Interventions to Decrease Postoperative Edema and Ecchymosis After Rhinoplasty

A Systematic Review of the Literature

Adrian A. Ong, M.D.; Zachary Farhood, M.D.; Andrew R. Kyle, B.S.; Krishna G. Patel, M.D., Ph.D.

Plast Reconstr Surg. 2016;137(5):1448-1462.

Abstract and Introduction

Abstract

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

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

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

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

Introduction

Rhinoplasty is considered one of the most common facial plastic surgical procedures; however, it is associated with significant morbidities, including bleeding intraoperatively and periorbital edema and ecchymosis postoperatively, which may influence patient and surgeon perception of surgical outcome.^[1] The edema and ecchymosis may be distressing to patients, which could lead to a prolonged postoperative recovery and disruption of the patient's social life.^[2,3] The patient's desire to have minimal downtime and return to normal activities has become a very influential force causing many surgeons to adopt more minimally invasive procedures. For this reason, identifying means of improving and hastening recovery after rhinoplasty procedures is essential.

A number of investigators have studied various methods for decreasing edema and ecchymosis since the 1950s, with variable success.^[4] These methods include medications such as steroids and decongestants, herbal supplements, and various surgical techniques, including different approaches to lateral osteotomies.^[5–11] Although there have been meta-analyses on the efficacy of corticosteroids in the management of rhinoplasty and a recent survey of practice patterns on the management of rhinoplasty patients, no concise review of all possible techniques for decreasing postoperative edema currently exists.^[12,13] This review will detail the different pharmacologic treatments, postoperative practices, and surgical techniques that have been studied to minimize edema and ecchymosis in rhinoplasty along with their results. Although it is difficult to understand and apply all of the varying practices, the goal of this review is to summarize the literature and provide the evidence behind the current practices used by surgeons for decreasing postoperative edema and ecchymosis after rhinoplasty.

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Abstract and Introduction
Methods
Results
Discussion
Conclusions
References

Table 1. Corticosteroids in Rhinoplasty
Reference	Study Type	Treatment	No.	Controlling Factors	Type of RP	Measurement Tool	POD	Outcome
Alajmi et al., 2009¹⁸	RCT (placebo)	Dexamethasone 10 mg	84	NP, HE postoperatively; no pressure or CC	External	ED: 0–3	2, 5, 7, 10, 14, and 21	CS significantly decreases postoperative ED on POD 2, 5, 7, and 10
Berinstein et al., 1998¹⁶	DB RCT (placebo)	Dexamethasone 10 mg preoperatively	20	ND	ND	MRI measuring soft-tissue thickness	By POD 2	CS significantly increases postoperative ED compared
Goldman et al., 1952⁴	Prospective cohort	Cortogen (cortisone acetate)	70	ND	ND	Subjective	Variable	Cortogen has an inhibitory effect on ED and ECC with a more rapid return to relative normalcy
Griffies et al., 1989¹⁹	DB RCT (placebo)	Dexamethasone 10 mg preoperatively	30	HE intraoperatively; intranasal Telfa gauze, HE postoperatively	ND	ED and ECC: 1–4	1	CS significantly decreases edema and ecchymosis in the immediate postoperative period
Gurlek et al., 2006⁷	DB RCT (placebo)	BM 8 mg/day; dexamethasone 8 mg/day; MP 40 mg/day; tenoxicam 20 mg/day	40	No menstruating female patients intraoperatively hypotension (90/60) with remifentanil; HE, CC postoperatively	External	ED and ECC: 0–4	1, 3, and 7	No difference except reduction of ED with MP compared to placebo on POD 1
Gurlek et al., 2009²⁰	DB RCT (placebo)	MP 250 mg once; MP 500 mg once; MP 250 mg four doses; MP 500 mg four doses; placebo	40	Intraoperative hypotension (90/60) with esmolol; HE, CC postoperatively	External	ED and ECC: 0–4	1, 3, and 7	High-dose MP significantly decreases ED and ECC
Gutierrez and Wuesthoff, 2014²¹	DB RCT (placebo)	Dexamethasone sodium phosphate 4 mg plus dexamethasone acetate 16 mg	54	Intraoperative hypotension (MAP <65 mmHg) with remifentanil; no NP, HE, CC postoperatively	Endonasal	ED: 0–4; ECC: 0–13	1, 3, 7, and 14	No difference in ED and ECC
Hoffmann et al., 1991¹⁴	DB RCT (placebo)	Dexamethasone 10 mg intraoperatively with oral prednisone 50 mg POD 1 taper 10 mg/day for 5 days	49	ND	Both	ED and ECC: 0–4	1, 4, and 7	CS significantly decreases ED at POD 1 and 4, with a trend for decreased ECC
Kara and Gokalan, 1999⁹	DB RCT (placebo)	Dexamethasone 10 mg preoperatively; dexamethasone 10 mg postoperatively	55	No menstruating female patients; NP routinely; no pressure or CC postoperatively	Both	ED and ECC: 0–4	1–9	CS significantly decreases ED of the upper and lower eyelids and ECC of upper eyelid on POD 1 and 2
Kargi et al., 2003²	DB RCT (placebo)	Dexamethasone 8 mg 1 hr preoperatively; dexamethasone 8 mg immediately preoperatively; dexamethasone 8 mg 3 doses (dose 1 at 1 hr preoperatively); dexamethasone 8 mg 3 doses (dose 1 immediately preoperatively); dexamethasone 8 mg 3 doses (postoperatively)	60	NP routinely	Endonasal	ED and ECC: 0–4	1, 2, 5, 7, and 10	CS before osteotomy significantly decreases ED and ECC POD 1 and 2; ED significantly decreased on POD 5 with 3 doses of CS
Kittel and Masing, 1976²⁵	Unclear	Corticoid crystalline suspension 40 mg injected paranasally	54	CC postoperatively	ND	ED: 1–3	2	Paranasal MP appears to decrease ED more than intragluteal MP
Koc et al., 2011²²	RCT (placebo)	MP 1 mg/kg once; MP 3 mg/kg once	40	No menstruating female patients; intraoperative hypotension (MAP 55–65 mmHg) (sevoflurane with or without remifentanil); HE, CC postoperatively	External	ED and ECC: 0–4	1, 3, and 7	CS significantly decreases ED and ECC; no difference in dosage
Ozdel et al., 2006²³	DB RCT (placebo)	Dexamethasone 10 mg preoperatively	30	NP routinely; no pressure, CC postoperatively	Both	ED and ECC: 0–4	1 and 2	CS significantly decreases ED on POD 1 and 2, and upper eyelid ECC on POD 1
Valente et al., 2015²⁴	DB RCT (placebo)	Dexamethasone sodium phosphate 10 mg preoperatively	42	Intraoperative use of remifentanil; HE, CC postoperatively; no CS postoperatively	Endonasal	ED and ECC: 0–4	7	CS significantly decreases ED and ECC on POD 7

RP, rhinoplasty; POD, postoperative day; RCT, randomized controlled trial; DB, double-blinded; BM, betamethasone; MP, methylprednisolone; NP; nasal packing; HE, head elevation; CC, cold compresses; ND, no data; ED, edema; ECC, ecchymosis; CS, corticosteroids.

Table 2. Other Medications and Herbal Supplements in Rhinoplasty
Reference	Study Type	Treatment	No.	Controlling Factors	Type of RP	Measurement Tool	POD	Outcome
Bailey and Nahum, 1966¹⁵	DB RCT (placebo)	Tandearil (oxyphenbutazone)	42	ND	ND	ED: caliper measurements; ECC: 1–4	ED: 1 and 5; ECC up to 13 days for duration	Tandearil does not prevent post ED or ECC, but significantly enhances the clearing of ECC by 2 days compared with placebo
Chaiet and Marcus, 2015⁵	DB RCT (placebo)	SinEcch* (Arnica montana)	22	Dexamethasone intraoperatively; MP postoperatively	Both	Photoshop to measure intensity of ECC	2/3, 7, and 9/10	SinEcch significantly decreases extent ECC on POD 7, and intensity on POD 9/10
Kahn, 1965²⁶	DB RCT (placebo)	Carica papaya (papain)	88	ND	ND	ED and ECC: 1–4	By POD 2	Carica papaya does not decrease ED or ECC
Lewison, 1965²⁷	RCT (placebo)	Tandearil (oxyphenbutazone)	150	ND	ND	ED and ECC: 1–3	2 and 7	Tandearil significantly decreased ED and ECC
Moore, 1963²⁸	DB RCT (placebo)	Chymar† (α-chymotrypsin)	180	ND	ND	ED and ECC: 1–3	ND	α-Chymotrypsin may decrease ED and ECC
Rasi, 1958³²	Unclear (prospective cohort?)	Adrenosem salicylate (carbazochrome)	53	ND	ND	Subjective	1	Adrenosem appears to decrease ECC
Saedi et al., 2011³¹	Prospective cohort	Dexamethasone 8 mg 3 doses (1 hr preoperatively, 24 and 48 hr postoperatively); pseudoephedrine 60 mg BID for 1 wk; pseudoephedrine 60 mg BID for 2 wk	74	Internal osteotomy; no NP postoperatively	Both	ED: 0–3; ECC: 0–4	1, 7, and 30	Pseudoephedrine significantly decreases ED and ECC until POD 7 with extended use of pseudoephedrine significantly decreasing ECC 1 mo postoperatively
Seltzer, 1962²⁹	RCT (placebo)	Bromelain	53	ND	ND	Duration of ECC; satisfaction as disappearance <POD 3	Variable	Bromelain decreases the duration of ECC to POD 2 compared to placebo (POD 7)
Totonchi and Guyuron, 2007³⁰	DB RCT (placebo)	Dexamethasone 10 mg intraoperatively with MP tapering 6 days; SinEcch* (Arnica montana)	48	ND	ND	ED: 0–3; ECC intensity: 0–4; ECC extent: 0–5	2 and 8	Arnica montana and steroids significantly decreases ED by POD 2, not POD 8; Arnica montana and steroids significantly decrease intensity, extent, resolution of ECC on POD 2 and 8
Vallis and Lund, 1969¹⁰	DB RCT (placebo)	Carica papaya (papain)	48	ND	ND	ED and ECC: −2 (marked decrease) to 2 (marked increase)	1 and 2	Carica papaya decreases ED, most rapidly during POD 1 to 2

RP, rhinoplasty; POD, postoperative day; DB, double-blinded; RCT, randomized controlled trial; MP, methylprednisone; ND, no data; NP, nasal packing; ED, edema; ECC, ecchymosis.
*Alpine Pharmaceuticals, San Rafael, Calif.
†Rhone-Poulenc Rorer Pharmaceuticals, Inc., Strasburg, France.

Table 3. Decreasing Intraoperative Bleeding during Rhinoplasty
Reference	Study Type	Treatment	No.	Controlling Factors	Type of RP	Measurement Tool	POD	Outcome
Gun et al., 2011³⁴	PB RCT (self-controlled)	2% lidocaine with 1:100,000 adrenaline	48	No menstruating female patients; anesthesia with remifentanil, CS given intraoperatively; NP, HE, CC postoperatively	External	ED and ECC: 0–4	1, 3, and 7	Lidocaine with adrenaline does not decrease ED or ECC
Koşucu et al., 2014³⁵	DB RCT (placebo)	Remifentanil (MAP 50–60 mmHg)	52	HE, CC postoperatively	External	ED and ECC: 0–4	1, 3, and 7	Intraoperative hypotension significantly decreases ED on POD 1 and 3, and ECC on POD 1, 3, and 7
Prado et al., 2006³⁶	DB RCT (self-controlled)	Bovine-derived fibrin	22	External osteotomy; NP postoperatively	External	ED and ECC: 1–5	1 mo; 12 mo	No difference with use of fibrin glue with regard to ED or ECC
Pryor et al., 2008³⁷	DB RCT (self-controlled)	Human-derived fibrin	10	ND	ND	ED and ECC: 0–50	1, 7, and 21	Fibrin significantly decreases ED and ECC on POD 1 and 7; ECC continues to be significantly decreased by POD 21
Sakallioğlu et al., 2015³⁸	RCT (placebo)	TA 1 g PO 2 hr preoperatively with TA 1 g TID for 5 days; MP 1 mg/kg once preoperatively	75	No menstruating female patients; MAP 70–90 mmHg; NP, HE postoperatively; no intraoperative or postoperative pressure, CS or CC	External	ED and ECC: 0–4	1, 3, and 7	Oral TA and IV MP significantly decreases ED and ECC; however, no difference in ED or ECC between TA and MP groups Sari and
Simsek, 2015³⁹	DB RCT	TNB or CFB with 2% lidocaine with 1:100,000 adrenaline	60	NP postoperatively; no intraoperative or postoperative CS	External	ED and ECC: 0–4	1, 2, 5, and 7	Both TNB and CFB significantly decrease ED and ECC, with CFB being more effective than TNB
Shehadi, 1972³³	RCT (placebo)	Postoperative cooling; intraoperative and postoperative cooling; Ananase (bromelain); Co-Pyronil* (antihistamine); intraoperative cooling and Co-Pyronil	155	ND	ND	ED and ECC: 1–4	1, 2, 5, 7, and 14	Intraoperative hypothermia and Co-Pyronil significantly decreases ED until POD 2 and ECC until POD 7
Taskin et al., 2011³	DB RCT	Cold saline-soaked gauze with dexamethasone 10 mg; dry salinesoaked gauze with dexamethasone 10 mg	300	No menstruating female patients; CC intraoperatively; NP, CC postoperatively	External	ED: 0–4; ECC: 0–5	1, 2, 3, 5, and 7	CC with intraoperative CS significantly decreases ED and ECC on all POD
Tuncel et al., 2013⁴⁰	Retrospective	All groups with intraoperative hypotension (MAP 65–75 mmHg): dexamethasone 10 mg/kg immediately preoperatively; dexamethasone 10 mg/kg immediately preoperatively and 24 hr postoperatively; dexamethasone 10 mg/kg immediately preoperatively, before osteotomy, and 24 hr postoperatively	60	Periosteal elevation, MAP 65–75 mmHg with remifentanil intraoperatively; NP postoperatively	External	ED and ECC: 0–4	1, 2, 5, 7, and 10	ED and ECC was significantly decreased for all CS groups on POD 7 and 10; dexamethasone 10 mg/kg 3 doses significantly decreases lower eyelid ED, and upper and lower eyelid ECC on POD 5 and 7

RP, rhinoplasty; POD, postoperative day; PB, partially blinded; RCT, randomized controlled trial; DB, double-blinded; MAP, mean arterial pressure; TA, tranexamic acid; PO, per os; TID, three times daily; MP, methylprednisone; TNB, total nasal block; CFB, central facial block; CS, corticosteroids; NP, nasal packing; HE, head elevation; CC, cold compresses; ND, no data; ED, edema; ECC, ecchymosis.
*Eli Lilly and Co., Indianapolis, Ind.

Table 4. Other Postoperative Interventions in Rhinoplasty
Reference	Study Type	Treatment	No.	Controlling Factors	Type of RP	Measurement Tool	POD	Outcome
Al Arfaj, 2015⁴¹	SB RCT (self-controlled)	NP, no NP	74	Dexamethasone 8 mg preoperatively; use of sharp 4-mm guarded micro-osteotome, normothermia, and MAP 60–70 mmHg; NP, HE, CC preoperatively	Both	ED and ECC: 0–4	1, 4, and 7	NP significantly increases severity and duration of ECC on POD 4 and 7
Spooner et al., 1970⁴²	SB RCT (self-controlled)	Drainage tubes; no drainage tubes	30	ND	ND	ED and ECC: 0–3	1 and 3	Drainage tubes do not decrease ED or ECC and may have more ED
Stucker, 1974⁴⁴	SB prospective cohort	30 deg HE; 90 deg HE	50	No CS, enzymes, CC, antihistamines, osteotomy drains preoperatively	ND	ED: 1–2	1	90 deg HE has significantly less ED than 30 deg
Yates and Versaci, 1970⁴³	RCT (self-controlled)	Drainage tubes; no drainage tubes	20	HE, CC postoperatively	ND	ED: 1–3; ECC: 1–4	1–3	Drainage tubes do not decrease ED or ECC

RP, rhinoplasty; POD, postoperative day; SB, single-blinded; RCT, randomized controlled trial; NP, nasal packing; HE, head elevation; MAP, mean arterial pressure; CC, cold compresses; ND, no data; ED, edema; ECC, ecchymosis

Table 5. Surgical Techniques in Rhinoplasty
Reference	Study Type	Treatment	No.	Controlling Factors	Type of RP	Measurement Tool	POD	Outcome
Al-Arfaj et al., 2009⁴⁵	SB RCT (self-controlled)	Periosteal elevation; no periosteal elevation	78	4-mm guarded osteotome, periosteal elevation; no CS; HE postoperatively	ND	ECC: 0–2	1	Periosteal elevation significantly increases ECC
Erisir et al., 2008⁴⁶	SB RCT (self-controlled)	2-mm V-shaped osteotome; 4-mm straight Cottle osteotome	36	ND	Endonasal	Subjective	1 and 2	2-mm V-shaped osteotomes appear to decrease ED and ECC compared to a 4-mm straight Cottle osteotome
Ghazipour et al., 2014⁴⁷	DB RCT (self-controlled)	Buccal sulcus osteotomy; intranasal osteotomy	50	HE, CC postoperatively	ND	ED: 1–4; ECC: 1–3	2 and 7	Buccal sulcus approach significantly decreases upper and lower eyelid ED and upper eyelid ECC on POD 2 and 7
Giacomarra et al., 2001⁶	Retrospective	External osteotomy; internal osteotomy	142	HE, CC postoperatively	ND	Subjective	4, 8, and 15; 1 and 3; 6 mo; 1 yr	External osteotomy appears to decrease ED and ECC
Gryskiewicz et al., 2004⁴⁸	PB RCT (self-controlled)	Internal perforating osteotomy, internal continuous osteotomy; external perforating osteotomy, internal continuous osteotomy; external perforating osteotomy, internal perforating osteotomy	75	Pressure intraoperatively; no NP postoperatively	External	Opinion of clinic RN, patient with or without family, operating surgeon where majority ruled	2, 3, 7, and 21	Internal perforating osteotomy appears to reduce ED and ECC on POD 2/3 compared to continuous osteotomy
Hashemi et al., 2005⁸	SB RCT (self-controlled)	External osteotomy; internal osteotomy	30	ND	Both	ED and ECC: 0–4	1, 7	External osteotomy significantly decreases ED on POD 1 and ECC on POD 1 and 7
Kara et al., 2005⁴⁹	SB RCT (self-controlled)	Subperiosteal tunnel; no subperiosteal tunnel	18	No menstruating female patients; NP routinely; HE, CC postoperatively	Both	ED and ECC: 0–4	2	Subperiosteal tunnels significantly increase ECC, and with trend toward increased ED
Kiliç et al., 2015⁵²	Retrospective	External RP with internal osteotomy; endonasal RP with internal osteotomy; external RP with external osteotomy; endonasal RP with external osteotomy	120	No history of drug use or cigarette smoking; dexamethasone 10 mg preoperatively; intraoperative hypotension with remifentanil	ND	ED and ECC: 0–4	2 and 7	Closed RP with internal osteotomy had significantly decreased ED and ECC scores compared to open RP with internal osteotomy; closed RP with external osteotomy had significantly decreased ED POD 1 and ECC on POD 7 compared to open RP with external osteotomy; (closed RP superior to open RP, whereas lateral osteotomy should be surgeon-dependent)
Sakallioğlu et al., 2015⁵¹	Prospective cohort	External RP; endonasal RP	50	No menstruating female patients; no subperiosteal elevation, MAP 70–90 mmHg intraoperatively; NP routinely; HE postoperatively; no intraoperatively or postoperatively pressure, CS or CC	Both	ED and ECC: 0–4	1, 3, and 7	No significant difference in ED or ECC between open RP and closed RP
Sinha et al., 2007⁵³	Retrospective	External osteotomy; internal osteotomy	45	Local anesthesia only; CC and dexamethasone 4 mg injected paranasally TID for 1–2 days postoperatively	ND	ED: 1–4; ECC: 1–3	ND	External osteotomy appears to have less ED and ECC when compared to internal osteotomy
Tirelli et al., 2015⁵⁰	RCT	Piezosurgery device; external osteotomy	22	NP, HE, CC postoperatively	ND	ED and ECC: 0–2	4	Piezosurgery significantly decreases ED and ECC compared to using a 2-mm osteotome
van Loon et al., 2011¹⁷	RCT (self-controlled)	External osteotomy; internal osteotomy	20	Submucosal tunnel for osteotomy; local pressure intraoperatively; NP postoperatively	External	Volumetric threedimensional stereophotogrammetry	4/5	No significant difference between external osteotomy and internal osteotomy
Yücel, 2005¹¹	SB RCT (self-controlled)	External osteotomy; internal osteotomy	40	Anesthesia with remifentanil; no periosteal elevation; CC postoperatively	External	ED and ECC: 0–4	2 and 7	Internal continuous osteotomy significantly decreases ECC compared to external osteotomy on POD 2 with no significant difference in ECC on POD 7, or ED on POD 2 or 7

RP, rhinoplasty; POD, postoperative day; SB, single-blinded; RCT, randomized controlled trial; DB, double-blinded; PB, partially blinded; CS, corticosteroids; HE, head elevation; ND, no data; CC, cold compresses; ED, edema; ECC, ecchymosis