Zusammenfassung
Die Korrektur der äußeren Nase (Rhinoplastik) wird als risikoreich angesehen, weil das erzielte Ergebnis nicht immer den Erwartungen von Patient und Arzt entspricht. Neben diesen postoperativen Formstörungen gibt es jedoch zahlreiche weitere Risiken und Komplikationen. Verkleinerungen und Verschmälerungen der Pyramide können den Querschnitt der Nasenwege einengen, weshalb in etwa 70 % der Nachoperationen eine Nasenatmungsbehinderung angegeben wird. In bestimmten Fällen ist diese aber auch nur „gefühlt”, weil durch Narben die Sensibilität der Schleimhaut für Temperaturschwankungen gestört ist. Bei autogenen Transplantaten bestehen die Hauptrisiken in Dislokation und Resorption, während bei alloplastischen Materialien v. a. Infektion und Extrusion zu fürchten sind. Bei Silikonimplantaten muss damit mit einer Häufigkeit von 5 % bis 20 % gerechnet werden. Andere Materialien, wie z. B. PTFE (Gore-Tex), scheinen dagegen mit einer Komplikationsrate von ca. 3 % gewebeverträglicher zu sein. Haut und Weichteile können durch Atrophie, Fibrose, Gefühlsstörungen und durch die Entwicklung von Zysten (Schleimhautverlagerung) oder Granulomen (subkutane Einschwemmung von Salbe aus Nasentamponaden) betroffen sein. Das Ausmaß postoperativer Schwellungen ist u. a. auch von der Osteotomietechnik abhängig. Perkutane Osteotomien sind schonender, können aber in 6 % der Fälle erkennbare Narben hinterlassen. Infektionen sind trotz Operation in einem nicht sterilen Gebiet sehr selten, aber mitunter lebensbedrohlich (toxisches Schocksyndrom durch Staphylokokken-Exotoxin). Ein Infektionsrisiko besteht auch bei simultanem Eingriff an Nebenhöhlen und äußerer Nase. Die Augenregion kann durch osteotomiebedingte Verletzungen der Tränenwege oder anderer Anteile des Orbitainhaltes betroffen sein. Streptokokken können zu einer nekrotisierenden orbitalen oder periorbitalen Entzündung (Augenlider) führen. Über Erblindungen wird immer wieder berichtet, sie gehen meist auf Zentralarterienverschlüsse zurück. In Einzelfällen wird über Rhinoliquorrhö, Hirnverletzung, Karotis-Sinus-cavernosus-Fistel, Sinus-cavernosus-Thrombose und Aneurysmen berichtet. Etwas häufiger sind dentogene Komplikationen in Form von Schneidezahnverfärbung durch Verletzung des versorgenden Gefäß-Nerven-Bündels. Das Risiko eines unzufriedenen Patienten ist immer gegeben und eine Klage kann durchaus als „Komplikation” einer Rhinoplastik gewertet werden. Diese lässt sich am ehesten durch eine konsequente Patientenselektion vermeiden, wobei auch psychische Störungen berücksichtigt werden müssen. Vor allem sind es jedoch neu aufgetretene oder verbliebene Formstörungen, die als Hauptrisiko einer Rhinoplastik gelten und mit einer Häufigkeit zwischen 5 % und 15 % zu einer Revisionsoperation führen. Aus dem Vorkommen bestimmter Befunde bei Revisionen lassen sich in retrospektiven Untersuchungen Risikofaktoren oder Problemregionen erkennen. Am häufigsten finden sich Störungen des Profils (Pollybeak) bei „Risikonasen” (tiefe Nasenwurzel, knorpeliger Höcker, geringe Nasenspitzenprojektion). Etwa 50 % der Nachoperationen werden aufgrund dieser Deformität vorgenommen. Daneben finden sich auch häufig abgesunkene und verbreiterte Nasenspitzen, Columellaretraktionen und Unregelmäßigkeiten des Nasenrückens. Im eigenen Krankengut findet sich diese Befundkonstellation meist als Folge eines Spannungsverlustes durch eine verringerte Höhe des kaudalen Septumknorpels. Bei einem kombinierten Eingriff an der Nasenscheidewand und der äußeren Nase (Septorhinoplastik) ist daher die Stabilität des Septumknorpels der Schlüssel für ein gutes Resultat. Bei einer isolierten Rhinoplastik ist dieser Schlüssel v. a. die Projektion und Protektion der Nasenspitze sowie der Columella, die bei den Inzisionen und Zugängen zur Infrastruktur auf unterschiedliche Weise geschwächt werden. Die Risiken der Rhinoplastik können mit zunehmender Erfahrung minimiert werden. Diese setzt jedoch kontinuierliches Lernen und vor allem eine Unterscheidung zwischen einer Komplikation und einem Fehler bei Operation oder Planung voraus.
Schlüsselwörter
Rhinoplastik - Risiken - Komplikationen - Revision
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Prof. Dr. med. Gerhard Rettinger
Direktor der Hals-Nasen-Ohren-Universitätsklinik
Frauensteige 12
89075 Ulm
Email: gerhard.rettinger@uniklinik-ulm.de
