Steroids in septorhinoplasty

What repeats

Five findings that hold across the literature.

A dose around the operation reduces swelling and bruising in the first days

A Cochrane review of 10 trials and 422 participants found a single perioperative dose of 10 mg dexamethasone reduced oedema over the first two days, standardised mean difference -1.16, and ecchymosis, -1.06, on low quality evidence pooled from 60 participants. Meta-analysis of 336 patients across eight randomised trials found perioperative corticosteroid reduced worst edema, standardised mean difference -1.03, and worst ecchymosis, -0.78. At one day after surgery a single dose reduced edema, -1.15, and ecchymosis, -0.79. A separate meta-analysis of 374 participants across ten trials reported the same direction for dexamethasone against saline, with Hedge's g of -1.09 for edema and -1.03 for ecchymosis, and less blood loss during the operation.

Rests on: da Silva et al., Cochrane review · Coroneos et al., meta-analysis · Bian et al., dexamethasone meta-analysis.

The effect is gone by the seventh day

The trial that opened the question randomised 55 patients to 10 mg of dexamethasone before surgery, the same dose after surgery, or saline, and scored the eyelids to postoperative day 9. Eyelid edema and upper eyelid ecchymosis were lower in both steroid groups for the first 2 days only, and the day on which swelling reached its minimum was the same in every group. The Cochrane review reaches the same conclusion: the difference is not maintained past the first two days. The same meta-analysis of 336 patients found no clinical benefit in either edema or ecchymosis at seven days. A double-blind randomised trial of 42 patients did find lower scores at one week, rated from photographs by five blinded surgeons, at a difference of 0.68 for edema and 0.62 for ecchymosis. The earlier meta-analysis reports benefit at both one day and seven days. The size of the benefit after the first days is the point the literature disagrees on.

Rests on: Kara and Gokalan, single-dose randomised trial · da Silva et al. · Coroneos et al. · Valente et al., randomised trial · Hatef et al., meta-analysis.

Bleeding during surgery does not increase

The 336-patient meta-analysis found no increase in intraoperative bleeding with perioperative corticosteroid. The dexamethasone meta-analysis found a medium reduction in blood loss, Hedge's g of -0.69, against saline. Neither found harm attributable to the steroid. The two dose-comparison trials agree: single-dose dexamethasone did not alter blood loss in 55 patients, and neither did one or three doses of 8 mg in 60 patients. Where the steroid was combined with controlled hypotension, bleeding fell and the operation was shorter.

Rests on: Coroneos et al. · Bian et al. · Kara and Gokalan · Kargi et al., dose comparison · Tuncel et al., dexamethasone with controlled hypotension.

Tranexamic acid does the same job, and the two together do no more

A triple-blind trial of 60 patients in four groups found topical tranexamic acid and systemic dexamethasone each reduced edema and ecchymosis against control, with no difference between them and no added benefit from combining them. An earlier trial of 60 patients comparing 8 mg dexamethasone, 10 mg/kg tranexamic acid and both reached the same conclusion.

Rests on: Vural and Koycu, direct comparison · Mehdizadeh et al. · McGuire et al., tranexamic acid review.

The national guideline calls it an option, not a recommendation

The American Academy of Otolaryngology guideline lists perioperative systemic steroids as an option: the surgeon may give them. That is the weakest of the guideline's categories, and it sits alongside firmer statements against routine packing and against antibiotics beyond 24 hours.

Rests on: the clinical practice guideline · the plain language summary.

By when the steroid is given

The same drug class, three different jobs.

Before the incision

Preoperative administration is the timing most trials use, and one meta-analysis reports it as better than giving the dose after surgery. Extended dosing beat a single dose in the same analysis. The trials that report a benefit at seven days are the ones that continued the drug. The trial that compared the two timings head to head, in 55 patients, found no difference between a dose before surgery and the same dose at the end of it. What did change the result was the number of doses. In 60 patients split into six groups of 10, three doses of 8 mg beat one dose at day 5, provided the first dose was given before the osteotomy; giving the whole course after surgery was the worst arm. A meta-analysis of nine trials and 312 patients reports the same, with multiple dosing ahead of a single dose from the fourth day onwards.

Rests on: Kara and Gokalan · Kargi et al. · Hwang et al., meta-analysis · Hatef et al. · Coroneos et al..

Alongside the anaesthetic, for pain and nausea

Dexamethasone is also given as part of multimodal analgesia. In 60 patients, adding pregabalin and 8 mg of dexamethasone cut total tramadol use by 81.9% against control, against 54.5% for pregabalin alone, and reduced nausea in the first hours.

Rests on: Demirhan et al., multimodal analgesia.

Injected into the supratip, weeks to months later

This is a different drug and a different problem. Triamcinolone acetonide is injected into the skin above the tip when that skin stays thick and swollen and threatens a polly beak. A systematic review found six studies covering 1524 patients and reports the injection as a first-line treatment with limited complications, able to reduce the need for revision surgery. The controlled study inside that literature followed 42 thick-skinned patients, injected 21 of them in the supratip on the tenth day after surgery, and measured the skin by ultrasound at 40 days: every injected site was thinner, while in the untreated half the skin thickened. One report pairs triamcinolone with hyaluronidase for post-rhinoplasty fibrosis in thick, sebaceous skin.

Rests on: Khan et al., triamcinolone systematic review · Aydin et al., ultrasound-measured skin thickness · Nele et al., hyaluronidase and triamcinolone · and the polly beak deformity.

What to ask about steroids around a septorhinoplasty

Questions the evidence supports asking.

What will this actually change for me

Less puffiness and less bruising around the eyes in the first two or three days, measured on photographic scales rather than by how the nose ends up looking. No trial has shown a difference in the final result.

Rests on: Coroneos et al. · Ong et al., systematic review.

How long does the swelling take to go without any drug

Three-dimensional measurement of 40 patients across 146 photographs found roughly two-thirds of the edema gone at 1 month, 95 percent at 6 months and 97.5 percent at 1 year, settling at 84.4 percent of the volume measured at the first postoperative visit. That is the timetable a steroid is compressing at the front end, not replacing.

Rests on: Pavri et al., edema resolution · Gordon et al., spatial and temporal resolution · and rhinoplasty recovery.

What else reduces swelling

A systematic review of 50 articles found agreement that steroids, controlled hypotension during surgery, intraoperative cooling and keeping the head raised afterwards all reduce edema and ecchymosis, while nasal packing and lifting the periosteum before osteotomy increase them. In 300 septorhinoplasty patients who all had 10 mg of dexamethasone, the half whose dorsum was compressed with cold saline-soaked gauze during the operation had less eyelid edema and less periorbital ecchymosis to day 7, and a shorter operation.

Rests on: Ong et al. · Taskin et al., cold compression and corticosteroid · Tuncel et al. · Tasman, literature review and personal approach · and open versus closed rhinoplasty.

If my skin is thick, what is the plan

Ask when the first injection would be given, how many are planned, and what the interval is. Ask what else is on offer. A placebo-controlled trial of 48 patients found oral isotretinoin improved the result at 3 and 6 months but made no difference at 12 months.

Rests on: Khan et al. · Sazgar et al., oral isotretinoin · and the pinched tip.

The terms, defined

The words used about this part of the operation.

• Perioperative: around the time of surgery, before, during or straight after. [26773090]
• Dexamethasone: the corticosteroid used most often in these trials, given by vein. [32383002]
• Triamcinolone acetonide: the steroid injected into the skin of the nose after surgery, not the one given by vein during it. [38519572]
• Edema: swelling from fluid in the tissue. Reported in these trials as eyelid and periorbital edema, scored from photographs. [25719757]
• Ecchymosis: bruising. Scored on the same photographic scales as edema. [25719757]
• Supratip: the part of the nose just above the tip, where thick skin and fluid collect after surgery. [38519572]
• Polly beak: fullness in the supratip that leaves the profile convex above the tip, the deformity supratip steroid injection is used to prevent. [38519572]
• Standardised mean difference: the unit these meta-analyses report, an effect size rather than millimetres of swelling. [26773090]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology guideline on nasal form and function after rhinoplasty makes perioperative systemic steroids an option, and its plain language summary carries the same statement for patients.

Rests on: the clinical practice guideline · the plain language summary.

The reference summaries

The two drugs, on the National Library of Medicine's Bookshelf, with dosing and adverse effects in full text at no charge.

• Dexamethasone in StatPearls
• Triamcinolone in StatPearls
• Rhinoplasty in StatPearls, the operation and its complications.

The surgeons' own textbook chapter

Rhinoplasty Archive, the free online textbook edited by Daniel G. Becker, covers the deformity supratip steroid injection is aimed at.

• Polly Beak Deformity

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

The trials in progress

• Steroids for Rhinoplasty: Pain, Nausea, Edema and Ecchymosis, withdrawn, 0 participants.
• Tranexamic Acid in Rhinoplasty, recruiting, 60 participants.
• Dexamethasone versus Dexmedetomidine in Sphenopalatine Ganglion Block, enrolling by invitation, 90 participants.

What is not settled

• The dose and the schedule are not standardised. Trials use different steroids, different doses and different timings, which is why the meta-analyses report effect sizes rather than a regimen. [26773090] [32383002]
• Whether any benefit survives to seven days is contested between the two largest meta-analyses. [26773090] [21813878]
• No trial links the early reduction in swelling to the final appearance of the nose, which is the outcome the patient cares about. [26773090] [27119920]
• Supratip triamcinolone rests on six studies with no randomised comparison against no injection, and the review calls for trials. [38519572] [38438756]
• Harm is under-measured. Of the 10 trials in the Cochrane review, five did not report adverse effects at all, four reported none, and one recorded them in two treated participants and four on placebo. [24887069] [21813878] [29409099]
• Whether more doses are better is answered only by small trials and one meta-analysis of 312 patients, and the trials use different steroids at different doses. [14646651] [25131000] [22795164]
• Supratip triamcinolone has one controlled study of 42 patients measured by ultrasound, with no randomisation and no long-term follow-up. [34401482]
• See also the journal archive on revision and on complications.