CASE REPORT AESTHETIC

A Rare Complication of Rhinoplasty: Periorbital Emphysema

Ismail Kucuker Musa Kemal Keles

Engin Yosma Murat Sinan Engin

Received: 25 October 2013 / Accepted: 12 April 2014 / Published online: 31 May 2014

Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014

Abstract Subcutaneous emphysema is a clinical entity

that may be associated with trauma. Rhinoplasty is not an

atraumatic procedure. This report presents a case of acute

periorbital emphysema after cosmetic rhinoplasty.

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Keywords Subcutaneous emphysema Rhinoplasty Periorbital emphysema Cosmetic rhinoplasty

Subcutaneous emphysema is air deposition under the skin.

It may be associated with trauma of the sinuses, airways, or

direct extracorporeal exposures [13]. Acute bilateral per-

iorbital emphysema after cosmetic rhinoplasty is an

uncommon complication that may send the surgeon run-

ning for the hills. Although conservative treatment is suf-

ficient in such cases [2], it must be differentiated from the

other serious complications including allergic reactions,

hematoma, angioedema, esophageal rupture, and infection

[4, 5].

This report presents a case of acute periorbital emphy-

sema that developed immediately after extubation sub-

sequent to cosmetic rhinoplasty. We also discuss potential

differential diagnosis and treatment options.

Case

A 25-year-old woman was admitted to our clinic for

elective cosmetic rhinoplasty. She had no history of trauma

or surgery. Open rhinoplasty was performed via a transc-

olumellar incision. Septoplasty, dorsal septal excision,

hump excision, and medial and lateral osteotomies (with

3-mm unguided and 4-mm guided osteotomes, respec-

tively) were performed in an orderly fashion. The total

operation time was 65 min and involved no unusual

occurrences.

An external nasal splint was applied, and septomucosal

fixations were performed with mucosal mattress sutures.

The patient then was given into the care of the

anesthesiologist.

The patient recovered as expected and was sent to the

recovery room. In the recovery room, an unusual and fast

swelling involving both periorbital regions developed

(Fig. 1). At the first examination, the patient told us she

was fine, without pain or any other discomfort. Initially, a

hematoma was suspected, but her periorbital area was soft

and her ocular examination results were normal.

Both upper eyelids had crepitation at palpation. Aspi-

ration with a 20-gauge needle showed a number of air cells

on both upper eyelids, and 2 ml of air was removed from

each. In addition to confirming the diagnosis, this maneu-

ver brought partial but instant relief.

The emphysema was totally resolved by the next

morning, and the patient recovered uneventfully (Fig. 2). A

I. Kucuker E. Yosma M. S. EnginDepartment of Plastic, Reconstructive, and Aesthetic Surgery,

Faculty of Medicine, Ondokuz Mayis University, Samsun,

Turkey

M. K. Keles (&)Department of Plastic, Reconstructive and Aesthetic Surgery,

Konya Numune Hastanesi, Selcuklu, Konya, Turkey

e-mail: mukeke@gmail.com

123

Aesth Plast Surg (2014) 38:678680

DOI 10.1007/s00266-014-0325-3

postoperative computed tomography (CT) scan showed

little septal deviation, bilateral agger nasi cells, a conca

bullosa at the left medial conca, and an onodi cell at the

right sphenoid sinus (Fig. 3).

Discussion

Periorbital complications after rhinoplasty can be traumatic

or infectious [6]. In the reported case, we encountered a

periorbital emphysema immediately after the rhinoplasty.

The literature has two reports of subcutaneous emphysema

after rhinoplasty [2, 7]. Fndikcioglu and Findikcioglu [2]reported an orbital emphysema noted before osteotomy

was begun and hypothesized that the emphysema might

occur during the elevation of dorsal nasal skin. Perioper-

atively, they suspected a retrobulbar hematoma and per-

formed bilateral lateral canthotomy. But radiologic

assessments showed no hematoma, and periorbital air

deposition was reported.

In another study Celebioglu et al. [7] reported a case of

facial and neck emphysema 4 h after rhinoplasty. They

hypothesized that lateral osteotomy sites may act as a

check valve and cause subcutaneous emphysema. They

removed the nasal packs and allowed the air to resorb

spontaneously.

A third possible etiology for periorbital emphysema

may be a traumatic perforation or crack of the ethmoidal

air cells during osteotomy that cannot withstand the

increased pressure, which can be associated with high

pressure mask ventilation or with gagging or gasping

during recovery. Even if a small fracture occurs in the

lamina papyracea, subcutaneous emphysema can occur

[8]. This mechanism can lead to air access into the per-

iorbital subcutaneous space until the leakage is obliterated

spontaneously. It also is hypothesized that air leakage to

the orbital region can lead to visual loss via compressive

optic neuropathy [9].

In the reported case, the emphysema occurred immedi-

ately after extubation. We promptly addressed it by needle

aspiration, providing partial relief until it totally resolved

by itself. We did not perform canthotomy and cantholysis,

and we did not remove the nasal packs.

In conclusion, if a surgeon encounters an acute swelling

in the periorbital region during or after a rhinoplasty, he or

she needs to rule out an innocuous and self-resolving

emphysema before taking action against serious compli-

cations such as hematoma and allergic reactions.

Conflict of interest The authors declare that they have no conflictsof interest to disclose.

Fig. 1 Swelling in periorbital regions

Fig. 2 Day after the operation. Note that the emphysema was almosttotally resolved by the next morning

Fig. 3 a,b Postoperative computed tomography (CT) scans

Aesth Plast Surg (2014) 38:678680 679

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A Rare Complication of Rhinoplasty: Periorbital EmphysemaAbstractLevel of Evidence VCaseDiscussionReferences