What risks are involved with rhinoplasty?
Keywords
1. Introduction
Rhinoplasty is a common procedure for both functional and cosmetic purposes. In fact, the American Society of Plastic Surgery ranked it the sixth most common elective procedure for esthetic plastic surgery in 2013. However, it can be associated with significant postoperative periorbital edema and ecchymosis caused by manipulation and trauma of the soft and hard tissues of the nasal and paranasal regions. Postoperative periorbital edema and ecchymosis remain a concern, even for the most experienced surgeons. The surgery’s sequelae can cause social and work-related inconveniences that often result in an elevated level of patient anxiety.1
Osteotomies are a form of (controlled) trauma with a considerable disruption of the abundant blood vessels in this facial region and, therefore, are associated with postoperative effects. Edema and ecchymosis are main concerns for patients after rhinoplasty. Furthermore, in addition to the discomfort associated with excessive edema, such as obstructed vision and nasal blockage, it can also lead to an undesired healing process of the tissues involved, ecchymosis may lead to permanent, undesired pigmentation of the skin. These clinical findings were the origin of the question regarding the possibility of documenting change in intraocular pressure during the postoperative period.2
A normal intraocular pressure (IOP) is essential for normal eye structure and function. When the balance of aqueous formation and drainage is altered, the IOP changes. The IOP elevation results in corneal edema, iris atrophy, cataract, and optic nerve atrophy. The common symptoms of increased IOP are blurred vision, epiphora, headache, nausea, vomiting, or a sensation of pressure in the eyes.3
Glaucoma is characterized by optic nerve damage, leading ultimately to irreversible blindness. Glaucoma is estimated to affect approximately 70 million people worldwide and more than 2 million people in the USA. Variation in IOP has been increasingly considered to be important, with several studies suggesting that its fluctuations are an independent risk factor for glaucoma progression.4
No reports have delineated the possible effects of rhinoplasty on ocular physiological function. The purpose of the present study was to evaluate the IOP status before and after rhinoplasty with osteotomies and to determine whether the variations might produce adverse effects on ocular physiological function. To the best of our knowledge, the relationship of IOP and rhinoplasty on patients with deformed nose has not been addressed in any published literature.
2. Patients
The ethics committee of Ain Shams Faculty of Medicine approved the study. Informed consent was obtained from the patients. Patients with deformed nose undergoing septorhinoplasty were prospectively enrolled in the study. The age of the patients ranged from 21 to 35 years (mean: 28 years).
Exclusion criteria included patients with diabetes mellitus, hypertension, glaucoma, ocular hypertension, previous ocular trauma, history of ocular surgery, and previous use of topical corticosteroid eye drops. Because the fluctuation of episcleral venous pressure results in changes in IOP, any patients with systemic conditions, such as carotid-cavernous fistula and pulmonary hypertension that may induce changes in episcleral venous pressure were excluded from this study.
3. Surgical procedure
Open septorhinoplasty was performed using transcolumellar infracartilaginous incisions and nasal skin envelope elevation in the supraperichondrial and subperiosteal planes. The following steps were tailored according to the preexisting deformity and the patient needs and were discussed with the patient. First, component hump reduction was done in 18 cases [60%]. Next, medial fading osteotomies were performed in those patients without hump 12 cases (40% of cases). Next, lateral osteotomies were performed in fifteen patients with lateral osteotomies with the external perforated technique, and fifteen with the internal continuous technique with periosteal elevation from low to high manner. The osteotomies were followed by cephalic trimming, alar base reduction tip sutures including interdomal and intradomal sutures, lateral crural mattress sutures and alar spanning sutures, and finally tip grafts as columellar struts and tip shield grafts.
4. Evaluation
All patients underwent a complete preoperative ophthalmic examination that consisted of best-corrected visual acuity, slit lamp biomicroscopy, Goldmann applanation tonometry, and dilated funduscopy as baseline data. The IOP of each eye was measured 3 times, and the mean IOP was calculated. Repeated IOP measurements were performed at the same times on day 1, on day 2, and after removal of the internal nasal splints on day 7 postoperatively. Physiological factors, such as heart rate and systolic and diastolic blood pressures, were recorded 10 min after each IOP measurement.
5. Results
23 women and 7 men with a mean age of 27 years were enrolled in the study. All patients had osteotomies. The postoperative ocular symptoms on the first day were edema (23 of 30 [76.6%]) and ecchymosis (7 of 30 [23.3%]). On the second day edema was seen in 28 of 30[93.3%] and ecchymosis in 9 of 30[30%]. On the seventh day edema was resolved in all patients while mild ecchymosis persisted in 2 patients. The mean ± SD IOP of the eye was 15.69 ± 2.37 mmHg preoperatively. Postoperatively, the mean ± SD IOPs were 15.96 ± 1.92 mmHg on day 1, 15.45 ± 2.55 mmHg on day 2, and 15.72 ± 2.86 mmHg on day 7 (P = .863).
6. Statistical analysis
Results were expressed as mean ± SD (Table 1 and Fig. 1). The comparisons of IOPs and physiological factors such as heart rate, systolic blood pressure, diastolic blood pressure, and mean blood pressure were generated preoperatively and postoperatively. The comparisons of these values were determined by the paired t-test. Differences were considered to be statistically significant at P < 0.05 (Table 2, Table 3).
Table 1. Baseline and follow up postoperative intraocular pressure with rhinoplasty.
| N | Mean | Std. deviation | Minimum | Maximum | |
|---|---|---|---|---|---|
| Before | 30 | 15.69 | 2.37 | 12.40 | 19.87 |
| 1st day after | 30 | 15.96 | 1.92 | 11.37 | 18.45 |
| 2nd day after | 30 | 15.45 | 2.55 | 10.85 | 20.34 |
| 7th day after | 30 | 15.72 | 2.86 | 12.50 | 20.77 |
Figure 1. Baseline and follow up postoperative intraocular pressure with rhinoplasty.
Table 2. Comparison between baseline and follow up postoperative intraocular pressure with rhinoplasty using paired (t) test.
| Mean | P value | ||
|---|---|---|---|
| Pair 1 | Before | 15.69 | 0.369 |
| 1st day after | 15.96 | ||
| Pair 2 | Before | 15.69 | 0.241 |
| 2nd day after | 15.45 | ||
| Pair 3 | Before | 15.69 | 0.863 |
| 7th day after | 15.72 | ||
Table 3. Correlations between baseline and follow up postoperative intraocular pressure with rhinoplasty using Pearson correlation.
| 1st day after | 2nd day after | 7th day after | |
|---|---|---|---|
| Pearson correlation | 0.741 | 0.903 | 0.967 |
| P value | <0.001 | <0.001 | <0.001 |
| Sig. | HS | HS | HS |
7. Discussion
Rhinoplasty may cause serious orbital and periorbital complications such as orbital hemorrhage, enophthalmos, exophthalmos, periorbital cellulitis, and blindness.
Most acute orbito-periorbital complications are related to lateral osteotomies. Medial orbital wall damage following osteotomy may result in orbital emphysema as it allows air to enter the orbit from the paranasal sinuses, resulting in high retrobulbar pressure and compression of the bulb.5
Glaucoma is the second leading cause of blindness worldwide and intraocular pressure (IOP) is currently its only modifiable risk factor. Peak IOP has for a long time been considered as a major contributor to glaucoma progression, but its effects may depend not only on its magnitude, but also on its time course. Variation in IOP has been increasingly considered to be important. There is mounting evidence that IOP fluctuations play an important role in the development and progression of glaucoma.6
The Goldmann applanation tonometer (GAT) is still considered the gold standard and most commonly used method of tonometry. Nevertheless, the main disadvantages of the GAT include risk of contamination, the presence of common situations that lead to errors, and that it cannot be performed by assistant medical staff. It is commonly affected by corneal stiffness, thickness, scars, irregularities, and curvature. The presence of corneal epithelial defects and previous corneal surgeries also complicate measurements. Finally, there is a contamination risk, so the tool tip must be cleaned after each use. The more recent Tono-Pen® XL (TPXL), and the non-contact air puff tonometer (NCT) provide IOP measurements comparable to those of the gold standard GAT in normotensive eyes.7
It has been shown that many technical details may affect the incidence of orbital complications, as the usage of different type of osteotomies. It has been shown that using sharp and micro osteotomies reduce surgical trauma and postoperative ecchymosis.8, 9
As major movement of lateral nasal bone is required, authors have also advocated a low to low lateral osteotomy. After their work on thirty adult patients, Helal et al. concluded that both types of osteotomies namely internal continuous or external perforating osteotomy did not differ significantly as regards narrowing of the nasal airway.10
Gryskiewicz and Gryskiewicz compared the external perforating lateral osteotomy with a 2-mm straight osteotome and the internal continuous lateral osteotomy with a 4-mm curved guarded osteotome. The perforating lateral osteotomy reduced postoperative ecchymosis and edema in after rhinoplasty as compared to the internal continuous technique.11
In this study we found slight variations in the postoperative IOP however these variations were not statistically significant. We believe that rhinoplasty with osteotomies should be safe for patients with glaucoma, however monitoring the IOP peri-operatively is advised.
References
- 1
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- 2
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- 3
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- 5
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- 6
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- 7
- I. Yilmaz, C. Altan, E.D. Aygit, et al.Comparison of three methods of tonometry in normal subjects: Goldmann applanation tonometer, non-contact airpuff tonometer, and Tono-Pen XLClin Ophthalmol, 8 (2014), pp. 1069-1074
- 8
- D.G. Becker, R.B. McLaughlin Jr., L.A. Loevner, A. MangThe lateral osteotomy in rhinoplasty: clinical and radiographic rationale for osteotome selectionPlast Reconstr Surg, 105 (2000), pp. 1806-1816
- 9
- G.J. TreniteTrauma reduction in rhinoplastic surgeryRhinology, 29 (1991), pp. 111-116
- 10
- M.Z. Helal, M. El-Tarabishi, S. Magdy Sabry, A. Yassin, A. Rabie, S.J. LinEffects of rhinoplasty on the internal nasal valve: a comparison between internal continuous and external perforating osteotomyAnn Plast Surg, 64 (5) (2010), pp. 649-657
- 11
- J.M. Gryskiewicz, K.M. GryskiewiczNasal osteotomies: a clinical comparison of the perforating methods versus the continuous techniquePlast Reconstr Surg, l113 (2004), pp. 1445-1456discussion 1457–1448
