ex-
ploration if persistent. If a leak is noted intraoper-
atively, immediate neurosurgical consultation should
be procured. Exploration and reconstruction of the
dura via temporalis fascia grafting have proved help-
ful [29,30].
Blindness
A rare complication of rhinoplasty is blindness.
Blindness after rhinoplasty has been attributed to
mechanical trauma to the optic nerve. Most com-
monly, this trauma occurs after osteotomy, intranasal
steroid injection, or retrograde flow of an intraarterial
local anesthetic injection, which causes occlusion of
the central retinal artery with loss of optic nerve
function [26,31 – 34].
Hemorrhage
Most rhinoplastic procedures are performed on an
outpatient basis. Education of the patient as to the
expectation and amount of postoperative bleeding is
paramount. Patients are informed that they should
expect minimal bleeding or oozing for 1 to 2 days.
Patients are checked routinely on an outpatient basis
via a telephone call the evening of surgery. Patients
also are told that if they soak through more than one
2  2 mustache dressing every 30 minutes  3, they
should contact the surgeon. The most troublesome
bleeding occurs during the first 24 to 48 hours but
may occur up to 3 days after surgery. Secondarily, a
period exists between 10 to 14 days when the
possibility of delayed bleeding may occur as a result
of clot liquification.
The incidence of significant hemorrhage after
rhinoplasty is approximately 2% to 4% but can be
as high as 10% when combined with simultaneous
turbinate surgery [26 – 28]. The most commonly
involved vessels are the anterior ethmoidal and
sphenopalatine arteries. Patients should be screened
preoperatively regarding use of medications that
alter platelet aggregation, including aspirin and vita-
min E [35].
Treatment of epistaxis depends on the location
and amount of bleeding. If bleeding persists, it is best
not to pack the nose because this may alter the
surgery that has been performed and can lead to
residual deformity. Neosynephrine- or oxymeta-
zalone-soaked pledgets can be placed in the nose for
use as a mucosal vasoconstrictor followed by insertion
of a flexible endoscope to identify the source of
bleeding. When localized, the bleeding often can be
controlled simply with electrocautery. If this is not
adequate or if diffuse oozing persists, small pieces of
Surgicel or Gelfoam soaked with topical thrombin
may be used. If bleeding persists, then management
follows the usual treatment for persistent epistaxis.
This progressive management may involve nasal
packing or ligation of the offending vessels or embo-
lization with radiologic assistance [36,37].
Infection
Infection after rhinoplasty is a rare occurrence
considering the somewhat contaminated environment
in which the surgery is performed. The rate of infection
varies from 1% to 3% according to various studies
[27,28,38,39]. An argument for the routine use of
antibiotic prophylaxis in nasal surgery can be made
on the basis of the contaminated environment. Pro-
spective studies have failed to demonstrate a reduced
incidence of infection after rhinoplasty when prophy-
lactic antibiotics were used [40]. Although it is a
controversial issue, the routine use of prophylactic
antibiotics is generally not necessary in primary
uncomplicated rhinoplasties when grafts or implants
are not used [41,42]. Prophylactic antibiotic use after
rhinoplasty is recommended in the following in-
stances: (1) when nasal packing is used for more than
24 hours, (2) in the presence of hematoma, (3) when
alloplastic implants are used, (4) when active infection
occurs at the operative site, and (5) for immunocom-
promised patients [43]. If signs of infection do occur,
appropriate management should ensue in light of
serious sequelae, such as meningitis, cerebral abscess,
 G.E. Ghali, J.H. Lustig / Oral Maxillofacial Surg Clin N Am 15 (2003) 265–283 271

of the upper lateral cartilages or disruption of the

mucosa at this junction with webbing may allow
collapse and subsequent obstructive problems.
Preoperative evaluation for potential nasal airway
obstruction is essential and may avoid postoperative
obstructive sequelae. Elevation of the upper lateral
cartilage with a cotton-tip applicator intranasally in a
superiolateral direction increases the nasal valve
angle. If improved nasal breathing is experienced
with this maneuver, spreader grafts may be indicated
to reverse the nasal valve collapse (Fig. 7). A de-
pressed tip and columellar retraction may develop
after excess resection during a septorhinoplasty. A
thickened columella or excessive flaring of the
medial crura also may compromise the nasal airway.
Methods of compensation include intradomal sutur-
ing and intradomal resection of soft tissues.

Fig. 6. Nasal valve and nasal valve region.

subdural empyema, cavernous sinus thrombosis, and

endocarditis [34,44 – 46]. Another rare but uncommon
condition that necessitates early diagnosis and
aggressive treatment is toxic shock syndrome. Early
symptoms include nausea, vomiting, diarrhea, and
hypertension. Should toxic shock syndrome occur,
any packs or splints must be removed, a culture
obtained, and anti-staphylococcal antibiotic therapy
initiated [41,47 – 49].

Nasal obstruction

Postoperative transient nasal obstruction after rhi-

noplasty is common because of postoperative edema,
clotted blood, and crusting. These symptoms gen-
erally resolve spontaneously in a few weeks without
treatment; complete resolution to normal physiologic
function of the nasal respiratory complex may take
several months.
Nasal obstruction attributed directly to the rhi-
noplastic procedure has been reported in up to 10% of
cases. Most cases of postoperative nasal obstruction
are the result of mismanagement of the nasal septum,
damage to the nasal valve region, circumferential
contracture along the incisions, or inadequate man-
agement of hypertrophied inferior turbinates [50,51].
The nasal valve area, where the caudal portion of the
upper lateral cartilage joins the nasal septum, can be
disrupted during rhinoplasty (Fig. 6). This angle is Fig. 7. Spreader grafts placed bilaterally into a pocket
normally 10° to 15° and is freely mobile, which between upper lateral cartilages and the dorsal septum.
allows for variable resistance during respiration. Typical graft extends from the osseocartilaginous junction to
Injudicious removal of the caudal or dorsal aspect the anterior septal angle.
272 G.E. Ghali, J.H. Lustig / Oral Maxillofacial Surg Clin N Am 15 (2003) 265–283
Excessive narrowing of the nasal bones or col-
lapse of the lateral bony nasal wall also may result in
airway obstruction. The inferior bony pyramid of the
nasal skeleton is displaced medially, along with the
cartilaginous skeleton. If this narrowing results, out-
fracturing of the nasal bones in combination with
internal nasal stenting may be necessary [52,53].
Esthetic complications
Residual deformities that occur after a rhinoplasty
are subjective in nature depending on the viewpoints
of the patient and surgeon. Residual deformities that
necessitate revision surgery vary from 5% to 12% [54].
Dorsal overcorrection, undercorrection, asymmetry,
and irregularity
Dorsal bony hump removal is best accomplished
conservatively with a chisel, and further osseous
refinement is accomplished with a rasp. Most irregu-
larities that are only palpable generally disappear with
time and do not require treatment. It is better to err on
the conservative side with undercorrection than to
produce an excessively concave or ski-slope dorsum.
Asymmetry of the dorsum after surgery usually
results from unrecognized or preexisting structural
deviations. External bony nasal deviations may be
caused by a bony septal deformity, incomplete frac-
ture, or asymmetrical nasal bones not corrected by the
medial osteotomies. Camouflage dorsal grafts may be
necessary to achieve an esthetic outcome in individ-
uals in whom the dorsum has been overreduced
[55,56].
In an attempt to reduce the palpability of dorsal
irregularities, the nose should be checked at the
termination of surgery to assess that (1) the rhinion
is the highest point on the dorsum, (2) the superior
septal angle is the lowest point on the dorsum, and (3)
the dorsum is smooth and all fragments of cartilage or
bone have been removed via irrigation and suction-
ing. It is not uncommon for patients to complain
transiently of a palpable irregularity on the dorsum;
these irregularities are usually not visible to the naked
eye. Surgeons have used several masking materials to
smooth out and minimize the palpability of dorsal
irregularities [57,58].
Saddle nose deformity
A saddle nose deformity, the inward bowing of the
bony or cartilaginous dorsum, is seen most com-
monly in severe nasal fractures but can occur as a
sequela of rhinoplasty [38,59,60]. When it does occur
in association with a cosmetic rhinoplasty, the saddle
nose deformity is typically the result of overreduction
of the nasal dorsum (excessive hump removal) or the
osteotomized bones falling into the piriform aperture.
The latter may be prevented by preserving as much
periosteal integrity to the bones as possible (ie, use of
small 2-mm osteotomes). In saddle nose deformities
that result from nasal trauma, septal hematoma or
infection may lead to chondromalacia with loss of
vertical dorsal support.
Saddle nose deformity reconstruction depends on
the timing of recognition and degree of deformity;
correction is best done at the time of primary surgery
if recognized. The excised bony hump is trimmed and
replaced or placement of a graft is accomplished at
that time. If the excessive hump removal is not noted
at the time of surgery, it is best to wait for complete
healing (4 – 6 months) before graft placement. Autog-
enous materials, such as cranial bone or rib cartilage
grafts, are preferred materials for reconstruction of
the saddle nose deformity [60 – 62]. The major down-
side to cartilaginous grafts to the dorsum is their
tendency to warp over time, which leads to a visible
external dorsal deformity [63]. Cranial bone grafts
work best for deformities in the upper third of the
nose, the most common location for the saddle nose
deformity (Fig. 8). The major downside to cranial
bone grafts is their tendency to undergo irregular
resorption over time, even when rigidly fixed [62].
Open roof deformity
After dorsal reduction but before initiation of the
lateral osteotomy, a gap is intentionally created
between the bony septum and the lateral nasal bones.
This open roof deformity—or widened dorsum—is
caused by the lateral nasal bones not opposing each
other and the septum in the midline. Traditionally,
nasal osteotomies are performed to close this gap and
recreate the dorsal confluence of bone. A residual
open roof deformity may result from a thickened or
deviated dorsal septum, thickened bone at the radix,
or a greenstick fracture of the nasal bones with
incomplete mobilization. Treatment is directed at
straightening the septum, removing a medial triangle
of bone at the radix, or redoing the lateral osteoto-
mies. Often, all that is necessary is confirmation that
the nasal bones are adequately mobilized. In rare
instances, when a large hump is removed, lateral
osteotomies alone may be insufficient to create an
esthetic dorsum. In this situation, a dorsal graft may
be necessary [64]. At the other end of the spectrum is
the overly narrow dorsum that must be treated with
re-osteotomies, spreader grafts, or an onlay graft.
 G.E. Ghali, J.H. Lustig / Oral Maxillofacial Surg Clin N Am 15 (2003) 265–283 273

Rocker deformity Polly beak deformity

There is a natural tendency for the frontal process
of the maxilla and the nasal bones to thicken markedly
in the region of the radix at the superior aspect of the
medial canthus. If lateral osteotomies are placed too
high (ie, carried into this thickened bone), manipula-
tion of the osteotome medially frequently leads to a
greenstick fracture and the resultant stair-step or rocker
deformity. The rocker deformity can be prevented by
placing the lateral osteotomy deep into the nasomax-
illary and nasofrontal processes of the maxilla. By
using these guidelines, the osteotomy is maintained
within the thinner bone, below the radix. As a clinical
guideline, the medial extent of the lateral osteotomy
should never extend above the level of the medial soft
tissue canthi. Correction of the rocker deformity
should be attempted by communicating the ridge with
a transcutaneous 2-mm osteotome, performing a lower
lateral osteotomy, or rasping the ridge.
The polly beak deformity, or supratip swelling or
rounding, is the most common cause of revision
rhinoplasty. Key to prevention of the polly beak
deformity lies in understanding its causes. The
causes of a polly beak deformity may include
excessive postoperative scarring, insufficient or
inadequate lowering of the dorsal septal cartilage
(anterior septal angle), insufficient trimming of the
upper lateral cartilages, excessive excisions of the
lower lateral cartilages, short columella, thick skin,
loss of tip support, or a combination of these factors
[65 – 68].
At the termination of a typical rhinoplastic pro-
cedure, the tip must be elevated above the level of the
dorsum and superior septal angle. The performance
of tip surgery and a septal transfixion incision rou-
tinely results in some postoperative tip ptosis. This
ptosis must be compensated by adequate lowering of

Fig. 8. Saddle nose deformity that resulted from excessive dorsal lump removal during a cosmetic rhinoplasty. Preoperative
frontal (A), lateral (B), and close-up (C) views. Harvesting of autogenous cranial bone graft (D) and placement via an open
rhinoplasty approach (E). Postoperative frontal (F), lateral (G), and close-up (H) views.
274 G.E. Ghali, J.H. Lustig / Oral Maxillofacial Surg Clin N Am 15 (2003) 265–283
Fig. 8 (continued).
the septum; otherwise the tip ptosis results in an
apparent supratip prominence. Despite these precau-
tions, as a tip settles to a stable position during the
healing process, the dorsum may become relatively
higher than the tip, which results in the unesthetic
polly beak deformity.
The influence of skin thickness on the supratip
region has been noted [68]. As a result, patients with
thick, oily skin require some defatting of the tip
region to improve skin redraping. Intradomal sutur-
ing techniques (Fig. 9) and columellar struts (Fig. 10)
also may be necessary to increase tip definition and
projection. Correction should be directed at lowering
the dorsum to the appropriate height (3 – 4 mm)
below the lower lateral cartilages while maintaining
or increasing support of the nasal tip. Situations
exist in which the polly beak deformity may be the
result of excess hump removal, and augmentation
of the dorsum along with of the tip area would
be indicated.
Nasal tip deformities
Considered to be the most difficult aspect of
rhinoplasty, the nasal tip is the most noticeable region
to the patient. Nasal tip deformities are largely the
result of overreduction, underreduction, or asymmet-
rical reduction of the lower lateral cartilages and
result in the following deformities: (1) pinched tip,
(2) pig’s snout, (3) bifid tip, (4) ptotic tip, (5) boxed
tip, (6) asymmetrical tip, and (7) hanging or retracted
columella. Revision rhinoplasty is common for post-
operative nasal tip deformities because these asym-
metries or irregularities may not manifest until many
months or years after surgery [39,66,69,70].
Excessive resection or discontinuity of the alar
cartilages may result in tip collapse with the resultant
pinched tip deformity. In addition to its obvious
unesthetic appearance, severe nasal obstruction may
ensue because of narrowing in the nasal valve region.
Correction is achieved via an open rhinoplasty ap-
 G.E. Ghali, J.H. Lustig / Oral Maxillofacial Surg Clin N Am 15 (2003) 265–283
Fig. 8 (continued).
proach with placement of septal cartilage (spreader)
grafts. It is often desirable to achieve some degree of
tip narrowing, which may be achieved by complete
stripping of a cephalic portion of the lower lateral
cartilages, intradomal suturing, or domal interruption
techniques [71 – 75]. The pinched tip deformity can
be avoided by leaving a minimal residual lower
lateral cartilage width of approximately 5 mm. It
is generally not necessary to remove via a cephalic
trim of the lower lateral cartilages more than 15 mm
lateral to the intradomal regions bilaterally. Resec-
tion lateral to 15 mm often results in no beneficial
increase in tip refinement or projection and almost
always lead to a higher incidence of the pinched
tip deformity.
Excessive resection of the cephalic component of
the lower lateral cartilages also may result in over-
rotation of the nasal tip and the resultant pig’s snout
deformity. Avoidance of this deformity involves the
same guidelines in preservation of a minimum of
5mm of the caudal component of the lower lateral
cartilages. Correction requires an open rhinoplasty
approach that consists of cartilaginous grafts placed
275
between the upper and lower lateral cartilages,
which allows for derotation or caudal rotation of
the nasal tip.
A bifid tip deformity results from excessive
intracrural tissue or excess widening of the alar
domes. The bifid tip deformity is corrected by
resection of intracrural fibrofatty tissue or suturing
with nonresorbable suture to coadapt the alar
domes. The ptotic or droopy tip deformity results
from failure to reduce or suture the upper or lower
lateral cartilages in relation to the shortened caudal
septum. This allows the tip to fall away from the
septum in a caudal direction. Older noses have an
increased tendency toward a ptotic tip and must be
corrected by proper trimming of the upper or lower
lateral cartilages (ie, suturing the medial crura of
the lower lateral cartilages in proper relationship to
the caudal septum).
Unlike the polly beak deformity, which occurs
more often in thick, oily-skinned individuals, the
boxed tip occurs most commonly in thin-skinned
individuals. The boxed tip deformity is believed to
result from failure to weaken the lower lateral carti-
276 G.E. Ghali, J.H. Lustig / Oral Maxillofacial Surg Clin N Am 15 (2003) 265–283
Fig. 8 (continued).
lages adequately after cephalic trim. This deformity
typically appears gradually over several years. Cor-
rection of the boxed tip deformity necessitates an open
rhinoplasty approach with vertical resection of the
lower lateral cartilages using dome interruption tech-
niques (Fig. 11).
The hanging columella deformity is caused by
overly convex or prominent medial crura or, less
commonly, by an elongated nasal septum. Manage-
ment of the hanging columella is via an elliptical
excision of the membranous septum along with a
portion of the caudal septum or medial crura. The
retracted columella is typically a more difficult
problem that results from overaggressive resection
of the caudal septum, membranous septum, or
medial crura. Correction of the retracted columella
typically involves placement of a columellar strut
graft between medial crura obtained autogenously
from the septum and placed via an open rhi-
noplasty approach.
Rhytidectomy
Based on the literature, complication rates tend to
be lower for superficial rhytidectomy techniques
compared with the more complex composite and
deep plane techniques [76 – 84]. Major types of
surgical complications include hematoma, facial
nerve injury, skin loss, scarring, alopecia, auricular
deformities, and temporal hairline deformities.
Major complications
Hematoma
Hematoma formation is the most common major
complication that results from rhytidectomy. It occurs
postoperatively in roughly 2% to 4% of patients
within the first 48 hours; the cause varies [85 – 89].
Early recognition is essential because untreated he-
matomas are associated with an increased risk of
skin slough (Fig. 12). Typical signs and symptoms
 G.E. Ghali, J.H. Lustig / Oral Maxillofacial Surg Clin N Am 15 (2003) 265–283
Fig. 9. A single transdomal 5-0 nylon mattress suture assists
in setting the width between the domes and a more favorable
tip-supratip relation.
of hematoma include increased facial pain, tightening
of dressings, ecchymosis of the buccal mucosa and
lips, or bulging of the lips. Hematomas are best
treated with early exploration of the wound, with
the most common finding being diffuse oozing under
the skin flap. Removal of clots is indicated followed
rarely by bipolar cautery or suture ligation of larger
vessels (Fig. 13). Pressure dressings and drains may
Fig. 10. Placement of columellar strut. The strut sits above
(not contacting) the anterior nasal spine, just below the in-
termediate crura, and is symmetrically secured into the pock-
et between the medical crura via 5-0 nylon mattress sutures.
277
Fig. 11. Dome interruption technique by vertical incision.
Simple interrupted 5-0 nylon reapproximation helps correct
the boxed tip deformity.
be used to compliment these techniques but are no
substitute for meticulous hemostasis. Factors associ-
ated with increased risk of hematoma formation
include preoperative hypertension, intraoperative
hypotension, and postoperative hypertension.
A review of 500 face lifts demonstrated a 2.6%
incidence of hematoma formation; however, in this
same population, patients with preoperative hyper-
tension had a 9.2% incidence of hematoma formation
[88]. Preoperative hypertension in this review was
associated with a 2.6-fold increase in the risk of
hematoma formation. Conversely, intraoperative
hypotension was associated with increased hema-
toma formation, probably as a result of rebound
hypertension. In a review of 806 face lifts, Rees
reported 23 hematomas (2.8%), with 20 of the
23 associated with controlled intraoperative hypo-
tension [87]. Maintenance of a normotensive state
during surgery was associated with a decreased
incidence of hematomas.
In another review of 1236 face lifts by Rees, a
1.9% incidence of hematoma formation was noted.
278 G.E. Ghali, J.H. Lustig / Oral Maxillofacial Surg Clin N Am 15 (2003) 265–283
Fig. 12. Hematoma present in early postoperative period.
Fig. 13. Early exploration and clot evacuation are essential
in preventing skin slough. Clot being removed from left
temporal region.
The incidence drops to approximately 1% in normo-
tensive general anesthetic states [90]. Postoperative
hypertension also has been associated with an
increased risk of hematoma formation [85]. The
average maximum blood pressure postoperatively in
the preceding study was 152/98, a relatively minor
elevation in blood pressure. Finally, a recent study
described an increase in hematoma formation when
using propofol as the intraoperative anesthetic agent
[91]. With propofol, the overall incidence of hema-
toma formation was 4.2%. A combination of valium,
demerol, and brevital had only a 2% incidence of
hematoma formation, however.
Patient cooperation is helpful in the prevention of
hematomas. Instructions for the reduction of hema-
toma formation include eliminating aspirin, aspirin-
containing compounds, nonsteroidal antiinflammatory
drugs, and vitamin E for at least 2 weeks preopera-
tively and avoiding exertion and bending for 2 weeks
postoperatively. The importance of patient compliance
should be stressed in the preoperative visits.
Facial nerve injury
The facial nerve branch injured most often varies
with different reports in the literature [92,93]. In the
authors’ experience, the marginal mandibular and
temporal (frontal) branches of the facial nerve are
injured most often. These two branches are the most
superficial and have less crossover anastomosis
compared with other branches of the facial nerve.
Injury to the marginal mandibular branch invariably
 G.E. Ghali, J.H. Lustig / Oral Maxillofacial Surg Clin N Am 15 (2003) 265–283 279

occurs during extension of the subcutaneous dissec-

tion anteriorly to the lateral chin region, where the
nerve courses superficial to the depressors of the
mouth. Less commonly, it may be damaged during
dissection in the region of the mandibular angle
(Fig. 14). Injury to the temporal branch frequently
occurs during temporal dissection because the plane
is in transition from subgaleal to subcutaneous
levels. Damage to these structures may result in
temporary or permanent motor deficits to the
respective muscles of facial expression.
Compiled reviews of face lifting have demon-
strated a 0.7% (50 of 6500) incidence of temporary
injury and a 0.1% (7 of 6500) incidence of permanent
injury [94]. Facial nerve injury is less likely with
superficial musculoaponeurotic system (SMAS) pli-
cation techniques versus SMAS imbrication or more
complex composite and deep-plane techniques
[95,96]. Rates of facial nerve injury with sub-SMAS
dissections have been reported as high as 16% [97].
Prevention of facial nerve injury is achieved through a
complete understanding of face lift anatomy, the usual
course and common variations of the facial nerve, and
meticulous attention to detail during the procedure.
Most surgeons would agree that injury to the facial
nerve is the most devastating complication associated
with rhytidectomy; fortunately, permanent injury to
the facial nerve is rare [76,77,81,84,94,95,97 – 99]. Fig. 15. Most common site for skin slough located in
postauricular region.
Skin slough

Skin slough is the result of vascular compromise to
the involved soft tissue flap. It most commonly occurs
in the postauricular and mastoid regions because of the
thinness of the skin and it being farthest from the blood
supply of the cervicofacial skin flap (Fig. 15). For-
tunately, small sloughs in this region are concealed by
the hair and ear. The incidence of postoperative skin
slough is approximately 2% to 3% [92,100].
Fig. 14. Diagram illustrates typical findings associated with
unilateral injury to the marginal mandibular branch of the
facial nerve.
Delay in the evacuation of hematomas is a major
cause of skin slough and underlies the importance of
early detection. Hematomas of significant size prevent
the reestablishment of nutrient flow to the skin flap
from the richly vascularized underlying tissues and
cause tension within the flap, which creates further
ischemia. When skin necrosis does occur, a black
eschar forms that separates at approximately 1 week,
and the wound then heals by secondary intention.
Reassurance should be given to the patient because
most areas of minor skin necrosis heal without major
sequelae. A minimum of 3 to 6 months should elapse
before any major surgical revision is undertaken.
Local ischemia may result from various factors,
including diabetes mellitus and tobacco use. Without
a doubt, cigarette smoking increases the risk of skin
slough [101 – 108]. Nicotine has been implicated as a
factor that predisposes patients to skin necrosis by
affecting several aspects of wound healing, including
alteration of epithelialization, impairment of the
inflammatory phase of healing, and compromise of
small blood vessel flow [104]. In evaluating the
effects of tobacco on face lifts, Rees et al demon-
280 G.E. Ghali, J.H. Lustig / Oral Maxillofacial Surg Clin N Am 15 (2003) 265–283
strated a 12-fold greater risk of skin slough in
smokers compared with nonsmokers [107]. Webster
et al advocated a more conservative undermining
(short flap technique) in face lift patients who smoke
[108]. It is the authors’ opinion that abstinence from
smoking for at least 2 weeks—and preferably
1 month—is recommended before operating on a
patient who has not stopped smoking. Improper tissue
manipulation and flap design are easily preventable
causes of skin slough that result from inexperience.
Delicate handling of skin flaps is essential during
elevation to prevent a compromised result. Skin flaps
should be designed to maintain an adequate thickness
of subcutaneous tissue on their deep surface (3 –
4 mm) and, in the postauricular region, to maintain
a 90° angle at the tip of the flap.
Neurosensory disturbances
Neurosensory disturbances, particularly transient
numbness or hypesthesia, are common in the early
postoperative period as a result of elevation of the
skin flap and interruption of small sensory nerves. As
a result, a temporary, diffuse cutaneous numbness
that lasts 4 to 6 weeks is not uncommon. During this
time, patients should be warned about possible injury
to numb skin from razors, curling irons, and hair
dryers. The most common nerve injured during
rhytidectomy is the great auricular nerve. Injury to
this nerve is the result of an improper plane of
dissection over the sternocleidomastoid muscle.
Studies have shown the great auricular nerve to cross
the middle portion of the sternocleidomastoid muscle
approximately 6.5 cm below the caudal edge of the
bony external auditory canal, which courses cephalad
just deep to the SMAS [109,110]. Injury to the great
auricular nerve occurs when the postauricular dissec-
tion is carried too deep, thereby violating the strict
subcutaneous plane in this region.
Minor complications
The significance of a complication may vary
according to the patient’s ability to deal with the
complication. A particular patient may be frantic
over a mild postauricular skin slough, whereas
another patient may demonstrate minimal to no
anxiety associated with marginal mandibular nerve
weakness. Although the authors do not discuss minor
complications in detail, complications that occur
after rhytidectomy may include widened scars, auric-
ular deformities, edema or ecchymosis, loss of tem-
poral hair tuft or temporal alopecia, and sialoceles
[111 – 113]. When complications occur, the surgeon
must acknowledge them to the patient and take
appropriate measures to correct the problem. Avail-
ability of the surgeon in the postoperative period is
the key to successful management of most post-
operative complications.
Summary
Over the past two decades, numerous esthetic
techniques have been described to improve the results
of facial rejuvenation. When contemplating facial
rejuvenating surgery, the treatment requirements of
the surgeon must be balanced with the desires of the
patient. These requirements are critical in defining the
advantages of one technique over the other.
In the realm of oral and maxillofacial surgery,
cosmetic surgery finds great application as an adjunct
to traditional skeletal surgery. It seeks to reverse the
effects of aging. Although a wide variety of tech-
niques are reported for cosmetic surgery, the authors
have attempted to provide a specific overview of the
three most commonly performed procedures and their
associated complications.
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