Rhinoplasty ranks as the fifth most frequently performed aesthetic procedure globally, with 1,148,559 cases recorded worldwide in 2023 [1]. Despite its general safety, rhinoplasty carries potential complications, ranging from minor aesthetic issues to significant functional impairments [2–3]. Postoperative complications can be categorized as early—such as epistaxis, infection, edema, ecchymosis, and hematoma—and late, including asymmetry, nasal airway obstruction, collapse, deformities, and over- or under-correction of nasal features [4–7]. Pseudoaneurysms, or false aneurysms, are rare but clinically significant vascular complications characterized by a breach in the arterial wall that leads to blood leakage, forming a hematoma encapsulated by fibrous tissue. Unlike true aneurysms, which involve dilation of all three arterial layers, pseudoaneurysms maintain a persistent connection between the artery and the hematoma cavity [8]. In rhinoplasty, pseudoaneurysm formation is thought to result from iatrogenic trauma to the nasal vasculature, particularly the dorsal nasal artery—a terminal branch of the ophthalmic artery. Mechanisms of injury include osteotomies, aggressive rasping, or improper tissue handling. Clinically, patients may present with delayed-onset pulsatile swelling, localized discomfort, recurrent epistaxis, or overlying skin changes [9–10]. Diagnosis typically relies on Doppler ultrasound or angiographic imaging to evaluate vascular integrity and guide treatment planning. Management options range from conservative compression techniques to more invasive interventions such as thrombin injection, embolization, or surgical excision [11]. To date, only one published case has documented pseudoaneurysm formation following rhinoplasty [12], underscoring its rarity. This report presents a case of dorsal nasal artery pseudoaneurysm discovered six months postoperatively, highlighting the clinical features, diagnostic process, and surgical management.

Figure 1: 40 y.o. Patient Preoperative Photographs, Presenting Dorsal Hump and Elongated Nasal Tip

Clinical Case

A 40-year-old male presented seeking aesthetic rhinoplasty. Physical examination revealed rhinomegaly, a dorsal hump and elongated nasal tip (Figure 1).

He reported no nasal obstruction or respiratory symptoms. The patient’s medical history was unremarkable; he was a non-smoker with no significant medications, allergies, or family history of vascular disorders. Preoperative lab work was normal. A primary open rhinoseptoplasty was planned and performed under general anesthesia by the senior author(R.T.). Local infiltration included 5 mL lidocaine 2%, 5 mL bupivacaine

Figure 2: Postoperative Sequences Photographs, Showing Pseudoaneurysm’s Evolution in Time. A: Left Lateral View 3 Months Post op; B: Left Lateral View 6 Months Post op, C: Left Lateral View 12 Months Post op, D: Left Lateral View 14 Months Post op; E: 

Left Lateral View 24 Months Post op; F: Left Lateral View 30 Months Post op 0.25%, 1 mL tranexamic acid, and 0.25 mg of adrenaline. A transcolumellar incision was made, followed by subareolar dissection of the lower and upper lateral cartilages and subperichondrial access to the quadrangular cartilage.

Video 1: Lesion at 30 Months Post op

Figure 3: CT Angiography Showing the Pseudo Aneurismatic Formation on the Nasal Dorsum

Figure 4: 1-Year Postoperative Recovery with No Recurrence

Figure 5: Gross Pathology

Septoplasty and middle vault  opening were performed, with dorsal septal reduction and reconstruction using anatomical auto spreader flaps. Low lateral and transverse osteotomies were executed. Tip refinement included cephalic trim of the alar cartilages, lateral steal, dome creation via Gruber sutures, partial overlapping of the medial crura, and membranous tongue-in-groove fixation. Hemostasis was ensured throughout. Postoperative dressings included external taping, Doyle splints, and a dorsal cast. No intraoperative or immediate postoperative issues occurred. Follow-ups were scheduled at one week, two weeks, one month, three months, and six months. The postoperative period was uneventful, with no immediate or intraoperative complications. At six-month a small dorsal bump was noted at the level of the superior nasal dorsum. The lesion was painless. By the one-year visit, the bump had grown into a soft, pulsatile subcutaneous mass. An inconclusive Doppler ultrasound prompted clinical observation. At the two-year follow-up, the lesion had further enlarged. A consultation with the Dermatology Department suspected a postoperative pseudoaneurysm. Serial photographs tracked lesion evolution (Figure 2) Video 1 demonstrates the typical softness of the lesion.

CT angiography (Figure 3) confirmed an “infracentimetric aneurysmal formation on the nasal dorsum surface, receiving blood supply from branches of both dorsal nasal arteries [terminal branches of the ophthalmic arteries], with vascular connections to the facial artery territory.”

Surgical excision under local anesthesia was performed. A 1 cm horizontal incision was made along Langer’s lines in the nasal dorsum to optimize wound healing. The lesion was indentified, ischemia was maintained via digital compression of the pedicles. The pedicles were divided and ligated with 5/0 Vicryl sutures and the lesion removed.  The wound was closed with 5-0 Prolene sutures, and nasal taping was applied. Postoperative recovery was uneventful, with full resolution of symptoms and no recurrence at one-year follow-up (Figure 4).

Histopathology confirmed benign vascular proliferation with no malignancy, gross pathology (Figure 5).

Pseudoaneurysms following rhinoplasty are extremely rare, with only a handful of cases documented in the literature. The nasal blood supply is derived from both internal and external carotid systems, with contributions from the facial, maxillary, and ophthalmic arteries. The dorsal nasal artery, a branch of the ophthalmic artery, is particularly important for perfusion of the nasal dorsum and forms key anastomoses with external carotid branches. Lateral osteotomies, commonly used in rhinoplasty, pose a risk of vascular injury as they traverse the maxillary bone and approach arteries like the angular and dorsal nasal arteries [12]. Disruption in this region can lead to pseudoaneurysm formation—characterized by a pulsatile hematoma lacking an arterial wall, capable of expanding under pressure and compressing surrounding tissues. In this case, the pseudoaneurysm’s location suggests potential trauma from retractor traction or aggressive rasping in a predisposed individual. This was the first such incident encountered by the surgical team. Although facial artery pseudoaneurysms have been described following facial trauma and orthognathic procedures [13–15], their occurrence post-rhinoplasty remains extremely rare. Management includes surgical ligation, embolization, or sclerotherapy [16]. Surgical excision, especially when the lesion is superficial and localized, is effective and carries minimal risk due to abundant nasal collateral circulation. Strategic incision placement allows for optimal cosmetic results. Embolization is useful for deep or inaccessible lesions, but may carry risks such as tissue necrosis, neurologic complications, and revascularization due to collateral flow [17]. In our case, the lesion’s size and location made surgical excision preferable, yielding excellent cosmetic and clinical outcomes without recurrence.

Although pseudoaneurysm formation is a well-recognized complication in maxillofacial surgery, its occurrence following rhinoplasty is exceedingly rare. This case underscores the importance of considering vascular lesions in patients with delayed-onset, pulsatile nasal swellings after rhinoplasty. Prompt imaging, particularly CT angiography, is crucial for diagnosis and surgical planning. When accessible, surgical excision offers definitive treatment with low morbidity and favorable aesthetic results. Ultimately, this case highlights the necessity of precise surgical technique, thorough intraoperative hemostasis, and long-term postoperative surveillance to detect rare but potentially serious vascular events.

Acknowledgements
The authors received no specific funding or support from public, commercial, or nonprofit organizations.

Conflict of Interest Statement

The authors declare no conflicts of interest.

Statement on Human and Animal Rights

This article does not involve any studies with human participants or animals conducted by the authors.

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