Association of Periosteal Sweeping vs Periosteal Preservation With Early Periorbital Sequelae Among Patients Undergoing External Perforating Osteotomy During Rhinoplasty

Key Points

Question

Does periosteal sweeping decrease periorbital morbidities of the early postoperative period after external perforating lateral osteotomy in open rhinoplasty?

Findings

In this cohort study of 28 patients, compared with periosteal preservation, periosteal sweeping was associated with significantly greater eyelid edema and periorbital ecchymosis on postoperative day 1. All patients showed significant decreases in eyelid edema and ecchymosis on postoperative days 7 and 21 compared with day 1 and in subconjunctival hemorrhage between days 1 and 21.

Meaning

Periosteal preservation during external perforating lateral osteotomy may help minimize early postoperative periorbital sequelae.

Abstract

Importance

Periorbital sequelae are a significant source of early postoperative morbidity after rhinoplasty, particularly after an osteotomy is performed.

Objective

To compare postoperative periorbital sequelae after external perforating lateral osteotomy in rhinoplasty using a periosteal sweeping vs a periosteal preserving approach.

Design, Setting, and Participants

This prospective cohort study conducted at a tertiary referral center located in Mansoura, Egypt, included 28 patients who underwent external perforating lateral osteotomy in open rhinoplasty between January and May 2017.

Exposures

Periosteal sweeping was performed on one side of the nose and periosteal preservation was performed on the other side during external perforating lateral osteotomy.

Main Outcomes and Measures

Periorbital sequelae, including eyelid edema, periorbital ecchymosis, and subconjunctival hemorrhage, were assessed on both sides of the face on postoperative days 1, 7, and 21 by 2 independent surgeons using the scale first proposed by Kara and Gökalan in 1999. The scales for eyelid edema ranged from 0 to 4, for ecchymosis from 0 to 4, and for subconjunctival hemorrhage from 0 to 2, with higher values indicating greater edema, ecchymosis, and hemorrhage, respectively. Differences in the 3 time points and differences between the 2 osteotomy methods were analyzed.

Results

In total, 19 men and 9 women with a mean (SD) age of 23.7 (3.9) years were enrolled. All patients showed significant decreases in eyelid edema on postoperative days 7 and 21 compared with day 1 (1.71 and 1.39 vs 2.89 for the swept side, and 1.86 and 1.46 vs 2.68 for the preserved side; both P < .05) and in periorbital ecchymosis (2.02 and 1.13 vs 2.86 for swept side, and 2.05 and 1.13 vs 2.82 for the preserved side; both P < .05). A significant decrease in subconjunctival hemorrhage was observed on day 21 compared with days 1 and 7 (1.79 vs 2.11 and 2.11 for the swept side, and 1.71 vs 2.14 and 2.14 for the preserved side; both P < .05). The mean rank score for eyelid edema on day 1 for the swept side was significantly higher than that for the preserved side (33.18 vs 23.82, P = .02), and the mean rank score for periorbital ecchymosis on the swept side was significantly higher than that for the preserved side (33.59 vs 23.41, P = .01). Although both eyelid edema and periorbital ecchymosis appeared to remain greater on the swept side on postoperative days 7 and 21, the differences no longer reached statistical significance. Periosteal preservation was not associated with minimizing subconjunctival hemorrhage postoperatively.

Conclusions and Relevance

This study suggests that lateral nasal osteotomy is associated with varying degrees of eyelid edema, periorbital ecchymosis, and subconjunctival hemorrhage. Compared with sweeping the periosteum, preserving the periosteum in an external perforating lateral osteotomy was associated with less eyelid edema and periorbital ecchymosis in the early postoperative period.

Level of Evidence

2.

This single-center cohort study compares the postoperative periorbital sequelae of eyelid edema, periorbital ecchymosis, and subconjunctival hemorrhage after external perforating lateral osteotomy using periosteal sweeping vs preserving approaches among patients undergoing rhinoplasty.

Introduction

Postoperative swelling, edema, and ecchymosis are significant morbidities for patients undergoing rhinoplasty, increasing time away from meaningful social interaction. Thus, many facial plastic surgeons are seeking new methods to reduce these sequelae, which, despite having been discussed preoperatively are generally still shocking to many patients and their relatives postoperatively. The sequelae may range from reversible changes, such as intranasal bleeds, eyelid edema, and periorbital and subconjunctival ecchymosis, to more serious, unpleasant aesthetic outcomes, including step deformities and asymmetry, or functional outcomes (nasal obstruction) caused by lateral wall collapse.¹

Lateral osteotomy is a fundamental step in most rhinoplasty procedures, and surgeons have adopted different approaches or techniques for performing lateral osteotomies, including external vs internal and perforating vs continuous approaches.^2,3 The tools needed for performing lateral osteotomies also vary and are exposed to different development and modifications. Although osteotomes are considered the standard of care, the use of powered instruments has the potential of being more precise and less traumatic.^3,4 Every effort has been directed toward lessening reversible, unwanted sequalae associated with lateral osteotomy in the postoperative period. Minimizing these sequelae can be aided by the use of nasal taping and external splinting, and the use of corticosteroids, cold packs, head elevation, and osteotomy via the buccal sulcus have also been investigated.^5,6,7,8,9

Another considerable issue regarding these procedures is the preservation of the periosteum overlying the line of the lateral osteotomy. Previous studies concerned with preserving the periosteum have only examined its preservation in internal osteotomies.^10,11 In the external perforating approach, periosteal sweeping has been mentioned to displace the angular artery from the site of the osteotomy, providing protection against injury and subsequent bleeding.^2,9,12 However, this procedure has only been briefly mentioned, and no previous study has evaluated the role of periosteal preservation over the osteotomy trajectory for external perforating osteotomies. Thus, the present study compared the periorbital morbidity, namely, eyelid edema, periorbital ecchymosis, and subconjunctival hemorrhage, associated with sweeping vs nonsweeping (or preserving) the periosteum during performance of a perforating external osteotomy for the first 3 weeks after the procedure.

Methods

Patients who underwent rhinoplasty surgery from January to May 2017 and had bilateral lateral osteotomy at the tertiary referral center located in Mansoura University, Mansoura, Egypt, were included in the study. Patients younger than 16 years or older than 60 years, patients with revision surgery, or patients with previous maxillofacial intervention were excluded. Patients with a history of bleeding disorder, hypertension, or any cardiac disorder were also excluded. Female patients were advised to have their operation scheduled after their menstruation. Patients needing an additional osteotomy intraoperatively on either side, as for rocker or step deformities, were not included. This study was approved by the Faculty of Medicine Institutional Review Board/Human Subjects Committee of Mansoura University. All patients provided informed consent.

In all patients, osteotomies were conducted using an external perforating approach performed using the same instruments. Periosteal sweeping was performed on one side of the nose, whereas periosteal preservation was performed on the other side of each patient, with the side for each procedure randomly selected. Thus, each patient served as his or her own control. All patients had nontight nasal packing intraoperatively, and postoperative instructions were discussed with all patients. Antibiotics were prescribed for 5 days, and analgesics were prescribed until the patient could tolerate the pain. Head elevation was also recommended.

Postoperative eyelid edema, periorbital ecchymosis, and subconjunctival hemorrhage were assessed according to the grading system proposed by Kara et al^7,8 (Figure 1). The scales for lid edema ranged from 0 to 4, for ecchymosis from 0 to 4, and for subconjunctival hemorrhage from 0 to 2, with higher values indicating greater edema, ecchymosis, and hemorrhage, respectively. This assessment was performed by 2 independent surgeons (M.A.) who were blinded with regard to the swept vs preserved side. The 3 postoperative variables were evaluated 1, 7, and 21 days after the operation. The results of the assessments at each postoperative visit together with patient photographs were recorded and collected.

Figure 1. Periorbital Sequelae Grading.

Surgical Technique

A high-to-low lateral osteotomy was performed in combination with a transverse osteotomy for moving the lateral nasal wall. Prior to the lateral osteotomy, the medial component of the osteotomy was performed by a paramedian osteotomy or by a hump resection. In all cases, external perforating lateral osteotomy was started by a stab incision that was created using a No. 15 blade and was placed midway between the medial canthus and the nasal ala. The incision was in the nasofacial groove and involved the skin and underlying subcutaneous tissue but did not reach the bone. A 2-mm osteotome was inserted through the incision and moved anteriorly to pierce the periosteum a few millimeters anterior (dorsal) to the groove.

The periosteum was swept in a posterior direction toward the groove using a 2-mm straight osteotome, resulting in a 4- to 5-mm tunnel. This step was conducted in a craniocaudal direction to involve the area of the proposed vicinity to the angular artery through the skin incision site. Care was taken to avoid injuring the medial palpebral ligament. The osteotomy was then performed using the classic tap-tap technique at 2-mm distances, leaving portions of the intervening bone intact. Hammering was stopped when the sound changed to indicate completion of the bone cut in order to avoid injury to the underlying nasal mucosa. The lower limit of the osteotomy was just cephalad to the pyriform aperture, preserving the Webster triangle, whereas the upper limit was opposite the intercanthal line where the tapping sound turned dull, indicating the beginning of the thick frontal bone. The direction of the osteotomy was inclined toward the face, nearly tangent to the maxilla.

On the other side of the nose, the osteotomy was similarly performed, but the stab incision was continued to the bone, and no periosteal sweeping was conducted, leaving the periosteal attachment to the bone intact. Bony mobilization was accomplished by digital pressure indicating a green stick fracture without excess pressure to avoid undesired medialization and a consequent step deformity.

Statistical Analysis

Data analyses were performed using SPSS for Windows, version 21 (SPSS Inc). The normal distribution of variables was evaluated with the Shapiro-Wilk test. The results are expressed as numerals with percentages or as medians with ranges for both osteotomy procedures at each time point. The differences between the 3 time points for each approach used were analyzed using the Friedman χ² test, and for results that appeared to be significant, a Wilcoxon signed rank test was conducted to identify the specific differences. The differences between the 2 approaches were analyzed with Mann-Whitney tests. All statistical tests were 2-sided, and P ≤ .05 was considered statistically significant.

Results

In total, 28 patients (19 men and 9 women) who had undergone bilateral lateral osteotomies during their rhinoplasty conducted between January and May 2017 met the inclusion criteria and were included in the present study. Their ages ranged from 19 to 35 years, with a mean (SD) of 23.7 (3.9) years. The values of the 3 postoperative periorbital sequelae were determined during 3 postoperative visits by 2 surgeons blinded to which side had received which procedure (Table 1 and Table 2).

Table 1. Differences in Postoperative Eyelid Edema, Periorbital Ecchymosis, and Subconjunctival Hemorrhage Scores Between the 2 Approaches Assessed Using Wilcoxon Signed Rank Tests.

Periosteal Approach	Eyelid Edemaa			Periorbital Ecchymosisa			Subconjunctival Hemorrhagea
	Day 1	Day 7	Day 21	Day 1	Day 7	Day 21	Day 1	Day 7	Day 21
Swept
Mean rank score	2.89	1.71	1.39	2.86	2.02	1.13	2.11	2.11	1.79
95% CI	1.33-2.09	0.16-0.70	0.04-0.11	2.86-3.64	1.46-2.46	0.02-0.48	0.09-0.62	0.12-0.60	0.05-0.27
Preserved
Mean rank score	2.68	1.86	1.46	2.82	2.05	1.13	2.14	2.14	1.71
95% CI	0.80-1.49	0.11-0.46	0.04-0.11	2.27-3.01	1.09-2.05	0.03-0.32	0.18-0.67	0.18-0.67	0.04-0.28

^aIndicates a statistically significant difference (P ≤ .05).

Table 2. Postoperative Eyelid Edema, Periorbital Ecchymosis, and Subconjunctival Hemorrhage Scores for the 2 Approaches Assessed Using Mann-Whitney Tests.

Periosteal Approach	Mean Rank Score
	Eyelid Edema			Periorbital Ecchymosis			Subconjunctival Hemorrhage
	Day 1	Day 7	Day 21	Day 1	Day 7	Day 21	Day 1	Day 7	Day 21
Swept	33.18	29.43	29.00	33.59	31.30	29.52	27.29	27.57	27.57
Preserved	23.82a	27.57	28.00	23.41a	25.70	27.48	29.71	29.43	29.43
P Value	.02	.60	.32	.01	.18	.44	.49	.60	.43

^aIndicates statistical significance (P ≤ .05).

For both procedures, there was a significant decrease in eyelid edema scores on postoperative days 7 and 21 compared with day 1 (1.71 and 1.39 vs 2.89 for the swept side, and 1.86 and 1.46 vs 2.68 for the preserved side; both P <.05). There was a significant decrease in eyelid edema scores on day 21 compared with day 7 for both the swept (1.39 vs 1.71, P = .009) and preserved (1.46 vs 1.86, P = .005) sides.

For both procedures, there was also a significant decrease in periorbital ecchymosis scores on postoperative days 7 and 21 compared with postoperative day 1 (2.02 and 1.13 vs 2.86 for the swept side; and 2.05 and 1.13 vs 2.82 for the preserved side; both P ≤ .05). Periorbital ecchymosis scores were significantly higher on day 1 than on day 7 (2.86 vs 2.02, P = .001 for the swept side; 2.82 vs 2.05, P = .001 for the preserved side) and day 21 (2.86 vs 1.13, P = .001 for the swept side; 2.82 vs 1.13, P = .001 for the preserved side) and significantly higher on day 7 than on day 21 (2.02 vs 1.13, P = .001 for the swept side; 2.05 vs 1.13, P = .001 for the preserved side).

For both procedures, subconjunctival hemorrhage scores were significantly lower on day 21 than on days 1 and 7 (1.79 vs 2.11 and 2.11 for the swept side, and 1.71 vs 2.14 and 2.14 for the preserved side; both P <.05). Although there was a nonsignificant change in subconjunctival hemorrhage scores on day 7 compared with day 1, significant decreases in scores were observed on day 21 compared with day 1 for both the swept (1.79 vs 2.11, P = .02) and preserved (1.71 vs 2.14, P = .005) sides. There was also a significant decrease on day 21 compared with day 7 for both the swept (1.79 vs 2.11, P = .02) and preserved (1.71 vs 2.14, P = .005) sides (Table 1).

The eyelid edema, periorbital ecchymosis, and subconjunctival hemorrhage scores following both osteotomy procedures showed a gradual improvement with time. Mann-Whitney test results indicated that eyelid edema and periorbital ecchymosis scores were higher on the swept side relative to the preserved side, resulting in statistically significant differences between the 2 sides for the mean rank scores of both eyelid edema (swept side, 33.18 vs preserved side, 23.82; P = .02) and periorbital ecchymosis (swept side, 33.59 vs preserved side, 23.41; P = .01) scores on postoperative day 1 (Figure 2). Although the mean rank scores for both eyelid edema and periorbital ecchymosis appeared to be higher for the swept side on postoperative day 7, the differences did not reach statistical significance (Table 2).

Figure 2. Periorbital Sequelae Following Each Procedure on Postoperative Day 1.

Mean rank results of eyelid edema, periorbital ecchymosis, and subconjunctival hemorrhage after periosteal sweeping or preserving on the first postoperative day. Statistical significance between the 2 procedures is observed on the first day for eyelid edema (P = .02) and periorbital ecchymosis (P = .01) but not for subconjunctival hemorrhage.

On postoperative day 21, ecchymosis (swept side, 5 of 28 patients; preserved side, 3 of 28 patients) and subconjunctival hemorrhage scores (swept side, 2 of 7 patients; preserved side, 4 of 10 patients) remained above reference ranges, showing that these sequelae persisted in a minority of patients 3 weeks postoperative; eyelid edema was unlikely to persist to the third postoperative week (swept side, 1 of 26 patients; preserved side, 0 of 22 patients). Figure 3 shows examples of scoring application and results.

Figure 3. Examples of Periorbital Sequelae Among Patients Who Underwent Periosteal Sweeping or Periosteal Preservation.

A, Greater eyelid edema (1 vs 0) and ecchymosis (4 vs 2) on the side of the face with the swept periosteum (patient’s right) on perioperative day 1. B, The same patient shown in panel A 7 days postoperative. C, Greater eyelid edema (3 vs 1) and ecchymosis (3 vs 2) on the side of the face with the swept periosteum (patient’s right) on postoperative day 1. D, Greater ecchymosis (4 vs 3) on side of the face with the swept periosteum (patient’s right) on postoperative day 1.

Discussion

Sculpturing bones of the nasal framework is a mainstay in rhinoplasty. The core methods, including osteotomies, rasping, augmentation, or, rarely, digital pressure alone, are well known.^3,4 The lateral osteotomy approach is essential and useful for many situations in rhinoplasty. The aim is generally to mobilize the lateral nasal wall, to close an open roof deformity after hump resection, or to narrow a wide nasal dorsum. A lateral osteotomy can also help straighten a deviated nose and produce symmetry between the sides by changing the relationship of the lateral nasal walls to each other and to the rest of the facial skeleton.^12,13

The technical methods used to perform a lateral osteotomy are variable, yet the method of choice is dependent on the surgeon’s experience and prior training rather than on any other factor. The approach could be either external through skin incisions or internal through the vestibular covering of the pyriform aperture. The internal vs external approach has long been debated even among experts in the field because each approach has its pros and cons.¹² Furthermore, the choice of performing a perforating vs a continuous lateral osteotomy on the ascending maxillary process for achieving precise results with the least morbidity has also been a matter of argument and study.² Although many debates surrounding the use of lateral osteotomy exist, that discussion is beyond the scope of the present study.

Postoperative morbidity is an important consideration for patients and surgeons alike. The most frustrating of these problems associated with osteotomy are the periorbital complications, mainly periorbital edema, ecchymosis, and subconjunctival hemorrhage. Their pathogenesis appears to be attributable to disruption of the soft tissue surrounding the bony site targeted for osteotomy, namely, the internal mucosal lining, the surrounding periosteum and subcutaneous tissue, and the angular artery. Thus, some investigators have suggested limiting disruption of these structures, such as by elevating the periosteum, to limit sequelae.^14,15

However, the data presented in the present study do not support this hypothesis. For example, eyelid edema scores on postoperative days 1 and 7 were higher for the swept periosteum approach than for the preserved periosteum approach, although the difference was statistically significant only on day 1. By contrast, the subconjunctival hemorrhage mean rank score appeared higher following the procedure to preserve the periosteum vs the swept method, although this outcome was not statistically significant.

The findings of the present cohort study using validated rating systems to evaluate postoperative sequelae do not support the primacy of sweeping the periosteum (and thus keeping it intact) over not sweeping it. On the contrary, sweeping increased eyelid edema and periorbital ecchymosis for the first postoperative visits. This result can be explained by these morbidities being associated with more tissue trauma, which could be caused either by friction against hard bone during sweeping or by detaching or injuring the surrounding soft tissue (periosteum and subcutaneous tissue). Although previous studies have mentioned periosteal sweeping as a way to move the angular artery away from the osteotomy to decrease subsequent bleeding and ecchymosis,^9,12 none have compared the sequalae of sweeping vs preserving the periosteum in external perforating osteotomies.

The results of the present study can be supported by the outcomes of previous studies that investigated the value of periosteal elevation (preservation) in internal continuous osteotomies by comparing creating of a periosteal tunnel vs periosteal cutting. Although the results were controversial,^16,17 more recent studies^10,11 have recommended against constructing such a tunnel because tunnel elevation can cause greater vessel injury and create a potential space to accumulate blood and subsequent blood oozing from the surrounding tissue.¹¹ It is possible that periosteal sweeping establishes a route for blood formed intraoperatively to leak into the surrounding soft tissues (particularly the lower eyelid), resulting in greater ecchymosis. We believe that sweeping the soft tissue containing the artery does not essentially protect it. In addition, sweeping does not affect the periosteal layer alone, but transmitted sweeping injury could affect the surrounding subcutaneous tissue, resulting in greater edema and ecchymosis.

The mean rank scores for subconjunctival ecchymosis appeared to be higher on the preserved periosteum side than on the swept side, although the difference was not statistically significant; however, this outcome was opposite to those for eyelid edema and periorbital ecchymosis. Such a nonstatistically significant finding has also been reported in previous studies.¹¹

The 28 patients included in the present study had variable degrees of periorbital ecchymosis on their first postoperative visit following both the swept and preserved periosteum procedures. Thus, patients should always be warned preoperatively and assured postoperatively about early periorbital manifestations, particularly ecchymosis.

In all patients, ecchymosis as well as eyelid edema markedly decreased in the first week, as observed by the significant differences in the scores for these sequelae between days 1 and 7. By contrast, subconjunctival hemorrhage did not significantly decrease until postoperative day 21. Thus, eyelid edema was the fastest to resolve and subconjunctival hemorrhage was the slowest; among these 3 sequelae, subconjunctival hemorrhage had the lowest incidence.

Strengths and Limitations

The strengths of the present study included the design, the blinding of the observers to which side received which approach, and the use of a validated rating system. The limitations included a single institute and a small sample size; however, the sample size of groups in similar studies ranged from 17 to 25 patients.^7,11,14 Some patients showed no differences in edema and ecchymosis scores between the 2 procedures, indicating that other factors may contribute to postoperative sequelae. Although they were statistically significant, the variations in our results may be due to differences in wound healing among different individuals and populations; thus, a study conducted on a broader scale may be of value. For example, all patients in the current study were of Middle Eastern descent. Although we are unaware of any evidence that this factor would make a significant difference, it is possible, for example, that thicker skin could mask ecchymosis. Another addition to future studies would be the use of a global, rhinoplasty-specific validated instrument, such as the Standardized Cosmesis and Health Nasal Outcomes Survey, to study functional and aesthetic rhinoplasty outcomes.¹⁸

Conclusions

Many studies have been performed aiming to find appropriate methods to reduce periorbital sequelae after lateral osteotomy. The results of the present study support performing external perforating lateral osteotomies without lateral sweeping of the periosteum because this approach was associated with greater eyelid edema and periorbital ecchymosis in the early postoperative period.