Management of the Ischemic Nose

The Problem

Vascular compromise after surgical rhinoplasty is a rare but devastating complication that can lead to negative functional and aesthetic outcomes. Proper pre- and postoperative evaluation and management is critical, and include patient selection, limiting pre- and intraoperative risk factors, and aggressive postoperative treatment of any signs of ischemia. Failure to correctly manage the ischemic nose will result in nasal skin necrosis with subsequent deformity.

Background and Anatomy

To understand the causes and risks of an ischemic nose, knowledge of the vascular anatomy of the nasal skin is essential. Blood flow to the nose involves a dual blood supply from two main arterial systems, the ophthalmic artery and the facial artery. The nasal tip and columellar skin are perfused by five end-arteries of these systems: the dorsal nasal artery, external nasal branch of the anterior ethmoidal artery, lateral nasal artery, alar branches of the angular artery, and columellar branch of the superior labial artery.

The lateral nasal artery often originates from of the angular artery, travels 2 to 3 mm superior to the alar groove, courses along the cephalic border of the lateral crura of the lower lateral cartilage, and sends small branches toward the nasal tip. The superior labial artery gives rise to the columellar arteries, which course superficially and between the domes of the medial crura toward the nasal tip. The lateral nasal artery and columellar arteries combine dorsally to form an alar arcade located superficial to the musculoaponeurotic (SMAS) layer.

Another subdermal plexus exists superficial to this alar arcade with contributions from both the ophthalmic and facial artery systems. Thereby, the nasal tip can be potentially supplied solely by the external nasal branch of the anterior ethmoidal artery. Generally, venous and lymphatic drainage also run superficial to the SMAS layer. The lateral nasal vein is an exception that hugs the perichondrium of the middle nasal vault. There are no veins or lymphatics in the columellar region.

Traditional open rhinoplasty involves a transcolumellar incision, which removes the contribution of the columellar arteries to the blood supply of the tip. Awareness of the vascular anatomy facilitates safety in avoiding injury to the remaining blood supply. While the nasal tip can be supplied entirely by the external nasal branch of the anterior ethmoidal artery, it is not advised to rely on that alone, so care must be taken to avoid injury to the lateral nasal artery and plexuses. In secondary rhinoplasty, knowledge of prior surgical techniques can help with planning to avoid vascular insult during the procedure.

The Indications

The onset of nasal ischemia is evident upon placing the initial transcolumellar incision’s transcutaneous sutures. The tip will show signs of venous congestion, including purple discoloration. The outcome is reliant on quick recognition and implementation of the management tools below. The time-sensitive nature of the management of nasal ischemia facilitates decreased risk of necrosis and tissue loss.