Drs Muhammad Humayun Mohmand and Muhammad Ahmad discuss a novel technique to reduce nasal oedema after an open technique rhinoplasty
Cosmetic rhinoplasty is currently one of the most common cosmetic surgery procedures performed1, and is most often performed under general anaesthesia. It can be implemented using either a closed or open technique and the procedure is often associated with specific side-effects. The postoperative periorbital oedema is one of the postoperative issues which troubles patients and can increase the patients’ anxiety about having the procedure or its success2. This periorbital oedema may also be associated with ecchymosis. In addition to the discomfort, it can also cause obstructed vision.
Goldman3 documented the first use of steroids to manage the postoperative periorbital oedema in 1952. Later in 1976, Kittel et al., shared their experience4. Griffier et al. presented the first prospective randomised-controlled trial in 19892. Later, further studies followed documenting the use of different steroids in an attempt to decrease periorbital swelling. The range of steroids which have been used includes oral or intravenous corticosteroids. In 1970, the tumescent solution was described by Klein for liposuction5. Since then, the Klein solution has been used in many kinds of surgical procedures including liposuction, flap reconstructive surgery, and hair restoration5,6. Later, in early 2005, Abbasi added triamcinolone to the Klein solution and named it the ‘Abbasi solution’7. This solution dramatically reduced the postoperative oedema of the forehead and eyelids seen after hair transplant surgery. Different modifications of the original composition can also be used depending on the situation. The use of local steroid-infiltration in rhinoplasty has not been documented in the literature.
In order to understand the effectiveness of local steroid infiltration, the following study was carried out.
Materials and Methods
The study was conducted in a private clinic on adult patients who underwent cosmetic rhinoplasty. Written informed consent was taken from all patients. The related medical history was reviewed especially taking into consideration peptic ulcer disease, hypertension, diabetes mellitus, psychiatric conditions, and allergic reaction to the steroids. Only the patients undergoing cosmetic rhinoplasty using the open technique were included in the study. Any patient who underwent conchal cartilage/costal cartilage graft reconstruction were excluded. Similarly, the patients having cleft-lip nasal deformity were also not included in the study. Any patient having secondary or tertiary rhinoplasty were also excluded. Elevating the periosteum increases the incidence of periorbital bruising; with this in mind, during the bilateral dorsal osteotomies, the periosteum was not elevated to keep the variables to a minimum. Any presence of periorbital ecchymosis was also excluded.
Preoperative photographs were taken. All the surgeries were performed under general anaesthesia. The endotracheal tube was handled by the anaesthetist and a saline soaked gauze was placed in the throat to ensure the tube remained waterproof.
A solution was prepared using 1 ml of epinephrine (1:1000), 10 ml of 2% lidocaine, 40mg (1 ml) of triamcinolone and 100 ml of saline. Approximately 10ml of the fluid was injected in the dorsum of the nose and alar region, 3–5ml in the columella region and 10–15ml in the nasal septum (Figure. 1). Preoperative photos were taken. The postoperative photographs were taken on the first and fifth post-op day. The periorbital oedema was rated according to a 4-degree scale (Figure. 2). Moreover, the swelling of the nasal dorsum and tip area was evaluated subjectively as there is no scale to measure it. The data was collected and analysed statistically.
Ten adult patients were included in the study. The patients included six males and four females. The mean age of the patients was 29.1 years (31.3 years in males and 25.8 years in females). The average oedema score was 1.9 (2.0 in males and 1.75 for females) on the second post-op day (Table 1). Mean oedema on the fifth post-op day was 0.3 (0.33 in males and 0.25 in females) (p<0.0). Fifty percent of the patients were smokers. The average oedema score in smokers was 2.2 as compared to the average score in non-smokers (1.8) on the second day. While the average oedema score was 0.4 on the fifth post-op day in smokers and 0.2 in non-smokers (Table 1). Similarly, the nasal swelling (dorsum and tip) was also considerably reduced.
Rhinoplasty results in the disruption of vessels in the facial region around the nose. This disruption produces oedema and ecchymosis postoperatively8. The osteotomies performed are thought to be the major cause of periorbital oedema. The use of steroids is not new in rhinoplasty, with initial reports dating back as far as the 1950’s2. The use of intravenous or intramuscular steroids is administered on the belief the corticosteroids decrease the oedema formation by reducing tissue response to injury. There are two types of corticosteroids used, i.e., glucocorticoids and mineralocorticoids. Glucocorticoids come in three different types; these are short-acting, intermediate-acting, and long-acting (Table 2)9. A number of randomised controlled trials have been performed using prednisolone, methylprednisone, betamethasone, dexamethasone10–12, and even combinations of steroids have also been tried8.
Triamcinolone is an intermediate-acting corticosteroid9. Intralesional injection of keloid and hypertrophic scar with triamcinolone was performed by Marguire et al in 196513. It is also used in rheumatoid arthritis and vernal keratoconjunctivitis14. The use of various corticosteroids have been documented in a recent study by Gurlek et al., and no significant difference was observed in the use of different steroids14. The use of intravenous dexamethasone single dose by Valente et al., resulted in an average oedema scale of 1.56 which is comparable to our result of average 1.9 on the second postop day and 0.3 on the fifth post-op day15. Similarly, our results were found to be better than the average oedema score of 1.6±0.78 by Alzacko et al16.
An extensive literature search was conducted to find out any study documenting the effects of triamcinolone in rhinoplasty to reduce periorbital oedema but no such study was found. Although triamcinolone has been used for the correction of polly beak deformity17.
The use of triamcinolone in the current study defines the effectiveness to reduce post-rhinoplasty periorbital oedema. The rapid decrease of nasal swelling results in early patient recovery and reduced the morbidity and off-activity time. The initial results are found encouraging and require multicenter randomised controlled trials.