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Aesthetic Plastic Surgery - 1998
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Aesth. Plast. Surg. 22:245-252, 1998
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Andrι Camirand M.D., Jocelyne Doucet. R.N., and June Harris
Montreal, Quebec Canada
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Abstract
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In a review of 812 cases of rhinoplasty. none of our patients had early bone or septal displacement; swelling, bruising, and pain were almost nonexistent. This confirms that an external splint would not have been of any benefit in these cases. Packing should help prevent epistaxis, synechiae. and early bone and septal displacement. Not using any packing, we have not encountered these complications. Besides, we have not seen a single submucosal hematoma or a septal necrosis. Therefore, we doubt the value of packing in our patients. The inconveniences and complications of external splints and internal packing are described. Early postoperative photographs show the reduced swelling and bruising, and late photographs show the final results. Difficult primary and secondary rhinoplasty cases are demonstrated.
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Key words : Rhinoplasty-Nasal cast-Nasal splint-Nasal packing-Bruising (reduced)-Edema (reduced)
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Correspondence to Andrι Camirdand, M.D., 12245 Rue Grenet, bureau 112B. Montreal, Quebec H4J 2J6, Canada
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During residency training, plastic surgeons are taught to immobilize the bones of the nose after performing an osteotomy. A pliable metal splint or a paper-thin, weak cast is fixed to mobile skin and then attached with stretchable Elastoplast; logically, nothing could be more unstable. Packing is inserted into the nostrils to maintain immobilization, to prevent bleeding and septal hematomas, and to avert synechiae; however, this conventional approach may actually cause edema and hematomas. When both internal packing and an external splint are applied, the venous capillaries are compressed, interfering with venous return and the healing process. Thus, blood is evacuated upward toward the eyelids and creates "black eyes." In addition, packing is aversive because of the resulting pain, headaches, and nauseating odors. When the packing is removed, relief is immediate, but the removal is often painful and frequently causes bleeding.
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By using small instruments and reducing trauma to nasal tissues when performing rhinoplasty, we have been able to eliminate nasal packing and external immobilization. General edema and ecchymosis of the eyelids are decreased significantly. Some of our patients can breathe through the nose with little difficulty within minutes after surgery, and there is virtually no pain. Since 1979 we have surgically manipulated well over 1000 noses, with very few complications. The technique we use results in minimal swelling and bruising (Table 1) .
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Table 1. Outcomes of rhinoplasties performed without splints.*
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| Role of a splint |
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1. |
Immobilize bone |
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2. |
Immobilize septum |
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3. |
Decrease swelling |
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4. |
Decrease pain |
| Of our 8 I2 rhinoplasties without a splint |
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1. |
Early bone displacement |
0 |
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2. |
Early septal displacement |
0 |
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3. |
Excessive swelling |
0 |
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4. |
Excessive pain |
0 |
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*We reviewed only 812 charts but we have performed the technique in well over 1,OOO cases. |
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| Fig. 1. (A) Preoperative. (B ) Four days following a rhinoplasty, the patient presents minimal swelling and ecchymosis. |
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| Fig. 2. ( A ) Preoperative. (B ) Six days following an extensive septorhinoplasty. There is swelling and eyelid ecchymosis, but we feel that a splint and external immobilization could have made them worse. |
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Technique
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If rhinoplasty is done under local anesthesia, we use narcolepsy. When the patient arrives, we administer 15 mg of diazepam orally. Once the patient is on the operating table and the markings on the nose are made, we generally inject 2 ml of fentanyl intravenously (more fentanyl can be given to heavier patients) over a period of 3 min. Not only does this sedate the patient, but its strong analgesic effect facilitates infiltration of the nose, which must be undertaken within 10 min. Occasionally, at the time of osteotomy, we administer a further 1 ml of fentanyl. The patient is monitored with an oximeter and the attending staff are trained in cardiopulmonary resuscitation; however, we have used narcoleptics extensively, without any incidents.
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Undermining of the dorsum of the nose is kept to a minimum, allowing a rasp to be inserted. The bony dorsal hump is rasped down and the cartilaginous hump is resected with the blade of a scalpel. The nose is shortened by resecting the membranous septum and, if necessary, some cartilaginous septum. A narrow osteotome is used, with a narrow guard. Undermining of the skin or mucosa is avoided. We do not use a midline fracture because we want to maintain the nasoorbital line and keep the fractured bones stable. We rarely, if ever, see indications for this maneuver. A "greenstick fracture" is performed by inserting the osteotome past the midpoint of the bone. We then raise the osteotome and rotate it internally, creating a greenstick fracture with a very solid cephalic attachment (Figs.1-8) .
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| Fig. 3. (A,B) Preoperative views of a patient. (C,D) Frontal and lateral views of the patient 5 days following a rhinoplasty. |
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With this technique, the cephalic part of the bone is not separated from the forehead bone. It will not narrow the radix, which, in our experience, rarely requires narrowing. In addition to maintaining nasoorbital continuity, this technique ensures that there is strong stability without creating either the floating fragments of a conventional lateral bone fracture or the midline separation of a medial osteotomy. There is little chance that bone fragments can be displaced. In fact, once done, we often ask our visiting surgeons to mobilize the head by moving the reduced bones with their fingers. The fact that this can be done proves that the bones are very stable and do not require splinting or any other form of immobilization. Another advantage of this technique is that the osteotome will not transect the angular artery, the most common cause of excessive ecchymosis of the eyelids. A deviated septum is relocated by hatching its concavity. The septum may have to be detached from the vomer, and occasionnaly we fracture the nasal spine. Instead of resecting the cartilage or the bone, we relocate it. In cases with hypertrophied lower turbinates, we use bipolar cautery with good success. Unlike conventional turbinectomy, there is no need for packing. The coagulation prevents bleeding and risks of synechiae. We suture all the vestibular skin and mucosa, eliminating the risk of synechiae and septal hematomas*. If we undermine the mucosa of the septum, we use "U"-type stitches to reapproximate the mucosa onto the septum. A few Steri-strips are applied to shape the skin and the underlying bone and cartilage.
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*A tight anterior packing can prevent the evacuation of a submucosal hematoma posterior to this packing
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The outcomes of our rhinoplasty procedures performed without splints or packing are illustrated in Table 1 .
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The general public is at times afraid of a rhinoplasty because of the pain, the black eyes, and the dressing, but their greatest fear is of the removal of the packing.
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Results
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We have reviewed the operative protocols of the > 800 rhinoplasties performed. None of these patients had an external immobilization (splint or cast) and none had a nasal packing. We perform osteotomies on all of our patients.
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| Fig. 4. (A,B) A patient referred to us following a previous rhinoplasty. (C,D, ) Six days following an open secondary rhinoplasty. There is very little swelling and ecchymosis. (E,F) Five months following the secondary rhinoplasty. |
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We were very impressed to note that the swelling was minimal. A large number of our patients had no "black eyes," and if they did, it was minimal (Figs. 1-8) . We prescribe Arthrotec b.i.d. for 5 days and Tylenol Extra Strength every 4 h p.r.n. None of our patients complained of excessive pain and none required more medication.We had no bone or septal displacements in the early postoperative period (Table 1) . One hundred fifty-two patients returned for secondary rhinoplasties (Tables 2) . We follow our patients very closely for at least 1 year. We are very demanding and expect our patients not to hesitate to ask for further improvement even if it is minimal. We work very hard to maintain a good rapport with our patients; however, we realize that some patients must have gone to other surgeons for further opinions and possibly had secondary rhinoplasties, but we do not have any statistics on this occurrence.The majority of patients submitting to secondary rhinoplasty require one or more of the following: reduction of the dorsal projection, shortening of the nose, narrowing of the tip, or reduction of the lumen of the nostril caliber.
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| Fig. 5. (A,B) Postoperative nasal deformity. (C,D) Less than a week following the secondary rhinoplasty, there is minimal swelling and ecchymosis. (E,F) Final postoperative result, 3 years, 4 months later. |
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However, 16 patients required secondary osteotomies because of late bony displacement.
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The cause for these was either trauma or an underlying septal displacement redisplacing the bones. The absence of immobilization was never a cause (Table 2) .
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Another 16 patients required septal relocation. As we know, cartilage has a memory, and all of these displacements were late and would not have been prevented by the presence of a splint or packing left in place for 1 week.
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No epistaxis required treatment. We had very few patients with early adherence in the vestibular area, but all were freed using a speculum in the examining room. No one had synechiae as a cause for reoperation (Table 3) . None of our patients had submucosal hematoma necessitating drainage and there were no cases of septal necrosis. No patient suffered from rhinitis, otitis, or sinusitis and there were no cases of asphyxia by nocturnal aspiration or cases of septic shock.
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Table 2. Occurence of secondary rhinoplasties after our 812 rhinoplastises.
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1. |
Secondary rhinoplasties |
152 |
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2. |
Secondary osteotomies |
16 |
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3. |
Secondary septoplasties |
16 |
| Other reasons for our secondary rhinoplasties |
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1. |
To lower the dorsum |
0 |
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2. |
To shorten the nose |
0 |
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3. |
To narrow the tip |
0 |
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4. |
Alar plasty |
0 |
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Table 3. Outcomes of rhinoplasties performed without packing.
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| Role of packing |
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1. |
Prevent epistaxis |
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2. |
Prevent synechiae |
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3. |
Prevent early septal displacement |
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4. |
Prevent early bone displacement |
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6. |
Prevent submucosal hematoma |
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5. |
Prevent septal necrosis |
| Of our 812 rhinoplasties without packing |
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1. |
Epistaxis |
0 |
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2. |
Synechiae requiring treatment |
0 |
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3. |
Early septal displacement |
0 |
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4. |
Early bone displacement |
0 |
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5. |
Submucosal hematoma |
0 |
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6. |
Septal necrosis |
0 |
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| Fig. 6. (A-D ) Final result close to 2 years following feminization of the nose in a transsexual. |
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Table 4. Complications of external immobilization (metal splint or cast).*
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| Pain |
| Scar |
| Skin necrosis |
| Skin infection |
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*This occurs particulary when an internal packing is pressing from the inside against the exterior rigid immobilization.
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Discussion
Presumably, external splints (either a cast or metal splint) should immobilize bony fragments and possibly the septum.
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The splint, which is malleable, and a weak, paperthin cast cannot immobilize anything. Both offer no resistance as you can easily bend or break them with your thumb and index finger. Even if they were strong, any lateral blow such as lying on one's nose would displace the structures (bone or septum) if they were unstable. I am occasionally told that a splint is applied to remind the patient that he had a rhinoplasty! It has been our experience that all of our patients know they have had a rhinoplasty and even without a splint they will do anything to avoid a nasal trauma.
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If the splint has a frontal extension, it is fixed to the forehead which is a very mobile structure. By the same token, one should not expect much stability from a fixation on the mobile cheek. Some surgeons fix it with stretchable Elastoplast. It is not logical to believe that an immobilization could be accomplished using this method.
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Following a rhinoplasty patients will experience irregular swelling, and an external splint cannot mold to adjust to this swelling; therefore, there are inevitably areas of pressure. The inferior sharp edges will compress the skin and can cause pain; they will also interfere with venous return (Table 4) . This is compounded by the use of nasal packing. One must remember that the venous capillaries have a blood pressure of 25 mm Hg. There is inevitable congestion, which will create more swelling and pain, with the additional possibilities of necrosis, infection, and an ensuing scar. Congestion is not physiological and interferes with healing. A greenstick fracture without a midline fracture will provide greater stability and no need for an external splint. It eliminates the inconveniences and complications of an external splint, which is removed a few days or a week later. Remember that if there is displacement of the bones or septum, this occurs after weeks or months. Interestingly, we have also noticed that not using an external splint causes a further reduction in swelling and pain.
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The nasal packing is not physiological (Table 5) -- applies pressure on the internal structures, compresses venous capillaries, and is often a cause of swelling and pain. Our incisions are loosely sutured and will allow evacuation of blood. A packing will interfere with this evacuation and the blood will diffuse into a plane of lesser resistance---the eyelids---resulting in palpebral ecchymosis, which is one of the stigmas of a rhinoplasty. A packing is unpleasant and painful, and a cause of headache, bad odor, and airway obstruction. All of these symptoms improve on removal of the packing, but often this removal is accompanied b y some pain and persistent bleeding. Not only is a packing not hygienic, but it is unhealthy and dangerous. It can be a cause of rhinitis, sinusitis, and otitis, and septic shock or asphyxia by noc turnal aspiration has occasionally been reported (Table 6) . It has no immobilizing virtues because it is removed after a few days, and a bony or septal redeviation will take weeks or months to occur. We suture our vestibular skin incision and membranous septal incisions and we have not had one case of synechiae.
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As we do our septoplasties, we undermine the mucosa on the concave side and then hatch the septum to straighten it. We then use Plain Catgut to bring back the mucosa on the septum. We have never encountered submucosal hematomas, septal necrosis, or epistaxis requiring treatment.
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| Fig. 7. (A-D ) A patient referred to us following a rhinoplasty. One and a half years following a secondary rhinoplasty using our technique. |
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Table 5. Inconveniences arising from nasal packing following rhinoplasty.
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| Pain |
| Airway obstruction |
| Bleeding on removal |
| Unpleasant odor |
| Headaches |
| Ecchymosis and swelling of eyelids |
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Table 6. Complications (theoretical) of nasal packing.
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| Sinusitis |
| Rhinitis |
| Otitis |
| Asphyxia by nocturnal aspiration Septic shock |
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Conclusion Using the technique described for well over a thousand rhinoplasties without an external splint and nasal packing, we have not had a single case of epistaxis, syn echia, bony or septal displacement, submucosal hematoma, or necrosis. Based on objective observation, we conclude that this rhinoplasty technique reduces discomfort, pain, swelling, and ecchymosis.
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| Fig. 8. (A-B ) The final result in one of our patients. |
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Reference
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- Camirand A: Reducing to a minimum peri-orbital ecchymosis and oedema when performing a rhinoplasty. VIII Congress of ISAPS, Madrid, Spain, Sept 1985.
- Camirand A: Reducing to a minimum peri-orbital ecchymosis and oedema when performing a rhinoplasty, Canadian Society of Plastic Surgery, Toronto, Ontario, May 1986.
- Camirand A: Rhinoplasty. Reunion Internacional Controversias en Cirugia Plastica. Chihuahua, Mexico, July 1986.
- Camirand A: Nose. Canadian Society of Aesthetic Plastic Surgery, Toronto, Ontario, Sept 1986.
- Camirand A: How to reduce to a minimum peri-orbital oedema and ecchymosis when performing a rhinoplasty. Guadalajara, Mexico, November 1986.
- Camirand A: Rinoplastia sin ferulizacion ni taponamiento [Rhinoplasty without a splint and without packing]. VII Congreso Iberolatino American of Plastic Surgery, Cartagena, Colombia, May 22-28, 1988.
- Camirand A: Reducing periorbital edema and ecchymosis to a minimum when performing rhinoplasty without splints or packing.
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