Purpose: The timing, schedule, and doses of dexamethasone administration to control edema are a topic of debate. This prospective observational study was performed to evaluate the effects of perioperative and intraoperative administration of dexamethasone on the occurrence of edema in patients who underwent rhinoplasty. Methods: This study was conducted at Najran University Hospital, Najran University, Saudi Arabia, from June 2019 to August 2020. Seventy-five patients who underwent open rhinoplasty were assigned using a consecutive non-random sampling method into three groups, with 25 patients in each group. Group A patients received three doses of intravenous 8 mg dexamethasone perioperatively, and group B patients received a single dose of intravenous 8 mg dexamethasone intraoperatively. Group C patients received intravenous 2 mL of 0.9% normal saline solution intraoperatively and were considered as a control group. Digital photographs of patients were obtained and assessed on the 1 st, 7 th, and 14 th days post-operatively. Results: The mean duration of operation was comparable between the studied groups (p = 0.368). On comparing the studied groups, significant differences in the edema scores were observed on the 1 st and 7 th day post-operatively (p < 0.001 for both), but not on the 14 th day (p = 0.079). When comparing each group against the postoperative day of evaluation, statistically significant differences were detected between the 1 st vs. 7 th day and 1 st vs. 14 th day in Group A, whereas, in the other groups, no significant difference was detected (all p > 0.05). No Dexamethasone-related complications were observed. Conclusion: Dexamethasone significantly reduced periorbital swelling and edema after rhinoplasty compared to the control group. A short course of triple dose perioperative administration of dexamethasone is more potent in reducing edema from 1 st to 7 th day postoperative than a single dose intraoperatively.
Rhinoplasty is a common, popular, and challenging cosmetic procedure routinely performed in the domains of otolaryngology, maxillofacial, and plastic surgery [
To reduce this primary adverse effect of postoperative edema associated with rhinoplasty, various drugs, mechanisms, and techniques have been investigated. Drugs such as corticosteroids, tranexamic acid, decongestants, fibrin sealants, lignocaine with adrenaline, natural herbal products such as Arnica Montana, papaya extract papain have also been recommended. Specific mechanisms such as nasal packing, tapping, postoperative heal elevation, cold application, intraoperative hypotension, drainage tubes have also been investigated to reduce edema in the postoperative period. Some modifications in the traditional rhinoplasty technique such as subperiosteal tunneling, piezotome, sharp micro-osteotome, preserving periosteal attachment have also been reported in various literatures [
Nevertheless, corticosteroids remain the mainstay in managing postoperative complications by reducing the swelling, bruising, and recovery time. Steroids act by reducing vascular permeability, leading to less exudation of tissue fluid and decreased edema. This happens through a cascade of inflammatory responses involving fibrin deposition, capillary dilation, migration of lymphocytes, and phagocytic activity [
Dexamethasone is the most common and suitable corticosteroid used clinically due to its inexpensive availability, highest anti-inflammatory response, early-onset action, and long biological half-life of 36 - 72 hours [
This prospective cohort study was conducted at the College of Medicine, Najran University, Kingdom of Saudi Arabia, between June 2019 and August 2020. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement guidelines when reporting this manuscript [
Adult patients (aged between 18 and 50 years) of both genders who were operated for open rhinoplasty were included in the current study. We excluded patients with a history of coagulation disorders, diabetes mellitus, peptic ulcer, hypertension, tuberculosis, previous rhinoplasty, body dysmorphic disorder, glaucoma, and known allergy to steroids.
A consecutive non-random sampling method was used to recruit patients. The current study included three groups of patients. Group A included 25 patients who received three doses of 8 mg dexamethasone intravenous (IV) perioperatively, and group B included 25 patients who received a single dose of 8 mg dexamethasone IV intraoperatively. Group C included 25 patients who received 2 mL of 0.9% normal saline solution IV intraoperatively as a control group.
Demographic data, including age, gender, duration of surgery (minutes), and duration of anesthesia (minutes), were recorded for each patient. All patients were operated on by me using a similar technique. Operations were performed in general anesthesia with endotracheal intubation, and 5 mL of 1% lidocaine with 1:100,000 adrenaline was additionally infiltrated at the osteotomy sites. Propofol 2 - 3 mg/kg, rocuronium 0.6 mg/kg and fentanyl 50 - 75 mcg were administered during induction. Anesthesia was maintained with sevoflurane 2% in 40% - 60% oxygen-air mixture and remifentanil 0.125 µg/kg/min intravenously. Mean arterial blood pressure was maintained between 90 - 100 mmHg during the procedure, and any complications were recorded. Dorsal hump removal and bilateral lateral osteotomies via transcutaneous approach were performed on each patient. The nasal septum was supported using silastic sheets, and splints were placed for a week. No attempts were made to control the edema during or after the surgery with pressure packs or ice packs. All patients received similar postoperative care and instructions, including head elevation 30 - 45 degrees for 48 hours, paracetamol 500 mg four times a day, and antibiotic amoxicillin 500 mg three times a day for seven days.
All patients were discharged on the second day post-operatively and were recalled on the 7th and 14th days for regular follow-up. Digital photographs of patients were obtained on the 1st, 7th, and 14th days post-operatively. Two independent observers assessed the patients’ digital photographs and scored the edema as follows: no edema was graded as 0, mild edema with 0% - 25% involvement of the eyelid was graded 1, moderate edema with 25% - 50% eyelid involvement covering iris was graded 2, severe edema with 50% - 75% eyelid involvement getting to the pupil was graded 3, and inability to open the eye with >75% massive eyelid involvement was graded 4.
All analyses were done using the Statistical Package for Social Science (SPSS software version 20 for Windows). Categorical data were expressed as counts and percentages, while continuous data were presented as mean and standard deviation (SD). For comparison of categorical and continuous data, the chi-square test and one-way analysis of variance (ANOVA) were used as appropriate. The severity of edema between the groups was compared using the Kruskal-Wallis test and within the groups using the Friedman test. A p-value of < 0.05 was statistically significant.
A total of 75 patients (39 female and 36 male) were photographically evaluated in this study. The mean age was 22.14 years (SD = 5.45), 24.66 years (SD = 6.73), and 25.96 years (SD = 5.17) among group A, B, and C patients, with no significant difference between the studied groups (p = 0.087). The mean duration of operation was comparable between the studied groups; it was 170.42 in group A, 172.84 in group B, and 179.56 in group C (p = 0.368).
Postoperative periorbital edema was assessed on the 1st, 7th, and 14th days following rhinoplasty, as shown in
Group A (n = 25) | Group B (n = 25) | Group C (n = 25) | p-value | |
---|---|---|---|---|
Age (years) | 22.14 ± 5.45 | 24.66 ± 6.73 | 25.96 ± 5.17 | 0.087α |
Weight (kg) | 65.64 ± 11.54 | 68.26 ± 8.73 | 66.75 ± 9.36 | 0.452α |
Height (cm) | 165.32 ± 8.85 | 163.51 ± 9.11 | 169.93 ± 11.61 | 0.387α |
Gender (M/F) | 13/12 | 12/13 | 11/14 | 0.852β |
Duration of operation (min) | 170.42 ± 16.34 | 172.84 ± 15.67 | 179.56 ± 16.92 | 0.368α |
Values are expressed in mean ± standard deviation or number; αp > 0.05 One-way ANOVA between groups; βp > 0.05 chi-square test between groups; Group A included patients who received three doses of 8 mg dexamethasone IV perioperatively; Group B included patients who received a single dose of 8 mg dexamethasone IV intraoperatively; Group C (control group) included 25 patients who received 2 mL of 0.9% normal saline solution IV intraoperatively.
Edema (upper and lower eyelid) | Group A | Group B | Group C | p-valueα |
---|---|---|---|---|
Day 1 | 10 (40%) | 12 (48%) | 16 (64%) | <0.001 |
Day 7 | 5 (20%) | 9 (36%) | 13 (52%) | <0.001 |
Day 14 | 3 (12%) | 4 (16%) | 5 (20%) | 0.079 |
p-valueβ | <0.001 | <0.001 | <0.001 |
Values are expressed as frequencies and percentages; αKruskal-Wallis test; βFriedman test; Group A included patients who received three doses of 8 mg dexamethasone IV perioperatively; Group B included patients who received a single dose of 8 mg dexamethasone IV intraoperatively; Group C (control group) included 25 patients who received 2 mL of 0.9% normal saline solution IV intraoperatively.
When comparing each group against the postoperative day of evaluation, a statistically significant difference was found between the 1st vs. 7th day and 1st vs. 14th day in Group A, whereas, in the other groups, no significant difference was detected (all p > 0.05). No complications related to the administration of dexamethasone were detected among the study participants.
The details of postoperative edema along the period of study are shown in
The persistent edema and ecchymosis can change the patients’ perception of the procedure and produce a range of negative impactions. Edema post-rhinoplasty
Grade | Day 1 | Day 7 | Day 14 | |
---|---|---|---|---|
Group A (n = 25) | 0 | 15 (60%) | 20 (80%) | 22 (88%) |
I | 4 (16%) | 1 (4%) | 3 (12%) | |
II | 4 (16%) | 3 (12%) | 0 (0%) | |
III | 2 (8%) | 1 (4%) | 0 (0%) | |
IV | 0 (0%) | 0 (0%) | 0 (0%) | |
Group B (n = 25) | 0 | 13 (52%) | 16 (64%) | 21 (84%) |
I | 2 (8%) | 3 (12%) | 3 (12%) | |
II | 7 (28%) | 4 (16%) | 1 (4%) | |
III | 2 (8%) | 2 (8%) | 0 (0%) | |
IV | 1 (4%) | 0 (0%) | 0 (0%) | |
Group C (n = 25) | 0 | 9 (36%) | 12 (48%) | 20 (80%) |
I | 2 (8%) | 5 (20%) | 3 (12%) | |
II | 2 (8%) | 5 (20%) | 1 (4%) | |
III | 8 (32%) | 2 (8%) | 1 (4%) | |
IV | 4 (16%) | 1 (4%) | 0 (0%) |
0 = no edema, I = mild edema, II = moderate edema. III = severe edema, IV = inability to open the eye; Group A included patients who received three doses of 8 mg dexamethasone IV perioperatively; Group B included patients who received a single dose of 8 mg dexamethasone IV intraoperatively; Group C (control group) included 25 patients who received 2 mL of 0.9% normal saline solution IV intraoperatively.
could cause post-rhinoplasty dissatisfaction syndrome [
In this study, dexamethasone significantly reduced the periorbital edema and swelling in the postoperative period compared to the control group (normal saline). A triple dose perioperative administration of dexamethasone is more potent in reducing edema from the 1st to 7th day than a single dose intraoperatively. However, by the 14th day, the therapeutic effects of steroids wear off, and there is no difference regarding the severity of periorbital edema against the control group.
The efficacy of corticosteroids to reduce postoperative edema and ecchymosis remains debatable and controversial due to conflicting results of various research publications. The first attempt through a prospective randomized controlled trial was made by Griffies et al. in 1989, who concluded that a single dose of 10 mg dexamethasone could significantly reduce facial edema compared to a placebo [
In this study, a triple dose of perioperative dexamethasone would reduce the edema till the 7th day post-operatively, after which the difference is negligible. Previous studies have used superior imaging techniques such as 3D surface scans [
Dosage and timing of steroid administration for effective edema control after rhinoplasty has been suggested in previous literature. Hatef et al. reported that preoperative dosage was superior to postoperative dosage and extended administration was superior to single bolus dose [
This variation in the effect of dexamethasone with different timings and dosage can be attributed to its long half-life, gene expression on the target cells, patient profile, associated morbidity, and the extensiveness of the surgical procedures. The outcome can also differ due to the variable response of the hypothalamic-pituitary-adrenal axis and suppression of the adrenal glands. Moreover, the interference of steroids on the healing of tissue and infection of the surgical site can also be a cause of concern [
This study has a few limitations, including the small sample size and subjective assessment and evaluation method. Superior imaging techniques such as 3D scanning, MRI, ultrasonography, and stereophotogrammetry can be used to evaluate the extent and intensity of edema post-rhinoplasty; however, we could not assess it. Further investigations can be done employing various other drugs, regimes, schedules, and dosage to better understand the postoperative benefits, complications, associated adverse effects, surgeon satisfaction, and patient outcome.
In conclusion, dexamethasone has significantly reduced periorbital swelling and edema after rhinoplasty compared to the control group. A triple dose perioperative administration of dexamethasone significantly reduced edema from the 1st to 7th day compared to a single dose intraoperatively. However, by the 14th day, there is no difference regarding the effect of steroid administration on the severity of edema. This study supports the use of dexamethasone in rhinoplasty to reduce postoperative complications, associated morbidities and enhance the early recovery of the patients.
Dr. Ali Abdullah Alshehri would like to thank Dr. Ahmed Jalal and Dr. Habib Bashir for their efforts being independent assessors.
The author declares no conflicts of interest regarding the publication of this paper.
Alshehri, A.A. (2022) Perioperative Dexamethasone and Post-Rhinoplasty Edema: A Prospective Observational Study. International Journal of Otolaryngology and Head & Neck Surgery, 11, 1-11. https://doi.org/10.4236/ijohns.2022.111001