Why does a rhinoplasty patient experience prolonged bleeding?

Why Rhinoplasty Causes Prolonged Bleeding

Rhinoplasty patients experience prolonged bleeding due to the rich vascular supply of the nasal cavity, surgical disruption of blood vessels, and the limited ability of the nasal mucosa to contract after injury. 1

Anatomical and Physiological Factors

Nasal Vascularity

• The nose has an exceptionally rich blood supply from both internal and external carotid artery branches
• Key blood vessels involved:
  • Kiesselbach's plexus (anterior nasal septum)
  • Sphenopalatine artery branches
  • Angular vessels that can be disrupted during osteotomies 2

Surgical Disruption

• Rhinoplasty involves manipulation of highly vascular tissues:
  • Nasal bones during osteotomies
  • Septal cartilage and mucosa
  • Turbinate tissue
• Fibrovascular scar tissue from previous nasal trauma may increase bleeding risk 2

Post-Surgical Factors Contributing to Prolonged Bleeding

Impaired Hemostasis

• Unlike other surgical sites, nasal mucosa has limited ability to contract after injury
• Blood vessels remain patent and continue to ooze
• Nasal packing removal can disrupt early clot formation, causing renewed bleeding 1

Inflammatory Response

• Surgical trauma triggers inflammatory cascade
• Postoperative edema increases pressure on vessels
• Nasal packing can cause additional mucosal trauma upon removal 3

Timing of Bleeding Episodes

Rhinoplasty bleeding typically occurs in two distinct timeframes:

1. Early postoperative period (within 72 hours)

   • Due to surgical trauma and immediate vascular response
   • Most common and expected

2. Delayed bleeding (around 10 days postoperatively)

   • Often occurs during the healing phase
   • May coincide with packing removal or crust formation 3

Risk Factors for Excessive Bleeding

• Medication use:

  • Anticoagulant or antiplatelet medications significantly increase bleeding risk 1
  • Intranasal corticosteroids increase nosebleed risk (relative risk 2.74) 1

• Anatomical variations:

  • Septal deviation
  • Previous nasal trauma with altered anatomy 2

• Systemic factors:

  • Hypertension
  • Coagulation disorders 1

Management Strategies

Preventive Approaches

• Preoperative assessment for bleeding risk factors
• Consideration of hemostatic agents:
  • Tranexamic acid (10 mg/kg IV) stabilizes fibrin matrix 4, 5
  • DDAVP (desmopressin) for persistent bleeding 5, 6

Intraoperative Management

• Meticulous surgical technique
• Careful osteotomy placement to avoid angular vessels 2
• Use of vasoconstrictors in local anesthesia

Postoperative Care

• Head elevation and cold packs to reduce edema 3
• Careful nasal packing removal
• Patient education regarding packing type and removal plan 1

Common Pitfalls and Caveats

• Failure to identify bleeding source: Always perform anterior rhinoscopy to locate bleeding after clot removal 1
• Overlooking posterior bleeding: Consider nasal endoscopy for recurrent or difficult-to-control bleeding 1
• Ignoring medication effects: Document anticoagulant/antiplatelet use and consider temporary discontinuation for severe cases 1
• Inadequate patient education: Patients should understand expected bleeding duration and when to seek help 1

Rhinoplasty bleeding is typically self-limiting but can be concerning for patients. Understanding the vascular anatomy, surgical factors, and proper management techniques is essential for both surgeons and patients to navigate this common postoperative issue.