Haemophilia - unexpected complication of rhinoplasty

INTRODUCTION

It is generally well known that rhinoplasty belongs among the most difficult procedures in aesthetic surgery. This is because the nose is located in the central part of the face and any inappropriate or technically poorly performed surgical procedure could be a cause of difficult to treat complications, and it could also unfavourably influence the quality of life of the patient.

Good result of corrective rhinoplasty is influenced by many factors. On the first place should be mentioned the expertise and experience of the plastic surgeon with his/her manual skills and aesthetic feeling. Experience of the plastic surgeon undoubtedly plays the most important role (1). He/she is able to solve, as compared to less experienced surgeons, some situations, which could occur during the surgery, regardless whether it is a post-traumatic, congenitally deformed or previously operated nose. However, an experienced plastic surgeon cannot influence an unexpected situation, which could be encountered during rhinoplasty as well as during other operations.

Some less serious complications could occur during the course of nasal surgery immediately afterwards or within a period of several days, weeks or months. In our group of more than 2000 rhinoplasties was mostly present large bleeding during the surgery and it always subsided after a tamponade and application of a plaster splint. In one case we reported greater bleeding within several days, which occurred in a 20-year-old patient, who started to bleed one week after the operation during her menstruation cycle. Bleeding was sucessfully treated with introduction of posterior tamponade and it was kept in situ for several days. Once we experienced infection of the skeleton after rhinoplasty, which was treated with antibiotics.

Complications should include also postoperative deformity of the nose after a surgery performed in other sites, the number of which rises. The cause is often excessive reduction of nasal tissue, residual high cartilage septum, inadequate correction of soft nose only or a technical error.

CASE REPORT

35-year-old female healthy patient was admitted for elective rhinoplasty. There were no disorders of coagulation or previous diseases associated with increased tendency to bleeding present in the medical preoperation examination. Already on the first day after the surgery the patient developed unusually large swelling in the face, which did not subside even during the subsequent days (Fig. 1). Due to continuous bleeding from the incision on the edge of the nasal wing on the right side was added another suture on the third day after the surgery and a tamponade was exchanged bilaterally. In total were administered injections of Pamba each 8 hours, Dicynone each 6 hours. Even on the eighth day after surgery, the bleeding did not stop and after exchange of tamponade (Fig. 2) was the patient referred to the Medical Haematology Department of the University Hospital in Královské Vinohrady for detailed assessment. It was later found out in the family history that the brother and uncle of the mother suffer from haemophilia A, and the mother is a carrier. There was a suspicion of reduced factor VIII level and further examination was recommended; furthermore there was a disorder of primary haemostasis based on prolonged bleeding time and increased capillary fragility. Symptomatic therapy (Detralex 2-0-0, Ascorutin 2-2-2) supporting the strength of the capillaries improved the condition. The following permanent medication was recommended: Ascorutin 2-2-2. Two weeks after the surgery was removed the plaster splint; smaller hematomas in the face subsided within 4 weeks, there was no bleeding (Fig. 3). The postoperative result is satisfactory (Fig. 4−7).

DISCUSSION

Some literary data report occurrence of severe complications after rhinoplasties in 5 - 18% of patients. From these are the most common postoperative bleeding from the nose and then infectious complications including toxic shock syndrome (2). Other authors reported 13 serious complications in 259 patients within 5 year period (159 septo-rhinoplasties, 35 rhinoplasties, 29 septoplasties) − 5x haemorrhage, 4x septal perforation, 3x infection and 1x pneumocephalus (4). Haddad et al. reported anosmia, visual disturbances, thrombosis of carvernous sinus, meningitis, liquorrhoea, pneumocephalus, subarachnoideal bleeding, subdural empyema, brain abscess (3) after submucous resection of septum. One literature sorce reports occurrence of a haemophilic pseudocyst in the nasal bone in a patient with mild form of haemophilia (deficit of factor VIII, incidence 1−2%), where there were cystic changes in the bone in a form of subperiosteal haemorrhage, which resulted in bone destruction (5).

As far as concerns complications of rhinoplasty in association with haemophilia, we can find a report about a nasal surgery, which was performed in a 23 year old man with diagnosed mild form of haemophilia A/6/. The disease was diagnosed in childhood during surgery (circumcision), when excessive bleeding occurred, which was managed with administration of factor VIII. There were blood tests performed before elective rhinoplasty, when usual coagulation factors were normal, the level of factor VIII was 21%. In the patient was supplemented factor VIII to 50% and this level was maintained for 5 days after the surgery. Simultaneously was administered tranexamic axid (synthetic lysin derivate, which has an antifibrinolytic effect) before and after surgery. Rhinoplasty was accomplished without complications and without excessive bleeding.

Similar case report with great postoperative bleeding is reported also in the paper by Karabulut (7), when a female indicated for rhinoplasty with normal levels of usual coagulation factors was discharged on the 2nd postoperative day. On the fourth day after surgery, however, she attended for bleeding from the nose; tamponade was inserted and it was left in situ until the 6th day. Next day after removal of the tamponade had to be hospitalized due to massive epistaxis, after collections of blood for detection of coagulation factor levels was demonstrated deficit of factor XIII. Bleeding was managed with administration of frozen plasma.

CONCLUSION

Similarly as in case of other surgical procedures, also in case of rhinoplasties we encounter various complications, the occurrence of which we can expect and some others that we do not expect.  These include long term and very difficult to treat swelling, rarely occurring disorder of breathing, infection or haemorrhage within few days after surgery. Very rare complication is the presented case of unusually prolonged bleeding after rhinoplasty that is based on a disorder of hemostasis due to deficit of factor VIII, which was not demonstrated with tests of common coagulation factors. In spite of reported complicated postoperative course, it is possible to positively evaluate the fact that rhinoplasty helped to reveal a condition, which could otherwise put the life of the patient in danger without adequate preparation in case of larger operations or labour.

Address for correspondence:

Assoc. Prof. Jan Měšťák

Department of Plastic Surgery, 1st Medical Faculty Charles University in Prague and Na Bulovce Hospital

Budínova 2

180 01 Prague

Czech republic

E-mail: jan.mestak@bulovka.cz