Eur Arch Otorhinolaryngol DOI 10.1007/s00405-016-3907-7
RHINOLOGY
How can periorbital oedema and ecchymose be reduced in rhinoplasty? Erdem Caglar1 • Saban Celebi2 • Murat Topak3 • Necati Omer Develioglu3 Enis Yalcin4 • Mehmet Kulekci3
•
Received: 30 June 2015 / Accepted: 20 January 2016 Ó Springer-Verlag Berlin Heidelberg 2016
Abstract Oedema and ecchymose are frequent morbidities of septorhinoplasty, a facial surgical procedure for reforming the shape and functions of the nose. Periorbital oedema (PO) and periorbital ecchymose (PE) are normal occurrences, but are undesirable for patients undergoing the procedure for aesthetic purposes. The present study examined 65 patients who underwent open technique septorhinoplasty for aesthetic and functional complaints. Patients were divided into two groups: Group 1 patients underwent lateral osteotomy following tip plasty, at the end of the surgical operation; Group 2 patients underwent lateral osteotomy before tip plasty, at the beginning of the surgical operation. Patients were followed on the postoperative first, third and seventh days. PO and PE values of patients were scored from 0 to 4. The plastering time (Pt) was significantly shorter for Group I than Group II (p \ 0.05). The total surgical time (T) showed no significant difference (p [ 0.05). The PO value at the first, third and seventh days was significantly smaller for Group I than & Erdem Caglar [email protected] Saban Celebi [email protected]
Group II (p \ 0.05). The PE value at the first, third and seventh days was also significantly smaller for Group I than Group II (p \ 0.05). The obtained data indicate that performing a lateral osteotomy in the final stages of surgery, and subsequently applying a nasal plaster and splint as rapidly as possible, decreases PO and PE in the postoperative period. Keywords Rhinoplasty Lateral osteotomy Periorbital oedema Periorbital ecchymose Postoperative morbidity
Introduction Septorhinoplasty is a frequently performed facial surgical procedure which aims to reform the nose shape and functions [1]. Oedema and ecchymose are frequent morbidities of this procedure. Although the occurrence of periorbital oedema (PO) and periorbital ecchymose (PE) 2
Department of Otorhinolaryngology, Head and Neck Surgery, Yeni Yuzyil University, Gaziosmanpasa Hospital, Istanbul, Turkey
3
Department of Otorhinolaryngology, Head and Neck Surgery, Taksim Training and Research Hospital, Istanbul, Turkey
4
Department of Otorhinolaryngology, Head and Neck Surgery, Fatsa State Hospital, Ordu, Turkey
Murat Topak [email protected] Necati Omer Develioglu [email protected] Enis Yalcin [email protected] Mehmet Kulekci [email protected] 1
Department of Otorhinolaryngology, Head and Neck Surgery, Kiziltepe State Hospital, Mardin, Turkey
123
Eur Arch Otorhinolaryngol
is normal after septorhinoplasty, it is an undesirable situation for patients undergoing the procedure for aesthetic purposes [2]. The occurrence of PO and PE is quite distressing for patients during the postoperative period [3]. PO may cause vision disorders, especially in postoperative 24 h [4], whereas PE may disrupt the social life of patients and cause pigment increases in the operation area [5]. These postoperative results can lead to delays in the patients’ return to normal life [3]. These morbidities can be prevented by application of systemic steroid (preoperative and/or postoperative), pressure to the osteotomy line or cold compresses to the periorbital area [6, 7]. In addition to these methods, different osteotomy procedures (percutaneous and endonasal), which cause less PO and PE, have been described [8]. A literature review revealed no studies that have examined the effect of the time elapsed between performing a lateral osteotomy and plastering of the nasal dorsum on periorbital oedema and ecchymosis. Thus, the main objective of this study was to determine if shortening the time elapsed prior to plastering the nasal dorsum following lateral osteotomy would lessen the subsequent periorbital oedema and ecchymosis.
Materials and methods A total of 65 patients who had undergone open technique septorhinoplasty procedure for aesthetic and functional complaints between 2012/05/10 and 2014/03/10 at the Gaziosmanpas¸ a Taksim Training and Research Hospital were included in the study. The study group consisted of 33 males and 32 females patients. Signed informed consent forms for the study and surgical procedure were received from each patient. Patients who had septal deviation, external nasal deformity, and wanted to reform the shape of the nose were included in the study. Patients who suffered bleeding diathesis, hypertension, diabetes, chronic systemic disease, or psychological problems or females who were in or immediately after their menstrual cycles with hypertension during the operation were excluded from the study. All operations were performed under same hypotensive general anaesthesia protocol. An open technique septorhinoplasty procedure was conducted by the same operator using the same instruments. Septoplasty, tip plasty, dorsal hump resection, and medial, transverse and lateral osteotomies were performed. Operations were standardised by choosing patients having similar nasal deformities. Patients were assigned to one of the two groups using the MedCalc 11.5.1 randomisation programme. Surgical procedure was started with mid-columellar inverted-V
123
incision and bilateral marginal incision, then followed by skin flap elevation for each patient. After that, septoplasty and dorsal hump excision were performed, respectively. Group I included the patients who underwent lateral and medial osteotomies following upper lateral cartilage modifications and tip plasty shortly before the end of the surgical operation. Group II included the patients who underwent lateral and medial osteotomies before upper lateral cartilage modifications and tip plasty, at the earlier stage of surgical operation. Medial and median osteotomies were performed just before the lateral osteotomy procedure. Before performing lateral osteotomy, a 1:100000 adrenalin combination with 2 ml 2 % lidocaine (Jetokain; Adeka AS, Samsun, Turkey) was injected at both osteotomy lines. Osteotomies were performed 10 min after the completion of this infiltration. Lateral and medial osteotomies were performed bilaterally with guided, curved 4-mm lateral osteotomes by the endonasal approach. Blood pressures of patients were monitored during the surgical operations and early postoperative periods. Postoperatively, nasal packing was applied for 48 h, and ice packs were applied for 12 h for all patients. A nasal splint (Rhinofix, I˙stanbul, Turkey) remained in the nose dorsum for seven to ten days. After removal of the splint, the nose was monitored while the oedema became moderate by plastering the nasal dorsum if the nose was oedematous. Antibiotics were given routinely to each patient, as well as analgesics when needed. Steroids were not administered before or during the surgical operation. Each patient’s head was kept elevated at a 45° angle. The time elapsed between the lateral osteotomy and the nasal plaster and splint application was described as the plastering time (Pt), while the total surgical time (T) described the time elapsed from the beginning of operation to completion of nasal plastering. The Pt and T values were recorded separately for each patient. Patients were followed up at the first, third and seventh postoperative days by a second doctor who was blinded to the patient grouping. The patients’ PO and PE values were evaluated and scored from 0 to 4 according to graduated scoring systems. The PO scoring was as follows: Phase 1: minimal oedema; Phase 2: open eyelids reach the iris under the effect of oedema; Phase 3: open eyelids show only the pupils under the effect of oedema; Phase 4: eyelids are completely closed due to generalised oedema. The PE scoring was as follows: Phase 1: 1/4 of the medial part of the eyelid is affected by ecchymose; Phase 2: 1/2 of the medial part of the eyelid is affected by ecchymose; Phase 3: ecchymose passes the midline of the eyelid and affects 3/4 of the eyelid through the lateral; Phase 4: ecchymose exceeds 3/4 of the eyelid and covers the eyelid completely
Eur Arch Otorhinolaryngol
compared to the third day (Table 5: Comparison of PO values between the groups day by day). The PE values showed a statistically significant decrease (p \ 0.05) from the first day to the seventh day for Group I. The PE value for Group II on the third day did not show any significant difference (p [ 0.05) compared to the first day. The PE value for Group II showed a significant decrease (p \ 0.05) on the seventh day compared to the first day. The PE value for Group II showed a significant decrease (p \ 0.05) on the seventh day compared to the third day. The rate of decrease in PE on the third and seventh days was not significantly different (p [ 0.05) between the groups when compared to the 1st day. The rate of decrease in PE on the seventh day was not significantly different (p [ 0.05) between the groups when compared to the third day (Table 6: comparison of PE values between the groups day by day).
[4]. Photographs were taken at each follow-up of the patients and archived. Patients were followed up until the postoperative 12th month. Statistical analysis Statistical values included the mean, standard deviation, median, min–max. rate, and frequency. Distribution of variances was controlled by the Kolmogorov–Smirnov test. The independent sample T test and Mann–Whitney U test were used for analysis of quantitative values. When Chisquare conditions did not meet the requirement for analysis of qualitative values, the Fisher test was used. The SPSS 21.0 programme was used for analysis. A p value of 0.05 was considered statistically significant.
Results Discussion Patients were between in 18 and 49 years of age. The average age of the patients is 25.58 ± 7.08. The age and gender distributions of Group I and Group II did not show any significant difference (p [ 0.05). (Table 1: Gender distribution and the average age of the groups). The Pt value was significantly shorter in Group I than in Group II (p \ 0.05). The T times for both groups were not significantly different (p [ 0.05) (Table 2: Comparison of Pt and T values between the groups). The PO values on the first, third and seventh days were significantly smaller in Group I than in Group II (p \ 0.05) (Table 3: Comparison of PO values between the groups). The PE values on the first, third and seventh days were significantly smaller in Group I than in Group II (p \ 0.05) (Table 4: comparison of PE values between the groups). For both groups, PO values showed a statistically significant decrease (p \ 0.05) from the first day to the seventh day. The rate of decrease in PO between the two groups from the third to the seventh day did not show any significant difference (p [ 0.05) when compared to the first day. The rate of decrease in PO between the two groups at the seventh day did not show any significant difference
Table 1 Gender distribution and the average age of the groups
Many surgeons agree that the most challenging procedure among the facial aesthetic operations is rhinoplasty. The nose is the most apparent organ in the middle of the face; so deformities in that organ drive patients to surgical operations [9, 10]. Bleeding and inflammation into the soft tissue during surgical operation is responsible for the formation of PO and PE. These usually occur as a result of lateral osteotomy performed during rhinoplasty [11] and their development during this procedure depends on angular artery injury along the broken bone line [4]. If subcutaneous bleeding and oedema after lateral osteotomy can be prevented, significant improvements in the appearance of the patient can be achieved at an early postoperative stage [12]. Postoperative PO and PE always stand out as a problem in rhinoplasty. Swelling and changes in colour around the eyes are important sources of distress for patients who are sensitive about their appearance [12]. The experience of the surgeon, the osteotomy technique, and the patient’s blood pressure and skin thickness and type can be counted among the factors affecting postoperative PO and PE [3].
Group I
Age
Group II
p
Avg. ± SD/n %
Med.
Min.–max.
Avg. ± SD/n %
Med.
Min.–max.
24.3 ± 6.0
23
18–49
27.3 ± 8.1
27
18–48
0.093
Gender Male Female
20/53 % 18/47 %
13/48 % 14/52 %
0.722
t test/Chi-square test
123
Eur Arch Otorhinolaryngol Table 2 Comparison of Pt and T values between the groups
Group I
Group II
Avg. ± SD
Med.
T (min.)
134.4 ± 24.3
Pt (min.)
33.2 ± 12.3
p
Min.–max.
Avg. ± SD
Med
Min.–max.
136
75–200
130.7 ± 23.1
130
95–170
0.539
30
20–88
85.0 ± 22.2
85
50–125
0.000
t test
Table 3 Comparison of PO values between the groups
PO
Group I
Group II
p
Avg. ± SD
Med.
Min.–max.
Avg. ± SD
Med
Min.–max.
First day
1.9 ± 0.7
2
1–4
2.4 ± 0.8
3
1–4
0.001
Third day
1.0 ± 0.8
1
0–3
1.5 ± 0.6
2
0–2
0.005
Seventh day
0.2 ± 0.4
0
0–1
0.6 ± 0.5
1
0–1
0.004
Mann–Whitney U test
Table 4 Comparison of PE values between the groups
PE
Group I
Group II
p
Avg. ± SD
Med.
Min.–max.
Avg. ± SD
Med
Min.–max.
First day
2.5 ± 0.9
2
1–4
3.3 ± 0.8
4
2–4
0.000
Third day
2.0 ± 0.8
2
1–4
3.0 ± 0.9
3
2–4
0.000
Seventh day
1.1 ± 0.9
1
0–4
2.1 ± 1.3
2
0–4
0.001
Mann–Whitney U test
Table 5 Comparison of PO values between the groups day by day
PO change
First day/third day
Group I
Group II
Decrease
Increase
No change
Decrease
Increase
No change
n
%
n
%
n
%
n
%
n
%
n
%
25
65.8
1
2.6
12
31.6
19
70.4
0
0.0
8
29.6
0.867
3
11.1
0.299
7
25.9
0.543
p change First day/seventh day
0.000 37
97.4
0
p change Third day/seventh day p change
p
0.0
0.000 1
2.6
24
88.9
0
0.000 25
65.8
0
0.0 0.000
0.0 0.000
13
34.2
20
74.1
0
0.0 0.000
Wilcoxon test/Chi-square test (Fischret test)
Many studies have aimed to reduce the PO and PE that develops after rhinoplasty [4, 5]. One set of studies done sought new and optimal surgery methods, with the purpose of minimising the tissue trauma developing during surgery. Another group of studies aimed to reduce the oedema and ecchymosis using various new medical methods before, during and after surgery. Some surgeons perform lateral osteotomies at the final stage of surgical operation while the others perform earlier stages [13]. The surgeons who perform lateral osteotomies at earlier stages of the operation aim to harmonise the modifications of middle vault and the tip with the position of upper one third of the nose which is shaped by
123
osteotomy. In this study, it is aimed to search the effect of these two different methods on PO and PE. A study by Gu¨rlek et al. [4], who researched the effects of open and closed technique rhinoplasty on oedema and ecchymosis, reported that closed technique rhinoplasty causes less PO and PE when compared to open technique rhinoplasty. The absence of the columellar incision, limited soft tissue dissection and shorter operation time may be the main reasons for this finding. A literature search revealed some studies which show that the creation of a subperiosteal tunnel due to periosteal elevation lifts the vessels above the osteotomy plane, thereby decreasing PO and PE [14]. Another study by Kara
Eur Arch Otorhinolaryngol Table 6 Comparison of PE values between the groups day by day PE change
First day/third day
Group I
Group II
p
Decrease
Increase
No change
Decrease
Increase
No change
n
%
n
%
n
%
n
%
n
%
n
%
16
42.1
5
13.2
17
44.7
10
37.0
3
11.1
14
51.9
0.883
6
22.2
0.510
12
44.4
0.429
p change
0.007
First day/seventh day p change
31
81.6
1
2.6 0.000
Third day/seventh day
28
73.7
0
0.0
p change
0.080 6
15.8
19
70.4
2
7.4 0.000
10
26.3
15
55.6
0
0.0
0.000
0.000
Wilcoxon test/Chi-square test (Fischret test)
et al. reported that creation of a subperiosteal tunnel during osteotomy led to an increase in PO and PE [15]. The reason was that the tunnel formed during the elevation of the periosteum created a potential space for the accumulation of blood and tissue fluid [2]. External osteotomy was reported in another study to prevent the formation of the damage to the nasal mucosa, thereby reducing the formation of PO and PE [16]. On the other hand, the study done by Yu¨cel et al. concluded that internal and external osteotomies do not create a significant difference in terms of PO, but less PE is seen in cases that undergo internal osteotomies [17]. Many studies have aimed at causing less trauma to the surrounding tissue by using osteotomes with different features. Eris¸ ir et al. [12] established that PO and PE were significantly reduced in patients who underwent operations where 2 mm ‘‘V’’ shaped osteotomes were used, compared to a 4 mm Cottle osteotome. The smaller ‘‘V’’ shaped osteotome caused less trauma to the surrounding soft tissues and the angular artery during the operation; therefore, the 2 mm ‘‘V’’ shaped osteotome was claimed to cause less PO and PE [12]. Many surgeons have also studied the effects of various extracts and drugs on reducing the oedema and ecchymose caused as a result of facial surgery [5, 18, 19]. Corticosteroids are the most commonly used agents, at different doses, to reduce PO and PE [5, 18]. Corticosteroids have been used for many years to reduce the inflammatory response which occurs as a result of a trauma or a surgical operation, but no agreement has been reached in terms of their efficacy [5]. Some authors have determined that using steroid intra operatively and/or postoperatively has positive effects, while another group of surgeons argued that steroid use had no positive effect on postoperative morbidity if the actual side effects were taken into account [4]. A study by Gurlek et al. [4] revealed that poor administration of low doses of steroids was ineffective at preventing and removing PO and PE after open technique rhinoplasty [4]. A second study by Gurlek et al. [5] concluded that high dose methyl prednisolone administration
after open technique rhinoplasty decreased the PO and PE occurring in the postoperative period [5]. The aim of the present study was to minimise the extent and duration of bleeding caused by the osteotomy line as the source of PO and PE. This was done by controlling the bleeding and oedema by applying a physical compression to osteotomy line. Nasal plasters and a nasal splint acting as fixed splint were used along nasal dorsum and osteotomy lines as a source of physical compression. A study by Taskın et al. [3]. used a cold sterile saline soaked gauze application applied to the nasal dorsum and the osteotomy lines during operation. Similar to our study, the application of physical compression on the lateral osteotomy line provided a significant decrease in PO and PE values in postoperative period compared to the control group.
Conclusions Periorbital oedema and ecchymose are the most common morbidities of rhinoplasty. This leads to delays in the postoperative recovery period and in the patients’ return to normal life. A nasal plaster and splint applied following lateral osteotomy appear to work as a physical barrier that prevents bleeding in the fracture line and subcutaneous soft tissue and reduces the existing dead space to the minimum level by applying compression on the operation area. The result is a decrease in the PO and PE values. In summary, the data obtained in this study indicate that performing a lateral osteotomy in the final stages of surgery and following this with the application of a nasal plaster and splint, as rapidly as possible, will decrease PO and PE in the postoperative period.
References 1. Xavier R (2010) Does rhinoplasty improve nasal breathing? Facial Plast Surg 26:328–332
123
Eur Arch Otorhinolaryngol 2. Al-Arfaj A, Al-Qattan M, Al-Harethy S, Al-Zahrani K (2009) Effect of periosteum elevation on periorbital ecchymosis in rhinoplasty. J Plast Reconstr Aesthet Surg 62:e538–e539 3. Taskin U, Yigit O, Bilici S, Kuvat SV, Sisman AS, Celebi S (2011) Efficacy of the combination intraoperative cold salinesoaked gauze compression and corticosteroids on rhinoplasty morbidity. Otolaryngol Head Neck Surg 144:698–702 4. Gurlek A, Fariz A, Aydogan H, Ersoz-Ozturk A, Eren AT (2006) Effects of different corticosteroids on edema and ecchymosis in open rhinoplasty. Aesthet Plast Surg 30:150–154 5. Gurlek A, Fariz A, Aydog˘an H, Ersoz-Ozturk A, Evans GR (2009) Effects of high dose corticosteroids in open rhinoplasty. J Plast Reconstr Aesthet Surg 62:650–655 6. Ghali S, Knox KR, Verbesey J, Scarpidis U, Izadi K, Ganchi PA (2008) Effects of lidocaine and epinephrine on cutaneous blood flow. J Plast Reconstr Aesthet Surg 61:1226–1231 7. Kara CO, Gokalan I (1999) Effects of single-dose steroid usage on edema, ecchymosis and intraoperative bleeding in rhinoplasty. Plast Reconstr Surg 104:2213–2218 8. Gryskiewicz JM, Gryskiewicz KM (2004) Nasal osteotomies: a clinical comparison of the perforating methods versus the continuous technique. Plast Reconstr Surg 113:1445–1456 9. Hilger JA (1968) The internal lateral osteotomy in rhinoplasty. Arch Otolaryngol 88:211–212 10. Goldfarb M, Gallups JM, Gerwin JM (1993) Perforating osteotomies in rhinoplasty. Arch Otolaryngol Head Neck Surg 119:624–627
123
11. Gun R, Yorgancilar E, Yildirim M, Bakir S, Topcu I, Akkus Z (2011) Effects of lidocaine and adrenaline combination on postoperatitve edema and ecchymosis in rhinoplasty. Int J Oral Maxillofac Surg 40:722–729 12. Erisir F, Tahamiler R (2008) Lateral osteotomies in rhinoplasty: a safer and less traumatic method. Aesthet Surg J 28:518–520 13. Azizzadeh B, Murphy MR, Johnson CM, Numa W (2011) Master techniques in rhinoplasty. Elsevier, Philadelphia 14. Huizing EH, de Groot JAM (2003) Functional reconstructive nasal surgery. Thieme, Stuttgart 15. Kara CO, Kara IG, Topuz B (2005) Does creating a subperiosteal tunnel influence the periorbital edema and ecchymosis in rhinoplasty? J Oral Maxillofac Surg 63:1088–1090 16. Giacomarra V, Russolo M, Arnez ZM, Tirelli G (2001) External osteotomy in rhinoplasty. Laryngoscope 111:433–438 17. Yucel OT (2005) Which type of osteotomy for edema and ecchymosis: external or internal? Ann Plast Surg 55:587–590 18. Kargi E, Hosnuter M, Babuccu O, Altunkaya H, Altinyazar C (2003) Effect of steroids on edema, ecchymosis, and intraoperative bleeding in rhinoplasty. Ann Plast Surg 51:570–574 19. Xu F, Zeng W, Mao X, Fan GK (2008) The efficacy of Melilotusextract in the management of postoperative ecchymosis and edema after simultaneous rhinoplasty and blepharoplasty. Aesthetic Plast Surg 32:599–603
RHINOLOGY
How can periorbital oedema and ecchymose be reduced in rhinoplasty? Erdem Caglar1 • Saban Celebi2 • Murat Topak3 • Necati Omer Develioglu3 Enis Yalcin4 • Mehmet Kulekci3
•
Received: 30 June 2015 / Accepted: 20 January 2016 Ó Springer-Verlag Berlin Heidelberg 2016
Abstract Oedema and ecchymose are frequent morbidities of septorhinoplasty, a facial surgical procedure for reforming the shape and functions of the nose. Periorbital oedema (PO) and periorbital ecchymose (PE) are normal occurrences, but are undesirable for patients undergoing the procedure for aesthetic purposes. The present study examined 65 patients who underwent open technique septorhinoplasty for aesthetic and functional complaints. Patients were divided into two groups: Group 1 patients underwent lateral osteotomy following tip plasty, at the end of the surgical operation; Group 2 patients underwent lateral osteotomy before tip plasty, at the beginning of the surgical operation. Patients were followed on the postoperative first, third and seventh days. PO and PE values of patients were scored from 0 to 4. The plastering time (Pt) was significantly shorter for Group I than Group II (p \ 0.05). The total surgical time (T) showed no significant difference (p [ 0.05). The PO value at the first, third and seventh days was significantly smaller for Group I than & Erdem Caglar [email protected] Saban Celebi [email protected]
Group II (p \ 0.05). The PE value at the first, third and seventh days was also significantly smaller for Group I than Group II (p \ 0.05). The obtained data indicate that performing a lateral osteotomy in the final stages of surgery, and subsequently applying a nasal plaster and splint as rapidly as possible, decreases PO and PE in the postoperative period. Keywords Rhinoplasty Lateral osteotomy Periorbital oedema Periorbital ecchymose Postoperative morbidity
Introduction Septorhinoplasty is a frequently performed facial surgical procedure which aims to reform the nose shape and functions [1]. Oedema and ecchymose are frequent morbidities of this procedure. Although the occurrence of periorbital oedema (PO) and periorbital ecchymose (PE) 2
Department of Otorhinolaryngology, Head and Neck Surgery, Yeni Yuzyil University, Gaziosmanpasa Hospital, Istanbul, Turkey
3
Department of Otorhinolaryngology, Head and Neck Surgery, Taksim Training and Research Hospital, Istanbul, Turkey
4
Department of Otorhinolaryngology, Head and Neck Surgery, Fatsa State Hospital, Ordu, Turkey
Murat Topak [email protected] Necati Omer Develioglu [email protected] Enis Yalcin [email protected] Mehmet Kulekci [email protected] 1
Department of Otorhinolaryngology, Head and Neck Surgery, Kiziltepe State Hospital, Mardin, Turkey
123
Eur Arch Otorhinolaryngol
is normal after septorhinoplasty, it is an undesirable situation for patients undergoing the procedure for aesthetic purposes [2]. The occurrence of PO and PE is quite distressing for patients during the postoperative period [3]. PO may cause vision disorders, especially in postoperative 24 h [4], whereas PE may disrupt the social life of patients and cause pigment increases in the operation area [5]. These postoperative results can lead to delays in the patients’ return to normal life [3]. These morbidities can be prevented by application of systemic steroid (preoperative and/or postoperative), pressure to the osteotomy line or cold compresses to the periorbital area [6, 7]. In addition to these methods, different osteotomy procedures (percutaneous and endonasal), which cause less PO and PE, have been described [8]. A literature review revealed no studies that have examined the effect of the time elapsed between performing a lateral osteotomy and plastering of the nasal dorsum on periorbital oedema and ecchymosis. Thus, the main objective of this study was to determine if shortening the time elapsed prior to plastering the nasal dorsum following lateral osteotomy would lessen the subsequent periorbital oedema and ecchymosis.
Materials and methods A total of 65 patients who had undergone open technique septorhinoplasty procedure for aesthetic and functional complaints between 2012/05/10 and 2014/03/10 at the Gaziosmanpas¸ a Taksim Training and Research Hospital were included in the study. The study group consisted of 33 males and 32 females patients. Signed informed consent forms for the study and surgical procedure were received from each patient. Patients who had septal deviation, external nasal deformity, and wanted to reform the shape of the nose were included in the study. Patients who suffered bleeding diathesis, hypertension, diabetes, chronic systemic disease, or psychological problems or females who were in or immediately after their menstrual cycles with hypertension during the operation were excluded from the study. All operations were performed under same hypotensive general anaesthesia protocol. An open technique septorhinoplasty procedure was conducted by the same operator using the same instruments. Septoplasty, tip plasty, dorsal hump resection, and medial, transverse and lateral osteotomies were performed. Operations were standardised by choosing patients having similar nasal deformities. Patients were assigned to one of the two groups using the MedCalc 11.5.1 randomisation programme. Surgical procedure was started with mid-columellar inverted-V
123
incision and bilateral marginal incision, then followed by skin flap elevation for each patient. After that, septoplasty and dorsal hump excision were performed, respectively. Group I included the patients who underwent lateral and medial osteotomies following upper lateral cartilage modifications and tip plasty shortly before the end of the surgical operation. Group II included the patients who underwent lateral and medial osteotomies before upper lateral cartilage modifications and tip plasty, at the earlier stage of surgical operation. Medial and median osteotomies were performed just before the lateral osteotomy procedure. Before performing lateral osteotomy, a 1:100000 adrenalin combination with 2 ml 2 % lidocaine (Jetokain; Adeka AS, Samsun, Turkey) was injected at both osteotomy lines. Osteotomies were performed 10 min after the completion of this infiltration. Lateral and medial osteotomies were performed bilaterally with guided, curved 4-mm lateral osteotomes by the endonasal approach. Blood pressures of patients were monitored during the surgical operations and early postoperative periods. Postoperatively, nasal packing was applied for 48 h, and ice packs were applied for 12 h for all patients. A nasal splint (Rhinofix, I˙stanbul, Turkey) remained in the nose dorsum for seven to ten days. After removal of the splint, the nose was monitored while the oedema became moderate by plastering the nasal dorsum if the nose was oedematous. Antibiotics were given routinely to each patient, as well as analgesics when needed. Steroids were not administered before or during the surgical operation. Each patient’s head was kept elevated at a 45° angle. The time elapsed between the lateral osteotomy and the nasal plaster and splint application was described as the plastering time (Pt), while the total surgical time (T) described the time elapsed from the beginning of operation to completion of nasal plastering. The Pt and T values were recorded separately for each patient. Patients were followed up at the first, third and seventh postoperative days by a second doctor who was blinded to the patient grouping. The patients’ PO and PE values were evaluated and scored from 0 to 4 according to graduated scoring systems. The PO scoring was as follows: Phase 1: minimal oedema; Phase 2: open eyelids reach the iris under the effect of oedema; Phase 3: open eyelids show only the pupils under the effect of oedema; Phase 4: eyelids are completely closed due to generalised oedema. The PE scoring was as follows: Phase 1: 1/4 of the medial part of the eyelid is affected by ecchymose; Phase 2: 1/2 of the medial part of the eyelid is affected by ecchymose; Phase 3: ecchymose passes the midline of the eyelid and affects 3/4 of the eyelid through the lateral; Phase 4: ecchymose exceeds 3/4 of the eyelid and covers the eyelid completely
Eur Arch Otorhinolaryngol
compared to the third day (Table 5: Comparison of PO values between the groups day by day). The PE values showed a statistically significant decrease (p \ 0.05) from the first day to the seventh day for Group I. The PE value for Group II on the third day did not show any significant difference (p [ 0.05) compared to the first day. The PE value for Group II showed a significant decrease (p \ 0.05) on the seventh day compared to the first day. The PE value for Group II showed a significant decrease (p \ 0.05) on the seventh day compared to the third day. The rate of decrease in PE on the third and seventh days was not significantly different (p [ 0.05) between the groups when compared to the 1st day. The rate of decrease in PE on the seventh day was not significantly different (p [ 0.05) between the groups when compared to the third day (Table 6: comparison of PE values between the groups day by day).
[4]. Photographs were taken at each follow-up of the patients and archived. Patients were followed up until the postoperative 12th month. Statistical analysis Statistical values included the mean, standard deviation, median, min–max. rate, and frequency. Distribution of variances was controlled by the Kolmogorov–Smirnov test. The independent sample T test and Mann–Whitney U test were used for analysis of quantitative values. When Chisquare conditions did not meet the requirement for analysis of qualitative values, the Fisher test was used. The SPSS 21.0 programme was used for analysis. A p value of 0.05 was considered statistically significant.
Results Discussion Patients were between in 18 and 49 years of age. The average age of the patients is 25.58 ± 7.08. The age and gender distributions of Group I and Group II did not show any significant difference (p [ 0.05). (Table 1: Gender distribution and the average age of the groups). The Pt value was significantly shorter in Group I than in Group II (p \ 0.05). The T times for both groups were not significantly different (p [ 0.05) (Table 2: Comparison of Pt and T values between the groups). The PO values on the first, third and seventh days were significantly smaller in Group I than in Group II (p \ 0.05) (Table 3: Comparison of PO values between the groups). The PE values on the first, third and seventh days were significantly smaller in Group I than in Group II (p \ 0.05) (Table 4: comparison of PE values between the groups). For both groups, PO values showed a statistically significant decrease (p \ 0.05) from the first day to the seventh day. The rate of decrease in PO between the two groups from the third to the seventh day did not show any significant difference (p [ 0.05) when compared to the first day. The rate of decrease in PO between the two groups at the seventh day did not show any significant difference
Table 1 Gender distribution and the average age of the groups
Many surgeons agree that the most challenging procedure among the facial aesthetic operations is rhinoplasty. The nose is the most apparent organ in the middle of the face; so deformities in that organ drive patients to surgical operations [9, 10]. Bleeding and inflammation into the soft tissue during surgical operation is responsible for the formation of PO and PE. These usually occur as a result of lateral osteotomy performed during rhinoplasty [11] and their development during this procedure depends on angular artery injury along the broken bone line [4]. If subcutaneous bleeding and oedema after lateral osteotomy can be prevented, significant improvements in the appearance of the patient can be achieved at an early postoperative stage [12]. Postoperative PO and PE always stand out as a problem in rhinoplasty. Swelling and changes in colour around the eyes are important sources of distress for patients who are sensitive about their appearance [12]. The experience of the surgeon, the osteotomy technique, and the patient’s blood pressure and skin thickness and type can be counted among the factors affecting postoperative PO and PE [3].
Group I
Age
Group II
p
Avg. ± SD/n %
Med.
Min.–max.
Avg. ± SD/n %
Med.
Min.–max.
24.3 ± 6.0
23
18–49
27.3 ± 8.1
27
18–48
0.093
Gender Male Female
20/53 % 18/47 %
13/48 % 14/52 %
0.722
t test/Chi-square test
123
Eur Arch Otorhinolaryngol Table 2 Comparison of Pt and T values between the groups
Group I
Group II
Avg. ± SD
Med.
T (min.)
134.4 ± 24.3
Pt (min.)
33.2 ± 12.3
p
Min.–max.
Avg. ± SD
Med
Min.–max.
136
75–200
130.7 ± 23.1
130
95–170
0.539
30
20–88
85.0 ± 22.2
85
50–125
0.000
t test
Table 3 Comparison of PO values between the groups
PO
Group I
Group II
p
Avg. ± SD
Med.
Min.–max.
Avg. ± SD
Med
Min.–max.
First day
1.9 ± 0.7
2
1–4
2.4 ± 0.8
3
1–4
0.001
Third day
1.0 ± 0.8
1
0–3
1.5 ± 0.6
2
0–2
0.005
Seventh day
0.2 ± 0.4
0
0–1
0.6 ± 0.5
1
0–1
0.004
Mann–Whitney U test
Table 4 Comparison of PE values between the groups
PE
Group I
Group II
p
Avg. ± SD
Med.
Min.–max.
Avg. ± SD
Med
Min.–max.
First day
2.5 ± 0.9
2
1–4
3.3 ± 0.8
4
2–4
0.000
Third day
2.0 ± 0.8
2
1–4
3.0 ± 0.9
3
2–4
0.000
Seventh day
1.1 ± 0.9
1
0–4
2.1 ± 1.3
2
0–4
0.001
Mann–Whitney U test
Table 5 Comparison of PO values between the groups day by day
PO change
First day/third day
Group I
Group II
Decrease
Increase
No change
Decrease
Increase
No change
n
%
n
%
n
%
n
%
n
%
n
%
25
65.8
1
2.6
12
31.6
19
70.4
0
0.0
8
29.6
0.867
3
11.1
0.299
7
25.9
0.543
p change First day/seventh day
0.000 37
97.4
0
p change Third day/seventh day p change
p
0.0
0.000 1
2.6
24
88.9
0
0.000 25
65.8
0
0.0 0.000
0.0 0.000
13
34.2
20
74.1
0
0.0 0.000
Wilcoxon test/Chi-square test (Fischret test)
Many studies have aimed to reduce the PO and PE that develops after rhinoplasty [4, 5]. One set of studies done sought new and optimal surgery methods, with the purpose of minimising the tissue trauma developing during surgery. Another group of studies aimed to reduce the oedema and ecchymosis using various new medical methods before, during and after surgery. Some surgeons perform lateral osteotomies at the final stage of surgical operation while the others perform earlier stages [13]. The surgeons who perform lateral osteotomies at earlier stages of the operation aim to harmonise the modifications of middle vault and the tip with the position of upper one third of the nose which is shaped by
123
osteotomy. In this study, it is aimed to search the effect of these two different methods on PO and PE. A study by Gu¨rlek et al. [4], who researched the effects of open and closed technique rhinoplasty on oedema and ecchymosis, reported that closed technique rhinoplasty causes less PO and PE when compared to open technique rhinoplasty. The absence of the columellar incision, limited soft tissue dissection and shorter operation time may be the main reasons for this finding. A literature search revealed some studies which show that the creation of a subperiosteal tunnel due to periosteal elevation lifts the vessels above the osteotomy plane, thereby decreasing PO and PE [14]. Another study by Kara
Eur Arch Otorhinolaryngol Table 6 Comparison of PE values between the groups day by day PE change
First day/third day
Group I
Group II
p
Decrease
Increase
No change
Decrease
Increase
No change
n
%
n
%
n
%
n
%
n
%
n
%
16
42.1
5
13.2
17
44.7
10
37.0
3
11.1
14
51.9
0.883
6
22.2
0.510
12
44.4
0.429
p change
0.007
First day/seventh day p change
31
81.6
1
2.6 0.000
Third day/seventh day
28
73.7
0
0.0
p change
0.080 6
15.8
19
70.4
2
7.4 0.000
10
26.3
15
55.6
0
0.0
0.000
0.000
Wilcoxon test/Chi-square test (Fischret test)
et al. reported that creation of a subperiosteal tunnel during osteotomy led to an increase in PO and PE [15]. The reason was that the tunnel formed during the elevation of the periosteum created a potential space for the accumulation of blood and tissue fluid [2]. External osteotomy was reported in another study to prevent the formation of the damage to the nasal mucosa, thereby reducing the formation of PO and PE [16]. On the other hand, the study done by Yu¨cel et al. concluded that internal and external osteotomies do not create a significant difference in terms of PO, but less PE is seen in cases that undergo internal osteotomies [17]. Many studies have aimed at causing less trauma to the surrounding tissue by using osteotomes with different features. Eris¸ ir et al. [12] established that PO and PE were significantly reduced in patients who underwent operations where 2 mm ‘‘V’’ shaped osteotomes were used, compared to a 4 mm Cottle osteotome. The smaller ‘‘V’’ shaped osteotome caused less trauma to the surrounding soft tissues and the angular artery during the operation; therefore, the 2 mm ‘‘V’’ shaped osteotome was claimed to cause less PO and PE [12]. Many surgeons have also studied the effects of various extracts and drugs on reducing the oedema and ecchymose caused as a result of facial surgery [5, 18, 19]. Corticosteroids are the most commonly used agents, at different doses, to reduce PO and PE [5, 18]. Corticosteroids have been used for many years to reduce the inflammatory response which occurs as a result of a trauma or a surgical operation, but no agreement has been reached in terms of their efficacy [5]. Some authors have determined that using steroid intra operatively and/or postoperatively has positive effects, while another group of surgeons argued that steroid use had no positive effect on postoperative morbidity if the actual side effects were taken into account [4]. A study by Gurlek et al. [4] revealed that poor administration of low doses of steroids was ineffective at preventing and removing PO and PE after open technique rhinoplasty [4]. A second study by Gurlek et al. [5] concluded that high dose methyl prednisolone administration
after open technique rhinoplasty decreased the PO and PE occurring in the postoperative period [5]. The aim of the present study was to minimise the extent and duration of bleeding caused by the osteotomy line as the source of PO and PE. This was done by controlling the bleeding and oedema by applying a physical compression to osteotomy line. Nasal plasters and a nasal splint acting as fixed splint were used along nasal dorsum and osteotomy lines as a source of physical compression. A study by Taskın et al. [3]. used a cold sterile saline soaked gauze application applied to the nasal dorsum and the osteotomy lines during operation. Similar to our study, the application of physical compression on the lateral osteotomy line provided a significant decrease in PO and PE values in postoperative period compared to the control group.
Conclusions Periorbital oedema and ecchymose are the most common morbidities of rhinoplasty. This leads to delays in the postoperative recovery period and in the patients’ return to normal life. A nasal plaster and splint applied following lateral osteotomy appear to work as a physical barrier that prevents bleeding in the fracture line and subcutaneous soft tissue and reduces the existing dead space to the minimum level by applying compression on the operation area. The result is a decrease in the PO and PE values. In summary, the data obtained in this study indicate that performing a lateral osteotomy in the final stages of surgery and following this with the application of a nasal plaster and splint, as rapidly as possible, will decrease PO and PE in the postoperative period.
References 1. Xavier R (2010) Does rhinoplasty improve nasal breathing? Facial Plast Surg 26:328–332
123
Eur Arch Otorhinolaryngol 2. Al-Arfaj A, Al-Qattan M, Al-Harethy S, Al-Zahrani K (2009) Effect of periosteum elevation on periorbital ecchymosis in rhinoplasty. J Plast Reconstr Aesthet Surg 62:e538–e539 3. Taskin U, Yigit O, Bilici S, Kuvat SV, Sisman AS, Celebi S (2011) Efficacy of the combination intraoperative cold salinesoaked gauze compression and corticosteroids on rhinoplasty morbidity. Otolaryngol Head Neck Surg 144:698–702 4. Gurlek A, Fariz A, Aydogan H, Ersoz-Ozturk A, Eren AT (2006) Effects of different corticosteroids on edema and ecchymosis in open rhinoplasty. Aesthet Plast Surg 30:150–154 5. Gurlek A, Fariz A, Aydog˘an H, Ersoz-Ozturk A, Evans GR (2009) Effects of high dose corticosteroids in open rhinoplasty. J Plast Reconstr Aesthet Surg 62:650–655 6. Ghali S, Knox KR, Verbesey J, Scarpidis U, Izadi K, Ganchi PA (2008) Effects of lidocaine and epinephrine on cutaneous blood flow. J Plast Reconstr Aesthet Surg 61:1226–1231 7. Kara CO, Gokalan I (1999) Effects of single-dose steroid usage on edema, ecchymosis and intraoperative bleeding in rhinoplasty. Plast Reconstr Surg 104:2213–2218 8. Gryskiewicz JM, Gryskiewicz KM (2004) Nasal osteotomies: a clinical comparison of the perforating methods versus the continuous technique. Plast Reconstr Surg 113:1445–1456 9. Hilger JA (1968) The internal lateral osteotomy in rhinoplasty. Arch Otolaryngol 88:211–212 10. Goldfarb M, Gallups JM, Gerwin JM (1993) Perforating osteotomies in rhinoplasty. Arch Otolaryngol Head Neck Surg 119:624–627
123
11. Gun R, Yorgancilar E, Yildirim M, Bakir S, Topcu I, Akkus Z (2011) Effects of lidocaine and adrenaline combination on postoperatitve edema and ecchymosis in rhinoplasty. Int J Oral Maxillofac Surg 40:722–729 12. Erisir F, Tahamiler R (2008) Lateral osteotomies in rhinoplasty: a safer and less traumatic method. Aesthet Surg J 28:518–520 13. Azizzadeh B, Murphy MR, Johnson CM, Numa W (2011) Master techniques in rhinoplasty. Elsevier, Philadelphia 14. Huizing EH, de Groot JAM (2003) Functional reconstructive nasal surgery. Thieme, Stuttgart 15. Kara CO, Kara IG, Topuz B (2005) Does creating a subperiosteal tunnel influence the periorbital edema and ecchymosis in rhinoplasty? J Oral Maxillofac Surg 63:1088–1090 16. Giacomarra V, Russolo M, Arnez ZM, Tirelli G (2001) External osteotomy in rhinoplasty. Laryngoscope 111:433–438 17. Yucel OT (2005) Which type of osteotomy for edema and ecchymosis: external or internal? Ann Plast Surg 55:587–590 18. Kargi E, Hosnuter M, Babuccu O, Altunkaya H, Altinyazar C (2003) Effect of steroids on edema, ecchymosis, and intraoperative bleeding in rhinoplasty. Ann Plast Surg 51:570–574 19. Xu F, Zeng W, Mao X, Fan GK (2008) The efficacy of Melilotusextract in the management of postoperative ecchymosis and edema after simultaneous rhinoplasty and blepharoplasty. Aesthetic Plast Surg 32:599–603
