Keeping Rhinoplasty Complications to a Minimum

PHILADELPHIA-It’s a moment that rhinoplasty surgeons dread: They’ve performed a surgery, the operation is over, then they realize that something has gone wrong. To fix it, there will have to be another surgery.

Experts in the field, gathered at Rhinology World 2009 here, discussed ways to try to avoid complications in rhinoplasty, offering tales of caution as well as guidance on how to handle those delicate times when they have to break bad news to a patient.

If you do enough surgery, you will get complications, there’s no question about it, said Eugene Kern, MD, Professor Emeritus at Mayo Clinic, who has performed rhinoplasty for more than 40 years. Complications occur. They occur in the most sophisticated hands, and they occur in beginners, and they will occur throughout your entire career.

Cemal Cingi, MD, Professor of Otolaryngology at Osmangazi University in Turkey and the moderator of the panel, said doctors should always keep learning, but should also know their limitations. Let’s learn all the methods, set the ones that you can do successfully, and do not try your new ideas on your cases, Dr. Cingi said. Be honest to yourself and to your patients.

Clear Communication Is Crucial

Dr. Kern said one of the keys is clear communication-both with the patient and with the patient’s significant others. I would almost always demand that the significant other-which might include parents-be present at the consultation, he said. If they’re not present at the first consultation, I would not operate on that patient. I would like to see the rest of the family.

He pointed to studies showing that patients’ biggest complaint about doctors is that they felt they didn’t have enough time for them. You don’t want to have that complaint about you, he said.

A seemingly basic step that will go a long way toward avoiding missteps- although it is a step that is sometimes overlooked-is to really listen to the patient, always asking, What is it that you don’t like about your nose?

Dr. Kern told a story about a big, tall, husky man from Iowa who was a farmer and whose two brothers and father were also farmers. He said he had undergone an operation by another doctor for a breathing problem. When Dr. Kern asked him how his breathing was, he said, My breathing is perfect. The problem was the nose itself, he said, although Dr. Kern thought it was a good, masculine-looking nose.

I had a big bump on my nose, the farmer explained. And my brother has a big bump, and my younger brother’s got a big bump, and my father’s got a big bump, and doctor took my bump off and he never asked me if he could. So now my father and my two brothers call me ‘sissy girl.’

He was devastated, Dr. Kern recalled.

You have to ask the patient, ‘What bothers you-you– about your nose? he said. It sounds like a minimal thing, but it is key.

He said the last question he always asks patients in preoperative consultations is: Do you have any questions for me?

I think that is extremely important, because this will obviate that whole problem when the patient says, ‘Doctor didn’t have time for me, doctor was too rushed,’ Dr. Kern said. So I think it’s important for you to ask the patient now, ‘Do you have any questions, or does your family have any questions for me?’ And then just sit there and look the patient in the eyes.

Screening of Patients Also Important

Another point, said Dr. Kern, was that surgeons shouldn’t operate on everybody. He has even had prospective patients take personality tests to assess how well they might handle the procedure emotionally.

When you get that feeling in your gut that tells you this patient is a problem, listen to that little voice that’s speaking to you, Dr. Kern said. Don’t say to yourself, ‘Well, I don’t have a case next Tuesday, I could really do it. It’s, quote-unquote, an easy nose.’ If you don’t have a good feeling about it, don’t do it.

He would often refer patients to a psychologist or psychiatrist, and said he could probably count on one hand the number of times I was turned down. Most patients would welcome it.

Handling Complications

Dr. Kern recounted his first significant experience with the tricky territory of handling complications.

While a surgeon in the Air Force in 1968, he had performed surgery and thought it went pretty good. Then the patient took a deep breath and said his right side felt good, but he couldn’t breathe through the left nasal passage. Upon looking again, Dr. Kern saw a huge septal deformity.

I missed it-now what am I going to say? he said. I had my tail between my legs and I said something, I don’t remember what I said. But I was embarrassed, and I had no words to explain to the patient that they still had a problem.

The lesson is that surgeons should always be prepared for how they will communicate with the patient should something go wrong. The words might be different for each surgeon, but I’m not happy has proven to be a useful, versatile phrase.

I’m not happy with how the operation went. There was a great deal of bleeding and I had to stop the operation, Dr. Kern suggested. Or, ‘I’m not happy with our relationship. I don’t feel good about our relationship and I think you need to see somebody else.’

Daniel Becker, MD, Clinical Associate Professor in the Division of Facial Plastic Surgery in the Department of Otolaryngology at the University of Pennsylvania in Philadelphia, said studying the cases of other surgeons is invaluable. The key is a lifelong study of rhinoplasty, of nasal anatomy, of analysis and techniques and rhinoplasty philosophy, learning from other people, he said. I have always gravitated toward revision books or complication books because I would always rather learn from someone else’s mistake.

He emphasized getting a deep understanding of what the patient wants. The only reason a patient seeks a rhinoplasty in the first place is that they’re unhappy about their nose, he said. So it behooves you to find out what they want.

He said that a devastating problem, but one that is also avoidable, are turbinectomies that have been handled too aggressively. A patient he saw had had one to clear a blockage in one passage but afterward was a nasal cripple because the mucosa had been damaged and he couldn’t feel air.

It’s important to be a little introspective when considering a procedure, he continued. Maybe I won’t do it at all. Or maybe I’ll be ever so conservative. I’ll be more conservative, and I’ll save somebody’s life.

He said that some surgeons might think that because they rarely have patients come in to report complications, such as a worse breathing problem after a turbinectomy, that they don’t happen very often. That could be a mistaken perception, Dr. Becker said. Maybe they didn’t come back to you, he said. You have to understand that this problem absolutely happens.

©2009 The Triological Society