A Simple and Effective Combined Method for the Management of Postrhinoplasty Ecchymosis and Edema

Sir: Totonchi and Guyuron published a randomized, controlled comparison between arnica and steroids, in a series of 48 patients, in the management of postrhinoplasty ecchymosis and edema (Plast. Reconstr. Surg. 120: 271, 2007). Their conclusion was that arnica (three times a day for 4 days) does not appear to provide any benefit with regard to extent and intensity of ecchymosis, while the use of corticosteroids (10 mg of intravenous dexamethasone intraoperatively followed by a 6/day oral tapering dose of methylprednisone) caused a delay in resolution of ecchymosis, minimizing the benefit of reduction during the early postoperative period. I would like to share my experience based on a simple and effective combined method for the management of postrhinoplasty ecchymosis and edema. In my department, all patients who undergo rhinoplasty receive hypotensive general anesthesia. A solution of mepivacaine 2% and adrenaline local anesthetic is injected with a 25-gauge needle in the mucosa and subcutaneous tissue, reaching, distal to proximal, periosteum (“hydrodissection”). Adrenaline is added to mepivacaine to produce the desired quantity of 1:75,000. The ischemic effect of the adrenaline combined with a reduction of the anesthetic absorption is the advantage of the solution.1 Adrenaline percentage is calculated as in the following example: 25 cc of mepivacaine plus one-fourth of a vial of adrenaline gave a 1:75,000 solution, with one part of adrenaline for 75,000 parts of solution, and so on. Immediately after the osteotomies are performed, gentle pressure is applied on both sides of the bridge of the nose for about 5 minutes. After the operation, an ice bag is placed onto and around the splint for 3 to 6 hours (not continually and not directly onto the skin, but with a gauze interface); in the meantime, a drug solution for pain and sickness control (40 mg of ondansetron hydrochloridre, 30 mg of ketorolac, 100 mg of tramadol, and 10 mg of metoclopramide) is given at 2 ml/hour and blood pressure is monitored every 6 hours. After 24 to 48 hours, depending on the patient’s status, the intravenous drugs are suspended and the patient is discharged.2,3 For a period of 18 months (from January of 2006 to June of 2007), 52 patients underwent rhinoplasty with an osteotomy as part of their procedure. We observed severe postrhinoplasty ecchymosis and edema in fewer than 2 percent of our patients, who required a mean hospitalization of 4 days. Ecchymosis and edema disappeared almost completely within 2 weeks (complete edema absorption requires, in all patients, a mean time of 2 to 6 months to up to 1 year). In the remaining 98 percent of patients, minimal ecchymosis and mild or moderate edema were significantly reduced 10 days postoperatively. At this time, the nasal splints and sutures are removed. The nose may appear swollen and turned up, and the tip may feel numb3; both conditions are expected and resolve with time, with normal sensation returning within 3 to 6 months. Steri-Strips (3M, St. Paul, Minn.) are used for an additional 2 weeks postoperatively to help minimize edema. Finally, patients are instructed to restrict strenuous activity for at least 3 weeks postoperatively and should avoid hitting the nose for 4 weeks. Dimitrios Dionyssiou, M.D. Department of Plastic Surgery The Queen Victoria Hospital Holtye Road East Grinstead RH19 3DZ, England [email protected]