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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4366_Библиотеки_им_академика_М_И_Перельмана
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Chapter Postoperative Management of the Rhinoplasty Patient 135
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Rod J. Rohrich, MD
Plastic Surgery
Rhinoplasty (Nasal Surgery)
AFTERCARE INSTRUCTIONS
◾
When sleeping, keep your head elevated on two pillows for the first 7days after surgery.
◾
During the day for the first 72hours after surgery, apply crushed ice in an ice bag or Swiss eye pads (obtained
from the hospital) to minimize swelling and bruising. Do not put pressure on the nasal splint.
◾
It is normal to continue to swell after the first 48hours. Swelling reaches its peak at 48 to 72hours.
◾
If you have pain, take the pain medication every 4 to 6hours. It is best to take it with crackers, Jell-o, etc. If you
have no pain, do not take the medication. You should not use alcohol while you are taking a pain medication.
◾
If you feel anxious, take the antianxiety medication (Xanax) every 8hours for the first 24 to 48hours. DO NOT
TAKE THE SLEEPING PILL IF YOU TAKE XANAX.
◾
After surgery, begin on that day with a light diet of liquids only. The next day you can begin a soft, regular diet
but for 2weeks avoid foods that require excess lip movement such as apples, corn on the cob, etc.
◾
You will probably have a bloody nasal discharge for 3 to 4days, and you may change the drip pad under your
nose as often as needed. Do not rub or blot your nose, because this will tend to irritate it. You can discard the
drip pad and remove the tape on your cheeks when the drainage has stopped.
◾
To prevent bleeding, do not sniff or blow your nose for the first 2weeks after surgery. Try not to sneeze, but if
you do, sneeze through your mouth.
◾
While the nasal splint is on, you may have your hair washed beauty salon fashion. Take care to prevent the nasal
splint from getting wet.
◾
Keep the inside edges of your nostrils and any stitches clean by using a Q-tip saturated with hydrogen peroxide
followed by a thin coating of Polysporin ointment. This will help prevent crust from forming. You may advance the
Q-tip into the nose as far as the cotton on the Q-tip, but no farther. You will not hurt anything inside your nose
as long as you are gentle in your actions.
GENERAL POSTOPERATIVE INSTRUCTIONS
◾
Avoid strenuous activity (actions that increase your heart rate above 100 beats per minute [i.e., aerobics, heavy
lifting, and bending over]) for the first 3weeks after surgery. After 2weeks you should slowly increase your
activities so you will be back to normal by the end of the third week.
◾
Avoid hitting your nose for 4weeks after surgery.
◾
After the splint is removed, do not wear glasses or allow anything else to rest on your nose for 4weeks. Glasses
should be taped to the forehead. (We will show you how.) Contacts can be worn as soon as the swelling has
decreased enough for them to be inserted.
◾
The skin of your nose is sensitive to sunlight after surgery. Protect your nose from excessive exposure for 6
months. Wear a wide-brimmed hat and/or apply a good sunscreen (SPF-20 or greater) with both UVA and UVB
protection if you have to be in the sun for prolonged periods.
◾
The nasal splint will be removed 6 to 7days after surgery.
◾
After the nasal splint is removed, the nose can be washed gently with a bland soap, and makeup can be applied.
Moisturizing creams can be used if the nose is dry.
◾
The tip of the nose will sometimes feel numb after rhinoplasty and occasionally the front teeth will feel “funny.”
These sensations will gradually disappear.
◾
Much of the swelling will be gone 2 to 3weeks after surgery. It often takes approximately 1year for the last 10%
of the swelling to disappear. Your nose may feel stiff when you smile and not as flexible as before surgery. This
is not noticeable to others, and things will gradually return to normal.
◾
Take your medications carefully and only as directed.
◾
If you have nausea, vomiting, rash, shortness of breath, or diarrhea after taking your medications, or if you
develop a fever (oral temperature greater than 101.3° F [38.5° C]), develop redness, or have increased pain at
the site of your surgical incisions, CALL THE OFFICE IMMEDIATELY.
Continued
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Rhinoplasty (Nasal Surgery)—cont’d
◾
After your sutures are removed and the internal/external splints are removed, it is recommended that you use a
saline (salt water) solution (Ocean or Ayr Nasal Spray) to gently remove crusty formation from inside your nose,
especially if you have had internal nasal surgery such as septal reconstruction or inferior turbinate resection.
◾
You can use nasal spray (Afrin) intermittently ONLY for the first and second week postoperatively for improved
nasal breathing. If you are taking an airline flight, spray each nostril 30minutes before takeoff and thirty minutes
before landing to help prevent your ears/nose from popping.
◾
If you experience increased nasal bleeding with bright red blood (with a need to change your nasal pad every
30 to 40minutes), notify the doctor immediately. You should sit up and apply pressure to the end of your nose
for 15minutes, and you can use Afrin spray to stop the oozing in the interim. Bleeding usually stops with these
maneuvers.
DRESSINGS
Internal Splints and Packing
We prefer to use Doyle septal splints (Micromedics Inc., St. Paul, MN) in all patients undergoing septal reconstruction and/or turbinate surgery.
e goal is to avoid hematomas between the mucoperichondrial aps, support
and stabilize the septal structures in the midline, protect the mucosa, and prevent the formation of synechiae by apposition of adjacent mucosal surfaces. e
splints are lubricated with antistaphylococcal antibiotic ointment and are inserted
at the end of the operation. ese internal nasal splints should be placed using a
speculum under direct visualization to avoid damage and possible perforation of
the mucoperichondrium. ey are secured with a single through-and-through
- nylon horizontal mattress suture tied loosely to avoid strangulation of the
septum as the tissues swell in the postoperative period.
Chapter Postoperative Management of the Rhinoplasty Patient 137
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Internal nasal splints should be placed using a speculum under direct visualization to avoid damage and possible perforation of the mucoperichondrium.
e splints are removed in the oce, generally days aer surgery. In patients
who have undergone extensive septal reconstruction or repair of septal perforations, the splints may need to be le in place for longer periods (approximately
to days). When nasal splints are le for this duration, the patient should
gently inhale antibiotic ointment through the nose to keep the nasal airway and
splints moist and well lubricated. Comfort is improved with hygiene, keeping
the splints free of clot and mucous plugs to maintain a patent nasal airway. It is
important to remove the internal splints before removing the external splint to
prevent potential displacement of the osteotomies and/or rupture of sutures as
the splints are extracted. Removal is facilitated by removal of the nylon suture,
grasping the leading edge of the splint with a hemostat or toothed forceps, and
asking the patient to breathe out through the nose as the surgeon gently pulls
the splint out.
It is important to remove the internal splints before removing the external splint
to prevent potential displacement of the osteotomies and/or rupture of sutures
as the splints are extracted.
Nasal packing is generally unnecessary and is uncomfortable for the patient.
However, it may be necessary in rare instances, such as to support a ap or gra,
or for uncontrolled bleeding at the end of a procedure. Packing should be removed within hours on the rare occasions it is used.
Nasal packing is generally unnecessary and is uncomfortable for the patient.
Doyle septal splints are frequently used aer septal reconstruction and/or turbinate surgery, because they stabilize septal structures in the midline, protect the
mucosa, and prevent synechiae.
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External Splints
External dressings consist of so tissue taping and application of an external
splint. At the completion of the procedure, the edema is compressed from the so
tissues of the lobule, and the skin is prepared with alcohol and skin adhesive. e
so tissues are taped with -inch paper tape or Steri-Strips. Taping begins at the
supratip break to drape the so tissue in this location intimately to the underlying
nasal skeleton. Strips of dierent lengths are then carefully applied transversely
over the nose, without applying excessive pressure over the sculpted framework.
An additional piece may be applied along the caudal aspect of the nasal lobule to
provide support to the new tip.
A Denver Dorsal Splint (Shippert Medical Technologies Corp., Denver, CO) is
shaped over a cylindrical object whose diameter is similar to the width of the
dorsum and the osseous base of the nose.
As shown above, it is then carefully applied over the upper two thirds of the dor
sum, and its edges are compressed medially to keep the osteotomized nasal bones
in position. Overcompression of the nasal structures with the splint should be
avoided, because this can lead to medial displacement of the osteotomized segments of bone. It is essential to keep the distal end of the splint cephalad to the
supratip area. When extended over this area, the splint may distract the supratip
skin away from the osteocartilaginous framework, creating a dead space that will
be lled by scar tissue. is may compromise the end result because of loss of
the supratip break and/or a supratip deformity. In our practice we have avoided
this problem by using small-sized splints that simply do not extend onto the supratip area. Finally, a drip pad is secured under the nose with esh-colored tape,
secured to tape on the cheeks.
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Overcompression of the nasal structures with the splint should be avoided, because this can lead to medial displacement of the osteotomized segments of bone.
e splint and tape are removed in the oce aer to days using a ne stylet.
e stylet is inserted between the tape and the skin over the dorsum. Gentle sideto-side sweeping movements elevate the tape from the skin, allowing the splint
to be removed without elevating the skin from the underlying osteocartilaginous
framework. Use of the ne stylet minimizes the patient’s pain and discomfort
because virtually no pressure is applied onto the underlying framework during
the removal process.
SUTURES
Columellar sutures (- black nylon) are removed in the oce aer to days.
Some or all of the alar base sutures may be le in place for up to days. Fine-tip
suture scissors or a No. blade can be used to precisely remove these sutures.
Internal nasal sutures are resorbable and do not require removal.
MEDICATIONS
For surgical site infection prophylaxis, an intravenous dose of cephazolin is given
before incision and oral cephalexin is given as postoperative antibiotic prophylaxis for hours.
Vitamins and supplements in general are encouraged as long as they do not cause
excessive bleeding. We have patients stop using any anticoagulants including
aspirin, sh oil, and axseed oil for weeks preoperatively and weeks postoperatively.
Pain medications are prescribed as needed. Patient discomfort with rhinoplasty is
extremely variable and may be attributable to the degree of skeletal manipulation.
Patients more commonly complain of congestion. Narcotics are used for the rst
several days and nonsteroidal antiinammatory drugs (NSAIDs) are frequently
sucient thereaer. Constipation prophylaxis is important when narcotics are
being used to prevent straining, which could cause postoperative bleeding.
Minimal postoperative pain medication is normally required aer rhinoplasty.
Antibiotic agents and steroids are routinely used preoperatively.
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Nausea is not uncommon postoperatively because of the cathartic eect of swallowed blood. Nausea can be prevented or minimized by placing a moistened
throat pack at the beginning of surgery and suctioning the oronasopharynx aer
the throat pack is removed. Intravenous odansetron (mg) is also given intraoperatively and continued for hours postoperatively to prevent nausea and
vomiting. Intravenous dexamethasone (mg) is administered preoperatively to
help reduce postoperative nausea. A short course of oral methylprednisolone
(Medrol Dose-Pak) can be given to help reduce postoperative edema although
no conclusive data exists to show its ecacy.
Incision lines are gently cleaned three times daily using a cotton tip applicator to
apply % hydrogen peroxide diluted to half strength in saline. is will facilitate
easy removal of the sutures. Antistaphylococcal antibiotic ointment is applied to
the incisions and nares for or days.
POSTOPERATIVE PROBLEMS
Bleeding/Hematoma
Light postoperative bleeding is not uncommon in the rst hours aer rhinoplasty.
,,
e patient can control it by elevating the head degrees (to decrease venous pressure) and by spraying oxymetolazone topical solution into the
aected nostril and gently applying pressure to the nostril for minutes. is
process may be repeated twice but if bleeding still persists, the surgeon must see
the patient immediately to control the problem. Initially the surgeon will place
an anterior nasal packing made of wet cotton or Surgicel lubricated with antibiotic ointment in the anterior nasal cavity.
In general, postoperative bleeding will be mild and can be controlled by elevating the head to 60 degrees and gentle nostril pressure for 15minutes. is should
be followed by spraying each nostril with oxymetazoline. If these measures fail,
the patient should be seen. Cauterization with silver nitrate, anterior/posterior
nasal packing, operative exploration and cauterization, and angiographic embolization (rare) may be required.
If these measures fail, the surgeon should remove the internal nasal splints and
irrigate and suction the nasal cavity to remove blood clots and crusts. Cauterization with silver nitrate of oending areas followed by anterior packing of the
nasal cavity is then recommended. If bleeding still persists, hospitalization and/
or posterior packing is considered. Serious bleeding occurs in less than % of patients and must be addressed with operative exploration and cauterization. When
Chapter Postoperative Management of the Rhinoplasty Patient 141
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Mild epistaxis
Head elevation greater than 60 degrees
Oxymetazoline nasal spray
Gentle pressure for 15minutes
Persistent mild epistaxis
Patient should be seen and examined
Oxymetazoline nasal spray
Anterior nasal packing with saline moistened ribbon
gauze or Surgicel
Moderate epistaxis
Removal of nasal splints/packing
Saline irrigation and suctioning to remove blood clots
and crusting to allow identification of bleeding source
Silver nitrate to cauterize the area followed by
anterior nasal packing
Persistent moderate epistaxis
Posterior nasal packing with saline moistened gauze
Consider hospital admission for observation
Major epistaxis
Exploration and cauterization in operating room
Persistent major epistaxis
Consultation for emergent angiographic embolization
this occurs, it is usually aer inferior turbinate resection. Bleeding that is refractory to all of these measures is best addressed with angiographic embolization.
Postoperative hematomas require drainage, regardless of location. Septal hematomas can lead to septal perforations if untreated, and hematomas underlying
the skin ap lead to brosis and deformation of the nasal appearance. Hematomas may be drained in the oce using a beroptic light source as needed. e
surgeon must carefully pack a -inch gauze strip into the drainage site to prevent
recurrence. It should be removed the following day.
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Infection
Infection following rhinoplasty is very rare. Early signs of infection are typical of
cellulitis and include tenderness, erythema, and warmth. Early cellulitis usually
responds appropriately to cephalosporin antibiotic agents but all internal splints
may need to be removed at this time. Infection refractory to this treatment may
necessitate treatment with a quinolone or other antibiotic agent providing gram
negative coverage and Pseudomonas coverage more specically. Any purulent
material or exudates should be cultured to guide antibiotic therapy. Purulent
collections require drainage and irrigation. Toxic shock syndrome is extremely
rare aer rhinoplasty but has been reported with both nasal packing and internal nasal splints. Nasal packing and/or internal nasal splints should be removed
immediately, appropriate antibiotic treatment and supportive treatment should
be started, and hospital admission is frequently required.
Purulent collections require drainage and irrigation.
Persistent Edema
Edema should be considered in two distinct postoperative phases: early and late.
Early edema occurs within the rst weeks. Minimizing early edema is best addressed by prevention using cold compresses, head elevation, taping, and avoiding salt laden foods.
Late edema is that which is present over the following several months to the rst
postoperative year (or longer following secondary rhinoplasty) and actually rep
resents scar remodeling. Persistent edema will therefore resolve on its own; the
patient should be reassured about this. In certain situations steroid injections may
be helpful to control the production of the excessive scar tissue that may occur
in some areas of the nose, masking the result. e most common indication in
our practice has been attenuation or loss of the supratip break, which is caused
by the proliferation of scar tissue in the dead space between the skin and underlying osteocartilaginous framework, as seen in secondary rhinoplasty patients
and in men with thick skin.
In these patients, triamcinolone acetate (mg/ml) mixed with % lidocaine
plain at a : ratio can be injected into the supratip area with a -gauge needle.
ese injections should be deep in a plane, just supercial to the perichondrium.
Subdermal steroid injections should be avoided, because they can lead to hypopigmentation, tissue atrophy, and ulceration. Typically to mg of triamcinolone is delivered to the aected area per treatment. is may be performed
,
-
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as early as week postoperatively. Treatment may be repeated at - to -week
intervals, depending on the clinical picture.
Steroid injections may be required to treat persistent edema and should be deep
in a plane just supercial to the perichondrium. Subdermal steroid injections
should be avoided, because they can lead to hypopigmentation, tissue atrophy,
and ulceration.
e dose, volume, and frequency of injections should be limited to avoid overtreatment leading to subdermal atrophy. is may result in unsightly contour
deformities, translucency of the epidermis, and visibility of the underlying cartilages.
Taping of the so tissues is an eective treatment for both early and late edema.
Aer removal of the initial dressing, patients are instructed to apply Blenderm
surgical tape (M, St. Paul, MN) to the supratip area for several hours overnight.
is prevents accumulation of edema when the patient is recumbent while sleeping and helps to mold the so tissues in the supratip area when needed. is may
be interrupted when a permanent depression is generated in the supratip area.
Taping is particularly useful in the rst week or two aer the dorsal splint is removed. Alternatively, the nasal dorsum may be taped using Steri-Strips from
the supratip to radix immediately aer removal of the external splint and this
tape can be le in place for another week. If the tape causes skin irritation, its
use should be discontinued, and the patient should apply hydrocortisone cream
three times a day until the irritation resolves.
Taping to control so tissue edema is particularly useful in the rst week or two
aer removal of the dorsal splint.
Dorsal Irregularity/Deviation
Occasionally, dorsal irregularities or deviations will occur in the postoperative
period. e patient is examined to determine the cause and severity. Palpation of
the dorsal irregularity may reveal displacement of cartilage, bone or gras and it
may be possible to correct this with digital repositioning of the structure. Minor
fullness at the keystone area may develop in the rst few weeks following rhinoplasty and may be due to a periosteal inammatory reaction. In this case, the
patient is instructed to massage the area in a very controlled manner to help prevent the formation of scar tissue and periosteal thickening at the keystone area.
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Mild irregularities are observed for the rst year. ose that persist and remain
objectionable are corrected operatively. Signicant early postoperative irregularities should be corrected immediately because they will not improve. is early
intervention will help prevent unnecessary patient distress and dissatisfaction.
Signicant early postoperative irregularities should be corrected immediately
because they will not improve. is early intervention will help prevent unnecessary patient distress and dissatisfaction.
Dorsal deviations are treated similarly. Deviations noted in the early postoperative period may be corrected with manual pressure. Signicant deviations in the
early postoperative period may require early operative intervention. Late presenting deviations will require operative intervention aer allowing year for
resolution of edema and scar maturation.
Nasal Airway Obstruction
Nasal airway obstruction in the postoperative period is either secondary to
edema or anatomic. Most patients have some degree of transient airway obstruction that will resolve over to weeks. It is dicult to perform internal examination of the nose before weeks because it causes patient discomfort; the
surgeon must reassure the patient that the obstruction should resolve. When
the obstruction persists, the surgeon should examine the patient with and without topical vasoconstrictors to determine the cause of obstruction. Obstruction
secondary to edema is monitored. In many instances, the patient will notice improvement of their symptoms secondary to edema and mucosal hyperreactivity by using saline nasal spray two or three times per day. Nasal decongestants
may be used if symptoms are signicant but topical agents should not be used
for more than to days because of rebound eects of the medication. Maximal
recovery of nasal airow should occur between to months aer rhinoplasty.
Anatomic obstruction requires surgical intervention but this should be delayed
for at least year to allow for scar tissue maturation. e most common anatomic
cause is internal nasal valve collapse or scarring in the internal nasal valve area.
POSTOPERATIVE FOLLOW-UP
Patients return for follow-up visits at week, weeks, weeks, months (postoperative photographs are taken at this time), year, and then every to years
for evaluation of long-term results.
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