- Email: [email protected]
Buccal sulcus versus intranasal approach for postoperative periorbital oedema and ecchymosis in lateral nasal osteotomy
Accepted Manuscript Buccal sulcus versus intranasal approach for postoperative periorbital edema and ecchymosis in lateral nasal osteotomy Ali Ghazipour, Nadereh Alani, Shervin Ghavami Lahiji, Nader Akbari Dilmaghani PII:
S1010-5182(14)00133-4
DOI:
10.1016/j.jcms.2014.04.010
Reference:
YJCMS 1786
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 26 October 2013 Revised Date:
8 March 2014
Accepted Date: 22 April 2014
Please cite this article as: Ghazipour A, Alani N, Lahiji SG, Dilmaghani NA, Buccal sulcus versus intranasal approach for postoperative periorbital edema and ecchymosis in lateral nasal osteotomy, Journal of Cranio-Maxillofacial Surgery (2014), doi: 10.1016/j.jcms.2014.04.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Buccal sulcus versus intranasal approach for postoperative periorbital edema and ecchymosis in lateral nasal osteotomy
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ALI GHAZIPOUR1; NADEREH ALANI2; SHERVIN GHAVAMI LAHIJI 3 ;NADER AKBARI DILMAGHANI*1 1
Assistant professor of Otolaryngology, Shahid Beheshti Medical University, Loghman Hakim
2
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Hospital, Tehran, Iran
Resident of Otolaryngology, Shahid Beheshti Medical University, Loghman Hakim Hospital,
Tehran, Iran
Assistant professor of Otolaryngology, Ahwaz University of Medical Sciences, Ahwaz, Iran.
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3
*Corresponding Author: NADER AKBARI DILMAGHANI, MD, Assistant professor of Otolaryngology Email: [email protected]
Address: Loghman Hakim Hospital, Kargar St, Tehran, Iran
Mobile: +989123450082
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Tel/Fax:+982155419005-11
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Keywords: rhinoplasty, osteotomy, edema, ecchymosis
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Abstract:
Background: Lateral Osteotomies are used in rhinoplasty to narrow the nasal bones, close the open roof deformity
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after hump removal, and achieve symmetry of an asymmetrical framework. But this procedure causes periorbital ooedema &ecchymosis. Different techniques have been described for lateral osteotomy.
Objective: To compare the post-operative ecchymosis and oedema after buccal sulcus lateral osteotomy versus intra nasal lateral osteotomy.
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Methods and Materials: In a prospective experimental study, buccal sulcus approach was performed on the right side and an intranasal approach performed on the left side of patients randomly. Then blind analysis of
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postoperative photographs was performed to determine the incidence of oedema and ecchymosis on each side. Results: fifty patients were enrolled in the study after exclusion of unfit patients. On the right side (buccal approach osteotomies), a significantly lower incidence of upper and lower eyelid oedema and upper eyelid th
ecchymosis was seen on both the 2nd day and after 7 day (P<0.05). The odds ratio of progression of ecchymosis
complication observed.
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was 2.66 (OR=2.66, 95% CI: 1.09-5.52, p=0.048) in intranasal group compare to buccal sulcus group. No significant
Conclusion: The buccal sulcus approach is a safe method for lateral osteotomy with a lower rate of post-operative oedema and ecchymosis and no significant complications.
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Keywords: Rhinoplasty, Osteotomy, Oedema, Ecchymosis
Introduction:
Postoperative oedema and ecchymosis can affect the cosmetic results, causing dissatisfaction in both the surgeon and the patient. With standard rhinoplasty, osteotomies account for a notable proportion of this periorbital swelling and ecchymosis because of the injury in angular vessels and tearing periosteum crossing the osteotomy sites and fractured nasal bone (Kargi et al., 2003). Osteotomy is part of a rhinoplasty that induces abundant
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oedema and ecchymosis and cause discomfort in patients. Lateral Osteotomies are used in rhinoplasty to narrow the nasal bones (Most and Murakami, 2005) , close the open roof deformity after hump removal, and achieve symmetry of an asymmetrical framework (Zoumalan et al., 2010). By using lateral osteotomy, it is possible to
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narrow the ventral width of the nose (Kortbus et al., 2006). Different authors use different techniques to perform osteotomy. The two basic techniques for lateral osteotomies are internal and external lateral osteotomies. Internal osteotomies can be performed itranasaly or through the buccal sulcus. The continuous lateral osteotomy creates a single fracture along the lateral portion of the nasal process of the maxilla and nasal bones. Buccal technique
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avoids intranasal scarring and violation of the anterolateral part of intranasal valve near the anterior head of inferior turbinate (Vacher et al., 2003). On the other hand, internal nasal approaches result in scarring and scar
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retraction that may compromise nasal air flow (Kim and Hwang, 2010).
Postoperative squealae and complications of rhinoplasty fall into two categories: aesthetic (may require a revision rhinoplasty) and nonaesthetic such as post op bleeding, oedema and ecchymosis. Postoperative nasal-periorbital oedema and ecchymosis are regarded as unavoidable but may be lessened significantly by postoperative head
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elevation and cold packs or using corticosteroides (Holt et al., 1987). Lateral osteotomy from the buccal-sulcus approach is an outstanding method of controlling the width of the nasal bones and it eliminates an extra incision (Helal et al., 2010). It allows exit of accumulated blood through mouth rather than through the nose, and thereby minimizes nasal bleeding (Byrne et al., 2003). Numerous investigators have subjectively perceived less
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postoperative ecchymosis and oedema, but no clinical study has compared the two techniques considering
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ecchymosis and oedema post-operatively.
The aim of this study is to compare the postoperative complications of these two techniques and to determine if there are any necessities to make an intranasal incision.
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Material &Methods:
The study was reviewed and approved by the hospital ethics committee and performed in accordance with the ethical standards laid down in an appropriate version of the 2000 Declaration of Helsinki. Information
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about the trial was given comprehensively both orally and in a written form to all patients or their accompanying adult. They gave back their informed consent prior to their inclusion in the study according to University Hospital Ethical Board Committee.
SC
A double blind randomized prospective study was conducted on 50 healthy candidates for primary
reduction rhinoplasty. Secondary cases were excluded. Patients with a history of coagulopathy or hypertension or
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diabetes mellitus were excluded from the study. Coagulation tests were performed prior to surgery and patients with abnormal results were also excluded. Patient’s informed consent was obtained to perform buccal sulcus approach on one side and intranasal approach on the other side randomly. The operating master surgeon was informed about the side and technique just before osteotomy. Buccal sulcus approach was used on the one side and intranasal approach applied to the other side randomly. All the operations were performed by one master
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surgeon with the same technique.
On one side (right or left), first a 3-mm incision was made transversely lateral to the superior part of inferior turbinate. A 4-mm curved guarded osteotome (Medtronic-Xomed) was inserted into the incision,
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perpendicular to the bony rim of the ascending process of the maxilla. The guard of osteotome was palpated transcutaneously and was used as a guide for the trajectory of the osteotome. The osteotome was tapped toward
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the face of the maxilla with a mallet in a high-to-low direction. It was then turned cephalically to cut the ascending process of the maxilla from the body of the maxilla in a low-to-high direction. At the end of procedure a controlled fracture was made by light digital compression.
On the other side an upper buccal sulcus approach near the entrance of pyriform aperture was used: A 3mm incision was made transversely at by using a number 15 surgical blade intra orally, at the reflection of the upper buccal sulcus immediately medial to upper most area of canine fossa (Photo 2). The same guarded osteotome was inserted into the incision, perpendicular to the bony rim of the ascending process of the maxilla.
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The remainder of the technique was similar to the right side. We used ice packing and head elevation for all patients in recovery room and for next 12 hours.
Preoperative and postoperative photographs were obtained on day 2 and day 7 post-operatively, using a
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digital camera (Sony HXV-9). Photographic analysis took place in a blinded manner. In order to determine the severity of post-operative ecchymosis and oedema we used the following described grading method (Table1).
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Statistical Analysis:
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Data are expressed as mean ± standard deviation (SD) and categorical data are presented as numbers. Comparisons between the two groups were conducted using independent T tests. Logistic regression analyses were used to calculate univariate crude odds ratio (OR) with 95% confidence intervals (CIs) with oedema and
Results:
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ecchymosis as the outcomes. Statistical significance was defined as p < 0.05.
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Fifty patients were enrolled in our study (22 female and 28 male). The patient’s age ranged from 18 to 35 years, regardless of gender. The incidence and severity of post-operative oedema and ecchymosis which was
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determined at day 2 and day 7 of post-operative follow-up is presented in Table 2.
Buccal approach osteotomies induced a significant decrease in the incidence of upper and lower eyelid nd
th
oedema and upper eyelid ecchymosis on both 2 and 7 day post-operation follow-up (p=0.035, p=0.015, respectively). Besides, the scores for both oedema and ecchymosis on the second day is significantly less in the buccal technique (P < 0.05) when it is compared with the intranasal technique. In Fisher’s exact test, when compared grade 2 ecchymosis progression in intranasal and buccal approaches, there was a significant discrepancy between incidence of ecchymosis in intranasal approach compare to buccal approach (p=0.048).
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The odds ratio of progression of ecchymosis was 2.66 (OR=2.66, 95% CI: 1.09-5.52, p=0.048) in intranasal group compare to buccal group. None of other time points or grade of ecchymosis turned out to be significant in Fisher exact test. The Odds ratio of grade 2 oedema progression was 1.09 (OR=1.09, 95% CI: 0.47-2.56, p>0.05) in
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intranasal group compare to buccal group. Based on our regression model using buccal approach decreased oedema and ecchymosis score significantly (p=0.002, p =0 .001, respectively).These data showed the significant benefit of buccal procedure in decreasing oedema and ecchymosis score compare to intranasal group. We did not see any postoperative bleeding in our in the site of osteotomies. There was a small amount of bloody oral
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secretions during first 6h postoperatively which was not annoying for patients. We did not see any infection or
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temporary numbness of face in our patients.
Discussion:
Lateral osteotomies are used in rhinoplasty to narrow the nasal bones and close the open roof deformity after
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hump removal. Different techniques for doing a lateral osteotomy are available like internal or external lateral osteotomy .It has been discussed and approved that external lateral osteotomy causes less periorbital oedema and ecchymosis because the bone stump is more stable (Hashemi et al., 2005, Sinha et al., 2007)and damage to the intra nasal mucosa is much less(Rohrich et al., 1997) .Different methods have been introduced for reduction of
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post operative periorbital oedema and ecchymosis after rhinoplasty like cold compress, head elevation,
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corticosteroid administration(Kara and Gökalan, 1999) or using thinner osteotomes (Becker et al., 2000).
Injection of lidocaine with epinephrine provides not only haemostasis but also some degree of hydrodissection, which may protect the intranasal mucosa and cause less post surgical oedema and ecchymosis(Becker, McLaughlin Jr et al., 2000) . Internal lateral osteotomy is preferred by many authors because it takes much less time and is easy to do in experienced hands. In this study for the first time we compared two different techniques for internal lateral osteotomy regarding oedema and ecchymosis. The upper buccal sulcus approach is a well-established method for surgical access to the middle third of the face in craniofacial and orthognathic surgery. The upper buccal sulcus approach for nasal surgery has been introduced by Kim, in which lateral nasal osteotomies of the
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frontal processes of the maxilla is performed endoscopically (Kortbus, Ham et al., 2006). Helel et al observed a measurable decrease in the nasal airway after lateral osteotomy in all their patients (Helal, El-Tarabishi et al., 2010). At the beginning of internal lateral osteotomy, surgeon has to make an incision superolateraly to inferior
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turbinate for insertion of lateral osteotomy. This incision may induce a later scar near internal valve area. In the buccal sulcus approach for lateral osteotomy no intranasal incision is made, so we do not see any scar formation near valve area. Kim et al found it necessary to use intranasal incisions in conjunction with the buccal approach, thereby violating the nasal valve and introducing intranasal scar(Kim and Kim, 2001). We decided to avoid the
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violation of the internal nasal valve and the introduction of internal nasal scarring, by using only the upper buccal sulcus approach. Gola described success with this manoeuvre, via endonasal incisions(Gola et al., 1989). Thus,
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successful skeletal correction of the nose in selected cases can be achieved with minimal disruption of the tipsupra-tip structures and no endonasal incision can minimize the associated morbidity (haemorrhage, oedema, and ecchymosis) in the rhinoplasty patient (Kortbus, Ham et al., 2006, Fettman et al., 2009).In our study buccal approach osteotomies induced a significant decrease in the incidence of upper and lower eyelid oedema and upper eyelid ecchymosis on both 2nd and 7th day post-operation follow-up that was statically significant . Buccal
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osteotomy takes only approximately 2 minutes longer than intranasal osteotomy. The site of incision and osteotomy are two determining factors for the outcomes. It seems that buccal sulcus technique provides greater preservation of the periosteal support of the bony segments, supraperiosteal arteries, veins, and lymphatics than
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intranasal osteotomy, which may subsequently lead to decrease intra and post operative bleeding and less post op oedema and ecchymosis (Kortbus, Ham et al., 2006).In buccal sulcus technique there is a small drainage pathway
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for blood, so accumulation and infiltration of blood inside the extracellular space is reduced. On the other hand, this technique causes preservation and improvement of the nasal airway by avoiding of any incision in lateral nasal wall adjacent to internal valve area.
The procedure is ideal for managing the bony nasal segment that needs lateralization, particularly in revision rhinoplasties or after trauma (Kortbus, Ham et al., 2006).
Conclusion:
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The buccal sulcus approach is an effective, safe, and reliable method for lateral osteotomy in rhinoplasty with an emphasis on decreasing post osteotomy oedema and ecchymosis .It is a less traumatic technique especially to the
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internal nasal valve area.
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Conflict of Interest:
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The authors of this article declare no conflict of interest, no financial, consulting, and personal relationships with
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any other people or organizations that could influence (bias) the author’s work.
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References:
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Becker DG, McLaughlin Jr RB, Loevner LA, Mang A: The lateral osteotomy in rhinoplasty: Clinical and radiographic rationale for osteotome selection. Plastic and reconstructive surgery 105(5): 1806-1816, 2000
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Byrne PJ, Walsh WE, Hilger PA: The use of inside-out lateral osteotomies to improve outcome in rhinoplasty. Archives of facial plastic surgery 5(3): 251-255, 2003
Fettman N, Sanford T, Sindwani R: Surgical management of the deviated septum: techniques in septoplasty. Otolaryngologic clinics of North America 42(2): 241-252, 2009
plastique et esthétique. 1989
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Gola R, Nerini A, Laurent-Fyon C, Waller P: Conservative rhinoplasty of the nasal canopy. Annales de chirurgie
Hashemi M, Mokhtarinejad F, Omrani M: A Comparison between External versus Internal Lateral Osteotomy in Rhinoplasty. Journal of Research in Medical Sciences 10(1): 10-15, 2005
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Helal MZ, El-Tarabishi M, Sabry SM, Yassin A, Rabie A, Lin SJ: Effects of rhinoplasty on the internal nasal valve: a comparison between internal continuous and external perforating osteotomy. Annals of plastic surgery 64(5): 649-
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657, 2010
Holt G, Garner E, McLarey D: Postoperative sequelae and complications of rhinoplasty. Otolaryngologic clinics of North America 20(4): 853-876, 1987 Kara COGökalan I: Effects of single-dose steroid usage on oedema, ecchymosis, and intraoperative bleeding in rhinoplasty. Plastic and reconstructive surgery 104(7): 2213-2218, 1999 Kargi E, Hosnuter M, Babucçu O, Altunkaya H, Altinyazar C: Effect of steroids on oedema, ecchymosis, and intraoperative bleeding in rhinoplasty. Annals of plastic surgery 51(6): 570-574, 2003
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Kim DWHwang HS: Traumatic Rhinoplasty in the Non-Caucasian Nose. Facial plastic surgery clinics of North America 18(1): 141-151, 2010 Kim JTKim SK: Endoscopically assisted, intraorally approached corrective rhinoplasty. Plastic and reconstructive
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surgery 108(1): 199-205, 2001 Kortbus MJ, Ham J, Fechner F, Constantinides M: Quantitative analysis of lateral osteotomies in rhinoplasty. Archives of facial plastic surgery 8(6): 369-373, 2006
Most SPMurakami CS: A modern approach to nasal osteotomies. Facial plastic surgery clinics of North America
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13(1): 85-92, 2005
Rohrich RJ, Minoli JJ, Adams WP, Hollier LH: The lateral nasal osteotomy in rhinoplasty: an anatomic endoscopic
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comparison of the external versus the internal approach. Plastic and reconstructive surgery 99(4): 1309-1312, 1997 Sinha V, Gupta D, More Y, Prajapati B, Kedia B, Singh SN: External vs. internal osteotomy in rhinoplasty. Indian Journal of Otolaryngology and Head & Neck Surgery 59(1): 9-12, 2007
Vacher C, Accioli de Vasconcellos JJ, Britto JA: The upper buccal sulcus approach, an alternative for post-trauma rhinoplasty. British journal of plastic surgery 56(3): 218-223, 2003
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Zoumalan RA, Shah AR, Constantinides M: Quantitative comparison between microperforating osteotomies and
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continuous lateral osteotomies in rhinoplasty. Archives of facial plastic surgery 12(2): 92-96, 2010
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Table 1 : Grading of the severity of post rhinoplasty ecchymosis and oedema.
Oedema
Ecchymosis
1
cornea not covered by eyelids
limited to 1/3 nasal part of lower/ upper eyelid
2
cornea mildly covered by eyelids
limited to 1/3 medial part of lower/upper eyelid
3
cornea completely covered by eyelids
limited to 1/3 lateral part of lower/upper eyelid
4
complete closure of the eye
NA
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NA: not applicable
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Grade
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sides (intranasal versus buccal sulcus side).
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Table 2: Incidence and severity of post-operative oedema and ecchymosis on 2nd and 7th day after surgery in two
Intranasal side 2
Oedema grade 0
nd
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Days
Buccal sulcus side
7
th
2
nd
7
th
86%
2%
86%
8%
10%
50%
10%
60%
4%
40%
4%
26%
3
0
6%
0
6%
4
0
2%
0
0
0
80%
0
90%
4%
1
20%
58%
10%
60%
2
0
32%
0
30%
3
0
10%
0
6%
4
0
0
0
0
1
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2
Ecchymosis grade
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Sublabial osteotomy
intranasal osteotomy
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Photo.1: Second day after surgery, sublabial osteotomy on right side and intranasal lateral osteotomy on the left
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side.
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Photo 2: Buccal sulcus lateral osteotome insertion technique in left side
S1010-5182(14)00133-4
DOI:
10.1016/j.jcms.2014.04.010
Reference:
YJCMS 1786
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 26 October 2013 Revised Date:
8 March 2014
Accepted Date: 22 April 2014
Please cite this article as: Ghazipour A, Alani N, Lahiji SG, Dilmaghani NA, Buccal sulcus versus intranasal approach for postoperative periorbital edema and ecchymosis in lateral nasal osteotomy, Journal of Cranio-Maxillofacial Surgery (2014), doi: 10.1016/j.jcms.2014.04.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Buccal sulcus versus intranasal approach for postoperative periorbital edema and ecchymosis in lateral nasal osteotomy
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ALI GHAZIPOUR1; NADEREH ALANI2; SHERVIN GHAVAMI LAHIJI 3 ;NADER AKBARI DILMAGHANI*1 1
Assistant professor of Otolaryngology, Shahid Beheshti Medical University, Loghman Hakim
2
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Hospital, Tehran, Iran
Resident of Otolaryngology, Shahid Beheshti Medical University, Loghman Hakim Hospital,
Tehran, Iran
Assistant professor of Otolaryngology, Ahwaz University of Medical Sciences, Ahwaz, Iran.
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3
*Corresponding Author: NADER AKBARI DILMAGHANI, MD, Assistant professor of Otolaryngology Email: [email protected]
Address: Loghman Hakim Hospital, Kargar St, Tehran, Iran
Mobile: +989123450082
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Tel/Fax:+982155419005-11
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Keywords: rhinoplasty, osteotomy, edema, ecchymosis
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Abstract:
Background: Lateral Osteotomies are used in rhinoplasty to narrow the nasal bones, close the open roof deformity
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after hump removal, and achieve symmetry of an asymmetrical framework. But this procedure causes periorbital ooedema &ecchymosis. Different techniques have been described for lateral osteotomy.
Objective: To compare the post-operative ecchymosis and oedema after buccal sulcus lateral osteotomy versus intra nasal lateral osteotomy.
SC
Methods and Materials: In a prospective experimental study, buccal sulcus approach was performed on the right side and an intranasal approach performed on the left side of patients randomly. Then blind analysis of
M AN U
postoperative photographs was performed to determine the incidence of oedema and ecchymosis on each side. Results: fifty patients were enrolled in the study after exclusion of unfit patients. On the right side (buccal approach osteotomies), a significantly lower incidence of upper and lower eyelid oedema and upper eyelid th
ecchymosis was seen on both the 2nd day and after 7 day (P<0.05). The odds ratio of progression of ecchymosis
complication observed.
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was 2.66 (OR=2.66, 95% CI: 1.09-5.52, p=0.048) in intranasal group compare to buccal sulcus group. No significant
Conclusion: The buccal sulcus approach is a safe method for lateral osteotomy with a lower rate of post-operative oedema and ecchymosis and no significant complications.
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Keywords: Rhinoplasty, Osteotomy, Oedema, Ecchymosis
Introduction:
Postoperative oedema and ecchymosis can affect the cosmetic results, causing dissatisfaction in both the surgeon and the patient. With standard rhinoplasty, osteotomies account for a notable proportion of this periorbital swelling and ecchymosis because of the injury in angular vessels and tearing periosteum crossing the osteotomy sites and fractured nasal bone (Kargi et al., 2003). Osteotomy is part of a rhinoplasty that induces abundant
ACCEPTED MANUSCRIPT
oedema and ecchymosis and cause discomfort in patients. Lateral Osteotomies are used in rhinoplasty to narrow the nasal bones (Most and Murakami, 2005) , close the open roof deformity after hump removal, and achieve symmetry of an asymmetrical framework (Zoumalan et al., 2010). By using lateral osteotomy, it is possible to
RI PT
narrow the ventral width of the nose (Kortbus et al., 2006). Different authors use different techniques to perform osteotomy. The two basic techniques for lateral osteotomies are internal and external lateral osteotomies. Internal osteotomies can be performed itranasaly or through the buccal sulcus. The continuous lateral osteotomy creates a single fracture along the lateral portion of the nasal process of the maxilla and nasal bones. Buccal technique
SC
avoids intranasal scarring and violation of the anterolateral part of intranasal valve near the anterior head of inferior turbinate (Vacher et al., 2003). On the other hand, internal nasal approaches result in scarring and scar
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retraction that may compromise nasal air flow (Kim and Hwang, 2010).
Postoperative squealae and complications of rhinoplasty fall into two categories: aesthetic (may require a revision rhinoplasty) and nonaesthetic such as post op bleeding, oedema and ecchymosis. Postoperative nasal-periorbital oedema and ecchymosis are regarded as unavoidable but may be lessened significantly by postoperative head
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elevation and cold packs or using corticosteroides (Holt et al., 1987). Lateral osteotomy from the buccal-sulcus approach is an outstanding method of controlling the width of the nasal bones and it eliminates an extra incision (Helal et al., 2010). It allows exit of accumulated blood through mouth rather than through the nose, and thereby minimizes nasal bleeding (Byrne et al., 2003). Numerous investigators have subjectively perceived less
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postoperative ecchymosis and oedema, but no clinical study has compared the two techniques considering
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ecchymosis and oedema post-operatively.
The aim of this study is to compare the postoperative complications of these two techniques and to determine if there are any necessities to make an intranasal incision.
ACCEPTED MANUSCRIPT
Material &Methods:
The study was reviewed and approved by the hospital ethics committee and performed in accordance with the ethical standards laid down in an appropriate version of the 2000 Declaration of Helsinki. Information
RI PT
about the trial was given comprehensively both orally and in a written form to all patients or their accompanying adult. They gave back their informed consent prior to their inclusion in the study according to University Hospital Ethical Board Committee.
SC
A double blind randomized prospective study was conducted on 50 healthy candidates for primary
reduction rhinoplasty. Secondary cases were excluded. Patients with a history of coagulopathy or hypertension or
M AN U
diabetes mellitus were excluded from the study. Coagulation tests were performed prior to surgery and patients with abnormal results were also excluded. Patient’s informed consent was obtained to perform buccal sulcus approach on one side and intranasal approach on the other side randomly. The operating master surgeon was informed about the side and technique just before osteotomy. Buccal sulcus approach was used on the one side and intranasal approach applied to the other side randomly. All the operations were performed by one master
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surgeon with the same technique.
On one side (right or left), first a 3-mm incision was made transversely lateral to the superior part of inferior turbinate. A 4-mm curved guarded osteotome (Medtronic-Xomed) was inserted into the incision,
EP
perpendicular to the bony rim of the ascending process of the maxilla. The guard of osteotome was palpated transcutaneously and was used as a guide for the trajectory of the osteotome. The osteotome was tapped toward
AC C
the face of the maxilla with a mallet in a high-to-low direction. It was then turned cephalically to cut the ascending process of the maxilla from the body of the maxilla in a low-to-high direction. At the end of procedure a controlled fracture was made by light digital compression.
On the other side an upper buccal sulcus approach near the entrance of pyriform aperture was used: A 3mm incision was made transversely at by using a number 15 surgical blade intra orally, at the reflection of the upper buccal sulcus immediately medial to upper most area of canine fossa (Photo 2). The same guarded osteotome was inserted into the incision, perpendicular to the bony rim of the ascending process of the maxilla.
ACCEPTED MANUSCRIPT
The remainder of the technique was similar to the right side. We used ice packing and head elevation for all patients in recovery room and for next 12 hours.
Preoperative and postoperative photographs were obtained on day 2 and day 7 post-operatively, using a
RI PT
digital camera (Sony HXV-9). Photographic analysis took place in a blinded manner. In order to determine the severity of post-operative ecchymosis and oedema we used the following described grading method (Table1).
SC
Statistical Analysis:
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Data are expressed as mean ± standard deviation (SD) and categorical data are presented as numbers. Comparisons between the two groups were conducted using independent T tests. Logistic regression analyses were used to calculate univariate crude odds ratio (OR) with 95% confidence intervals (CIs) with oedema and
Results:
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ecchymosis as the outcomes. Statistical significance was defined as p < 0.05.
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Fifty patients were enrolled in our study (22 female and 28 male). The patient’s age ranged from 18 to 35 years, regardless of gender. The incidence and severity of post-operative oedema and ecchymosis which was
AC C
determined at day 2 and day 7 of post-operative follow-up is presented in Table 2.
Buccal approach osteotomies induced a significant decrease in the incidence of upper and lower eyelid nd
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oedema and upper eyelid ecchymosis on both 2 and 7 day post-operation follow-up (p=0.035, p=0.015, respectively). Besides, the scores for both oedema and ecchymosis on the second day is significantly less in the buccal technique (P < 0.05) when it is compared with the intranasal technique. In Fisher’s exact test, when compared grade 2 ecchymosis progression in intranasal and buccal approaches, there was a significant discrepancy between incidence of ecchymosis in intranasal approach compare to buccal approach (p=0.048).
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The odds ratio of progression of ecchymosis was 2.66 (OR=2.66, 95% CI: 1.09-5.52, p=0.048) in intranasal group compare to buccal group. None of other time points or grade of ecchymosis turned out to be significant in Fisher exact test. The Odds ratio of grade 2 oedema progression was 1.09 (OR=1.09, 95% CI: 0.47-2.56, p>0.05) in
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intranasal group compare to buccal group. Based on our regression model using buccal approach decreased oedema and ecchymosis score significantly (p=0.002, p =0 .001, respectively).These data showed the significant benefit of buccal procedure in decreasing oedema and ecchymosis score compare to intranasal group. We did not see any postoperative bleeding in our in the site of osteotomies. There was a small amount of bloody oral
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secretions during first 6h postoperatively which was not annoying for patients. We did not see any infection or
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temporary numbness of face in our patients.
Discussion:
Lateral osteotomies are used in rhinoplasty to narrow the nasal bones and close the open roof deformity after
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hump removal. Different techniques for doing a lateral osteotomy are available like internal or external lateral osteotomy .It has been discussed and approved that external lateral osteotomy causes less periorbital oedema and ecchymosis because the bone stump is more stable (Hashemi et al., 2005, Sinha et al., 2007)and damage to the intra nasal mucosa is much less(Rohrich et al., 1997) .Different methods have been introduced for reduction of
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post operative periorbital oedema and ecchymosis after rhinoplasty like cold compress, head elevation,
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corticosteroid administration(Kara and Gökalan, 1999) or using thinner osteotomes (Becker et al., 2000).
Injection of lidocaine with epinephrine provides not only haemostasis but also some degree of hydrodissection, which may protect the intranasal mucosa and cause less post surgical oedema and ecchymosis(Becker, McLaughlin Jr et al., 2000) . Internal lateral osteotomy is preferred by many authors because it takes much less time and is easy to do in experienced hands. In this study for the first time we compared two different techniques for internal lateral osteotomy regarding oedema and ecchymosis. The upper buccal sulcus approach is a well-established method for surgical access to the middle third of the face in craniofacial and orthognathic surgery. The upper buccal sulcus approach for nasal surgery has been introduced by Kim, in which lateral nasal osteotomies of the
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frontal processes of the maxilla is performed endoscopically (Kortbus, Ham et al., 2006). Helel et al observed a measurable decrease in the nasal airway after lateral osteotomy in all their patients (Helal, El-Tarabishi et al., 2010). At the beginning of internal lateral osteotomy, surgeon has to make an incision superolateraly to inferior
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turbinate for insertion of lateral osteotomy. This incision may induce a later scar near internal valve area. In the buccal sulcus approach for lateral osteotomy no intranasal incision is made, so we do not see any scar formation near valve area. Kim et al found it necessary to use intranasal incisions in conjunction with the buccal approach, thereby violating the nasal valve and introducing intranasal scar(Kim and Kim, 2001). We decided to avoid the
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violation of the internal nasal valve and the introduction of internal nasal scarring, by using only the upper buccal sulcus approach. Gola described success with this manoeuvre, via endonasal incisions(Gola et al., 1989). Thus,
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successful skeletal correction of the nose in selected cases can be achieved with minimal disruption of the tipsupra-tip structures and no endonasal incision can minimize the associated morbidity (haemorrhage, oedema, and ecchymosis) in the rhinoplasty patient (Kortbus, Ham et al., 2006, Fettman et al., 2009).In our study buccal approach osteotomies induced a significant decrease in the incidence of upper and lower eyelid oedema and upper eyelid ecchymosis on both 2nd and 7th day post-operation follow-up that was statically significant . Buccal
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osteotomy takes only approximately 2 minutes longer than intranasal osteotomy. The site of incision and osteotomy are two determining factors for the outcomes. It seems that buccal sulcus technique provides greater preservation of the periosteal support of the bony segments, supraperiosteal arteries, veins, and lymphatics than
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intranasal osteotomy, which may subsequently lead to decrease intra and post operative bleeding and less post op oedema and ecchymosis (Kortbus, Ham et al., 2006).In buccal sulcus technique there is a small drainage pathway
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for blood, so accumulation and infiltration of blood inside the extracellular space is reduced. On the other hand, this technique causes preservation and improvement of the nasal airway by avoiding of any incision in lateral nasal wall adjacent to internal valve area.
The procedure is ideal for managing the bony nasal segment that needs lateralization, particularly in revision rhinoplasties or after trauma (Kortbus, Ham et al., 2006).
Conclusion:
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The buccal sulcus approach is an effective, safe, and reliable method for lateral osteotomy in rhinoplasty with an emphasis on decreasing post osteotomy oedema and ecchymosis .It is a less traumatic technique especially to the
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internal nasal valve area.
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Conflict of Interest:
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The authors of this article declare no conflict of interest, no financial, consulting, and personal relationships with
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any other people or organizations that could influence (bias) the author’s work.
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References:
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Becker DG, McLaughlin Jr RB, Loevner LA, Mang A: The lateral osteotomy in rhinoplasty: Clinical and radiographic rationale for osteotome selection. Plastic and reconstructive surgery 105(5): 1806-1816, 2000
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Byrne PJ, Walsh WE, Hilger PA: The use of inside-out lateral osteotomies to improve outcome in rhinoplasty. Archives of facial plastic surgery 5(3): 251-255, 2003
Fettman N, Sanford T, Sindwani R: Surgical management of the deviated septum: techniques in septoplasty. Otolaryngologic clinics of North America 42(2): 241-252, 2009
plastique et esthétique. 1989
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Gola R, Nerini A, Laurent-Fyon C, Waller P: Conservative rhinoplasty of the nasal canopy. Annales de chirurgie
Hashemi M, Mokhtarinejad F, Omrani M: A Comparison between External versus Internal Lateral Osteotomy in Rhinoplasty. Journal of Research in Medical Sciences 10(1): 10-15, 2005
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Helal MZ, El-Tarabishi M, Sabry SM, Yassin A, Rabie A, Lin SJ: Effects of rhinoplasty on the internal nasal valve: a comparison between internal continuous and external perforating osteotomy. Annals of plastic surgery 64(5): 649-
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657, 2010
Holt G, Garner E, McLarey D: Postoperative sequelae and complications of rhinoplasty. Otolaryngologic clinics of North America 20(4): 853-876, 1987 Kara COGökalan I: Effects of single-dose steroid usage on oedema, ecchymosis, and intraoperative bleeding in rhinoplasty. Plastic and reconstructive surgery 104(7): 2213-2218, 1999 Kargi E, Hosnuter M, Babucçu O, Altunkaya H, Altinyazar C: Effect of steroids on oedema, ecchymosis, and intraoperative bleeding in rhinoplasty. Annals of plastic surgery 51(6): 570-574, 2003
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Kim DWHwang HS: Traumatic Rhinoplasty in the Non-Caucasian Nose. Facial plastic surgery clinics of North America 18(1): 141-151, 2010 Kim JTKim SK: Endoscopically assisted, intraorally approached corrective rhinoplasty. Plastic and reconstructive
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surgery 108(1): 199-205, 2001 Kortbus MJ, Ham J, Fechner F, Constantinides M: Quantitative analysis of lateral osteotomies in rhinoplasty. Archives of facial plastic surgery 8(6): 369-373, 2006
Most SPMurakami CS: A modern approach to nasal osteotomies. Facial plastic surgery clinics of North America
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13(1): 85-92, 2005
Rohrich RJ, Minoli JJ, Adams WP, Hollier LH: The lateral nasal osteotomy in rhinoplasty: an anatomic endoscopic
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comparison of the external versus the internal approach. Plastic and reconstructive surgery 99(4): 1309-1312, 1997 Sinha V, Gupta D, More Y, Prajapati B, Kedia B, Singh SN: External vs. internal osteotomy in rhinoplasty. Indian Journal of Otolaryngology and Head & Neck Surgery 59(1): 9-12, 2007
Vacher C, Accioli de Vasconcellos JJ, Britto JA: The upper buccal sulcus approach, an alternative for post-trauma rhinoplasty. British journal of plastic surgery 56(3): 218-223, 2003
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Zoumalan RA, Shah AR, Constantinides M: Quantitative comparison between microperforating osteotomies and
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continuous lateral osteotomies in rhinoplasty. Archives of facial plastic surgery 12(2): 92-96, 2010
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Table 1 : Grading of the severity of post rhinoplasty ecchymosis and oedema.
Oedema
Ecchymosis
1
cornea not covered by eyelids
limited to 1/3 nasal part of lower/ upper eyelid
2
cornea mildly covered by eyelids
limited to 1/3 medial part of lower/upper eyelid
3
cornea completely covered by eyelids
limited to 1/3 lateral part of lower/upper eyelid
4
complete closure of the eye
NA
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NA: not applicable
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Grade
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sides (intranasal versus buccal sulcus side).
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Table 2: Incidence and severity of post-operative oedema and ecchymosis on 2nd and 7th day after surgery in two
Intranasal side 2
Oedema grade 0
nd
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Days
Buccal sulcus side
7
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2
nd
7
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86%
2%
86%
8%
10%
50%
10%
60%
4%
40%
4%
26%
3
0
6%
0
6%
4
0
2%
0
0
0
80%
0
90%
4%
1
20%
58%
10%
60%
2
0
32%
0
30%
3
0
10%
0
6%
4
0
0
0
0
1
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2
Ecchymosis grade
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Sublabial osteotomy
intranasal osteotomy
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Photo.1: Second day after surgery, sublabial osteotomy on right side and intranasal lateral osteotomy on the left
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side.
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Photo 2: Buccal sulcus lateral osteotome insertion technique in left side