Effects of high dose corticosteroids in open rhinoplasty

Peroperative Cooling in Rhinoplasty: Does it Differ?

The main causes of ecchymosis and edema are osteotomy (bone manipulation), dissection of subcutaneous tissue, and skin manipulation in the rhinoplasty procedure. Eyelid edema following surgery can potentially affect visual acuity, particularly during the initial twenty-four hours after the procedure. These may also delay the patient's return to their normal social life therefore hampering their quality of life. Various surgical and medical methods have been reported to address these issues. This study aimed to compare the effects of using cold saline (0-4 °C) versus room temperature saline (20-25 °C) irrigation throughout the surgery on postoperative edema, ecchymosis, and pain. Fifty patients who underwent open-approach primary rhinoplasty between August 2022 and August 2023 at a tertiary academic center were included. Fifty patients were randomly divided into two groups depending on using cold saline (0-4 °C) (group 1) or room temperature saline (20-25 °C) (group 2) during surgical site irrigation. Patients were assessed for pain, edema, and bruising using a VAS (Visual Analog Scale) on the second and seventh postoperative days. Visual analog score (VAS) was used for subjective outcome analyses. Each patient scored the severity of their periorbital ecchymosis on day two and seven. Periorbital ecchymosis was also evaluated on the second and seventh postoperative days using the SPREE (Surgeon Periorbital Rating of Edema and Ecchymosis) scale. On the second postoperative day, the VAS pain score in group 1, where cold water was used, was found to be statistically and significantly different from the control group (group 2) (p < 0.05). However, there was no statistically significant difference between both groups when comparing the VAS pain scores on the seventh postoperative day. Regarding the VAS ecchymosis score on the seventh postoperative day, there was a statistically significant difference favoring group 1 (p < 0.05). The SPREE scale data also indicated that group 1 had significantly lower scores on the seventh day (p < 0.05). While the SPREE scores on the second day were lower in group 1 than in group 2, this difference did not reach statistical significance (p = 0.061). The findings from our study show that cold saline irrigation may contribute to intraoperative hemostasis by inducing local vasoconstriction. We observed that intraoperative bleeding decreased with the use of cold saline. This approach has the potential to improve patient satisfaction and overall quality of life by reducing postoperative ecchymosis without significantly increasing the cost of the surgical procedure.Level of Evidence III 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 .

The Effect of Cold Saline Irrigation of Dissection Planes in Rhinoplasty on Postoperative Edema and Ecchymosis

BACKGROUND

Periorbital edema and ecchymosis are frequently encountered after rhinoplasty and may be distressing to patients. Cold therapy is frequently employed in rhinoplasty to reduce postoperative edema and ecchymosis.

PURPOSE

The aim of this study was to evaluate the effect of cold saline irrigation (CSI) of dissection planes in rhinoplasty on postoperative edema and ecchymosis.

STUDY DESIGN, SETTING, SAMPLE

The investigators designed a retrospective cohort study. The data of patients who underwent rhinoplasty in our clinic between January 2021 and January 2023 were scanned. Patients who underwent primary open rhinoplasty from the same surgeon and standard rhinoplasty steps were applied in the same way and order were included in the study. Patients who had systemic diseases and previous nose surgery, and patients whose photographs could not be accessed from the photograph archive were excluded.

PREDICTOR VARIABLE

According to whether CSI was applied to the dissection plans during rhinoplasty, the patients were divided into the CSI group and the control group (without CSI).

MAIN OUTCOME VARIABLES

Patients' grades of periorbital edema and ecchymosis were the main outcome variables. The differences of outcome variables were compared between the 2 groups.

COVARIATES

Demographics (age, sex), and surgical detail (duration of surgery) were collected as covariates.

ANALYSES

The numerical variables were compared between the two groups using the student's t-test and Mann-Whitney U test, whereas the categorical variables were compared using Pearson's χ2 and Fisher's exact tests. P < .05 was considered statistically significant.

RESULTS

Among the 167 patients who met the inclusion criteria, 60 patients were randomly selected, 30 patients in each group. No statistically significant difference was found between the two groups in terms of age (P = .45) and sex (P = .27). The mean ecchymosis grade was statistically significant lower in the CSI group than in the control group for all evaluation times (P < .05). Similarly, the mean edema grade was statistically significant lower in the CSI group than in the control group for all evaluation times, with the exception of the 10th and 15th day (P < .05).

CONCLUSION AND RELEVANCE

CSI of the dissection planes in rhinoplasty reduced the development of periorbital edema and ecchymosis. This procedure is straightforward, inexpensive, and effective.

Reducing Postoperative Swelling, Edema, and Ecchymosis after Open Rhinoplasty Using Intranasal Drainage

Reducing postoperative strain on the patient after rhinoplasty is an important goal for the surgeon. Many strategies are described to reach that goal. One strategy is to remove blood from under the dissected soft tissue envelope by drains, before it can infiltrate the different layers causing ecchymosis, edema, and swelling. In our setting with wide degloving and using drains, we could show a significant reduction in ecchymosis on day 2 and 14 after surgery (p = 0.006 and p = 0.017). We also observed a significant effect for edema and general swelling on day 2 (p = 0.027 and p = 0.004), but this effect did not reach significance for these two parameters on day 14. And although the long-term effect needs to be assessed in the future, we found that using drains in open rhinoplasty with wide degloving is an easily applicable, cheap, and reproducible approach to reduce postoperative ecchymosis, edema, and swelling.

Demographic and physiological factors associated with clinically significant eyelid edema in patients following upper eyelid surgery

PURPOSE

To investigate demographic and physiological variables associated with clinically significant edema after upper eyelid surgery.

METHODS

A retrospective chart review was performed on patients who underwent blepharoplasty or external levator advancement with or without lid crease formation between January 2018 and January 2021 at the University of Southern California. Age, sex, pertinent medical history (medications causing edema and comorbidities), and pertinent surgical procedures were all collected. Postoperative photos were graded by two independent physician graders on a newly developed photographic scale ranging from 0 (no edema) to 3 (severe edema). Clinically significant edema of the eyelids was defined as Grade 3 edema at any postoperative point or ≥ Grade 1 edema after 90 days post operation. Patients without postoperative photos were excluded. Mann-Whitney U test, Fisher's exact test, and χ2 test were used to compare groups with and without significant edema. All analyses were conducted using SAS version 9.4 (SAS Institute Inc.) with α=0.05.

RESULTS

Out of 217 patients, East Asian participants had higher odds of developing edema than White participants (odds ratio, 7.92; CI, 3.15-19.93, p < 0.0001) and Hispanic participants (odds ratio, 3.47; CI, 1.51-7.97, p = 0.003). Southeast Asian participants also had higher odds of developing CSEE than White participants (odds ratio, 6.19; CI, 1.71-22.43, p = 0.006). Fifty-four (24.9%) patients had clinically significant edema. Although BMI, medical comorbidities, medication use, and age did not affect edema, there was a statistically significant relationship between race and incidence of edema (p = 0.0001). Those in the CSEE group were also more likely to require reoperation (p = 0.0143).

CONCLUSIONS

There is a statistically significant relationship between Asian race and the incidence of clinically significant eyelid edema. CSEE is associated with a higher incidence of reoperation.

Neutrophil/lymphocyte ratio as a predictor of severe postoperative edema and ecchymosis in open rhinoplasty surgery

Purpose: This study investigated the relationship between preoperative neutrophil-to-lymphocyte ratio (NLR) and severe postoperative edema and ecchymosis after open rhinoplasty. Materials and Methods: The study was carried out retrospectively in 165 ASA I-II patients aged 18-45 years who underwent open rhinoplasty in the Department of Plastic and Reconstructive Surgery. The patients were grouped based on their scores on the edema and ecchymosis scales. The degree of edema and ecchymosis was considered “minimal” (Group M) in those scoring 0-2 points and “severe” (Group S) in those scoring 3-4 points. Periorbital edema and ecchymosis of the patients in both groups were scored based on the digital photographs taken on the 1st postoperative day. Results: There was no significant difference in the demographic and clinical characteristics of the patients grouped according to the degree of edema and ecchymosis. The optimal cut-off value of NLR was 2.1 (AUC = 0.747, Sensitivity = 0.666, Specificity = 0.707) for edema and 1.5 (AUC = 0.747, Sensitivity = 0.869, Specificity = 0.470) for ecchymosis. Multivariable analyzes for the development of edema and ecchymosis identified NLR (4.67 [2.38-9.40] and 6.54 [3.02-15.08, respectively) as a statistically significant independent prognostic factor. Conclusion: This study identified preoperative NLR as a predictor value of severe postoperative edema and ecchymosis after open rhinoplasty.

Drainage tube use for the reduction of postoperative ecchymosis in rhinoplasty

BACKGROUND

Postoperative healing after rhinoplasty can have a negative impact on patient quality of life.

OBJECTIVES

In our study, we aimed to reduce postoperative edema and ecchymosis by applying a minidrain system. We evaluated this intervention's benefit on postoperative morbidity by observing the patient with left and right sides, intervention side and control side respectively.

METHODS

All surgeries were performed using a piezo device with an open technique septorhinoplasty. We only used a left-sided minidrain system through the osteotomy lines just in front of the piriform aperture for all patients with no other intervention on the right side of the same patient.

RESULTS

Use of a drain on the left side was associated with a statistically significant decrease in ecchymosis at postoperative day 7 (P<0.05).

CONCLUSIONS

We found that using a minidrain system through internal osteotomy lines was effective in reducing the amount of ecchymosis by day seven after surgery.

Complications Associated with Rhinoplasty: An Umbrella Review of Meta-analyses

BACKGROUND

An increasing number of studies have investigated the effect of various methods in avoiding complications in rhinoplasty. Our study aims to analyze the connections between various choices in rhinoplasty and the rate of multiple complications by summarizing results in related meta-analyses.

MATERIALS AND METHODS

Through Pubmed, MEDLINE, Embase, and the Cochrane Database were associated systematic reviews searched to gather and review the available evidence of different plans and health outcomes in rhinoplasty for this umbrella review.

RESULTS

The study included 14 systematic reviews with 128 meta-analyses of randomized clinical trials. Edema and ecchymosis were the two most investigated outcomes. The implementations of steroid, tranexamic acid, periosteal preservation, external approach in lateral osteotomy, and piezoelectric osteotomy were linked with significantly lower incidence of several complications. Multiple administration of steroids was found to be associated with fewer complications in a prolonged time.

CONCLUSIONS

With summarized evidence of complications related to rhinoplasty, this research can help surgeons to avert patients from suffering complications and optimize cosmetic outcomes.

LEVEL OF EVIDENCE III

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 .

The effects of 5-degree, 10-degree and 20-degree reverse Trendelenburg positions on intraoperative bleeding and postoperative Edemea and ecchymosis around the eye in open rhinoplasty

PURPOSE

In this study, we investigated the effect of reverse Trendelenburg position (RTP), with five, ten, and twenty degrees, on intraoperative bleeding and postoperative edema and ecchymosis around the eye in open rhinoplasty operations.

MATERIALS AND METHODS

Ninety patients undergoing open rhinoplasty were divided into three groups, 5° angle RTP (Group 5; n = 30), 10° angle RTP (Group 10; n = 30), and 20° angle RTP (Group 20; n = 30). After 3 min of preoxygenation, anesthesia was induced with 3 mg.kg^-1 propofol, 1 μg.kg^-1 fentanyl, and 0.6 mg/kg rocuronium for muscle relaxation. Maintenance of anesthesia was provided with a minimum alveolar concentration of 1-1.5 with sevoflurane, 1:1 O2/N2O. Hemodynamic variables, intraoperational bleeding, postoperative 1st, 3rd and 7th days ecchymosis and edema around the eyes of the patients were compared between the groups.

RESULTS

Edema changes on postoperative 1st, 3rd and 7th days and ecchymosis changes around the eyes on postoperative 1st and 3rd days in Group 20 were found significantly lower than Group 5 (p < 0.017). Besides, the change of ecchymosis on the postoperative 1st day was found significantly lower in Group 20 compared to Group 10 (p < 0.017). The amount of intraoperative bleeding and surgical field evaluation score were found to be significantly lower in Group 10 and Group 20 compared to Group 5 (p < 0.017).

CONCLUSION

We concluded that in open rhinoplasty surgeries, 20° degree RTP reduces intraoperative blood loss and provides a more bloodless surgical field, as well as reducing edema and ecchymoses around the eyes in the postoperative period.

The Effect of Subcutaneous Dexamethasone to Reduce Edema and Ecchymosis in Rhinoplasty Patients

Background

Rhinoplasty is one of the most common types of cosmetic surgery undertaken. In most rhinoplasty patients, an osteotomy is used to reshape the nasal pyramid. The most common complications following osteotomy are edema and ecchymosis. Edema and ecchymosis have a significant effect on a patients' satisfaction with surgery and their return to social activities. For this purpose, various methods have been used to reduce edema and ecchymosis, including intravenous injection of corticosteroids, cold compresses, and tranexamic acid.

Objective

To reduce edema and ecchymosis in rhinoplasty patients by administering a subcutaneous injection of dexamethasone and thereby prevent unwanted systemic side effects of corticosteroid treatments.

Method

We conduct a hospital-based nonrandomised study of rhinoplasty patients, with their informed consent treated over the course of one year. Dexamethasone was injected on one side of consenting patient's face immediately before surgery and the results were compared with the opposite side that was not injected. The face images of patients were taken on the front view on the first, third, seventh, and fourteenth days following the treatment. The grade of edema and ecchymosis encountered in each patient was determined by three ENT specialists. The degree of edema and ecchymosis was compared on the injected and noninjected sides and the findings were statistically analysed. The nonrandomised study considered 42 rhinoplasty patients. The mean age of patients was 27.9 years and their age ranged between 17 and 52 years. For 20 patients (47.6%), injection was performed on the right side, and for 22 patients (52.3%), injection was performed on the left side. Findings. The statistical analysis of patient outcomes reveals that a supraperiosteal injection of dexamethasone was not effective in reducing edema and ecchymosis after rhinoplasty.

Effect of Nasal Soft-Tissue Envelope Thickness on Postoperative Healing Process Following Rhinoplasty

OBJECTIVE

Understanding the postoperative dynamics of the nasal soft-tissue envelope (NSTE) is necessary to obtain the desired cosmetic results after rhinoplasty. This study was conducted to determine the changes of NSTE thickness and its effects on periorbital edema and ecchymosis following rhinoplasty.

METHODS

Thirty-five patients who underwent rhinoplasty were included in the study. Nasal skin and subcutaneous tissue thickness at the tip, supratip, rhinion, and nasion were measured using ultrasonography preoperatively and at the postoperative 3rd and 10th months. Periorbital edema and ecchymosis were evaluated at postoperative days 1, 3, and 7. The patients were categorized as the thick NSTE group (n = 17) and the thin NSTE group (n = 18) according to the preoperative median NSTE thickness.

RESULTS

In the thin NSTE group, supratip skin, subcutaneous tissue, and total NSTE thickness were lowest on the preoperative day but no statistically significant difference was found for the thick NSTE group. In the thin NSTE group, total NSTE thickness of the rhinion was highest at the postoperative 3rd month, but in the thick NSTE group, there was no statistically significant difference between postoperative 3rd and 10th months. In both groups, total NSTE thickness of the nasion was highest at the postoperative 3rd month and lowest at the postoperative 10th month.

CONCLUSIONS

Supratip fullness occurs more prominent in patients with thin NSTE. Postoperative edema in the rhinion is greater in patients with thin NSTE for the early postoperative period but it lasts longer in patients with thick NSTE. Soft-tissue envelope atrophy at the nasion occurs in both groups in the late postoperative period. Periorbital edema and ecchymosis severity are not affected by NSTE thickness.

The Comparison of Conventional Osteotomes and Magic Saws in Terms of Edema and Ecchymosis After Rhinoplasty

OBJECTIVE

The goal of this study was to compare conventional osteotomes and Magic Saws in terms of edema and ecchymosis, in rhinoplasty patients.

STUDY DESIGN

A retrospective, case-control study.

METHODS

In this prospective, randomized study, we evaluated the results of 258 rhinoplasty patients who underwent osteotomy by either conventional osteotomes or new designed saws called; "Magic Saws." On postoperative days 2 and 7, the patients were photographed by the surgeon; photographs were evaluated by another otolaryngologist, blinded from the osteotomy procedure.

RESULTS

There were no statistically differences between the groups, in terms of age, sex, weight, or average arterial blood pressure (P > 0.05). The postoperative periorbital edema (days 2 and 7) and ecchymosis (day 2) scores were significantly higher in the conventional osteotomy group, as compared to Magic Saw group (P < 0.05). However, on postoperative day 7, the differences in the periorbital ecchymosis scores between the groups, were not statistically significant (P > 0.05).

CONCLUSIONS

As compared to conventional osteotomes, Magic Saws were reported to be associated with minimal soft tissue injury, as well as decreased edema and ecchymosis, in the early postoperative period after rhinoplasty.

Quantitative Analysis of Tranexamic Acid Effects on Ecchymosis in Rhinoplasty

Background: Many methods have been described to reduce postoperative ecchymosis in rhinoplasty with tranexamic acid (TXA) remaining controversial. TXA remains a consideration for surgeons, however, may have serious side effects, including seizures, blood clots, and vision changes. Methods: A prospective study of primary rhinoplasty patients was performed from March 2019 to June 2019. TXA was used in 50 patients and postoperative ecchymosis was compared with 50 control patients. Adobe Photoshop was used to quantitate postoperative ecchymosis using multiple objective color scales. Results: One hundred subjects were enrolled in the study. Eighty-four females and 16 males were included. Photographs were taken on postoperative day 7. There were no significant differences among any of the Red, Green, Blue (RGB) and L*a*b* color subgroups with p > 0.05. There were no adverse events with TXA. Conclusions: In this study, TXA did not reduce postoperative ecchymosis in rhinoplasty when used both through intravenous and intraoperative injections.

Modalities of Post-Rhinoplasty Edema and Ecchymosis Measurement: A Systematic Review

Background:

Post-rhinoplasty edema and ecchymosis can influence patient satisfaction with surgery as well as result in poor quality of life. Methods to quantify such edema and ecchymosis have been described in the literature. Despite this, there is currently no collective understanding of which methods are the most effective. Hence, this systematic review aims to describe and analyze the literature on post-rhinoplasty edema and ecchymosis measurement techniques.

Methods:

Standard bibliographic databases (OVID Medline, EMBASE, and PubMed) were searched from their inception to December 2019 for the terms: “rhinoplasty”, “postoperative”, “edema”, and “ecchymosis”. Descriptive analysis was completed.

Results:

The search revealed 1116 articles of which 33 met inclusion criteria and were included for qualitative synthesis. A total of 1801 patients from all studies were included. Of the 33 included studies, there were 57 unique ecchymosis/edema measurements. The majority of studies measured edema/ecchymosis on post-operative day 1, 2, 3 and 7. Ninety-three percent of measurements described were taken subjectively from a human rater. Other techniques described included magnetic resonance imaging, ultrasound, 3-dimensional imaging, and digital analysis. Less than half of the subjective ecchymosis/edema gradings were completed by a blinded rater.

Conclusion:

There are a wide variety of post-rhinoplasty edema and ecchymosis techniques being used by rhinoplasty surgeons. The majority of post-rhinoplasty edema and ecchymosis measurements are completed by unblinded subjective raters. It is important that facial plastic surgeons select an accurate measurement tool so they may be able to initiate precise patient-specific management of edema and ecchymosis.

Effects of perioperative magnesium sulfate with controlled hypotension on intraoperative bleeding and postoperative ecchymosis and edema in open rhinoplasty

PURPOSE

This randomized, double-blind study was planned to evaluate the effect of perioperative magnesium sulfate with controlled hypotension on intraoperative bleeding, postoperative ecchymosis and edema, and side-effects.

MATERIALS AND METHOD

Forty-nine patients undergoing open rhinoplasty were divided into two groups - magnesium sulfate and control. The magnesium sulfate group received 30-50 mg·kg^-1 intravenously as a bolus before induction of anesthesia, followed by 10-20 mg·kg^-1 h^-1 by continuous intravenous infusion during surgery. Anesthesia was induced with propofol 3 mg·kg^-1, fentanyl 15 μg·kg^-1 and cisatracurium 0.6 mg·kg^-1. Mean arterial pressure was maintained at 50 to 60 mmHg under controlled hypotensive anesthesia with magnesium sulfate titration. Hemodynamic variables, operational bleeding, early postoperative side-effects and postoperative first-, third- and seventh-day ecchymosis and edema were compared between the groups. Ecchymosis and edema were evaluated using a graded scale from 0 to 4.

RESULTS

In the magnesium sulfate group, mean arterial pressure decreased during most of the perioperative period. Intraoperative bleeding also decreased. A distinct reduction in ecchymosis and edema was observed in both the upper and lower eyelids on the first, third and seventh days. Patients in the magnesium sulfate group also had a more peaceful postoperative course with less postoperative nausea vomiting, and shivering.

CONCLUSION

Magnesium sulfate with controlled hypotension can lower ecchymosis and edema of the upper and lower eyelids in rhinoplasty surgery by reducing bleeding.

Comparison of Rhinoplasty Patients Informed With Standard Verbal Information in Preoperative Period and Rhinoplasty Patients Informed and Treated With Visual Information Through Catalog in Terms of the Development of Agitation, Edema and Ecchymose in the Postoperative Period

AIM

In this study, we aimed to compare the effects of standard verbal information in the preoperative period and the information by visual expression and physical applications in the development of agitation, edema and ecchymosis in the postoperative period.

MATERIALS AND METHODS

The study was carried out in 60 ASA I-II patients who were going to undergo open rhinoplasty by plastic surgery. In the Preoperative Anesthetic Assessment the patients were divided into two groups as the patients given standard verbal information (Group S; n = 30) and those informed with a catalog which contains visuals (Group V; n = 30) In the preoperative period, anxiety levels of the patients were evaluated. Standard anesthesia induction was performed in both groups after standard monitoring. Patients were monitored in the post-anesthesia care unit and ward. Patient's extubation quality, presence of postoperative agitation and periorbital edema and ecchymosis at the 6th, 12th, 18th, and 24th hours were evaluated.

RESULTS

No significant difference was found between the groups in terms of intraoperative and postoperative MAP, HR, extubation quality, presence of recovery agitation, postoperative pain, development edema and ecchymosis (P > 0.05). Significant positive correlation was found between post-extubation MAP and edema scores at the 16th and 24th hours postoperatively and between the post-anesthesia care unit entry MAP and ecchymosis at the 24th postoperative hours independently of the groups (r = 0.27; P = 0.038, r = 0.302; P = 0.019, r = 0.345; P = 0.007, respectively).

RESULT

In our study, it was concluded that detailed visual information and physical application in the preoperative period among rhinoplasty patients had no effect on the incidence of postoperative agitation, development of edema and ecchymosis.

Effect of Nasal Skin Type on Skin Problems following Rhinoplasty

Skin problems following rhinoplasty may cause dissatisfaction concerning the esthetic expectations of the patients. This study was conducted to determine whether nasal skin type has an effect on skin problems after rhinoplasty. Thirty-five patients undergoing rhinoplasty in our tertiary referral center between May 2018 and August 2019 were included in the study. The nasal skin sebum level was measured with Sebumeter preoperatively and patients were divided into two groups according to the median sebum level. Among the 35 patients, half of them with higher nasal skin sebum were categorized as oily skin group (n = 17; 14 males, 3 females; mean sebum level: 200.3 ± 26.9), and the other half were categorized as dry skin group (n = 18; 10 males, 8 females; mean sebum level: 101.9 ± 38). Periorbital edema and ecchymosis were assessed at postoperative days 1, 3, and 7. Acne and seborrhea severity determined with Global Acne Grading System and Seborrheic Dermatitis Area Severity Index the day before operation and postoperative days 7 and 14 and months 1, 3, and 10. Compared with dry skin group, upper eyelid ecchymosis score at postoperative day 7 was statistically higher in oily skin group (p = 0.044). There was no significant difference in upper eyelid edema scores between postoperative days 1 and 3 for oily skin group (p = 0.020). No statistically significant differences were found for acne and seborrhea severity. Nasal skin sebum levels may affect periorbital edema and ecchymosis after the procedure but no significant effect has been observed for acne and seborrhea. Predicting the effect of nasal skin types on these problems may help the surgeon to inform patients more correctly.

A meta-analysis of pre- and postoperative corticosteroids for reducing the complications following facial reconstructive and aesthetic surgery

INTRODUCTION

Edema and ecchymosis after facial plastic surgery are a troublesome concern for both patients and surgeons. Corticosteroid administration is thought to shorten the recovery period and reduce these sequelae. Data regarding the efficacy of corticosteroid administration remains controversial among surgeons.

OBJECTIVE

We conducted this systematic review and meta-analysis to determine the effect of pre- and postoperative corticosteroids on postoperative complications in patients undergoing facial reconstructive surgery supported with different subgroup analysis.

METHODS

A comprehensive literature search of articles was conducted in PubMed, Cochrane Central, SCOPUS, and EBSCO through October 2019. We included all clinical trials in which patients underwent any type of facial plastic surgery to study the effect of corticosteroids on postoperative complications. We performed subgroup analysis according to the types and doses of corticosteroid preparation, in addition to a subgroup analysis of pre- or postoperative corticosteroid usage. All statistical analysis was performed using the RevMan software.

RESULTS

Nineteen studies were included in this systematic review, but only 10 of them were eligible for meta-analysis. The periorbital edema and ecchymosis scores were significantly reduced in the corticosteroids group compared to placebo -0.82, 95% CI (-1.37, -0.26), and -0.95, 95% CI (-1.32, -0.57), respectively. However, these significant differences were not maintained at day 3 and 7. Smaller doses of corticosteroid (8 mg and 10 mg) were associated with smaller differences in the mean score of upper and lower eyelid edema and ecchymosis, while the higher doses were associated with greater differences. Furthermore, preoperative corticosteroid usage significantly reduced the intraoperative bleeding when compared to placebo for higher doses > 50 mg per day (p < 0.0001), but not for 8 mg corticosteroid (p = 0.06). Adding postoperative steroid dose to the preoperative one was associated with less edema and ecchymosis than preoperative administration alone.

CONCLUSION

This comprehensive meta-analysis confirms a statistically significant benefit of preoperative corticosteroids. Furthermore, continuing the steroids postoperatively is associated with long-term reduction of complications. Higher doses of corticosteroids are associated with a more significant reduction in edema and ecchymosis, but further studies are recommended to determine the postoperative side effects, including surgical site infection and delayed healing.

The safety of pulse corticosteroid therapy- Systematic review and meta-analysis

OBJECTIVE

To amass all available evidence from randomized controlled trials regarding the safety of pulse corticosteroids therapy, in order to establish its safety.

PATIENTS AND METHODS

All electronic databases from 1/1966 up to 02/2019 were reviewed to find all randomized controlled trials comparing pulse corticosteroids to oral corticosteroids or to placebo/no treatment. Two reviewers independently extracted and recorded data regarding type of corticosteroid treatment, dosages, length of treatment and follow-up. Risk ratios (RR) with 95% (CI) for differences between pulse corticosteroids and comparator were pooled using a fixed effect meta-analysis. The primary outcome was occurrence of severe adverse events (SAEs). Secondary outcomes included any adverse events (AEs), AEs requiring discontinuation, AEs per system involved and all-cause mortality.

RESULTS

A total of 64 trials were included: 18 trials which compared pulse corticosteroids to oral corticosteroids and 46 trials which compared pulse corticosteroids to placebo/no intervention. Pulse corticosteroids was not associated with increased risk for SAEs for both comparators: RR 0.77 (95% CI 0.52-1.14), and RR 0.99 (95% CI 0.93-1.06), respectively. Sensitivity analysis based on adequate allocation concealment and use of a valid AE grading did not alter the results. Subgroup analysis revealed no increased risk of specific SAEs or AEs with pulse corticosteroids compared to oral corticosteroids.

CONCLUSION

Pulse corticosteroids was not associated with an increase risk of SAEs and should be regarded as safe.

Reporting Outcomes and Outcome Measures in Open Rhinoplasty: A Systematic Review

BACKGROUND

Comparative studies have shown little statistical difference in outcomes following rhinoplasty, demonstrating near equivalent results across all surgical techniques. Cross-study comparisons of these trials are difficult because variation in outcome reporting prevents statistical pooling and analysis.

OBJECTIVES

The authors sought to identify all outcomes and outcome measures used to evaluate postoperative results in rhinoplasty.

METHODS

An extensive computerized database search of MEDLINE and EMBASE was performed; all trials involving n ≥ 20 patients, aged 18 years and older undergoing a primary, open rhinoplasty procedure, were included for review.

RESULTS

Of the 3235 citations initially screened, 72 studies met the stated inclusion criteria. A total of 53 unique outcomes and 55 postoperative outcome measures were identified. Outcomes were divided into 6 unique domains: objective signs, subjective symptom severity, physical function related to activities of daily living, patient satisfaction, surgeon satisfaction, and quality of life. The identified outcome measures consisted of 5 nasal-specific, author-reported instruments; 5 nasal specific, patient-reported instruments; 5 patient-reported, generic instruments; and 40 author-generated instruments. Of the outcome measures identified, the Rhinoplasty Outcomes Evaluation, Sino-Nasal Outcome Test-22, and FACE-Q were the only instruments to demonstrate adequate validity, reliability, and responsiveness to change in patients who underwent a rhinoplasty procedure.

CONCLUSIONS

There is heterogeneity in the outcomes and outcome measures employed to assess postsurgical outcomes following rhinoplasty. A standardized core outcome set is urgently needed to make it possible for future investigators to compare results of various techniques in rhinoplasty surgery.

LEVEL OF EVIDENCE: 2

Preoperative Tranexamic Acid for Treatment of Bleeding, Edema, and Ecchymosis in Patients Undergoing Rhinoplasty: A Systematic Review and Meta-analysis

Importance

Evidence has emerged on the efficacy of tranexamic acid to control blood loss and postoperative complications after rhinoplasty.

Objective

To investigate the results of tranexamic acid use to reduce intraoperative bleeding, postoperative eyelid edema, and periorbital ecchymosis in rhinoplasty.

Data Sources and Study Selection

For this systematic review of randomized clinical trials, searches were performed in PubMed, Cochrane Central Register of Controlled Trials, Web of Science, SCOPUS, Science Direct, Google Scholar, OpenThesis, and ClinicalTrials.gov from inception to December 23, 2017. Key words included tranexamic acid, rhinoplasty, and nasal surgical procedures. The following elements were used to define eligibility criteria: (1) population: patients undergoing rhinoplasty surgery; (2) intervention and controls: tranexamic acid vs placebo solution or no-treatment control group; (3) outcomes: intraoperative bleeding, postoperative eyelid edema and periorbital ecchymosis, and thromboembolic events; and (4) study type: randomized clinical trials.

Data Extraction and Synthesis

Two reviewers extracted data and assessed study quality according to the Cochrane guidelines for randomized clinical trials. Treatment effects were defined as weighted mean difference (WMD) and 95% CIs. The strength of evidence was analyzed using the Grading of Recommendations Assessment, Development, and Evaluation rating system.

Main Outcomes and Measures

Intraoperative bleeding, postoperative eyelid edema and periorbital ecchymosis. To calculate the effect sizes, means and SDs were obtained for each study group and outcome of interest.

Results

Five studies comprising 276 patients were included in the systematic review: 177 patients (64.1%) were women, and mean age was 26.8 (range, 16-42) years. Four studies comprising 246 patients estimated the amount in intraoperative bleeding as a primary outcome and were included in the meta-analysis. Eyelid edema and ecchymosis were evaluated as outcomes in 2 studies. Tranexamic acid was associated with reduced bleeding during rhinoplasty was found (WMD, -42.28 mL; 95% CI, -70.36 to -14.21 mL), with differences (P = .01) between oral (WMD, -61.70 mL; 95% CI, -83.02 to -40.39 mL; I2 = 0%) and intravenous (WMD, -23.88 mL; 95% CI, -45.19 to -2.58 mL; I2 = 56%) administration. Eyelid edema and ecchymosis scores in patients receiving tranexamic acid were significantly lower compared with the control group within the first postoperative week: lower eyelid edema, WMD, -0.76; 95% CI, -1.04 to -0.49 and lower eyelid ecchymosis, WMD, -0.94; 95% CI, -1.80 to -0.08. No cases of thromboembolic events were reported.

Conclusions and Relevance

Current available evidence suggests that preoperative administration of tranexamic acid is safe and may reduce intraoperative bleeding as well as postoperative eyelid edema and ecchymosis in patients undergoing rhinoplasty.

Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty

Objective Rhinoplasty, a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway, ranks among the most commonly performed cosmetic procedures in the United States, with >200,000 procedures reported in 2014. While it is difficult to calculate the exact economic burden incurred by rhinoplasty patients following surgery with or without complications, the average rhinoplasty procedure typically exceeds $4000. The costs incurred due to complications, infections, or revision surgery may include the cost of long-term antibiotics, hospitalization, or lost revenue from hours/days of missed work. The resultant psychological impact of rhinoplasty can also be significant. Furthermore, the health care burden from psychological pressures of nasal deformities/aesthetic shortcomings, surgical infections, surgical pain, side effects from antibiotics, and nasal packing materials must also be considered for these patients. Prior to this guideline, limited literature existed on standard care considerations for pre- and postsurgical management and for standard surgical practice to ensure optimal outcomes for patients undergoing rhinoplasty. The impetus for this guideline is to utilize current evidence-based medicine practices and data to build unanimity regarding the peri- and postoperative strategies to maximize patient safety and to optimize surgical results for patients. Purpose The primary purpose of this guideline is to provide evidence-based recommendations for clinicians who either perform rhinoplasty or are involved in the care of a rhinoplasty candidate, as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The target audience is any clinician or individual, in any setting, involved in the management of these patients. The target patient population is all patients aged ≥15 years. The guideline is intended to focus on knowledge gaps, practice variations, and clinical concerns associated with this surgical procedure; it is not intended to be a comprehensive reference for improving nasal form and function after rhinoplasty. Recommendations in this guideline concerning education and counseling to the patient are also intended to include the caregiver if the patient is <18 years of age. Action Statements The Guideline Development Group made the following recommendations: (1) Clinicians should ask all patients seeking rhinoplasty about their motivations for surgery and their expectations for outcomes, should provide feedback on whether those expectations are a realistic goal of surgery, and should document this discussion in the medical record. (2) Clinicians should assess rhinoplasty candidates for comorbid conditions that could modify or contraindicate surgery, including obstructive sleep apnea, body dysmorphic disorder, bleeding disorders, or chronic use of topical vasoconstrictive intranasal drugs. (3) The surgeon, or the surgeon's designee, should evaluate the rhinoplasty candidate for nasal airway obstruction during the preoperative assessment. (4) The surgeon, or the surgeon's designee, should educate rhinoplasty candidates regarding what to expect after surgery, how surgery might affect the ability to breathe through the nose, potential complications of surgery, and the possible need for future nasal surgery. (5) The clinician, or the clinician's designee, should counsel rhinoplasty candidates with documented obstructive sleep apnea about the impact of surgery on nasal airway obstruction and how obstructive sleep apnea might affect perioperative management. (6) The surgeon, or the surgeon's designee, should educate rhinoplasty patients before surgery about strategies to manage discomfort after surgery. (7) Clinicians should document patients' satisfaction with their nasal appearance and with their nasal function at a minimum of 12 months after rhinoplasty. The Guideline Development Group made recommendations against certain actions: (1) When a surgeon, or the surgeon's designee, chooses to administer perioperative antibiotics for rhinoplasty, he or she should not routinely prescribe antibiotic therapy for a duration >24 hours after surgery. (2) Surgeons should not routinely place packing in the nasal cavity of rhinoplasty patients (with or without septoplasty) at the conclusion of surgery. The panel group made the following statement an option: (1) The surgeon, or the surgeon's designee, may administer perioperative systemic steroids to the rhinoplasty patient.

A comparison of piezosurgery with conventional techniques for internal osteotomy

To compare conventional osteotomy with the piezosurgery medical device, in terms of postoperative edema, ecchymosis, pain, operation time, and mucosal integrity, in rhinoplasty patients. In this prospective study, 49 rhinoplasty patients were randomly divided into two groups according to osteotomy technique used, either conventional osteotomy or piezosurgery. For all patients, the total duration of the operation was recorded, and photographs were taken and scored for ecchymosis and edema on postoperative days 2, 4, and 7. In addition, pain level was evaluated on postoperative day 2, and mucosal integrity was assessed on day 4. All scoring and evaluation was conducted by a physician who was blinded to the osteotomy procedure. In the piezosurgery group, edema scores on postoperative day 2 and ecchymosis scores on postoperative days 2, 4, and 7 were significantly lower than in the conventional osteotomy group (p < 0.05). On postoperative day 2, the pain level was lower in the piezosurgery group than in the conventional osteotomy group (p < 0.05). In an endoscopic examination on postoperative day 4, while 24% of the patients in the conventional osteotomy group had mucosal damage, no such damage was observed in the piezosurgery group. When total operation duration was compared, there was no significant difference between the groups (p > 0.05). Piezosurgery is a safe osteotomy method, with less edema (in the early postoperative period) and ecchymosis compared with conventional osteotomy, as well as less pain, a similar operation duration, and no mucosal damage.

Interventions to Decrease Postoperative Edema and Ecchymosis after Rhinoplasty: A Systematic Review of the Literature

BACKGROUND

Today, minimally invasive procedures are becoming more popular because of the fast recovery. Rhinoplasty is a common facial plastic surgery procedure that can be associated with significant postoperative morbidities, especially periorbital edema and ecchymosis. The aim of this review is to summarize the results of published literature that studied interventions that decrease postoperative edema and ecchymosis after rhinoplasty, and provide evidence-based strategies for surgeons to incorporate into practice.

METHODS

A systematic review of the PubMed, Scopus, and EMBASE databases was performed to investigate interventions studied to decrease postoperative edema and ecchymosis after rhinoplasty. After inclusion and exclusion criteria were applied, articles were grouped into one of the following categories: corticosteroids, other medications and herbal supplements, interventions to decrease intraoperative bleeding, other postoperative interventions, and surgical techniques.

RESULTS

A total of 50 articles were included for review. Fourteen articles studied corticosteroids exclusively, whereas another 10 articles reviewed other medications and herbal supplements. Nine articles evaluated methods to decrease intraoperative bleeding during rhinoplasty, and four articles studied postoperative interventions to decrease edema and ecchymosis. Thirteen articles studied various surgical techniques to decrease postoperative morbidities.

CONCLUSIONS

There was a consensus within the literature that steroids, intraoperative hypotension, intraoperative cooling, and head elevation postoperatively decrease postoperative edema and ecchymosis, whereas nasal packing and periosteal elevation before osteotomy increased these postoperative morbidities. Studies of herbal supplements may be incorporated into practice with minimal risk to the patient. More studies must be performed before recommending an external or internal approach to lateral osteotomy.

How can periorbital oedema and ecchymose be reduced in rhinoplasty?

Oedema and ecchymose are frequent morbidities of septorhinoplasty, a facial surgical procedure for reforming the shape and functions of the nose. Periorbital oedema (PO) and periorbital ecchymose (PE) are normal occurrences, but are undesirable for patients undergoing the procedure for aesthetic purposes. The present study examined 65 patients who underwent open technique septorhinoplasty for aesthetic and functional complaints. Patients were divided into two groups: Group 1 patients underwent lateral osteotomy following tip plasty, at the end of the surgical operation; Group 2 patients underwent lateral osteotomy before tip plasty, at the beginning of the surgical operation. Patients were followed on the postoperative first, third and seventh days. PO and PE values of patients were scored from 0 to 4. The plastering time (Pt) was significantly shorter for Group I than Group II (p < 0.05). The total surgical time (T) showed no significant difference (p > 0.05). The PO value at the first, third and seventh days was significantly smaller for Group I than Group II (p < 0.05). The PE value at the first, third and seventh days was also significantly smaller for Group I than Group II (p < 0.05). The obtained data indicate that performing a lateral osteotomy in the final stages of surgery, and subsequently applying a nasal plaster and splint as rapidly as possible, decreases PO and PE in the postoperative period.

Perioperative Corticosteroids Reduce Short-Term Edema and Ecchymosis in Rhinoplasty: A Meta-Analysis

BACKGROUND

A number of randomized controlled trials (RCTs) have investigated the role of perioperative corticosteroids in rhinoplasty. Each of these trials however has an insufficient sample sizes to reach definitive conclusions and detect harms. Three recent reviews have analyzed edema and ecchymosis outcomes following rhinoplasty; each arrived at a different conclusion and recommendation.

OBJECTIVE

To estimate the effectiveness of systemic perioperative corticosteroid treatment compared to placebo for clinical outcomes in rhinoplasty using a methodologically rigorous meta-analysis.

METHODS

Electronic databases were searched without language restriction. Included trials were randomized controlled trials of systemic perioperative corticosteroid treatment vs placebo in rhinoplasty evaluating at least one of: edema, ecchymosis, bleeding, cosmetic outcome, and patient satisfaction. The Cochrane risk of bias tool was applied to included trials, and the quality of evidence for each outcome was assessed using the GRADE approach.

RESULTS

Analyses included 336 patients from eight trials. Perioperative corticosteroids reduced the worst edema (SMD: -1.03, 95%CI -1.30 to -0.76, P < .001) and ecchymosis (SMD: -0.78, 95%CI -1.09 to 0.47, P < .001) after rhinoplasty. At one day postoperative, a single dose of perioperative corticosteroid reduced edema (SMD -1.15, 95%CI -1.42 to -0.87, P < .001) and ecchymosis (SMD -0.79, 95%CI -1.05 to -0.52, P < .001). No clinical benefit in edema or ecchymosis was found seven days postoperatively, nor did intraoperative bleeding increase.

CONCLUSIONS

There is high quality evidence to support perioperative systemic corticosteroid treatment in rhinoplasty to reduce short-term edema and ecchymosis without increased intraoperative bleeding. These findings are not present at seven days. For future trials, we suggest evaluation of patient satisfaction, and correlation with long-term cosmetic outcome. LEVEL OF EVIDENCE 2: Therapeutic.

The efficacy of tranexamic acid and corticosteroid on edema and ecchymosis in septorhinoplasty

The aim of this study was to investigate the efficacy of tranexamic acid (TA) and methylprednisolone on periorbital edema, ecchymosis, and intraoperative bleeding in patients who underwent open septorhinoplasty (oSRP). Seventy-five patients performing hump extraction and osteotomies were allocated into 3 groups as follows: group 1, 25 patients as control; group 2, 25 patients who were administered oral TA as first dose 1 g starting 2 hours before surgery, 3 g daily in divided doses (1 g, every 8 hours) for 5 days; and group 3, 25 patients who were administered a single dose of 1 mg/kg intravenous methylprednisolone at the beginning of the surgery. Operation time, amount of intraoperative bleeding, and complications were recorded. Scoring of eyelid edema and periorbital ecchymosis was evaluated on postoperative first, third, and seventh days using scale of 0 to 4 by 2 observers. In groups using TA and methylprednisolone, periorbital edema and ecchymosis scores were significantly lower compared with the control group (P < 0.05). No significant difference was seen clinically and statistically in preventing or decreasing both periorbital edema and ecchymosis between group 2 and group 3. Patients given TA showed significantly less intraoperative bleeding compared with controls and patients who were administered methylprednisolone. We observed that the administration of methylprednisolone significantly decreases periorbital edema and ecchymosis. Additionally, our results support that TA use in patients who underwent oSRP with osteotomies was found clinically and statistically effective for prevention of bleeding during oSRP operations and reduction of both periorbital edema and ecchymosis.

Perioperative corticosteroids for preventing complications following facial plastic surgery

BACKGROUND

Early recovery is an important factor for people undergoing facial plastic surgery. However, the normal inflammatory processes that are a consequence of surgery commonly cause oedema (swelling) and ecchymosis (bruising), which are undesirable complications. Severe oedema and ecchymosis delay full recovery, and may make patients dissatisfied with procedures. Perioperative corticosteroids have been used in facial plastic surgery with the aim of preventing oedema and ecchymosis.

OBJECTIVES

To determine the effects, including safety, of perioperative administration of corticosteroids for preventing complications following facial plastic surgery in adults.

SEARCH METHODS

In January 2014, we searched the following electronic databases: the Cochrane Wounds Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase; EBSCO CINAHL; and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS). There were no restrictions on the basis of date or language of publication.

SELECTION CRITERIA

We included RCTs that compared the administration of perioperative systemic corticosteroids with another intervention, no intervention or placebo in facial plastic surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the trials for inclusion in the review, appraised trial quality and extracted data.

MAIN RESULTS

We included 10 trials, with a total of 422 participants, that addressed two of the outcomes of interest to this review: swelling (oedema) and bruising (ecchymosis). Nine studies on rhinoplasty used a variety of different types, and doses, of corticosteroids. Overall, the results of the included studies showed that there is some evidence that perioperative administration of corticosteroids decreases formation of oedema over the first two postoperative days. Meta-analysis was only possible for two studies, with a total of 60 participants, and showed that a single perioperative dose of 10 mg dexamethasone decreased oedema formation in the first two days after surgery (SMD = -1.16, 95% CI: -1.71 to -0.61, low quality evidence). The evidence for ecchymosis was less consistent across the studies, with some contradictory results, but overall there was some evidence that perioperatively administered corticosteroids decreased ecchymosis formation over the first two days after surgery (SMD = -1.06, 95% CI:-1.47 to -0.65, two studies, 60 participants, low quality evidence ). The difference was not maintained after this initial period. One study, with 40 participants, showed that high doses of methylprednisolone (over 250 mg) decreased both ecchymosis and oedema between the first and seventh postoperative days. The only study that assessed facelift surgery identified no positive effect on oedema with preoperative administration of corticosteroids. Five trials did not report on harmful (adverse) effects; four trials reported that there were no adverse effects; and one trial reported adverse effects in two participants treated with corticosteroids as well as in four participants treated with placebo. None of the studies reported recovery time, patient satisfaction or quality of life. The studies included were all at an unclear risk of selection bias and at low risk of bias for other domains.

AUTHORS' CONCLUSIONS

There is limited evidence for rhinoplasty that a single perioperative dose of corticosteroids decreases oedema and ecchymosis formation over the first two postoperative days, but the difference is not maintained after this period. There is also limited evidence that high doses of corticosteroids decrease both ecchymosis and oedema between the first and seventh postoperative days. The clinical significance of this decrease is unknown and there is little evidence available regarding the safety of this intervention. More studies are needed because at present the available evidence does not support the use of corticosteroids for prevention of complications following facial plastic surgery.

Periorbital edema: a puzzle no more?

PURPOSE OF REVIEW

Periorbital edema is a common problem that deserves scrutiny. Although a variety of healthcare providers may see this clinical entity, ophthalmologists are often consulted along the way toward diagnosis. It can challenge even the most astute clinicians. A diagnosis may reveal merely a bothersome issue or potentially a sight-threatening or life-threatening problem.

RECENT FINDINGS

Comprehensive reviews on this topic are scarce. Textbooks are brief. There are, however, many studies in the scientific literature of notable cases of periorbital edema. The causes generally fall into the categories of infectious, inflammatory or tumors, medication related, and postsurgical or trauma.

SUMMARY

This article synthesizes the current literature on the topic with a case series from our institution. It aims to provide a thorough resource for all practitioners to make the prospect of triaging, diagnosing, and treating periorbital edema less daunting.

Efficacy of dexamethasone with controlled hypotension on intraoperative bleeding, postoperative oedema and ecchymosis in rhinoplasty

PURPOSE

The aim of this retrospective study was to evaluate the efficacy of dexamethasone with controlled hypotension on intraoperative bleeding and postoperative morbidity in rhinoplasty.

MATERIALS AND METHODS

Sixty rhinoplasty patients required hump resection and lateral osteotomy were included in this study. The patients were randomized into four groups. In group I (n=15), a single dose of 10mg/kg dexamethasone was intravenously administered at the beginning of the operation. In group II (n=15), the patients were given 2 doses of 10mg/kg intravenously dexamethasone at the beginning of the operation, and 24 hours after the operation. In group III (n=15), 3 doses of 10mg/kg intravenously dexamethasone were given at the beginning of the operation, before osteotomy and 24 hours after the operation. Group IV (n=15) was assigned as control group and the patients were neither administered dexamethasone nor applied hypotension. All cases in groups I, II and III were operated under controlled hypotension. Systolic arterial pressure was aimed to keep between 65 and 75 mmHg for controlled hypotensive anaesthesia. Controlled hypotension was achieved by a remifentanil infusion of 0.1-0.5 microg/kg/min, following a bolus of 1 microg/kg. Degree of eyelid oedema and periorbital soft-tissue ecchymosis was evaluated separately using a scale of 0-4. Intraoperative blood loss was recorded for each patient. Patients were evaluated at 24 hours and postoperative days 2, 5, 7, and 10.

RESULTS

In groups I, II and III, intraoperative bleeding was more decreased and the operation time was significantly shorter compared with control group (P<0.001). Eyelid oedema and periorbital ecchymosis were significantly decreased in groups I, II and III at the following postoperative 7 and 10 days (P<0.001). There was statistically significant difference between group III and other groups at the postoperative 5 and 7 days in lower eyelid oedema (P<0.001), upper and lower eyelid ecchymosis (P<0.001 and 0.004, respectively). There were no postoperative complications with using steroid in any of the groups.

CONCLUSION

Three doses of dexamethasone with controlled hypotension considerably reduced postoperative morbidities of rhinoplasty with osteotomy as well as intraoperative bleeding. Thus, in group III receiving 3 doses of steroid, when compared to other groups, more uneventful postoperative period were provided for surgeon and the patients.

Comparison of the effect of corticosteroid therapy and decongestant on reducing rhinoplasty edema

BACKGROUND

Comparison of the two methods of decongestant and three doses of dexamethasone on reducing edema and ecchymosis after septorhinoplasty.

METHODS

Seventy-four patients who were candidates for rhinoplasty were randomly divided into three groups. Group A received 8 mg of i.v. dexamethasone preoperatively and again after 24 and 48 hours after surgery, group B received three pseudoephedrine tablets (60 mg) per day for 1 week, and group C received three pseudoephedrine tablets (60 mg) per day for 2 weeks. Finally, their effects on the eye, tip and dorsal edema, and ecchymosis were evaluated.

RESULTS

Our findings showed that both decongestant and corticosteroid had significant short-term effects on edema and ecchymosis, but only continuation of pseudoephedrine could reduce the evaluated variables after 1 week.

CONCLUSION

Pseudoephedrine can be effective for reducing eyelid edema and ecchymosis after rhinoplasty. Also, administration of three doses of dexamethasone in the postoperative care of nasal plastic surgery harmlessly diminished postsurgical edema.

Perioperative steroids for minimizing edema and ecchymosis after rhinoplasty: a meta-analysis

BACKGROUND

Minimizing complications after rhinoplasty is a priority for every surgeon performing the procedure. Perioperative steroid administration has been shown to decrease postoperative edema and ecchymosis in a number of prospective randomized trials.

OBJECTIVES

In an effort to further elucidate the significance of the data and develop an evidence-based algorithm for steroid administration, the authors offer a meta-analysis of the existing literature.

METHODS

A systematic review of the literature was performed. All articles were reviewed for relevant data, which were extracted, pooled, and compared. Seven prospective randomized trials investigating perioperative steroid use in rhinoplasty have been conducted and reported. Four of these studies had the same method of patient edema and ecchymosis assessment, and their data were compared.

RESULTS

Based on results from the four relevant studies, perioperative steroid use significantly reduces postoperative edema and ecchymosis of the upper and lower eyelids at one day and seven days postoperatively (P < .0001). Preoperative steroid administration decreases postoperative upper and lower eyelid edema at one day preoperatively, when compared to postoperative administration (P < .05). Extended dosing is superior to one-time dosing (P < .05).

CONCLUSIONS

Perioperative steroid use decreases postoperative edema and ecchymosis associated with rhinoplasty. Preoperative administration is superior to postoperative, and extended dosing is superior to singular. Based on these results, evidence-based guidelines for perioperative steroid administration can be given.

The Effectiveness of Steroids for Edema, Ecchymosis, and Intraoperative Bleeding in Rhinoplasty

Background

The aim of this study was to investigate the dose-related effectiveness of steroids on periorbital edema, ecchymosis, and intraoperative bleeding in patients who underwent open rhinoplasty with osteotomy.

Methods

Forty patients were divided into three groups: those in group 1 (n = 15) were given a single dose of 1-mg/kg intravenous (i.v.) methylprednisolone, those in group 2 (n = 15) were given a single dose of 3-mg/kg i.v. methylprednisolone preoperatively, and group 3 (n = 10) was the control group. Eyelid edema and periorbital soft-tissue ecchymosis were evaluated separately using a scale of 0–4.

Results

In groups using the steroid preoperatively, periorbital edema and ecchymosis were significantly lower compared with the control group (p < 0.05). No significant differences were seen clinically or statistically in preventing or reducing either the periorbital ecchymosis or the periorbital edema between groups 1 and 2. Also, there was no significant difference among the groups in terms of bleeding (p > 0.05). No complications with regard to the operation or steroid use were observed.

Conclusion

Our results support that steroids significantly decrease periorbital ecchymosis and periorbital edema in open rhinoplasty with osteotomy. Additionally, our results suggest that if the dose of steroids is adjusted according to body weight, there is no significant benefit in a single dose of 3 mg/kg of methylprednisolone over a lower dose of 1 mg/kg and there is no need for higher doses of methylprednisolone administration.

Efficacy of the Combination of Intraoperative Cold Saline-Soaked Gauze Compression and Corticosteroids on Rhinoplasty Morbidity

Objective. The basic aim of this study was to minimize intraoperative bleeding, postoperative eyelid edema, and periorbital ecchymosis and to reduce morbidity with a combination of cold saline-soaked gauze compression and intraoperative single-dose corticosteroids.

Study Design. The study was designed as a prospective, double-blind, randomized controlled study. Three hundred patients who underwent septorhinoplasty were included.

Setting. A tertiary referral hospital in Turkey.

Subjects and Methods. Three hundred patients undergoing septorhinoplasty were divided into 2 groups. A single dose of 10 mg dexamethasone was intravenously administered in all cases at the beginning of the operation. In the study group, the nasal dorsum was continuously compressed with cold saline-soaked gauze during the operation. In the control group, the nasal dorsum was compressed with dry gauze continuously during surgery. The operation time and amount of bleeding were recorded during surgery. Degree of eyelid edema and periorbital soft tissue ecchymosis was recorded at 24 hours and on postoperative days 2, 3, 5, and 7 by 2 investigators.

Results. The operation time was significantly shorter in the study group than in the control group. Eyelid edema and periorbital ecchymosis were significantly decreased in the study group at the following postoperative days 1, 3, 5, and 7 ( P < .05).

Conclusion. Bleeding, edema, and ecchymosis are the main morbidities of rhinoplasty. It is highly probable that cold compression and intraoperative corticosteroids have synergistic effects on these morbidities, especially by the intraoperative control of bleeding.