Abstract
Nasal osteotomies are the most important cause of periorbital edema and ecchymosis. Injection of lidocaine and adrenaline is recommended to reduce bleeding. Whilst the lidocaine and adrenaline combination (LAC) is claimed to reduce postoperative ecchymosis and edema, this effect remains to be proven conclusively. This study, on 48 patients, was designed to investigate the effects of LAC injection on postoperative edema/ecchymosis in rhinoplasty. LAC was applied at a random side prior to the lateral osteotomy. The opposite side was used as a control. The relationship between edema/ecchymosis and the degree of LAC on the injected and uninjected sides was evaluated on the first, third and seventh day postoperatively. The relationships between edema and ecchymosis with operation time and intraoperative systolic blood pressure were also evaluated. Bleeding was reduced on the side treated with LAC ( p = 0.050). The degrees of edema/ecchymosis increased with increases in the duration of operation and the systolic blood pressure on the first postoperative day for the LAC-applied side ( p < 0.05). This correlation was not observed on the opposite side ( p > 0.05). Application of LAC reduces bleeding during rhinoplasty and pain control postoperatively but reduced edema and ecchymosis should not be expected following LAC application.
Inflammation and bleeding of the soft tissue result in periorbital edema and ecchymosis during the postoperative period. These commonly occur as a result of lateral osteotomies during rhinoplasty. Different lateral osteotomy techniques have been described to reduce edema, ecchymosis and to achieve the best aesthetic results, including percutaneous and endonasal lateral osteotomies . Other techniques used during the postoperative period include steroid administration (preoperative and/or postoperative), applying pressure on osteotomy sites and taping and periorbital cold pack application . The other controversial issue is whether lateral osteotomy should be performed with or without a subperiosteal tunnel. Some authors have suggested that developing a subperiosteal tunnel carries a greater risk of damage to the overlying vessels . Other authors have suggested that creation of a subperiosteal tunnel due to periosteal elevation lifts the vessels above the osteotomy plane . Some studies have suggested that lidocaine and adrenaline combination (LAC) injection be performed prior to osteotomy, regardless of whether local or general anaesthesia is used . As described above, it has been suggested that LAC injection reduces the extent of postoperative edema and ecchymosis, but many factors contributed to formation of the edema and ecchymosis. The purpose of this study is to investigate the effect of LAC administered to the lateral osteotomy plane on the postoperative degree of edema and ecchymosis.
Materials and methods
Forty-eight consecutive patients were included in this study. The study group consisted of 36 male and 12 female patients with an age range of 20–42 years (mean 27.4 ± 5.7 years). Informed consent was obtained. Permission was obtained from the local ethics committee of Dicle University. Exclusion criteria for this study included history of peptic ulcer, hypertension, psychiatric problems, and allergy to LAC. Female patients were operated on when they were not menstruating. All operations were performed under general anaesthesia composed of remifentanil, propofol, and vecuronium. An open technique was preferred for all patients, with two surgeons operating. A randomly chosen lateral osteotomy side was infiltrated with 2 ml of 2% lidocaine with 1:100,000 adrenaline (Jetokain; Adeka AS, Samsun, Turkey) in a standard manner, taking particular care to avoid intraconchal and intravascular injections. In addition, LAC injection was applied to the tip of the nose and columellar regions in order to facilitate dissection in these regions. LAC injection was not applied to the nasal dorsum, so as not to affect postoperative results.
Osteotomies were performed 10 min after the completion of infiltration. Dorsal hump resection was performed in all patients. Lateral osteotomies were applied bilaterally with guided, curved 4-mm lateral osteotomies without creation of a subperiosteal tunnel by the endonasal approach at the end of the surgery. The lateral osteotomies were carried out to the level of the intercanthal line. Blood pressure was monitored during the operation and early postoperative period. Intraoperative bleeding was recorded by insertion of a plastic tube into each lateral osteotomy plane during the operation. Operation time and problems, if any, were recorded. After surgery, nasal package (3 days) and cast (10 days) were applied to all patients. Analgesics and antibiotics were given to all patients. Steroids were not administered. All patients’ heads were elevated 45° above the horizontal plane, and cold compresses were applied to the cheeks intermittently during the first 12 h postoperatively. The package was removed on the third postoperative day. The patients were examined on the first, third and seventh days for periorbital edema and ecchymosis by a third physician who was unaware which side was treated with LAC. Patients’ data were evaluated and recorded according to a scoring diagram, as described previously ( Figs 1 and 2 ) . The patients’ uninjected sides were taken as the control group. The χ 2 test was used to evaluate differences between the two sides with respect to degrees of edema and ecchymosis. The p value was considered as statistically significant ( p < 0.05). Spearman’s correlation (rho coefficient) test was used to analyse the correlation between operation time, systolic blood pressure, degree of ecchymosis and edema.
Results
All patients experienced some degree of periorbital edema and ecchymosis. Edema and ecchymosis decreased daily in the majority of patients. Edema and ecchymosis were not observed on the seventh day. Grade IV edema and ecchymosis were not seen in any patient ( Fig. 3 ).
Operation times were between 100 and 145 min (120.5 ± 12.21). The systolic and diastolic blood pressures were between 95 and 135 mm Hg (116.8 ± 10.03) and between 55 and 95 mm Hg (69.7 ± 10.6), respectively. The amount of intraoperative bleeding was 204 ± 61 cc on the LAC-injected side and 226 ± 47 cc on the uninjected side. An increase in the degree of ecchymosis was observed on the third day with respect to the first day (in six uninjected and two injected sides) for eight patients. Edema increased in only one patient after the first day. The amount of bleeding on the injected side was lower compared with the opposite side ( p = 0.050). Sex and age had no effect on postoperative edema or ecchymosis ( p > 0.05). There were no statistically significant differences between the LAC-injected and uninjected sides with regard to edema and ecchymosis on the first, third or seventh days ( p > 0.05). The degree of edema ( r = 0.50088) and ecchymosis ( r = 0.40621) increased in association with the duration of the operation (a positive correlation) on the first postoperative day on the LAC-treated side ( p < 0.05) ( Fig. 4 ). This correlation was not observed for the third and seventh days for the LAC-injected side. No correlation was observed between the degree of edema/ecchymosis and operation time/systolic blood pressure on the first, third and seventh days postoperatively on the side that was not injected with LAC ( Fig. 5 ).
There was a positive correlation between systolic blood pressure and degree of edema ( r = 0.34104) and ecchymosis ( r = 0.37654) on the LAC-injected side on the first postoperative day ( Fig. 6 ). This correlation was not seen on the third and seventh days for the LAC-injected side. There was no significant correlation between systolic blood pressure and the degree of edema/ecchymosis in the LAC-uninjected side on the first, third and seventh days postoperatively ( Fig. 7 ).
