Rhinoplasty Surgery can produce excess swelling post-operatively in the nasal tip area of some patients, especially if improper surgical techniques are employed. Should the nasal tip area remain swollen without appropriate treatment during the recovery period, scar tissue may form, contributing to extra fullness in the supratip area and possibly causing what is known as a Pollybeak Appearance or Deformity. What steps can a surgeon take to prevent this complication?
Kenalog, (triamcinolone acetonide), is a steroid that is typically used post-operatively on Rhinoplasty patients to manage and reduce excess swelling and formation of scar tissue in the nasal tip. Kenalog has a history of being used to treat a variety of conditions that include breathing issues, and diseases of the skin. In order to understand the action of Kenalog Injections post operatively in Rhinoplasty patients, it is important to understand the swelling and inflammatory processes that take place post-surgery.
Immediately following surgery, there may be a period of acute inflammation involving accumulation of blood and interstitial fluid (tissue fluid) in a "dead space" created from the surgery itself. This particular fluid matter is comprised of blood and inflammatory fluid that is slowly reabsorbed over a period of several weeks. In addition to the initial acute inflammatory process, there is a secondary inflammatory process that takes place. This secondary inflammatory process is typically a response of the immune system where white blood cells and macrophages are released in order to collect and break down blood products and tissue fluid within the dead space. This type of secondary inflammatory response can typically last several weeks. The combination of both inflammatory processes contributes to nasal tip swelling, especially in Ethnic Rhinoplasty, due to the extensive nature of the surgery in the tip area for correction of bulbous tip deformities.
To reduce the initial acute inflammatory process, Dr. Slupchynskyj employs several techniques to control or reduce any swelling. The initial treatment is pre-operative preparation, (i.e. prior to the surgery). All patients are given Arnica Montana tablets, a homeopathic herb, which is clinically proven to reduce any incidence of post-operative swelling. Patients are also advised to refrain from high salt intake or avoid specific over the counter medication that would increase their fluid volume. The second treatment is intra-operative or during the surgery, where Dr. Slupchynskyj employs specific surgical techniques that limit the amount of bleeding intra-operatively in order to reduce possible inflammation. Dr. Slupchynskyj uses his proprietary minimally invasive Rhinoplasty technique. Last, he does not use nasal packing following surgery. This contributes to even more reduced or little swelling and a much faster recovery.
Subsequently, the patient is pre-operatively, intra-operatively and post-operatively prepared for the minimal and amount of swelling following surgery; however, should the patient be pre-disposed to excess swelling, Dr. Slupchynksyj will use intra-operative steroids, or Kenalog, to help minimize any post-operative inflammation.
Kenlaog, a mild steroid, has strengths that vary from K10 to K40. Kenalog may be injected conservatively and in small quantities into the supratip and nasal tip area during the post-operative course. Dr. Slupchynskyj has the patient wait 4-6 weeks for evaluation of any response to the primary Kenalog Injection. If there has been positive response, (i.e. reduced swelling, an additional small injection will be given). However, if there has been no response at this point, Dr. S. will employ a full dose to the tip area. Patients will then return in 4-6 weeks for Dr. Slupchynskyj's further re-evaluation. In most cases, there is a significant response to Kenalog and reduction in tip swelling.
Kenalog acts as an anti-inflammatory agent that reduces the chronic inflammatory response to surgical procedures. This in turn reduces the amount of scar tissue that is laid down during the post-operative healing phase of the tip area. This healing phase is crucial to prevent post-operative scar formation. Scar formation can contribute to bulbous tip persistence, which is a swollen and rounded appearance of the nasal tip. If scar formation is allowed to continue, tip definition created by grafts cannot be seen and (persistent) bulbousness of the tip can become permanent.
Patients of other surgeons often come to see Dr. Slupchynskyj in the post-operative healing phase where a persistent bulbous tip is present. The patient may require Kenalog Injections to be administered for up to a year or two years post-surgery. A patient with a persistent bulbous tip can be injected with Kenalog as a trial to reduce the scar formation in the tip area therefore reducing the bulbosity of the tip. In most cases, however, after one to two years post-surgery, a persistent bulbosity is not about swelling or scar formation but is a result of poor surgical technique employed which did not properly reduce the nasal tip in the first place.