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Effect of periosteum elevation on periorbital ecchymosis in rhinoplasty
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e538ee539
CORRESPONDENCE AND COMMUNICATION
Effect of periosteum elevation on periorbital ecchymosis in rhinoplasty A technique used to reduce the degree of postoperative ecchymosis following osteotomy is periosteal preservation at the osteotomy site, achieved by elevating the periosteum prior to performing the osteotemy. The intact periosteum is then supposed to act as a barrier for the blood to extravasate to the subcutaneous tissue. However, a recent study by Kara et al.1 on 18 patients showed that the opposite is true. The aim of this study is to reinvestigate this factor in a prospective group of patients. Seventy-eight patients were included in this prospective study from March 2004 to March 2006. All patients included in the study were medically fit and all agreed to sign an informed consent. All operations were performed under general anaesthesia and 1% lidocaine with 1:200 000 epinephrine solution used for local infiltration. After removing the dorsal hump a lateral low to high osteotomy was performed using a 4 mm guarded (curved) osteotome. The osteotomy was performed bilaterally using the same instruments in all patients. Every patient acted as his own control. The osteotomy was done without periosteal elevation on one randomly selected side and after periosteal elevation on the contralateral side using McKenty Freer. The incisions were made at the pyriform aperture just above the level of the anterior end of the inferior turbinate and were not closed thereafter. The subperiosteal tunnel extended from the incision site to the inner canthal level. The osteotomy was completed with a gentle greenstick fracture. After surgery all patients received the same postoperative care, including head elevation at 45 ; no steroids were given.
Patients were seen on the first postoperative day and the degree of ecchymosis was determined by a surgical intern and/or a resident unaware of the elevated side, using the grading system adapted from Hofmann et al. with modification2 (Table 1 and Figure 1). Comparing the two groups of patients (Table 2), GI ecchymosis (moderate ecchymosis) occurred more on the non-elevated side (24.3% compared to 8.9%), while GII ecchymosis (severe ecchymosis) occurred more on the elevated side (88.4% compared to 73.1%). This was proven to be statistically significant (P value Z 0.03) using the Chisquare test. Having facial oedema and ecchymosis after any surgical procedure on the face is normal, but it is very unpleasant for patients coming for an aesthetic procedure. The relationship between postoperative ecchymosis and periosteal elevation is a relatively controversial issue.1e5 In our study, ecchymosis developed to a lesser extent (GI) on the sides where the periosteum was not elevated, despite the higher chance of disrupting blood vessels and causing bleeding. This may be due to the haematoma being contained by the subcutaneous tissues. Ecchymosis was more severe (GII) on
Figure 1
Table 2 Table 1 Grade 0 (G0) Grade I (GI) Grade II (GII)
Ecchymosis grading system
Results Side with elevated periosteum
Side with non-elevated periosteum
G0 GI GII
2 (2.5%) 7 (8.9%) 69 (88.4%)
2 (2.5%) 19 (24.3%) 57 (73.1%)
Total
78
78
No ecchymosis Moderate ecchymosis extending from medial canthus to the level of the pupil Severe ecchymosis extending beyond the level of the pupil.
Left eye, ecchymosis grading system.
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.05.047
Correspondence and communication sides where the periosteum was elevated. This may be explained by the fact that creating a tunnel, though intended to protect the vessels, may at the same time create a plane into which the haematoma may spread to cover a wider area. Based on the results of our study, we recommend performing lateral osteotomy without periosteal elevation.
References 1. Kara CO, Kara IG, Topuz B. Does creating a subperiosteal tunnel influence the periorbital edema and ecchymosis in rhinoplasty? J Oral Maxillofac Surg 2005;63:1088e90. 2. Huizing HG, de Groot JAM. Functional reconstructive nasal surgery. Stuttgart, Germany: Georg Thieme Verlag; 2003. p. 201.
e539 3. Pastorek MJ. The large nose. In: Gates GA, editor. Current therapy in otolaryngology-head and neck surgery. St Louis, MO: Mosbi; 1998. p. 157. 4. Berman WE. Osteotomies. In: Berman WE, editor. Rhinoplastic surgery. Philadelphia, PA: Mosby; 1989. p. 156. 5. Sullvian PK, Harshbarger RJ, Oneal RM. Nasal osteotomies. In: Gunter JP, Rodrich RJ, Adams WP, editors. Dallas rhinoplasty. St Louis, MO: Quality Medical Publishing; 2002. p. 595e611.
Ahmed Al-Arfaj Mohammed Al-Qattan Sami Al-Harethy Khalid Al-Zahrani Department of ENT, Division of Plastic Surgery, King Saud University, Riyadh, Saudi Arabia E-mail address: [email protected]
CORRESPONDENCE AND COMMUNICATION
Effect of periosteum elevation on periorbital ecchymosis in rhinoplasty A technique used to reduce the degree of postoperative ecchymosis following osteotomy is periosteal preservation at the osteotomy site, achieved by elevating the periosteum prior to performing the osteotemy. The intact periosteum is then supposed to act as a barrier for the blood to extravasate to the subcutaneous tissue. However, a recent study by Kara et al.1 on 18 patients showed that the opposite is true. The aim of this study is to reinvestigate this factor in a prospective group of patients. Seventy-eight patients were included in this prospective study from March 2004 to March 2006. All patients included in the study were medically fit and all agreed to sign an informed consent. All operations were performed under general anaesthesia and 1% lidocaine with 1:200 000 epinephrine solution used for local infiltration. After removing the dorsal hump a lateral low to high osteotomy was performed using a 4 mm guarded (curved) osteotome. The osteotomy was performed bilaterally using the same instruments in all patients. Every patient acted as his own control. The osteotomy was done without periosteal elevation on one randomly selected side and after periosteal elevation on the contralateral side using McKenty Freer. The incisions were made at the pyriform aperture just above the level of the anterior end of the inferior turbinate and were not closed thereafter. The subperiosteal tunnel extended from the incision site to the inner canthal level. The osteotomy was completed with a gentle greenstick fracture. After surgery all patients received the same postoperative care, including head elevation at 45 ; no steroids were given.
Patients were seen on the first postoperative day and the degree of ecchymosis was determined by a surgical intern and/or a resident unaware of the elevated side, using the grading system adapted from Hofmann et al. with modification2 (Table 1 and Figure 1). Comparing the two groups of patients (Table 2), GI ecchymosis (moderate ecchymosis) occurred more on the non-elevated side (24.3% compared to 8.9%), while GII ecchymosis (severe ecchymosis) occurred more on the elevated side (88.4% compared to 73.1%). This was proven to be statistically significant (P value Z 0.03) using the Chisquare test. Having facial oedema and ecchymosis after any surgical procedure on the face is normal, but it is very unpleasant for patients coming for an aesthetic procedure. The relationship between postoperative ecchymosis and periosteal elevation is a relatively controversial issue.1e5 In our study, ecchymosis developed to a lesser extent (GI) on the sides where the periosteum was not elevated, despite the higher chance of disrupting blood vessels and causing bleeding. This may be due to the haematoma being contained by the subcutaneous tissues. Ecchymosis was more severe (GII) on
Figure 1
Table 2 Table 1 Grade 0 (G0) Grade I (GI) Grade II (GII)
Ecchymosis grading system
Results Side with elevated periosteum
Side with non-elevated periosteum
G0 GI GII
2 (2.5%) 7 (8.9%) 69 (88.4%)
2 (2.5%) 19 (24.3%) 57 (73.1%)
Total
78
78
No ecchymosis Moderate ecchymosis extending from medial canthus to the level of the pupil Severe ecchymosis extending beyond the level of the pupil.
Left eye, ecchymosis grading system.
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.05.047
Correspondence and communication sides where the periosteum was elevated. This may be explained by the fact that creating a tunnel, though intended to protect the vessels, may at the same time create a plane into which the haematoma may spread to cover a wider area. Based on the results of our study, we recommend performing lateral osteotomy without periosteal elevation.
References 1. Kara CO, Kara IG, Topuz B. Does creating a subperiosteal tunnel influence the periorbital edema and ecchymosis in rhinoplasty? J Oral Maxillofac Surg 2005;63:1088e90. 2. Huizing HG, de Groot JAM. Functional reconstructive nasal surgery. Stuttgart, Germany: Georg Thieme Verlag; 2003. p. 201.
e539 3. Pastorek MJ. The large nose. In: Gates GA, editor. Current therapy in otolaryngology-head and neck surgery. St Louis, MO: Mosbi; 1998. p. 157. 4. Berman WE. Osteotomies. In: Berman WE, editor. Rhinoplastic surgery. Philadelphia, PA: Mosby; 1989. p. 156. 5. Sullvian PK, Harshbarger RJ, Oneal RM. Nasal osteotomies. In: Gunter JP, Rodrich RJ, Adams WP, editors. Dallas rhinoplasty. St Louis, MO: Quality Medical Publishing; 2002. p. 595e611.
Ahmed Al-Arfaj Mohammed Al-Qattan Sami Al-Harethy Khalid Al-Zahrani Department of ENT, Division of Plastic Surgery, King Saud University, Riyadh, Saudi Arabia E-mail address: [email protected]