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

Optimizing Postoperative Care in Rhinoplasty and Septoplasty: A Review of the Role of Nasal Packing and Alternatives in Complication Management

Rhinoplasty, a common surgical procedure for nose reshaping, demands meticulous preoperative evaluation and precise execution. When coupled with septoplasty to address medical issues stemming from a deviated nasal septum, these procedures can lead to noteworthy postoperative complications. These encompass early issues like epistaxis and hematoma, as well as long-term challenges such as scarring and aesthetic deformities. Strategies like steroids and tranexamic acid are employed to prevent and manage these complications. A contentious aspect in postoperative care is the use of nasal packing. While some argue it aids healing and hemostasis, others avoid it due to patient discomfort. This review assesses the pros and cons of postoperative nasal packing following rhinoplasty and septoplasty. A thorough literature review spanning 2000-2023 yielded 30 relevant articles from 62. Discussion reveals that nasal packing offers limited benefits in reducing bleeding, edema and ecchymosis. In conclusion, the decision to employ nasal packing in rhinoplasty and septoplasty should be made carefully, considering patient comfort and surgical context. Evidence suggests that nasal packing may not consistently provide significant advantages and could lead to adverse outcomes. Nasal splints offer similar advantages and may be considered viable alternatives. Surgeons should tailor their approach to individual patient needs, with further research needed to refine postoperative management for these procedures.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 Two Different Cold Application Times on Edema, Ecchymosis, and Pain After Rhinoplasty: A Randomized Clinical Trial

PURPOSE

This study was performed to determine the effects of different cold application times to the periorbital area after rhinoplasty on edema, ecchymosis, and pain.

DESIGN

A randomized clinical study.

METHODS

Patients were divided into two groups, and cold application was applied to one group for 4 hours and to the other for 48 hours. The cold application was applied with ice packs for 20 minutes every hour to the periorbital region in both groups. Data were collected with the Patient Information Form, Scoring Diagram for Edema, the Scoring Diagram for Ecchymosis, and the Visual Analogue Scale for Pain.

FINDINGS

Periorbital edema, eyelid ecchymosis, and pain were not significantly different between the two groups. The mean edema score of the 48-hour group was 0.87 ± 0.93, while the mean edema score of the 4-hour group was 0.70 ± 0.87 (P = .48) on the 2nd day. The mean ecchymosis score was found as 2.03 ± 1.12 in the 48-hour group and 2.10 ± 1.09 in the 4-hour group (P = .817). The mean pain score was 12.50 ± 17.40 in the 48-hour group and 13.00 ± 16.00 in the 4-hour group (P = .98).

CONCLUSIONS

The effects of 48-hour and 4-hour cold applications are similar. Cold application for 4 hours may be recommended to patients who undergo rhinoplasty, as it is more practical and easier to apply than the 48-hour practice.

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.

Application of dual-frequency ultrasound for reduction of perilesional edema and ecchymosis after rhinoseptoplasty

OBJECTIVES

Biological aspect and clinical research demonstrated that dual-frequency ultrasound (local dynamic micro-massage, LDM) waves of very high frequency can significantly modify cellular signaling providing anti-inflammatory and anti-fibrotic effects. During the recent past, these waves were successfully applied for the treatment of various inflammatory skin conditions, hypertrophic scars, and chronical wounds. Since the main complications after rhinoseptoplasty are caused by excessive inflammatory reactions and development of fibrosis along nasal implants which can lead to a revision rhinoseptoplasty, in this retrospective multicenter blinded study we have evaluated the efficacy of LDM ultrasound for the treatment of the postoperative perilesional ecchymosis and edema in patients after rhinoseptoplasty.

METHODS

Twenty-four patients received daily LDM treatment (study group) for 5 days starting from the first day postoperative, whereas 24 patients (control group) were treated with conventional ice packs. Dynamic reduction of the postoperative perilesional ecchymosis and edema was followed up, and the total duration of these side effects was determined within specific paranasal anatomical areas.

RESULTS

Post-rhinoseptoplasty ecchymosis and edema were observed in the areas of anterior cheek, lower eyelids, and upper eyelids. Duration of the postoperative perilesional edema was significantly reduced in the group treated with LDM (1.9 ± 0.9 days) compared with control group (4.5 ± 2.1 days). Duration of the ecchymosis was also significantly reduced in LDM group (2.8 ± 1.4 days) compared with controls (7.4 ± 2.8 days). Postoperative patient satisfaction in LDM-treated and control groups was 3.1 ± 1.3 and 1.5 ± 0.7, respectively, demonstrating significantly higher satisfaction in LDM-treated group.

CONCLUSIONS

This study proved that the post-rhinoseptoplasty group treated with LDM ultrasound showed a significantly shorter duration of the postsurgical perilesional ecchymosis and edema, with no substantial adverse effects other than those observed in the control group. It can be suggested that ultrasound treatment can serve as an alternative option for the noninvasive management of postoperative perilesional ecchymosis and edema.

The Effect of Topical Tranexamic Acid on Postrhinoplasty Periorbital Ecchymosis and Eyelid Edema

BACKGROUND

This study aimed to examine the effectiveness of topical tranexamic acid application in overcoming periorbital ecchymosis and eyelid edema in patients who have undergone open-technique rhinoplasty.

METHODS

Fifty patients were included in the study and divided into two groups: those who had topical tranexamic acid applied and those who did not (controls). In the tranexamic acid group, tranexamic acid-soaked pledgets were placed under the skin flap in a way that both sides could reach the osteotomy area and left for 5 minutes. In the control group, isotonic saline-soaked pledgets were placed under the skin flap in the same manner and left for 5 minutes. Digital photographs were obtained on postoperative days 1, 3, and 7. Eyelid edema and periorbital ecchymosis were scored by two different examiners and averaged for comparison.

RESULTS

Edema that developed in the patients who had tranexamic acid applied was significantly less than in the control group on postoperative day 1. There was no difference between the two groups on postoperative day 3 or 7. Ecchymosis that developed in patients who had tranexamic acid applied was significantly less than in the control group on all days.

CONCLUSIONS

Topical tranexamic acid applied to the surgical field immediately after osteotomy in rhinoplasty surgery reduces the development of postoperative periorbital ecchymosis. In addition, the topical tranexamic acid application also reduces the development of eyelid edema in the early postoperative period.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Evaluating the Effect of Tranexamic Acid Local Injection on the Intraoperative Bleeding Amount and the Postoperative Edema and Ecchymosis in Primary Rhinoplasty Patients: A Randomized Clinical Trial

BACKGROUND AND AIMS

The purpose of this study was assessing the effect of local injection of tranexamic acid (TXA) on the amount of bleeding during the primary rhinoplasty and edema and ecchymosis following the surgery.

METHODS

In this randomized clinical trial, 50 patients applying for primary rhinoplasty were divided into two groups of intervention and observation. In the intervention group, 10 mg/kg of TXA was injected locally to the operation field. In the observation group, no medicine was injected. The same anesthesia technique was used during the operation for all the patients. Age, sex, blood pressure, bleeding amount during the operation, the amount of edema and ecchymosis on the first and seventh day after the surgery were noted. The data were analyzed by the SPSS software version 24 and using descriptive statistics of frequency and percentage of frequency and Fisher and Mann-Whitney's exact statistical tests.

RESULTS

Our results showed that there was a significant difference between the amounts of bleeding during the surgery between two groups (P-value < 0.001). Also, the postoperative edema on the first and seventh day in intervention group was less than the observation group (P-value < 0.001). There were no complications during the surgery and in the follow-up of the patients.

CONCLUSION

We revealed that local injection of TXA during the rhinoplasty procedure and decreased the intraoperative bleeding and postoperative ecchymosis and edema without any side effects and complications.

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.

Evaluation of Periorbital Edema and Ecchymosis After Osteotomy in Septorhinoplasty Cases by Measuring Bone Density and Thickness

PURPOSE

Periorbital edema and ecchymosis that may occur after surgery in septorhinoplasty patients who have undergone lateral osteotomy are common morbidities and are seen as the main limiting factors for the recovery process of the patients. There are many different studies in the literature about the causes of periorbital edema and ecchymosis. In this study, the authors aimed to investigate the possible relationships between the bone density and bone thickness measured in the frontal process of the maxillary bone, and postoperative periorbital edema and ecchymosis, which are suitable for the osteotomy lines that they will detect in computerized tomography.

METHODS

Between January 1, 2019 and November 11, 2020, 59 patients whose nasal pathologies were determined by paranasal sinus computed tomography examination due to nasal deformity and nasal deformity and who underwent septorhinoplasty operation were included in this study. Bone density and thickness measurements were performed on the frontal process of the maxillary bone in accordance with the lateral osteotomy lines on the lateral nasal wall in each patient, right and left side. According to the bone density values measured at the point determined on the lateral osteotomy line, 2 groups were formed as "very dense" and "less dense." According to the bone thickness values of the patients, 2 groups were determined as "thick" and "thin." Thus, the authors investigated the relationship between periorbital edema and ecchymosis on the postoperative first, third, and seventh days obtained from the examination files of the patients.

FINDINGS

When bone density subgroups are examined, it has been shown that the degree of periorbital edema of the patients in the "very dense" and "less dense" group categories decreased from the first day to the seventh postoperative day. The degrees of periorbital edema on the third postoperative day were statistically higher in the "less dense" group than in the "very dense" group. In the authors' study, no correlation was found between the degrees of postoperative periorbital edema and ecchymosis and bone density subgroups on other days. While an increase was observed in the periorbital ecchymosis grades of the patients in the "less dense" subgroup category from the first day to the third postoperative day, the periorbital ecchymosis grades of the patients in the "very dense" subgroup category decreased from the first day to the third day. In both subgroups, the lowest periorbital ecchymosis levels were observed on the postoperative seventh day.When bone thickness subgroups are examined, it has been shown that the degree of periorbital edema of the patients in the "thick" and "thin" group categories decreases from the first day to the seventh day postoperatively. When the bone thickness subgroups were examined, the periorbital ecchymosis degrees of the patients in the "thick" and "thin" group categories increased on the third postoperative day, while it reached the lowest level on the postoperative seventh day. There was no significant difference between the first, third, and seventh-day periorbital edema and ecchymosis conditions in the "thick" and "thin" groups.

CONCLUSION

The authors observed that periorbital edema and ecchymosis that may occur after septorhinoplasty can be affected by the variable features of the lateral nasal wall bone structure. The authors conclude that the changes in the healing process can be affected by different bone density values in particular.

Role of External Nasal Splinting Following Rhinoplasty: Is It Really Important? A Comprehensive Systematic Review of Literature

BACKGROUND

Following rhinoplasty, external nasal splints are used to reshape the cartilage and reposition the nasal bone. Despite the popularity of using an external nasal splint in rhinoplasty procedures, there is still a lack of evidence of the effectiveness of using the external nasal splint post-rhinoplasty. This systematic literature review aimed to evaluate the evidence regarding the use of external nasal splints following rhinoplasty.

METHODS

A systematic search of Cochrane, Medline, and Embase databases was conducted in September 2022. The literature was screened independently by two reviewers, and the data were extracted. Our search terms included septorhinoplasty, rhinoplasty, osteotomy, splinting, nasal splinting, and external nasal splinting.

RESULTS

Initially, 1617 articles were identified, but only four articles were included in the final review. The included studies were all published between 2016 and 2021. The included studies recruited 2425 patients, 20 of whom used external splints and 2415 did not. Out of 2415 patients who did not use an external nasal splint, there were 151 patients with moderate periorbital edema and ecchymosis. There was a decrease in nasal width in 99% of the patients who did not use external nasal splinting postoperatively.

CONCLUSION

According to our findings, nasal splinting should not be routinely used following rhinoplasty, but only in certain patients. There is no clear evidence that nasal splints reduce complications, and complications occurred among both patients with and without external nasal splints. Further studies need to be conducted to confirm this conclusion.

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 .

Comparing Postoperative Taping vs Customized 3D Splints for Managing Nasal Edema after Rhinoplasty

Background

Significant swelling after rhinoplasty can temporarily obscure results and lead to distress for patients and surgeons. We recently developed three dimensional (3D)-printed nasal splints that aim to protect the nose and limit edema by applying gentle compression. This prospective, randomized study compares postoperative nasal edema in patients being treated with traditional taping versus 3D-printed splints.

Methods

Patients undergoing primary rhinoplasty (2019-2020) were randomized into two groups: taping versus 3D-printed splinting. For 12 weeks, patients either applied steri-strips to the dorsum and tip, or used 3D-printed splints, which were based on nasal simulations. The percentage change in volume (cm3) was calculated for the total nose, dorsum, and nasal tip at various time points.

Results

Nasal taping (n = 34) demonstrated a volume reduction of 4.8%, 9.9%, 10.0%, 10.3%, and 10.6% (compared with baseline) at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year, respectively. In contrast, the resolution of swelling with 3D splints (n = 36) was 5.0%, 8.6%, 11.0%, 14.9%, and 15.1% at the same time points. Inter-group comparison showed that 3D splints led to significantly less edema of the total nose at 6 months and 1 year (P ≤ 0.05), as well as consistent reductions in the tip and dorsum, specifically (1 year, P ≤ 0.1, 0.01, respectively).

Conclusions

3D-printed splints after rhinoplasty leads to a significant reduction of edema, most noticeable at 6 months and 1 year. This study suggests that customized 3D-printed splints offer an effective clinical alternative to traditional taping to reduce postoperative edema after rhinoplasty.

Periorbital Ecchymosis Post Closed Rhinoplasty: Natural History, Risk Factors, and Validation of a New Scoring System

Postrhinoplasty periorbital ecchymosis is an inevitable side effect contributing to patients' psychological aspect and early postoperative morbidity. Efforts are constantly being made to reduce ecchymosis using different methods with varying success. To evaluate treatment response, it is mandatory to have a reliable score. Several studies suggest other scoring systems, but none has been postrhinoplasty-specific, validated, and accepted. This study aimed to demonstrate the natural history of postrhinoplasty ecchymosis, find potential risk factors for worsening patterns, and suggest a useful and reliable periorbital ecchymosis scoring system for postrhinoplasty follow-up.

Methods

This prospective study included 183 patients who underwent closed rhinoplasty by the same surgeon and the same principle method. Photographs of the periorbital ecchymosis were taken on postoperative days 1, 2, and 7. The periorbital area was divided into quarters, and three independent physicians assigned the dominant color of each quarter.

Results

There were no significant variations between the three physicians' scoring. The interobserver consistency defined as an excellent scoring system reliability, according to our statistical analysis. The postoperative ecchymosis demonstrated a consistent pattern of spread over time, dominating the medial quarters on early postoperative days 1 and 2, following into the lower lateral quarters in postoperative day 7. We found no correlation between patient demographics and clinical characteristics to ecchymosis patterns and temporal spread.

Conclusions

Our study suggests a reliable and easy-to-use postrhinoplasty ecchymosis scoring system. This scoring method can be used for postrhinoplasty ecchymosis assessment and as a research-validated tool to quantify different perioperative treatments to reduce ecchymosis and estimate mid-face trauma.

Investigation of the effects of intranasal desmopressin on the bleeding of the patients during open septorhinoplasty: A randomized double-blind clinical trial

Objectives

Rhinoplasty is one of the most common cosmetic surgeries in the world. Lack of adequate local homeostasis may lead to excessive bleeding during the operation, which increases the time of operation and recovery period, and the prevalence of complications. This study investigated the effects of nasal desmopressin on the quality of the surgical field and the volume of bleeding during rhinoplasty.

Materials and methods

This double-blind randomized clinical trial was performed on 120 patients aged 18-40 years who were candidates for rhinoplasty. Patients were randomly divided into three groups: low-dose desmopressin group and high-dose desmopressin group and placebo group. Hemodynamic changes and surgical field based on BOEZAART criteria, and the volume of bleeding were calculated.

Results

In this study 115 women (95.8%) and 5 men (4.2%) participated. The mean age of patients was (27 ± 6.8). Bleeding volume in high dose desmopressin group was (21.7 cc ± 12.3), (27.7 cc ± 12.3) in low dose group, and (38.3 cc ± 12.3) in the placebo group, The difference in blood volume among the three groups was statistically significant with p < 0.005. Clean surgical field according to BOEZAART classification was marginally significant in both desmopressin groups. The differences in blood pressure, heart rate, blood and urine sodium, and hemoglobin before and after surgery between groups there not statistically significant.

Conclusion

Based on the results of the present study topical nasal spray desmopressin can reduce surgical field bleeding during rhinoplasty. To generalize the results to other surgeries in the ENT field it is recommended to conduct studies.

Skin Contour Sutures in Rhinoplasty

BACKGROUND

The skin-soft tissue envelope (STE) is a critical component of rhinoplasty and can have a significant impact on the final result. Skin contour sutures (SCSs) can be used to prevent potential complications related to skin detachment and to improve rhinoplasty results.

OBJECTIVES

The aim of this study was to assess the efficiency of SCSs for nasal skin approximation.

METHODS

SCSs involve the use of external sutures to stabilize the STE flap based on the principle that the pressure of the sutures helps to approximate the STE to the underlying nasal skeleton. The first study group demonstrated the utilization of SCSs in 459 consecutive rhinoplasty cases between December 2016 and April 2022 which were retrospectively reviewed. The second study group consisted of 30 patients with thick skin who had insertion of SCSs with ultrasonic evaluation both preoperatively and postoperatively.

RESULTS

The average postoperative follow-up period in the first study group was 41 months (range, 12-64 months). Any suture site that was visible after removal of the suture disappeared completely after 6 weeks in most patients. No complications were reported. In the second group the ultrasound data indicated that STE healing was faster as its thickness returns to its preoperative state earlier in the healing process when SCSs were used.

CONCLUSIONS

SCSs appear to help to decrease severe nasal edema, hematomas, loss of tip definition, fibrosis, and pollybeak deformity, thereby improving the results and predictability of rhinoplasty surgery.

LEVEL OF EVIDENCE: 4

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.

Postoperative Periorbital Edema and Ecchymosis After External Lateral Osteotomy "Comparing Conventional Osteotome and Piezo Scalpel in Rhinoplasty"

The piezo surgery was reported to cause minimal trauma to the soft tissue. The aim of this study was to compare the periorbital edema and ecchymosis after transcutaneous lateral osteotomy in rhinoplasty using 2-mm osteotome versus Piezo scalpel respectively. In a randomized clinical trial and split-mouth-design, we performed primary rhinoplasty in 15 patients (7 men, 8 women; age 18-35 years, mean age 26.6 ± 5.7 years). Transcutaneous lateral osteotomy was performed using a 2-mm osteotome on the one side and a piezo scalpel on the opposite side. We took digital photographs of the face on 1, 3, 7 and 14 postoperative days. Three examiners used a standard 5-point Kara-Gokalan scale to assess the early postoperative periorbital edema and ecchymosis on each side. We found more difficult to use the piezo scalpel via only one incision and found easier to use two stab incisions for inserting the piezo scalpel. The time spend for each osteotomy was similar (P > 0.05). The inter-observer agreement was high (> 0.676). The postoperative edema showed to be significantly different on day 1, 3 and 7 (P-value < 0.05), ecchymosis was much less on piezo side but not significantly. It was more difficult to use piezo scalpel via only one incision. The piezo scalpel showed to reduce the postoperative edema significantly and improved the ecchymosis. Swelling and bleeding could have crossed the midline and blurred the comparison of two sides. However, this is the best design to achieve the highest similarity in study condition. Level of Evidence Level I, therapeutic study.

A Modified Technique in Rhinoplasty: A Septal Extension Graft Complex Using Septal Cartilage, Ethmoid Bone, and Auricular Cartilage

BACKGROUND

Due to the small and weak septal cartilage of Asians, it is a challenge to obtain ideal tip projection and nose lengthening in this population by performing septal extension grafts with only septal cartilage.

OBJECTIVES

The aim of this study was to introduce a septal extension graft complex incorporating nasal septal cartilage, the perpendicular plate of the ethmoid bone, and bilateral auricular cartilage, and to examine its effectiveness in terms of morphological and mechanical support.

METHODS

Septal cartilage was harvested under an endoscope according to standard techniques. Two pieces of the perpendicular plate of the ethmoid bone, placed on either side of the "L" strut, served as 2 spreader grafts. A double layer of auricular cartilage was fixed as columellar strut grafts. Three-dimensional facial scanning was used to examine the change of 3 parameters. Nasal tip resistance was evaluated by a digital Newton meter.

RESULTS

In total, 25 patients were followed up postoperatively for a mean of 25.9 months. The analysis showed significant differences in both contour parameters and nasal resistance: nasal length (mean [standard deviation], 41.4 [4.0] vs 46.2 [3.4] mm, P < 0.05) and nasal tip projection (21.3 [3.2] vs 24.4 [2.7] mm, P < 0.05) appeared to increase postoperatively, whereas nasolabial angle (117.6° [5.9°] vs 109.5° [5.3°], P < 0.05) showed a significant decrease after surgery. The resistance of the nasal tip also increased significantly (P < 0.05) at displacements of 1, 2, and 3 mm. All patients were satisfied with the aesthetic results, and no serious complications occurred.

CONCLUSIONS

This kind of modified septal extension graft technique can effectively adjust nasal morphology for short-nose East Asians.

LEVEL OF EVIDENCE: 4

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.

Comparison of pregabalin with magnesium sulfate in the prevention of remifentanil-induced hyperalgesia in patients undergoing rhinoplasty: A randomized clinical trial

Objective

Remifentanil is usually used for controlled hypotension during rhinoplasty under general anesthesia (G/A). One of the complications of the remifentanil is postoperative hyperalgesia. In this study, we compare the effectiveness of pregabalin with that of Mg sulfate in postoperative remifentanil-induced hyperalgesia prevention.

Methods

In this prospective, randomized, double-blinded placebo-controlled trial, 105 patients who candidates rhinoplasty with G/A were enrolled and randomly allocated into three groups. Patients in group A received 300 mg pregabalin before anesthesia. They received physiologic saline infusion during the perioperative period. Those in group B received placebo capsules before anesthesia and intravenous Mg sulfate 30 mg/kg during the perioperative period. Those in group C received a placebo capsule before anesthesia and normal intravenous saline during the operation. Then, pain severity, sedation score, postoperative nausea and vomiting (PONV) were assessed and compared.

Results

In the Mg sulfate and placebo group, the mean numerical rating scale in the postoperative period was higher compared to the pregabalin group (p < .001). The mean total amount of morphine requirement, meanwhile the 24 h post-operation, was significantly decreased in the pregabalin group compared to the other groups (p < .001). Participants in the pregabalin group had less PONV compared to those in the pregabalin and placebo groups (p = .015).

Conclusions

In patients undergoing G/A with remifentanil for rhinoplasty, preoperative 300 mg pregabalin could effectively prevent not only remifentanil-induced hyperalgesia but also PONV.

Level of evidence

1b.

Evaluation of Skin-Soft Tissue Envelope Thickness by Ultrasonography after Primary and Revision Rhinoplasty

BACKGROUND

Excessive nasal edema is among the complications after rhinoplasty translating into Skin-Soft Tissue Envelope (SSTE) thickening and disruption in the nasal framework's definition. Revision rhinoplasties are suspected of causing even more nasal edema. The objective postoperative SSTE thickness between revisionary and primary rhinoplasties is compared in this study.

METHODS

A study was conducted over a recorded database of eligible candidates who had attended the senior author's private clinic in a 12-month period and underwent primary and revisionary open-approach rhinoplasties. The SSTE thickness was measured by ultrasonography in each nasion, rhinion, supratip, and tip region at months 1, 3, 6, and 12 after each episode of rhinoplasty. Paired T-test was used for pairwise comparisons of the corresponding region-time thicknesses between primary and revisionary rhinoplasties. Repeated measure ANOVA tests were used to assess mean thickness changes over time after each surgery-P < 0.05 indicated significance.

RESULTS

Of the 36 participants analyzed, the SSTE was significantly thicker after revisionary surgery in all the follow-up sessions and nasal regions, except for the 1-month follow-up in the nasion (p = 0.273) and 12-month follow-up in the rhinion (p = 0.050). Mean nasal SSTE thickness showed decreasing trends in each region after either primary or revisionary surgery, with a lower level of resolution in the nasion region after revision rhinoplasty (p < 0.001).

CONCLUSIONS

The nasal SSTE had been significantly thicker in most regions after revisionary procedures than primary ones, and the swelling had subsided slightly slower. Surgeons are recommended to consider revisionary rhinoplasties based on these findings cautiously.

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 Mild Hypocapnia on Postoperative Ecchymosis in Rhinoplasty

PURPOSE

Ecchymosis and edema are the most common complications in patients following rhinoplasty in the early postoperative period. Vasoconstriction created by hypocarbia may have a positive effect on postoperative ecchymosis. The aim of this study was to evaluate the effect of mild hypocapnia induced in rhinoplasty on the severity of periorbital ecchymosis.

METHODS

The study was carried out retrospectively in the digital photographs (control group and study group) of 31 participants who underwent open technical rhinoplasty between January and March 2019. During the operation, partial carbon dioxide pressure in the study group was kept in the range of 32 to 38 mmHg and in the control group between 42 and 46 mmHg and this was confirmed by arterial blood gas measurements taken during the operation. Measuring the brightness and shadows of digital photos Digital color meter was used in MacOS X as a computer software.

RESULTS

The mean ratio of periorbital ecchymosis to forehead brightness was 0.84 ± 0.05 in the study group and 0.81 ± 0.03 in the control group. There was no significant difference between the study and control groups (P > .05).

CONCLUSION

This study investigates the potential role of hypocapnia on postoperative ecchymosis during rhinoplasty. The severity of ecchymosis was less in the patients with induced mild hypocapnia regarding both subjective and objective evaluations, but this difference didn't reach statistical significance compared to the normocapnic control group.

The "3 Points Compartmentalization" Technique in Subperichondrial-Subperiosteal Dissection in Primary Rhinoplasty to Reduce Edema and Define Contour

Proper control of postoperative edema in rhinoplasty matters significantly, both regarding patient satisfaction and preventing loss of definition and aesthetic surface contour in the dorsum and tip. The "3 points compartmentalization" technique described in this paper aims to fulfill the above goals by (1) dissection in a subperichondrial-subperiosteal plane and (2) reducing the dead space by three strategically placed key sutures that compartmentalize the nose and redrape the single-plane dissection in an anatomically correct position.Level of Evidence IV 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 .

Early Postoperative Sequelae After Open Sky Access in Nasal Osteotomy: A Comparative Study

INTRODUCTION

Nasal osteotomy is a powerful cornerstone step in almost all rhinoplasty procedures and is a major cause of postoperative periorbital ecchymosis and edema after rhinoplasty. Different accesses for osteotomy have been described, the most popular of which is the external perforating and the internal continuous methods. These accesses are blind maneuvers and have some drawbacks such as possible visible scar formation in the percutaneous access or high rate of mucosal tear in the endonasal access. Open sky access osteotomy after wide subperiosteal dissection had been described to overcome those disadvantages. Early postoperative sequelae have not been assessed in the literature after using this access. In the present study, we aim to assess early postoperative sequelae after using this technique in comparison with percutaneous perforating osteotomy.

MATERIALS AND METHODS

The study was conducted between November 2017 and January 2021. Forty patients were randomly assigned into 2 equal groups. Group A was subjected to lateral osteotomy by percutaneous perforating method, whereas group B underwent lateral osteotomy by the open sky access technique using a 2-mm curved osteotome. Early postoperative periorbital sequelae were assessed on the second and seventh postoperative days, using the grading system suggested by Kara et al (Plast Reconstr Surg. 1999;104:2213-2218). Mucosal tear was assessed on the second postoperative day using nasal endoscopy after removal of nasal packs.

RESULTS

There was a statistically nonsignificant difference between the studied groups regarding ecchymosis and edema occurring on the second or seventh days. Meanwhile, mucosal tear was significantly less in the open sky access osteotomy group.

CONCLUSIONS

Open sky access osteotomy is a safe method for lateral nasal osteotomy with direct visualization of the surgical field. It does not require a skin incision that could lead to a scar formation. It produces less mucosal tear than percutaneous perforating osteotomy. No statistically significant difference is found between both techniques regarding postoperative periorbital ecchymosis and edema on the second and seventh postoperative days.

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 .

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.

Use of quantum molecular resonance energy for managing postrhinoseptoplasty perilesional edema and ecchymosis

BACKGROUND

Quantum molecular resonance (QMR) technology employs nonionizing high-frequency waves ranging from 4 to 64 MHz to generate low-intensity quanta of energy that interacts with cellular components.

AIMS

To evaluate the efficacy and safety of QMR treatment on postoperative perilesional edema and ecchymosis in patients with rhinoseptoplasty or revision rhinoseptoplasty.

PATIENTS/METHODS

In total, 30 patients were treated with QMR stimulation therapy (QMR group) once daily for 5 days, while another 30 patients were treated with conventional icepack application (control group). The duration of perilesional edema and ecchymosis were comparatively evaluated according to anatomic regions.

RESULTS

In both groups, the longest duration of postoperative edema and ecchymosis was found on the left anterior cheek, followed by the right anterior cheek, left lower eyelid, right lower eyelid, and right and left upper eyelids. The mean duration of overall postoperative perilesional edema was significantly shorter in the QMR group (2.0 ± 0.8 days) than the control group (4.6 ± 2.0 days); the mean duration of overall ecchymosis was also markedly shorter in the QMR group (2.9 ± 1.5 days) than control group (7.5 ± 2.9 days). Patient satisfaction after postoperative QMR treatment was rated as 2.2 ± 0.8, whereas patient satisfaction in control group was rated as 1.6 ± 0.9.

CONCLUSION

Our clinical study demonstrated that postrhinoseptoplasty QMR treatment effectively reduces the duration of postoperative perilesional edema and ecchymosis without remarkable side effects. We suggest that QMR treatment can be considered as an alternative option for noninvasively managing postrhinoseptoplasty perilesional edema and ecchymosis.

The Impact of Surgical Procedures During Septorhinoplasty on the Intraoperative Pain Response

BACKGROUND

During septorhinoplasty, many different surgical procedures are employed to bring the nose to the desired shape and solve breathing complaints. As a matter of course, intraoperative pain response occurs due to these procedures.

OBJECTIVES

With this study, the authors aimed to evaluate the intraoperative pain formed during septorhinoplasty surgery with numerical values and to determine which stage of surgery is more painful.

METHODS

Between April 2019 and March 2020, a total of 30 female patients who were planned to undergo septorhinoplasty were included in this prospective study. Standard anesthesia and analgesia were applied to all patients. During surgery, state entropy measure was utilized to evaluate the depth of anesthesia, and Surgical Pleth Index was employed to evaluate the response of the central nervous system to pain "nociception."

RESULTS

The age of the patients ranged from 18 to 42 years (average, 25.3 ± 6.1 years). The average value of state entropy recorded during the surgery for all patients was found to be 45.43 ± 5.37. The mean beginning Surgical Pleth Index value recoded from all of the patients was 23.4 ± 8.84 compared with the beginning value; the values recorded during periost dissection, lateral osteotomy, and lower turbinate lateralization were statistically significantly higher (P < 0.005).

CONCLUSIONS

Although sufficient depth of anesthesia and standard protocol of analgesia were applied, pain response was found to be significantly higher at some procedures during septorhinoplasty. The authors think that increasing the depth of anesthesia during these procedures will increase the comfort of this operation by inhibiting pain response.

LEVEL OF EVIDENCE: 4

The Effect of Different Dose Regimens of Tranexamic Acid in Reducing Blood Loss in Rhinoplasty: A Prospective Randomized Controlled Study

ABSTRACT

Rhinoplasty is a common surgical procedure. Bleeding prevention is a crucial part of the surgery. We aimed to evaluate the different dose regimens of tranexamic acid (TXA) in reducing intraoperative blood loss among patients undergoing rhinoplasty.This prospective randomized study was performed in patients scheduled for rhinoplasty surgery between March 2019 and March 2020. The patients were divided into 3 groups containing 30 patients in each group. The patients in Group 1 received the first dose of 1 g intravenous (IV) TXA 10 minutes before the surgery, and the second dose was administered at the end of the operation. The patients in Group 2 received only a single dose of 1 g of IV TXA 10 minutes before the surgery. The patients in Group 3 did not receive medication. Demographic data were obtained through a review of patient's medical records. Preoperative and postoperative hemoglobin levels, postoperative transfusion, and complications rate were compared between the study groups.No significant differences were observed between the study groups in terms of age, gender, body mass index, American Society of Anesthesiologists scores, and the level of preoperative Hb values (P > 0.05). The mean total blood loss was lower in Group 1 than the other groups, but the difference was not statistically significant (P = 0.464).The administration of single-dose IV TXA or intermittent IV doses of TXA could decrease total blood loss in rhinoplasty, but the statistical and clinical relevance was not significant.

Evidence-Based Performance Measures for Rhinoplasty: A Multidisciplinary Performance Measure Set

SUMMARY

The American Society of Plastic Surgeons, the American Academy of Otolaryngology-Head and Neck Surgery, and the American Academy of Facial Plastic and Reconstructive Surgery commissioned the multidisciplinary Rhinoplasty Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing both functional and aesthetic rhinoplasty. One outcome measure and three process measures were identified. The outcome looked at patient satisfaction with rhinoplasty procedures. The process measures look at motivations and expectations of the procedure, airway assessment, and nonnarcotic shared decision-making strategies for pain management. All measures in this report were approved by the American Society of Plastic Surgeons Quality and Performance Measures Work Group and Executive Committee, and the American Academy of Otolaryngology-Head and Neck Surgery Foundation, the American Academy of Facial Plastic and Reconstructive Surgery, The Rhinoplasty Society, and the American Association of Oral and Maxillofacial Surgeons. The Work Group recommends the use of these measures for quality initiatives, Continuing Medical Education, Maintenance of Certification, Qualified Clinical Data Registry reporting, and national quality reporting programs.

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.

Surgical and Nonsurgical Management of the Nasal Skin-Soft Tissue Envelope

Management of the skin-soft tissue envelope (SSTE) in rhinoplasty is challenging and critical for the overall outcome. The preoperative identification of patients with thick or thin skin and with preexisting skin conditions may contribute significantly to the postsurgical result. Most publications and textbooks focus on the management of the osseocartilaginous framework, but the SSTE management is often not addressed in detail. However, nonsurgical treatments, such as skin preconditioning, topical steroid-injections, oral isotretinoin, and topical vitamin A derivatives, may provide strong benefits. In this article, we reviewed the literature to present a comprehensive review on the available surgical and nonsurgical approaches pre-, intra-, and postoperatively dealing with SSTE in rhinoplasty.

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.

Surgical Burr-Assisted Lateral Osteotomy Technique in Septorhinoplasty

ABSTRACT

Achieving aesthetic and functional results in rhinoplasty requires meticulous techniques, and postoperative edema, ecchymosis, and pain can deteriorate the desired outcomes. Different osteotomy techniques are defined to have optimal outcomes while reducing edema, ecchymosis, and pain. In this study, the authors compared conventional and power-assisted surgical burr osteotomy techniques in terms of early postoperative complications. Patients who underwent primary open septorhinoplasty were included in the study and were divided into 2 groups. The first group had lateral endonasal osteotomy with conventional guided osteotomes, and the second group had lateral osteotomy with surgical round burr. Edema and ecchymosis scoring systems were used on the postoperative first, third, and seventh day to evaluate postoperative edema and ecchymosis, and the visual analog scale was used to evaluate pain severity on the postoperative period. Out of 70 patients who had undergone septorhinoplasty, 36 received conventional osteotomy and 34 received surgical round burr osteotomy. Periorbital ecchymosis scores were significantly lower in the second group on the postoperative first, third, and seventh days. The periorbital edema scores were significantly lower in the second group on the first postoperative day but no difference was found between postoperative days 3 and 7. Also, the pain scores were significantly lower in the second group. Osteotomy with surgical round burr yields less ecchymosis, edema, and pain in the early postoperative period than conventional osteotomy in primary septorhinoplasty patients.

The Effect of 3D-Printed Custom External Nasal Splint on Edema and Ecchymosis After Rhinoplasty

PURPOSE

The aim of this study was to investigate the effects of traditional thermoplastic splints vs a 3D-printed custom external nasal splint designed to apply pressure to the lateral osteotomy lines and neighboring periorbital region on edema and ecchymosis after rhinoplasty.

PATIENTS AND METHODS

Forty patients undergoing open rhinoplasty were included in this prospective randomized controlled study. The patients were divided into 2 groups. In the study group, the new 3D-printed custom external nasal splint was used. In the control group, the thermoplastic external nasal splint was used. Periorbital edema and ecchymosis scores were assessed peroperative before external nasal splint application, postoperatively at the 1st and 4th hours, and 1st, 2nd, 5th, 7th, 10th, and 15th days.

RESULTS

There were lower scores of ecchymosis and edema in the study group compared to the control group for all the follow-up controls. There was a significant difference between the 2 groups with respect to the occurrence of ecchymosis for all follow-up controls except for the first postoperative hour and the seventh postoperative day (P < .05). Comparison of the 2 groups with respect to the grade of edema showed a significant difference only in the first and fourth postoperative hours (P < .05).

CONCLUSIONS

The study detected less edema and ecchymosis scores using this 3D custom external nasal splint, thus creating a new area of use for 3D printers in the field of facial esthetic surgery. New thermoplastic splints of different shapes and sizes can be produced that can compress the osteotomy lines and the neighboring periorbital region.

Is angular artery trauma seen frequently in lateral osteotomy and responsible for peri-orbital ecchymosis?

OBJECTIVE

This study was performed on fresh frozen cadavers to investigate the role of angular artery damage.

METHODS

Lateral osteotomies ('high-low-high' method) were carried out bilaterally, with a 4 mm guarded lateral osteotome, after the creation of a subperiosteal tunnel. Following completion of the lateral osteotomy, a skin incision was made in the midline dorsum. The dermis and subcutaneous tissues were carefully dissected, taking care not to damage the angular artery. Overlying tissues were cut and retracted to show the course of the angular artery.

RESULTS

The angular artery was not damaged in any of the cadavers. The angular artery was always lateral to the lateral osteotomy line.

CONCLUSION

The high-low-high lateral osteotomy does not damage or traumatise the angular artery. The ecchymosis and oedema are related to other factors.

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.

The Effects of Vibration and Pressure Treatments in the Early Postoperative Period of Rhinoplasty

BACKGROUND

The early postoperative period can be distressing for the patients undergoing rhinoplasty since edema and ecchymosis are common complications.

OBJECTIVES

To analyze the effects of the vibration and pressure treatments in the early postoperative period of rhinoplasty.

METHODS

Sixty patients, who had undergone rhinoplasty, were randomized into 3 groups: group 1 (control group, n = 20) received classic nasal casting, group 2 (n = 20) received nasal cast with an elastic bandage to hold it on the face, and group 3 (n = 20) received vibration treatment in addition to that in group 2 following the rhinoplasty. They were evaluated preoperatively and postoperatively at 3 and 7 days in a prospective study. The postoperative edema and ecchymosis were scored by 2 independent surgeons. The postoperative pain was measured using the visual analog scale, and the necessity of anti-inflammatory medication (and the dose needed) and the cast comfort was questioned. The sebaceous activity of the nose skin was examined. A preoperative and postoperative seventh day sonographic study was performed to evaluate the tissue edema objectively.

RESULTS

The pressure treatment decreased the edema and ecchymosis significantly compared with the control group. The vibration treatment minimized edema, ecchymosis, sebaceous activity of the nose skin, pain score, and the need for anti-inflammatory medication, and increased the cast comfort significantly compared with the other groups (P < 0.0001).

CONCLUSIONS

Rapid regression of edema and ecchymosis may be achieved using the vibrating nasal cast technique that may minimize patient discomfort, pain, and sebaceous activity following rhinoplasty.

LEVEL OF EVIDENCE: 1

Effects of Periosteal Elevation Before Lateral Osteotomy in Rhinoplasty: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

Although osteotomy is an important part of rhinoplasty, it is known to be closely related to postoperative eyelid edema and ecchymosis. We aimed to evaluate the effects of periosteal elevation prior to osteotomy on eyelid edema and ecchymosis.

METHODS

Two authors reviewed studies in the Medline, Scopus, and Cochrane databases published through May 2019. Randomized controlled trials comparing periosteal elevation (subperiosteal tunneling) with periosteal preservation that reported eyelid edema or ecchymosis or subconjunctival hemorrhage as outcomes of interest were included. From each study, the baseline characteristics of the study subjects, the quality of the study, the number of patients in the treatment and control groups, and outcomes were extracted.

RESULTS

Data for meta-analysis were identified in six studies with a total of 208 patients. Eyelid ecchymosis and edema within 3 days postoperatively were significantly more common in the periosteal elevation group than in the preservation group, although such an association was not found for edema on postoperative day 7 (standardized mean difference [SMD], 0.21; 95% confidence interval [CI], -0.09 to 0.50; I2 =0%). There was no significant difference in subconjunctival hemorrhage on day 1 (SMD, 0.31; 95% CI, -0.09 to 0.72; I2 =0%).

CONCLUSION

Periosteal preservation during lateral osteotomy may reduce eyelid edema and ecchymosis compared to periosteal elevation. Further studies with rigorous research methods should be carried out to determine the effectiveness of different techniques in lateral osteotomy.

Evaluation of the Efficacy of Hilotherapy for Postoperative Edema, Ecchymosis, and Pain After Rhinoplasty

PURPOSE

Edema and ecchymosis are among the most important morbidities after rhinoplasty. The aim of the present study was to investigate the effects of hilotherapy application compared with traditional ice applications after rhinoplasty in terms of periorbital edema, ecchymosis, and pain.

PATIENTS AND METHODS

A total of 60 patients (35 women and 25 men) had undergone primary rhinoplasty with the same surgeon. In the postoperative period, 30 patients in the study group received continuous cooling at 15°C using Hilotherm (Hilotherm GmbH, Argenbühl-Eisenharz, Germany), and 30 patients in the control group were treated with conventional cryotherapy with ice packs. Both treatments started within 45 minutes after the end of the surgery and were maintained for 24 hours. For the following 1 week, the patients were examined for edema, ecchymosis, and pain.

RESULTS

When the postoperative periorbital region was evaluated for mean edema and mean ecchymosis for 7 days, less edema and less ecchymosis were detected in the Hilotherm group compared with that observed in the ice pack group (P < .001). When the mean pain scores were compared both morning and evening for 7 days, less pain had been recorded with Hilotherm application compared with ice application (P < .001).

CONCLUSIONS

Hilotherapy is a useful method to prevent postoperative edema, ecchymosis, and pain compared with traditional ice application.

Postoperative Ecchymosis and Edema After Creation of Subperiosteal Tunnels in Rhinoplasty: A Randomized Clinical Trial

Importance

Periorbital ecchymosis and edema are commonly associated with rhinoplasty and are the principal limiting factors for return to daily activities after rhinoplasty. Several methods have been evaluated to minimize these sequelae including creation of subperiosteal tunnels, which involves elevating the vascular periosteal layer, preserving it from trauma when creating osteotomies.

Objective

To assess the efficacy of the creation of subperiosteal tunnels prior to lateral osteotomies during rhinoplasty for reducing postoperative ecchymosis and edema.

Design, Setting, and Participants

A randomized, blinded, matched-paired, prospective, clinical trial took place between April 1 and August 30, 2015, in a private practice in a stand-alone clinic and surgical center. All patients who were undergoing aesthetic rhinoplasty requiring bilateral lateral osteotomies were offered inclusion in the trial. All 34 enrolled patients completed the follow-up requirements.

Intervention

Creation of subperiosteal tunnels prior to lateral osteotomies on 1 randomly selected side.

Main Outcomes and Measures

Three blinded evaluators independently graded the degree of ecchymosis and edema on a visual analog scale of 0 to 10 on each side of the nose on postoperative days 2 and 7. Each patient had 1 side that was randomly selected to undergo creation of subperiosteal tunnels. A difference in mean score between sides of the nose was calculated for each patient using a paired t test.

Results

Of the 34 patients (28 females and 6 males; mean [SD] age, 27.3 [9.2]), the mean (SD) difference in ecchymosis scores between sides on day 2 was -0.05 (1.94) (95% CI, -0.43 to 0.33) and on day 7 was -0.22 (1.23) (95% CI, -0.47 to 0.02), favoring the side without tunnels. The mean (SD) difference in edema scores on day 2 was -0.21 (1.66) (95% CI, 0.53-0.12) and on day 7 was -0.29 (1.11) (95% CI, -0.51 to -0.07). There were no clinically significant differences between sides in terms of postoperative ecchymosis and edema.

Conclusions and Relevance

Ecchymosis and edema can have significant postoperative practical, emotional, and financial effects on patients. Creation of subperiosteal tunnels prior to lateral osteotomies showed no clinically significant differences in edema and ecchymosis after the procedure.

Level of Evidence

1.

Trial Registration

isrctn.org Identifier: ISRCTN42741475.

Role of Tranexamic Acid in Reducing Intraoperative Blood Loss and Postoperative Edema and Ecchymosis in Primary Elective Rhinoplasty: A Systematic Review and Meta-analysis

Importance

Blood loss from surgical procedures is a major issue worldwide as the demand for blood products is increasing. Tranexamic acid is an antifibrinolytic agent commonly used to reduce intraoperative blood loss.

Objective

To systematically examine the role of tranexamic acid in reducing intraoperative blood loss and postoperative edema and ecchymosis among patients undergoing primary elective rhinoplasty.

Data Sources

A systematic review and meta-analysis was undertaken in an academic medical setting using Medline, Embase, and Google Scholar from inception to June 30, 2018. All references of included articles were screened for potential inclusion. The search was mapped to Medical Subject Headings, and the following terms were used to identify potential articles: reconstruction or rhinoplasty and tranexamic acid or anti-fibrinolysis or antifibrinolysis and bleeding or ecchymosis or bruising or edema or complications.

Study Selection

The population of interest consisted of adult patients undergoing primary elective rhinoplasty. The intervention was the use of tranexamic acid. The control group was composed of patients receiving a placebo. Primary outcomes were intraoperative blood loss and postoperative edema and ecchymosis. In vitro or animal studies were excluded, and only English-language articles were included.

Data Extraction and Synthesis

The PRISMA guidelines were followed, and articles were assessed using the Cochrane Collaboration's tool for assessing risk of bias and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Random-effects meta-analysis was performed to determine the overall effect size.

Main Outcomes and Measures

The primary outcomes were intraoperative blood loss and postoperative edema and ecchymosis.

Results

Five studies (comprising 332 patients) were included in the qualitative analysis, all of which were randomized clinical trials published within the past 5 years. The mean (SD) patient age was 27 (7) years (age range, 16-42 years), while the mean (SD) sample size was 66 (19) (range, 50-96). Meta-analysis of 4 studies (271 patients) indicated that tranexamic acid treatment resulted in a mean reduction in intraoperative blood loss of -41.6 mL (95% CI, -69.8 to -13.4 mL) compared with controls (P = .004). Three studies indicated that postoperative edema and ecchymosis were reduced with tranexamic acid treatment compared with controls; however, there was no significant difference compared with corticosteroid use. Four studies were considered of high methodological quality, with a low risk of bias. The overall quality of evidence was high.

Conclusions and Relevance

Tranexamic acid has the ability to significantly reduce intraoperative blood loss and postoperative edema and ecchymosis among patients undergoing primary elective rhinoplasty.

Level of Evidence

4.

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

Predictors of Hematoma Enlargement in Patients with Spontaneous Intracerebral Hemorrhage Treated with Rapid Administration of Antifibrinolytic Agents and Strict Conservative Management

Objective

Spontaneous intracerebral hemorrhage (ICH) is caused by the rupture of small blood vessels and other health problems. In ICH patients, hematoma enlargement is the most critical risk factor for poor outcomes. Tranexamic acid, an anti-fibrinolytic agent, has been used to reduce hematoma expansion. We analyzed the risk factors for hematoma expansion in ICH patients and compared the predictability of hematoma expansion in ICH patients with the use of tranexamic acid.

Methods

We performed retrospective analysis of ICH patients who underwent follow-up computed tomography scans from October 2008 to October 2018. Of the 329 included patients, 67 who received tranexamic acid and 262 who did not receive tranexamic acid were compared. We also analyzed the risk factors of 45 and 284 patients who did and did not experience hematoma expansion, respectively.

Results

Hematoma expansion was observed in 7 (10.4%) of 67 patients in the tranexamic acid group and 38 (14.5%) of the 262 patients who did not receive tranexamic acid. There was no statistically significant difference between patients who did and did not received tranexamic acid (p=0.389). In the multivariate logistic regression analysis of risk factors for hematoma expansion, spot sign and a maximal diameter of 40 mm were identified as risk factors.

Conclusion

We could not confirm the effect of tranexamic acid on hematoma expansion in ICH patients. Spot sign and the maximal diameter of hematomas were confirmed as risk factors of hematoma expansion. If the maximal diameter is greater than 40 mm, the hematoma should be closely monitored.

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.