Research
Original Investigation
Effect of Postrhinoplasty Taping on Postoperative Edema and Nasal Draping A Randomized Clinical Trial Berke Ozucer, MD; Yavuz Selim Yıldırım, MD; Bayram Veyseller, MD; Selahattin Tugrul, MD; Sabri Baki Eren, MD; Fadullah Aksoy, MD; Omer Uysal, MD; Orhan Ozturan, MD Invited Commentary BACKGROUND Edema persists for months after rhinoplasty. Numerous modalities have been described to counteract postoperative edema.
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OBJECTIVE To evaluate the effect of postrhinoplasty taping (PRT) on nasal edema and nasal
draping. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial, 57 patients undergoing rhinoplasty at a tertiary reference center from August 1, 2014, to January 31, 2015, were assigned to a control group or to 2- or 4-week PRT groups. Baseline nasal thickness was measured with ultrasonography at the nasion, rhinion, supratip, and tip, and mean nasal skin thickness (MNST) was calculated. Participants in each group were categorized by the baseline MNST measurement from the lowest to greatest MNST; those in the upper half were categorized as having thick skin; those in the lower half, thin skin. The control group underwent no PRT after the removal of external packing. Patients in the 2- and 4-week PRT groups received additional taping during the allocated time. Data were collected from August 1, 2014, to June 31, 2015. Follow-up was completed on June 31, 2015, and data were analyzed from July 1 to August 1, 2015. MAIN OUTCOMES AND MEASURES Postoperative measurements of MNST were performed at the end of weeks 1, 3, and 5 and month 6. RESULTS Of the 57 total patients (33 male and 24 female patients; mean [SD] age, 30.0 [11.7] years), 17 were in the 2-week PRT group; 20, the 4-week PRT group; and 20, the control group. Compared with the control group, 4-week PRT had a significant effect on the supratip (P = .001). Comparisons of MNST with the control group revealed significant effects of 2-week (P = .02) and 4-week (P = .007) PRT. The effect on the tip was not significant (P = .052). Postrhinoplasty taping had no effect in thin-skinned patients. Comparison among thick-skinned patients revealed a significant effect on the MNST (P = .01) and the rhinion (P = .02) but not the tip (P = .06) and supratip (P = .07). CONCLUSIONS AND RELEVANCE Postrhinoplasty taping helps the skin envelope to compress to the underlying framework and decrease postoperative edema. The procedure can be used particularly in thick-skinned patients, in whom skin draping and nasal refinement is crucial to the surgical outcome. LEVEL OF EVIDENCE 1. TRIAL REGISTRATION clinicalTrials.gov Identifier: NCT02626585
JAMA Facial Plast Surg. doi:10.1001/jamafacial.2015.1944 Published online February 25, 2016.
Author Affiliations: Department of Otorhinolaryngology, Gaziosmanpasa Taksim Research and Education Hospital, Istanbul, Turkey (Ozucer); Department of Otorhinolaryngology, Medical Faculty, Bezmiâlem Vakıf University, Istanbul, Turkey (Yıldırım, Veyseller, Tugrul, Eren, Aksoy, Ozturan); Department of Biostatistics, Bezmiâlem Vakıf University, Istanbul, Turkey (Uysal). Corresponding Author: Berke Ozucer, MD, Department of Otorhinolaryngology, Gaziosmanpasa Taksim Research and Education Hospital, Karayolları Mah, Gaziosmanpasa, Istanbul, Turkey 34093 ([email protected]).
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Research Original Investigation
Effect of Postrhinoplasty Taping on Postoperative Edema
R
hinoplasty is generally and predominantly concerned with the osseocartilaginous framework and sometimes overlooks the soft-tissue envelope. After rhinoplasty, nasal swelling can persist for many months. Thick and sebaceous skin can experience exacerbated swelling owing to poor draping capability and is more prone to undesirable outcomes.1 Formation of dead space and filling of granulation tissue can prolong the persistence of chronic edema. This process may result in an unfavorable outcome by hindering nasal tip refinement and causing supratip deformity.2,3 Many intraoperative4-6 and postoperative3,7,8 techniques have been described to overcome this effect. Although anecdotal evidence suggests that taping after rhinoplasty may help, its efficiency is unknown.2,9 The aim of this study was to evaluate the effect of postrhinoplasty taping (PRT) on nasal edema. This study was designed to observe patients undergoing rhinoplasty in a controlled, prospective, randomized fashion with 6 months of follow-up.
62 Patients assessed for eligibility
2 Excluded 2 Standardized bilateral lateral osteomy was not used in the operation
60 Randomized
20 Randomized to control group
20 Randomized to 2-wk PRT group
20 Randomized to 4-wk PRT group
20 Included in analysis
3 Excluded from analysis 2 Lost to follow-up Reasons: unknown 1 Discontinued intervention
20 Included in analysis
17 Included in analysis
Two patients in the 2-wk PR=T group were unavailable for follow-up for unknown reasons; 1 patient in the group who discontinued the intervention did not see the need and was therefore excluded from the analysis. PRT indicates postrhinoplasty taping.
Methods Fifty-seven patients who underwent consecutive, primary, open-approach rhinoplasty at our tertiary reference center from August 1, 2014, to January 31, 2015, were enrolled in the study. Data were collected from August 1, 2014, to June 31, 2015, and follow-up was completed on June 31, 2015. The trial protocol is described in Supplement 1. Inclusion criteria consisted of open-approach reduction rhinoplasty and osteotomy with guarded lateral osteotomes. Patients were questioned regarding adherence to the allocated PRT therapy, and only patients who applied the minimal allocated therapy (nighttime taping) were included in the study. Revision surgery, abnormal hemostatic values, and a history of decongestant or corticosteroid use constituted exclusion criteria. The ethics committee of Bezmiâlem Vakıf University approved the study, which conformed to the Declaration of Helsinki.10 All patients individually provided written informed consent. Patients were assigned to control, 2-week PRT, or 4-week PRT groups in a randomized consecutive fashion (Figure 1). The external thermoplastic splint was removed at the end of the first postoperative week. Patients in the control group underwent no further nasal taping after cast removal. All patients in the 2- and 4-week PRT groups received taping during their allocated time in addition to the 1 week with the external nasal splint. Both PRT groups were provided with 1.27-cm (0.5-inch)-wide tan, hypoallergenic surgical tape (Micropore; 3M). Each patient was shown how to use the tape (Figure 2) and given written instructions regarding PRT (Box). Nasal swelling was evaluated individually with a 7.5-mHz linear ultrasonographic (US) probe. A small amount of US gel was used to scan the skin in a noncontact mode to prevent distortion of nasal anatomy from transducer pressure. The examiner (B.O.) did not have access to the results of the previously obtained measurements to prevent measurements from being biased. Measurements were performed on the nasion, rhinion, supratip, and tip; from these 4 measurements, we calculated the mean nasal skin thickness (MNST). E2
Figure 1. CONSORT Diagram
Figure 2. Representative Postrhinoplasty Taping
Patients in each group were categorized by the baseline MNST measurement from the lowest to highest MNST. Half of the patients with higher MNST measurements was categorized as thick skinned (n = 29), and the other half was categorized as thin skinned (n = 28) (Table 1). The electronic caliper of the machine measured the perpendicular distance from the outer epidermal surface to the underlying cartilage on the 2-dimensional B-mode US image (Capasee II unit; Toshiba Medical Systems). The US measurements were obtained 5 times for each patient, including preoperatively and at the end of postoperative weeks 1, 3, and 5 and postoperative month 6. Measurements were typically performed in the morning to avoid the effect of diurnal variation on the dermal edema.
Surgical Technique All patients underwent open-approach rhinoplasty under general anesthesia for cosmetic and functional purposes. All cases
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Effect of Postrhinoplasty Taping on Postoperative Edema
Box. Instructions for Postrhinoplasty Taping
Original Investigation Research
Table 1. Demographic Characteristics
Taping
No. of Patients
Sex, No. of Patientsa Female
Male
Age, Mean (SD) [Range], yb
Operative Duration, Mean (SD), minc
• Only use the allocated taping approved by your physician.
Group
• Stay nasal taped “as many hours as is socially feasible,” especially at night.
Control
20
9
11
30.3 (12.7) [18-61] 137 (22)
2-wk PRT
17
8
9
30.1 (10.9) [16-50] 136 (29)
• Before applying the tape, make sure to clean your nasal skin with an alcohol pad.
4-wk PRT
20
7
13
29.7 (11.8) [16-55] 149 (33)
All
57
24
33
30.0 (11.7) [16-61] 141 (29)
• Place your taping in front of a mirror for proper placement. Apply horizontally oriented, single-layer taping—as you were instructed— from top to tip. Do not overlap the tapes more than 2%.
Abbreviation: PRT, postrhinoplasty taping.
• Pull the tape tightly on the skin; the idea is to compress the skin down to underlying cartilage and/or bone.
a
For comparison among groups, P = .72.
b
For comparison among groups, P = .99.
c
For comparison among groups, P = .27.
Untaping
• Before peeling off, contact with water or alcohol (during shower or after washing your face). • Pull the tape gently back over itself 180 degrees to minimize pulling the skin up. • Make sure to wash your nose skin 2 to 3 times a day. Patients are advised to contact their physician for any questions. The quotation is attributed to Guyuron et al.2
were distributed evenly among the surgeons (B.O., Y.S.Y., B.V., and S.T.). A supraperichondrial and subperiosteal dissection plane was preferred in all cases. The surgical procedure was mainly reduction rhinoplasty and consisted of dorsal reduction and bilateral lateral osteotomies. All lateral osteotomies were performed intranasally with guarded, curved lateral osteotomes. Incision-to-closure operative duration was recorded for each patient. All patients were routinely administered dexamethasone sodium phosphate, 0.1 mg/kg, during the operation. All patients underwent internal splinting, taping, and casting with external thermoplastic splints at the end of the operation. Postoperative suggestions, orders, and medications were identical for all groups. Patients were discharged from the hospital on the first postoperative day. All patients returned at the end of the first postoperative week for removal of external nasal packing.
Statistical Analysis Data were analyzed from July 1 to August 1, 2015. Statistical analysis used SPSS software (version 20.0; SPSS, Inc). All values were calculated and stated in descriptive statistics as mean (SD) unless otherwise indicated. We used analysis of variance for comparison of means. Pairwise comparison was performed with Bonferroni correction. A repeated-measures analysis of variance was used for each patient with the US measurements (preoperative; postoperative weeks 1, 3, and 5; and postoperative month 6) as the repeated factor. Correlation analysis used the Pearson product moment correlation test. P < .05 was considered statistically significant.
Results Of the total 57 patients, 20 were in the control group; 17, the 2-week PRT group; and 20, the 4-week PRT group (Figure 1). jamafacialplasticsurgery.com
All 3 groups were similar in terms of mean age (P = .99), sex distribution (P = .72), and operative duration (P = .27) (Table 1). Comparison of baseline skin thicknesses among the 3 groups revealed similar measurements for all 4 points and MNSTs (P > .05) (Figure 3A). Patients categorized as thin skinned included 10 from the control group, 8 from the 2-week PRT group, and 10 from the 4-week PRT group. Those categorized as thick skinned included 10 from the control group, 9 from the 2-week PRT group, and 10 from the 4-week PRT group. Baseline skin thicknesses for thinskinned and thick-skinned subgroups were also similar among in the 3 treatment groups (Figure 3B-C). Operative duration and postoperative nasal skin thickness were not correlated (P > .05). Analysis of US skin thickness measurements for each individual point by subgroup is given in Figure 4 and the eTable in Supplement 2. Nasion skin thickness was unaffected by PRT. Although rhinion region skin thickness was unaffected by PRT, the comparison among thick-skinned subgroups alone revealed a significant effect (P = .02). Pairwise comparison revealed a significant effect between the control and 4-week PRT groups (P = .03) (Table 2). Analysis of postoperative supratip skin thickness showed PRT had a significant effect (P = .01). Although the benefit increased with prolonged taping, pairwise comparison of the 4-week PRT group and the control group found a significant effect (P = .001) (Figure 4 and Table 2). Postrhinoplasty taping had no effect on supratip skin thickness in thin-skinned patients (P = .14), whereas analysis among only thickskinned patients revealed an effect on supratip skin thickness (P = .07) (Figure 4 and Table 2). We did not find a significant effect on the tip region (P = .052). Statistical analysis among thin-skinned patients only revealed no effect of PRT on postoperative skin thickness, whereas a comparison of thick-skinned patients had an effect on the tip (P = .06) and supratip (P = .07) regions. Pairwise comparison of MNST with the control group revealed a significant effect in the 2-week (P = .02) and 4-week (P = .007) PRT groups. This effect was similar in the thickskinned subgroup for 2-week PRT (P = .03) and 4-week PRT (P = .005) ( Table 2), whereas PRT did not show any effect on postoperative MNST among the thin-skinned patient subgroup (Figure 4). (Reprinted) JAMA Facial Plastic Surgery Published online February 25, 2016
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Effect of Postrhinoplasty Taping on Postoperative Edema
Figure 3. Comparison of Baseline (Preoperative) Skin Thickness A All patients (N = 57)
5.0 Control group
4.5
2-wk PRT group
Mean Skin Thickness, mm
4.0
4-wk PRT group
3.5 3.0 2.5 2.0 1.5 1.0 0.5 0
Nasion
Rhinion
Supratip
Tip
MNST
Tip
MNST
Tip
MNST
Measurement B
Thick-skinned group (n = 29) 5.0 4.5
Mean Skin Thickness, mm
4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0
Nasion
Rhinion
Supratip
Measurement C
Thin-skinned group (n = 28) 5.0 4.5
Mean Skin Thickness, mm
4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0
Nasion
Rhinion
Supratip
Measurement
Comparison of mean baseline skin thickness revealed similar measurements among groups (P > .05). MNST indicates mean nasal skin thickness; PRT, postrhinoplasy taping.
Discussion Skin thickness plays an important role on the outcome of rhinoplasty, particularly in nasal tip refinement. Patients with thick skin are considered poor candidates for rhinoplasty beE4
cause nasal tip edema may require months to resolve, and desired sculpturing of the nose cannot always be achieved. Many methods have been reported in the literature for expediting removal of swelling.11-14 Postoperative swelling and ecchymosis also complicate the initial perception of rhinoplasty results at the time of splint removal. Postrhinoplasty taping has been used as a practical, cheap, and easy way to aid the psychological status of the patient and to provide more time for emotional adjustment to the surgical results.15 Supratip deformity is one of the most common problems that require a secondary rhinoplasty. Guyuron et al2 reported a 9% and 36% incidence for primary and secondary cases, respectively.16 The granulation and scar tissue that fill the potential dead space in the supratip area contribute to supratip fullness, which can take months to resolve and can be challenging for the patient and surgeon. According to a previous publication,17 supratip height was the lowest rated outcome in terms of predictability and the patient’s overall satisfaction level. Many intraoperative and postoperative methods have been described in the literature to avoid supratip fullness.3-5,8,18,19 Although investigators have achieved a consensus of opinion on most postrhinoplasty practice patterns, PRT and its effects are fairly unknown and not studied in terms of evidencebased medicine.20 Hoefflin9(p375) was the first investigator to report the effect of PRT with the following: “4 to 6 weeks of nighttime postoperative nasal taping will help decrease swelling, and will give patients something to do.” In 1995, Vega-Villasante and Covarrubias7 described a nasal tip splint that is applied on top of nasal taping and maintained postoperatively for a period of 2 to 3 weeks. The authors advocated that the splint “reduces the disadvantages of prolonged postoperative edema and fibrosis after thick-skinned Mestizo surgery, thus offers more predictable results, by maintaining those observed during surgery.”7(p193) Guyuron et al2(p1140) also stated: “If supratip overprojection is noted early after surgery, and the supratip fullness is judged to be swelling and scar tissue in an early stage, taping the supratip area vigorously for 6 to 8 weeks (as many hours as is socially feasible) is advised before trying further interventions.” The present study shows the significant effect of PRT, particularly in thick-skinned patients. Despite the small number of patients with thick skin (n = 29), PRT had a benefit at every point and MNST except the nasion and tip (Table 2). Four weeks of PRT generally resulted in an increased benefit compared with 2 weeks of PRT, although the pairwise comparison did not reveal a significant difference. Duration of PRT can be adjusted according to preference of the surgeon and the needs of the patient. Longer periods of taping have been shown to cause an increase in the incidence of skin acne vulgaris, which is already shown to be exacarbated with rhinoplasty.21,22 In the present study, single-layer hypoallergic taping was preferred, and patients were instructed to clean the nasal skin carefully. Four weeks of PRT were generally well tolerated; a mild increase in acne formation occurred in 2 patients (in the 4-week RPT group). After onset of skin symptoms, PRT was limited to nighttime taping for these patients, and the symptoms alleviated without additional treatment.
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Effect of Postrhinoplasty Taping on Postoperative Edema
Original Investigation Research
Figure 4. Comparison of Postoperative Skin Thickness Changes All patients (N = 57) 4.5
P = .16
4.0
Skin Thickness, mm
3.5 3.0 2.5 2.0 1.5 Preoperative 1st wk
3rd wk
5th wk
3.5 3.0 2.5 2.0
Postoperative Measurement
3.5
4.0
Skin Thickness, mm
Skin Thickness, mm
3.5 3.0 2.5 2.0 1.5 Preoperative 1st wk
6th mo
Control group 2-wk PRT group 4-wk PRT group
3rd wk
5th wk
6th mo
Postoperative Measurement
Rhinion P = .27 3.0 2.5 2.0 1.5 1.0 Preoperative 1st wk
3rd wk
5th wk
3.0 2.5 2.0 1.5 1.0 Preoperative 1st wk
6th mo
4.5
P = .02
3.5
Postoperative Measurement
3rd wk
5th wk
P = .23
4.0 3.5 3.0 2.5 2.0 1.5 1.0 Preoperative 1st wk
6th mo
Postoperative Measurement
3rd wk
5th wk
6th mo
Postoperative Measurement
Supratip
10.5
P = .01
9.5
10.5
Skin Thickness, mm
Skin Thickness, mm
5th wk
P = .06
4.0
Postoperative Measurement
4.0
C
3rd wk
Skin Thickness, mm
B
4.5
P = .08
4.0
1.5 Preoperative 1st wk
6th mo
Thin-skinned group (n = 28)
8.5 7.5 6.5 5.5 4.5 3.5 Preoperative 1st wk
3rd wk
5th wk
P = .07
9.5 8.5 7.5 6.5 5.5 4.5 3.5 Preoperative 1st wk
6th mo
Postoperative Measurement
10.5
Skin Thickness, mm
Skin Thickness, mm
4.5
Thick-skinned group (n = 29)
Skin Thickness, mm
A Nasion
3rd wk
5th wk
P = .14
9.5 8.5 7.5 6.5 5.5 4.5 3.5 Preoperative 1st wk
6th mo
Postoperative Measurement
3rd wk
5th wk
6th mo
Postoperative Measurement
D Tip
4.5
3.5 3.0 2.5 2.0 1.5 Preoperative 1st wk
3rd wk
5th wk
3.5 3.0 2.5 2.0 1.5 Preoperative 1st wk
6th mo
Postoperative Measurement
5th wk
P = .81
4.0 3.5 3.0 2.5 2.0 1.5 Preoperative 1st wk
6th mo
Postoperative Measurement
3rd wk
5th wk
6th mo
Postoperative Measurement
Mean nasal skin thickness 6.0
6.0
P = .003
5.5
Skin Thickness, mm
Skin Thickness, mm
3rd wk
5.0 4.5 4.0 3.5 3.0 2.5 2.0 Preoperative 1st wk
3rd wk
5th wk
6th mo
Postoperative Measurement
6.0
P = .01
5.5
Skin Thickness, mm
E
4.5 P = .06
4.0
Skin Thickness, mm
P = .052
4.0
Skin Thickness, mm
Skin Thickness, mm
4.5
5.0 4.5 4.0 3.5 3.0 2.5 2.0 Preoperative 1st wk
3rd wk
5th wk
6th mo
P = .09
5.5 5.0 4.5 4.0 3.5 3.0 2.5 2.0 Preoperative 1st wk
Postoperative Measurement
3rd wk
5th wk
6th mo
Postoperative Measurement
PRT indicates postrhinoplasty taping.
In the literature, many techniques have been used for the evaluation of nasal skin thickness.19,23-25 Ultrasonography, above all, does not expose patients to ionizing radiajamafacialplasticsurgery.com
tion, has been shown to achieve reproducible results, and has very good soft-tissue compatibility. 26-28 Although a higher-frequency probe would be preferable owing to supe(Reprinted) JAMA Facial Plastic Surgery Published online February 25, 2016
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Research Original Investigation
Effect of Postrhinoplasty Taping on Postoperative Edema
Table 2. Pairwise Comparison of the Effect of PRT on Nasal Skin Thicknessa Pairwise Comparison Skin Thickness Measurement
All Patients (n = 57)
Thick-Skinned Patients (n = 29)
Control vs 2-wk PRT
NA
P = .11
Control vs 4-wk PRT
NA
P = .03
2- vs 4-wk PRT
NA
P = .08
Control vs 2-wk PRT
P = .12
NA
Control vs 4-wk PRT
P = .001
NA
2- vs 4-wk PRT
P = .46
NA
Control vs 2-wk PRT
P = .02
P = .03
Control vs 4-wk PRT
P = .007
P = .005
2- vs 4-wk PRT
P = .44
P = .10
Rhinion
Supratip
MNST
Abbreviations: MNST, mean nasal skin thickness; NA, not applicable; PRT, postrhinoplasty taping. a
Pairwise comparisons were performed using Bonferroni correction for subgroups and measurements with a significant effect of PRT. Statistical significance was set at P < .05.
ARTICLE INFORMATION Accepted for Publication: October 4, 2015. Published Online: February 25, 2016. doi:10.1001/jamafacial.2015.1944. Author Contributions: Drs Ozucer and Uysal had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Ozucer, Ozturan. Acquisition, analysis, or interpretation of data: Ozucer, Yıldırım, Veyseller, Tugrul, Eren, Aksoy, Uysal. Drafting of the manuscript: Ozucer, Veyseller. Critical revision of the manuscript for important intellectual content: Ozucer, Yıldırım, Tugrul, Eren, Aksoy, Uysal, Ozturan. Statistical analysis: Ozucer, Uysal. Obtained funding: Ozucer. Administrative, technical, or material support: Ozucer, Yıldırım, Veyseller, Tugrul, Eren, Ozturan. Study supervision: Ozucer, Veyseller, Eren, Aksoy, Ozturan. Conflict of Interest Disclosures: None reported. Previous Presentation: This paper was presented at the 9th Annual Meeting of the Turkish Facial Plastic Surgery Association; October 11, 2015; Istanbul, Turkey, and as a poster at the Annual Congress of the European Academy of Facial Plastic Surgeons; September 24-26, 2015; Cannes, France. Additional Contributions: Ipek Kuscu Ozucer, MD, Department of Child and Adolescent Psychiatry, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey, scrutinized the manuscript and provided feedback. She received no compensation for this role. REFERENCES 1. Hafezi F, Naghibzadeh B, Nouhi A. Management of the thick-skinned nose: a more effective approach. Ann Otol Rhinol Laryngol. 2006;115(6): 444-449. E6
rior resolution, the 7.5-MHz transducer provided adequate visualization and measuring of skin thickness overlying the nasal cartilage.26,27 All skin compartments overlying the cartilage were measured perpendicularly to the nearest 0.1 mm. Further analysis of skin subcomponents are beyond the scope of this report. Therefore, the US data do not limit our findings. The small number of patients while calculating significance for the subgroup analysis was a limitation of the study.
Conclusions Postrhinoplasty taping helps the skin envelope to compress to the underlying cartilaginous framework and decrease postoperative swelling. The overall effect on MNST is significant with 2- and 4-week PRT. Postrhinoplasy taping is particularly useful in thick-skinned patients and for reducing supratip fullness. This cheap and practical modality helps the rhinoplasty surgeon to control another anatomic element—the skin—during the postoperative period for better surgical outcomes.
2. Guyuron B, DeLuca L, Lash R. Supratip deformity: a closer look. Plast Reconstr Surg. 2000; 105(3):1140-1151. 3. Rees TD. An aid to the treatment of supratip swelling after rhinoplasty. Laryngoscope. 1971;81(2): 308-311. 4. Chu E, Davis RE. SMAS debulking for management of the thick-skinned nose. JAMA Facial Plast Surg. 2015;17(4):305-306. 5. Arslan E, Gencel E, Pekedis O. Reverse nasal SMAS-perichondrium flap to avoid supratip deformity in rhinoplasty. Aesthetic Plast Surg. 2012; 36(2):271-277. 6. Tosun F, Arslan HH, Hidir Y, Karslioglu Y, Durmaz A, Gerek M. Subcutaneous approximation suture for preventing soft tissue pollybeak deformity. Am J Rhinol Allergy. 2012;26(4):e111-e114. 7. Vega-Villasante P, Covarrubias H. A new splint for the nasal tip. Plast Reconstr Surg. 1995;96(1):189-193. 8. Kornstein AN. Ultherapy shrinks nasal skin after rhinoplasty following failure of conservative measures. Plast Reconstr Surg. 2013;131(4):664e666e. 9. Hoefflin SM. Postoperative nighttime nasal taping to decrease swelling. Plast Reconstr Surg. 1989;84(2):375.
13. Hwang SH, Lee JH, Kim BG, Kim SW, Kang JM. The efficacy of steroids for edema and ecchymosis after rhinoplasty: a meta-analysis. Laryngoscope. 2015;125(1):92-98. 14. Valente DS, Steffen N, Carvalho LA, Borille GB, Zanella RK, Padoin AV. Preoperative use of dexamethasone in rhinoplasty: a randomized, double-blind, placebo-controlled clinical trial. JAMA Facial Plast Surg. 2015;17(3):169-173. 15. Belek KA, Gruber RP. The beneficial effects of postrhinoplasty taping: fact or fiction? Aesthet Surg J. 2014;34(1):56-60. 16. Sheen JH. A new look at supratip deformity. Ann Plast Surg. 1979;3(6):498-504. 17. Mehta U, Mazhar K, Frankel AS. Accuracy of preoperative computer imaging in rhinoplasty. Arch Facial Plast Surg. 2010;12(6):394-398. 18. Nemati S, Banan R, Alizadeh A, Leili EK, Kerdari H. Ultrasonographic evaluation of long-term results of nasal tip defatting in rhinoplasty cases. Laryngoscope. 2013;123(9):2131-2135. 19. Berinstein TH, Bane SM, Cupp CL, DeMarco JK, Hunsaker DH. Steroid use in rhinoplasty: an objective assessment of postoperative edema. Ear Nose Throat J. 1998;77(1):40-43.
10. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191-2194.
20. Shadfar S, Deal AM, Jarchow AM, Yang H, Shockley WW. Practice patterns in the perioperative treatment of patients undergoing septorhinoplasty: a survey of facial plastic surgeons. JAMA Facial Plast Surg. 2014;16(2):113-119.
11. Totonchi A, Guyuron B. A randomized, controlled comparison between arnica and steroids in the management of postrhinoplasty ecchymosis and edema. Plast Reconstr Surg. 2007;120(1):271-274.
21. Nemati S, Golchay J, Iranfar K, Alizadeh A. Frequency of acne vulgaris and its exacerbation in facial and periorbital area after septorhinoplasty. Am J Otolaryngol. 2013;34(5):378-381.
12. Hatef DA, Ellsworth WA, Allen JN, Bullocks JM, Hollier LH Jr, Stal S. Perioperative steroids for minimizing edema and ecchymosis after rhinoplasty: a meta-analysis. Aesthet Surg J. 2011;31 (6):648-657.
22. Koc EA, Buyuklu F, Koç B, Demirci GT. Skin problems following septorhinoplasty. Laryngoscope. 2015;125(6):1291-1295. 23. Cho GS, Kim JH, Yeo N-K, Kim SH, Jang YJ. Nasal skin thickness measured using computed
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Effect of Postrhinoplasty Taping on Postoperative Edema
tomography and its effect on tip surgery outcomes. Otolaryngol Head Neck Surg. 2011;144(4):522-527. 24. Tatlidede S, Turgut G, Gönen E, Kayali MU, Baş L. Stereolithographic volume evaluation of healing and shaping after rhinoplasty operations. J Craniofac Surg. 2009;20(4):1082-1085. 25. Ozkul MH, Kocagöz DG, Balıkcı HH, Verim A, Yaşar H. A practical method for assessing nasal skin quality. Eur Arch Otorhinolaryngol. 2013;270(6): 1839-1842.
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26. De Melo Naves M, Sousa RC, Ferreira Tomé RA, Canazza Damian NG, Debs Diniz AL, Patrocinio LG. Evaluation of ultrasound reproducibility as a method to measure the subcutaneous tissue of the nasal tip [in Portuguese]. Int Arch Otorhinolaryngol. 2011;15(3):346-349.
28. Verim A, Duymuş R, Çalim OF, et al. Effect of nose skin on the columellar incision scar in a Turkish population. Otolaryngol Head Neck Surg. 2013;149 (3):438-444.
27. Tasman AJ, Helbig M. Sonography of nasal tip anatomy and surgical tip refinement. Plast Reconstr Surg. 2000;105(7):2573-2579.
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Original Investigation
Effect of Postrhinoplasty Taping on Postoperative Edema and Nasal Draping A Randomized Clinical Trial Berke Ozucer, MD; Yavuz Selim Yıldırım, MD; Bayram Veyseller, MD; Selahattin Tugrul, MD; Sabri Baki Eren, MD; Fadullah Aksoy, MD; Omer Uysal, MD; Orhan Ozturan, MD Invited Commentary BACKGROUND Edema persists for months after rhinoplasty. Numerous modalities have been described to counteract postoperative edema.
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OBJECTIVE To evaluate the effect of postrhinoplasty taping (PRT) on nasal edema and nasal
draping. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial, 57 patients undergoing rhinoplasty at a tertiary reference center from August 1, 2014, to January 31, 2015, were assigned to a control group or to 2- or 4-week PRT groups. Baseline nasal thickness was measured with ultrasonography at the nasion, rhinion, supratip, and tip, and mean nasal skin thickness (MNST) was calculated. Participants in each group were categorized by the baseline MNST measurement from the lowest to greatest MNST; those in the upper half were categorized as having thick skin; those in the lower half, thin skin. The control group underwent no PRT after the removal of external packing. Patients in the 2- and 4-week PRT groups received additional taping during the allocated time. Data were collected from August 1, 2014, to June 31, 2015. Follow-up was completed on June 31, 2015, and data were analyzed from July 1 to August 1, 2015. MAIN OUTCOMES AND MEASURES Postoperative measurements of MNST were performed at the end of weeks 1, 3, and 5 and month 6. RESULTS Of the 57 total patients (33 male and 24 female patients; mean [SD] age, 30.0 [11.7] years), 17 were in the 2-week PRT group; 20, the 4-week PRT group; and 20, the control group. Compared with the control group, 4-week PRT had a significant effect on the supratip (P = .001). Comparisons of MNST with the control group revealed significant effects of 2-week (P = .02) and 4-week (P = .007) PRT. The effect on the tip was not significant (P = .052). Postrhinoplasty taping had no effect in thin-skinned patients. Comparison among thick-skinned patients revealed a significant effect on the MNST (P = .01) and the rhinion (P = .02) but not the tip (P = .06) and supratip (P = .07). CONCLUSIONS AND RELEVANCE Postrhinoplasty taping helps the skin envelope to compress to the underlying framework and decrease postoperative edema. The procedure can be used particularly in thick-skinned patients, in whom skin draping and nasal refinement is crucial to the surgical outcome. LEVEL OF EVIDENCE 1. TRIAL REGISTRATION clinicalTrials.gov Identifier: NCT02626585
JAMA Facial Plast Surg. doi:10.1001/jamafacial.2015.1944 Published online February 25, 2016.
Author Affiliations: Department of Otorhinolaryngology, Gaziosmanpasa Taksim Research and Education Hospital, Istanbul, Turkey (Ozucer); Department of Otorhinolaryngology, Medical Faculty, Bezmiâlem Vakıf University, Istanbul, Turkey (Yıldırım, Veyseller, Tugrul, Eren, Aksoy, Ozturan); Department of Biostatistics, Bezmiâlem Vakıf University, Istanbul, Turkey (Uysal). Corresponding Author: Berke Ozucer, MD, Department of Otorhinolaryngology, Gaziosmanpasa Taksim Research and Education Hospital, Karayolları Mah, Gaziosmanpasa, Istanbul, Turkey 34093 ([email protected]).
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Research Original Investigation
Effect of Postrhinoplasty Taping on Postoperative Edema
R
hinoplasty is generally and predominantly concerned with the osseocartilaginous framework and sometimes overlooks the soft-tissue envelope. After rhinoplasty, nasal swelling can persist for many months. Thick and sebaceous skin can experience exacerbated swelling owing to poor draping capability and is more prone to undesirable outcomes.1 Formation of dead space and filling of granulation tissue can prolong the persistence of chronic edema. This process may result in an unfavorable outcome by hindering nasal tip refinement and causing supratip deformity.2,3 Many intraoperative4-6 and postoperative3,7,8 techniques have been described to overcome this effect. Although anecdotal evidence suggests that taping after rhinoplasty may help, its efficiency is unknown.2,9 The aim of this study was to evaluate the effect of postrhinoplasty taping (PRT) on nasal edema. This study was designed to observe patients undergoing rhinoplasty in a controlled, prospective, randomized fashion with 6 months of follow-up.
62 Patients assessed for eligibility
2 Excluded 2 Standardized bilateral lateral osteomy was not used in the operation
60 Randomized
20 Randomized to control group
20 Randomized to 2-wk PRT group
20 Randomized to 4-wk PRT group
20 Included in analysis
3 Excluded from analysis 2 Lost to follow-up Reasons: unknown 1 Discontinued intervention
20 Included in analysis
17 Included in analysis
Two patients in the 2-wk PR=T group were unavailable for follow-up for unknown reasons; 1 patient in the group who discontinued the intervention did not see the need and was therefore excluded from the analysis. PRT indicates postrhinoplasty taping.
Methods Fifty-seven patients who underwent consecutive, primary, open-approach rhinoplasty at our tertiary reference center from August 1, 2014, to January 31, 2015, were enrolled in the study. Data were collected from August 1, 2014, to June 31, 2015, and follow-up was completed on June 31, 2015. The trial protocol is described in Supplement 1. Inclusion criteria consisted of open-approach reduction rhinoplasty and osteotomy with guarded lateral osteotomes. Patients were questioned regarding adherence to the allocated PRT therapy, and only patients who applied the minimal allocated therapy (nighttime taping) were included in the study. Revision surgery, abnormal hemostatic values, and a history of decongestant or corticosteroid use constituted exclusion criteria. The ethics committee of Bezmiâlem Vakıf University approved the study, which conformed to the Declaration of Helsinki.10 All patients individually provided written informed consent. Patients were assigned to control, 2-week PRT, or 4-week PRT groups in a randomized consecutive fashion (Figure 1). The external thermoplastic splint was removed at the end of the first postoperative week. Patients in the control group underwent no further nasal taping after cast removal. All patients in the 2- and 4-week PRT groups received taping during their allocated time in addition to the 1 week with the external nasal splint. Both PRT groups were provided with 1.27-cm (0.5-inch)-wide tan, hypoallergenic surgical tape (Micropore; 3M). Each patient was shown how to use the tape (Figure 2) and given written instructions regarding PRT (Box). Nasal swelling was evaluated individually with a 7.5-mHz linear ultrasonographic (US) probe. A small amount of US gel was used to scan the skin in a noncontact mode to prevent distortion of nasal anatomy from transducer pressure. The examiner (B.O.) did not have access to the results of the previously obtained measurements to prevent measurements from being biased. Measurements were performed on the nasion, rhinion, supratip, and tip; from these 4 measurements, we calculated the mean nasal skin thickness (MNST). E2
Figure 1. CONSORT Diagram
Figure 2. Representative Postrhinoplasty Taping
Patients in each group were categorized by the baseline MNST measurement from the lowest to highest MNST. Half of the patients with higher MNST measurements was categorized as thick skinned (n = 29), and the other half was categorized as thin skinned (n = 28) (Table 1). The electronic caliper of the machine measured the perpendicular distance from the outer epidermal surface to the underlying cartilage on the 2-dimensional B-mode US image (Capasee II unit; Toshiba Medical Systems). The US measurements were obtained 5 times for each patient, including preoperatively and at the end of postoperative weeks 1, 3, and 5 and postoperative month 6. Measurements were typically performed in the morning to avoid the effect of diurnal variation on the dermal edema.
Surgical Technique All patients underwent open-approach rhinoplasty under general anesthesia for cosmetic and functional purposes. All cases
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Effect of Postrhinoplasty Taping on Postoperative Edema
Box. Instructions for Postrhinoplasty Taping
Original Investigation Research
Table 1. Demographic Characteristics
Taping
No. of Patients
Sex, No. of Patientsa Female
Male
Age, Mean (SD) [Range], yb
Operative Duration, Mean (SD), minc
• Only use the allocated taping approved by your physician.
Group
• Stay nasal taped “as many hours as is socially feasible,” especially at night.
Control
20
9
11
30.3 (12.7) [18-61] 137 (22)
2-wk PRT
17
8
9
30.1 (10.9) [16-50] 136 (29)
• Before applying the tape, make sure to clean your nasal skin with an alcohol pad.
4-wk PRT
20
7
13
29.7 (11.8) [16-55] 149 (33)
All
57
24
33
30.0 (11.7) [16-61] 141 (29)
• Place your taping in front of a mirror for proper placement. Apply horizontally oriented, single-layer taping—as you were instructed— from top to tip. Do not overlap the tapes more than 2%.
Abbreviation: PRT, postrhinoplasty taping.
• Pull the tape tightly on the skin; the idea is to compress the skin down to underlying cartilage and/or bone.
a
For comparison among groups, P = .72.
b
For comparison among groups, P = .99.
c
For comparison among groups, P = .27.
Untaping
• Before peeling off, contact with water or alcohol (during shower or after washing your face). • Pull the tape gently back over itself 180 degrees to minimize pulling the skin up. • Make sure to wash your nose skin 2 to 3 times a day. Patients are advised to contact their physician for any questions. The quotation is attributed to Guyuron et al.2
were distributed evenly among the surgeons (B.O., Y.S.Y., B.V., and S.T.). A supraperichondrial and subperiosteal dissection plane was preferred in all cases. The surgical procedure was mainly reduction rhinoplasty and consisted of dorsal reduction and bilateral lateral osteotomies. All lateral osteotomies were performed intranasally with guarded, curved lateral osteotomes. Incision-to-closure operative duration was recorded for each patient. All patients were routinely administered dexamethasone sodium phosphate, 0.1 mg/kg, during the operation. All patients underwent internal splinting, taping, and casting with external thermoplastic splints at the end of the operation. Postoperative suggestions, orders, and medications were identical for all groups. Patients were discharged from the hospital on the first postoperative day. All patients returned at the end of the first postoperative week for removal of external nasal packing.
Statistical Analysis Data were analyzed from July 1 to August 1, 2015. Statistical analysis used SPSS software (version 20.0; SPSS, Inc). All values were calculated and stated in descriptive statistics as mean (SD) unless otherwise indicated. We used analysis of variance for comparison of means. Pairwise comparison was performed with Bonferroni correction. A repeated-measures analysis of variance was used for each patient with the US measurements (preoperative; postoperative weeks 1, 3, and 5; and postoperative month 6) as the repeated factor. Correlation analysis used the Pearson product moment correlation test. P < .05 was considered statistically significant.
Results Of the total 57 patients, 20 were in the control group; 17, the 2-week PRT group; and 20, the 4-week PRT group (Figure 1). jamafacialplasticsurgery.com
All 3 groups were similar in terms of mean age (P = .99), sex distribution (P = .72), and operative duration (P = .27) (Table 1). Comparison of baseline skin thicknesses among the 3 groups revealed similar measurements for all 4 points and MNSTs (P > .05) (Figure 3A). Patients categorized as thin skinned included 10 from the control group, 8 from the 2-week PRT group, and 10 from the 4-week PRT group. Those categorized as thick skinned included 10 from the control group, 9 from the 2-week PRT group, and 10 from the 4-week PRT group. Baseline skin thicknesses for thinskinned and thick-skinned subgroups were also similar among in the 3 treatment groups (Figure 3B-C). Operative duration and postoperative nasal skin thickness were not correlated (P > .05). Analysis of US skin thickness measurements for each individual point by subgroup is given in Figure 4 and the eTable in Supplement 2. Nasion skin thickness was unaffected by PRT. Although rhinion region skin thickness was unaffected by PRT, the comparison among thick-skinned subgroups alone revealed a significant effect (P = .02). Pairwise comparison revealed a significant effect between the control and 4-week PRT groups (P = .03) (Table 2). Analysis of postoperative supratip skin thickness showed PRT had a significant effect (P = .01). Although the benefit increased with prolonged taping, pairwise comparison of the 4-week PRT group and the control group found a significant effect (P = .001) (Figure 4 and Table 2). Postrhinoplasty taping had no effect on supratip skin thickness in thin-skinned patients (P = .14), whereas analysis among only thickskinned patients revealed an effect on supratip skin thickness (P = .07) (Figure 4 and Table 2). We did not find a significant effect on the tip region (P = .052). Statistical analysis among thin-skinned patients only revealed no effect of PRT on postoperative skin thickness, whereas a comparison of thick-skinned patients had an effect on the tip (P = .06) and supratip (P = .07) regions. Pairwise comparison of MNST with the control group revealed a significant effect in the 2-week (P = .02) and 4-week (P = .007) PRT groups. This effect was similar in the thickskinned subgroup for 2-week PRT (P = .03) and 4-week PRT (P = .005) ( Table 2), whereas PRT did not show any effect on postoperative MNST among the thin-skinned patient subgroup (Figure 4). (Reprinted) JAMA Facial Plastic Surgery Published online February 25, 2016
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Effect of Postrhinoplasty Taping on Postoperative Edema
Figure 3. Comparison of Baseline (Preoperative) Skin Thickness A All patients (N = 57)
5.0 Control group
4.5
2-wk PRT group
Mean Skin Thickness, mm
4.0
4-wk PRT group
3.5 3.0 2.5 2.0 1.5 1.0 0.5 0
Nasion
Rhinion
Supratip
Tip
MNST
Tip
MNST
Tip
MNST
Measurement B
Thick-skinned group (n = 29) 5.0 4.5
Mean Skin Thickness, mm
4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0
Nasion
Rhinion
Supratip
Measurement C
Thin-skinned group (n = 28) 5.0 4.5
Mean Skin Thickness, mm
4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0
Nasion
Rhinion
Supratip
Measurement
Comparison of mean baseline skin thickness revealed similar measurements among groups (P > .05). MNST indicates mean nasal skin thickness; PRT, postrhinoplasy taping.
Discussion Skin thickness plays an important role on the outcome of rhinoplasty, particularly in nasal tip refinement. Patients with thick skin are considered poor candidates for rhinoplasty beE4
cause nasal tip edema may require months to resolve, and desired sculpturing of the nose cannot always be achieved. Many methods have been reported in the literature for expediting removal of swelling.11-14 Postoperative swelling and ecchymosis also complicate the initial perception of rhinoplasty results at the time of splint removal. Postrhinoplasty taping has been used as a practical, cheap, and easy way to aid the psychological status of the patient and to provide more time for emotional adjustment to the surgical results.15 Supratip deformity is one of the most common problems that require a secondary rhinoplasty. Guyuron et al2 reported a 9% and 36% incidence for primary and secondary cases, respectively.16 The granulation and scar tissue that fill the potential dead space in the supratip area contribute to supratip fullness, which can take months to resolve and can be challenging for the patient and surgeon. According to a previous publication,17 supratip height was the lowest rated outcome in terms of predictability and the patient’s overall satisfaction level. Many intraoperative and postoperative methods have been described in the literature to avoid supratip fullness.3-5,8,18,19 Although investigators have achieved a consensus of opinion on most postrhinoplasty practice patterns, PRT and its effects are fairly unknown and not studied in terms of evidencebased medicine.20 Hoefflin9(p375) was the first investigator to report the effect of PRT with the following: “4 to 6 weeks of nighttime postoperative nasal taping will help decrease swelling, and will give patients something to do.” In 1995, Vega-Villasante and Covarrubias7 described a nasal tip splint that is applied on top of nasal taping and maintained postoperatively for a period of 2 to 3 weeks. The authors advocated that the splint “reduces the disadvantages of prolonged postoperative edema and fibrosis after thick-skinned Mestizo surgery, thus offers more predictable results, by maintaining those observed during surgery.”7(p193) Guyuron et al2(p1140) also stated: “If supratip overprojection is noted early after surgery, and the supratip fullness is judged to be swelling and scar tissue in an early stage, taping the supratip area vigorously for 6 to 8 weeks (as many hours as is socially feasible) is advised before trying further interventions.” The present study shows the significant effect of PRT, particularly in thick-skinned patients. Despite the small number of patients with thick skin (n = 29), PRT had a benefit at every point and MNST except the nasion and tip (Table 2). Four weeks of PRT generally resulted in an increased benefit compared with 2 weeks of PRT, although the pairwise comparison did not reveal a significant difference. Duration of PRT can be adjusted according to preference of the surgeon and the needs of the patient. Longer periods of taping have been shown to cause an increase in the incidence of skin acne vulgaris, which is already shown to be exacarbated with rhinoplasty.21,22 In the present study, single-layer hypoallergic taping was preferred, and patients were instructed to clean the nasal skin carefully. Four weeks of PRT were generally well tolerated; a mild increase in acne formation occurred in 2 patients (in the 4-week RPT group). After onset of skin symptoms, PRT was limited to nighttime taping for these patients, and the symptoms alleviated without additional treatment.
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Effect of Postrhinoplasty Taping on Postoperative Edema
Original Investigation Research
Figure 4. Comparison of Postoperative Skin Thickness Changes All patients (N = 57) 4.5
P = .16
4.0
Skin Thickness, mm
3.5 3.0 2.5 2.0 1.5 Preoperative 1st wk
3rd wk
5th wk
3.5 3.0 2.5 2.0
Postoperative Measurement
3.5
4.0
Skin Thickness, mm
Skin Thickness, mm
3.5 3.0 2.5 2.0 1.5 Preoperative 1st wk
6th mo
Control group 2-wk PRT group 4-wk PRT group
3rd wk
5th wk
6th mo
Postoperative Measurement
Rhinion P = .27 3.0 2.5 2.0 1.5 1.0 Preoperative 1st wk
3rd wk
5th wk
3.0 2.5 2.0 1.5 1.0 Preoperative 1st wk
6th mo
4.5
P = .02
3.5
Postoperative Measurement
3rd wk
5th wk
P = .23
4.0 3.5 3.0 2.5 2.0 1.5 1.0 Preoperative 1st wk
6th mo
Postoperative Measurement
3rd wk
5th wk
6th mo
Postoperative Measurement
Supratip
10.5
P = .01
9.5
10.5
Skin Thickness, mm
Skin Thickness, mm
5th wk
P = .06
4.0
Postoperative Measurement
4.0
C
3rd wk
Skin Thickness, mm
B
4.5
P = .08
4.0
1.5 Preoperative 1st wk
6th mo
Thin-skinned group (n = 28)
8.5 7.5 6.5 5.5 4.5 3.5 Preoperative 1st wk
3rd wk
5th wk
P = .07
9.5 8.5 7.5 6.5 5.5 4.5 3.5 Preoperative 1st wk
6th mo
Postoperative Measurement
10.5
Skin Thickness, mm
Skin Thickness, mm
4.5
Thick-skinned group (n = 29)
Skin Thickness, mm
A Nasion
3rd wk
5th wk
P = .14
9.5 8.5 7.5 6.5 5.5 4.5 3.5 Preoperative 1st wk
6th mo
Postoperative Measurement
3rd wk
5th wk
6th mo
Postoperative Measurement
D Tip
4.5
3.5 3.0 2.5 2.0 1.5 Preoperative 1st wk
3rd wk
5th wk
3.5 3.0 2.5 2.0 1.5 Preoperative 1st wk
6th mo
Postoperative Measurement
5th wk
P = .81
4.0 3.5 3.0 2.5 2.0 1.5 Preoperative 1st wk
6th mo
Postoperative Measurement
3rd wk
5th wk
6th mo
Postoperative Measurement
Mean nasal skin thickness 6.0
6.0
P = .003
5.5
Skin Thickness, mm
Skin Thickness, mm
3rd wk
5.0 4.5 4.0 3.5 3.0 2.5 2.0 Preoperative 1st wk
3rd wk
5th wk
6th mo
Postoperative Measurement
6.0
P = .01
5.5
Skin Thickness, mm
E
4.5 P = .06
4.0
Skin Thickness, mm
P = .052
4.0
Skin Thickness, mm
Skin Thickness, mm
4.5
5.0 4.5 4.0 3.5 3.0 2.5 2.0 Preoperative 1st wk
3rd wk
5th wk
6th mo
P = .09
5.5 5.0 4.5 4.0 3.5 3.0 2.5 2.0 Preoperative 1st wk
Postoperative Measurement
3rd wk
5th wk
6th mo
Postoperative Measurement
PRT indicates postrhinoplasty taping.
In the literature, many techniques have been used for the evaluation of nasal skin thickness.19,23-25 Ultrasonography, above all, does not expose patients to ionizing radiajamafacialplasticsurgery.com
tion, has been shown to achieve reproducible results, and has very good soft-tissue compatibility. 26-28 Although a higher-frequency probe would be preferable owing to supe(Reprinted) JAMA Facial Plastic Surgery Published online February 25, 2016
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Table 2. Pairwise Comparison of the Effect of PRT on Nasal Skin Thicknessa Pairwise Comparison Skin Thickness Measurement
All Patients (n = 57)
Thick-Skinned Patients (n = 29)
Control vs 2-wk PRT
NA
P = .11
Control vs 4-wk PRT
NA
P = .03
2- vs 4-wk PRT
NA
P = .08
Control vs 2-wk PRT
P = .12
NA
Control vs 4-wk PRT
P = .001
NA
2- vs 4-wk PRT
P = .46
NA
Control vs 2-wk PRT
P = .02
P = .03
Control vs 4-wk PRT
P = .007
P = .005
2- vs 4-wk PRT
P = .44
P = .10
Rhinion
Supratip
MNST
Abbreviations: MNST, mean nasal skin thickness; NA, not applicable; PRT, postrhinoplasty taping. a
Pairwise comparisons were performed using Bonferroni correction for subgroups and measurements with a significant effect of PRT. Statistical significance was set at P < .05.
ARTICLE INFORMATION Accepted for Publication: October 4, 2015. Published Online: February 25, 2016. doi:10.1001/jamafacial.2015.1944. Author Contributions: Drs Ozucer and Uysal had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Ozucer, Ozturan. Acquisition, analysis, or interpretation of data: Ozucer, Yıldırım, Veyseller, Tugrul, Eren, Aksoy, Uysal. Drafting of the manuscript: Ozucer, Veyseller. Critical revision of the manuscript for important intellectual content: Ozucer, Yıldırım, Tugrul, Eren, Aksoy, Uysal, Ozturan. Statistical analysis: Ozucer, Uysal. Obtained funding: Ozucer. Administrative, technical, or material support: Ozucer, Yıldırım, Veyseller, Tugrul, Eren, Ozturan. Study supervision: Ozucer, Veyseller, Eren, Aksoy, Ozturan. Conflict of Interest Disclosures: None reported. Previous Presentation: This paper was presented at the 9th Annual Meeting of the Turkish Facial Plastic Surgery Association; October 11, 2015; Istanbul, Turkey, and as a poster at the Annual Congress of the European Academy of Facial Plastic Surgeons; September 24-26, 2015; Cannes, France. Additional Contributions: Ipek Kuscu Ozucer, MD, Department of Child and Adolescent Psychiatry, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey, scrutinized the manuscript and provided feedback. She received no compensation for this role. REFERENCES 1. Hafezi F, Naghibzadeh B, Nouhi A. Management of the thick-skinned nose: a more effective approach. Ann Otol Rhinol Laryngol. 2006;115(6): 444-449. E6
rior resolution, the 7.5-MHz transducer provided adequate visualization and measuring of skin thickness overlying the nasal cartilage.26,27 All skin compartments overlying the cartilage were measured perpendicularly to the nearest 0.1 mm. Further analysis of skin subcomponents are beyond the scope of this report. Therefore, the US data do not limit our findings. The small number of patients while calculating significance for the subgroup analysis was a limitation of the study.
Conclusions Postrhinoplasty taping helps the skin envelope to compress to the underlying cartilaginous framework and decrease postoperative swelling. The overall effect on MNST is significant with 2- and 4-week PRT. Postrhinoplasy taping is particularly useful in thick-skinned patients and for reducing supratip fullness. This cheap and practical modality helps the rhinoplasty surgeon to control another anatomic element—the skin—during the postoperative period for better surgical outcomes.
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