Aesth Plast Surg (2014) 38:678680

DOI 10.1007/s00266-014-0325-3

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.
Level of Evidence V This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
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 periorbital emphysema after cosmetic rhinoplasty is an
uncommon complication that may send the surgeon running for the hills. Although conservative treatment is sufficient in such cases [2], it must be differentiated from the
other serious complications including allergic reactions,
hematoma, angioedema, esophageal rupture, and infection
[4, 5].

I. Kucuker
E. Yosma
M. S. Engin

Department 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

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This report presents a case of acute periorbital emphysema that developed immediately after extubation subsequent 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 transcolumellar incision. Septoplasty, dorsal septal excision,
hump excision, and medial and lateral osteotomies (with
3-mm unguided and 4-mm guided osteotomes, respectively) 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. Aspiration 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 maneuver brought partial but instant relief.
The emphysema was totally resolved by the next
morning, and the patient recovered uneventfully (Fig. 2). A

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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

Fig. 1 Swelling in periorbital regions

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

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

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. Perioperatively, they suspected a retrobulbar hematoma and performed bilateral lateral canthotomy. But radiologic
assessments showed no hematoma, and periorbital air
deposition was reported.
In another study C
elebioglu 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 periorbital 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 immediately 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 complications such as hematoma and allergic reactions.
Conflict of interest The authors declare that they have no conflicts
of interest to disclose.

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