Packing and Postoperative Rhinoplasty Management: A Survey Report

Transcription

1 Kelley et al Rhinoplasty Packing and Postoperative Rhinoplasty Management: A Survey Report Aesthetic Surgery Journal 31(2) The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journalspermissions.nav DOI: / X Brian P. Kelley, BS; John Koshy, MD; Dan Hatef, MD; Larry H. Hollier, Jr, MD; and Samuel Stal, MD Abstract Background: Postoperative management following rhinoplasty varies greatly among aesthetic surgeons. Few studies have addressed practice trends in postoperative rhinoplasty care or questioned the frequency of packing and splinting. Many conventional postoperative techniques remain controversial (eg, packing). Objective: To investigate current postoperative practices in the United States, correlating the results with surgical education, practice type, and complication rates. Methods: An online survey was distributed to members of the American Society for Aesthetic Plastic Surgery. Respondents were polled about their background, route of education, type of practice, frequency and preference of postoperative nasal care, and most frequent rhinoplasty complications. Statistical analysis was performed with the χ 2 test. Results: Of the 1550 total surveys sent, 126 responses were received (8.1%). The majority of respondents were in private practice (86%) and trained in plastic surgery (83%). Approximately 33% continue to regularly employ packing following rhinoplasty, but data show that surgeons performing 21 or more rhinoplasties per year were less likely to utilize packing (P =.06). Those surgeons with higher rhinoplasty case volumes were significantly more likely to utilize a secondary therapy (eg, steroids, arnica) in combination with ice packs (P =.03) to prevent postoperative ecchymosis. Finally, surgeons with lower rhinoplasty case volumes reported more frequent postoperative nasal tip deformities (P =.01). Conclusions: Postoperative rhinoplasty care varies greatly among practicing aesthetic surgeons. Importantly, a high percentage of private practice aesthetic surgeons continue to utilize nasal packing following rhinoplasty. However, these numbers trend downward in surgeons who perform rhinoplasties more frequently. Keywords rhinoplasty, survey, aesthetic surgery Accepted for publication June 10, Rhinoplasty is one of the most complicated but also most common procedures performed by aesthetic surgeons. Even with the recent recession, the American Society for Aesthetic Plastic Surgery (ASAPS) estimated that 138,258 rhinoplasties were performed in Given the expanding breadth of clinical practice for aesthetic plastic surgeons in the United States, many of these operations were performed by nonnasal specialists. Therefore, it is important to evaluate the current postoperative rhinoplasty practices of US-based aesthetic surgeons. The postoperative care of rhinoplasty patients remains controversial. The frequency with which conventional practices are employed, such as packing, splinting, antibiotics, and steroids, has been shown to differ greatly among practitioners. Management seems to be largely aligned with surgical training and experience, which is easily demonstrated when comparing surgeons of different affiliations (eg, otolaryngology, head and neck) versus plastic surgeons. Specific practices namely, packing may pose a risk to patients, so surgeons are polarized in their support of it. In a survey by Warner et al, 2 data showed a bimodal distribution of nasal packing. In that study, packing occurred in less than 20% of cases for 37% of surgeons, but another 39% of surgeons said that they packed in more than 80% of cases. From the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA. Corresponding Author: Dr. Samuel Stal, Division of Plastic Surgery, Baylor College of Medicine, 6701 Fannin Street, CC610.00, Houston, TX samuel.stal@bcm.edu

2 Kelley et al 185 Few studies have attempted to query surgeons with regard to their rhinoplasty management. Those studies that are available did not focus on postoperative care among plastic surgeons in the United States. However, in studies that addressed postoperative management, current opinions on packing featured prominently. In a survey in the United Kingdom published in 1989, packing was more routine among surgeons performing less than 100 nasal operations per year (more than 70%; p <.005) 3 ; however, surgeons performing more than 100 nasal operations per year packed more rarely (less than 20%; p <.05). Additionally, surgeons classifying themselves as rhinologists in this study were found to pack more rarely than others. A survey conducted among Canadian surgeons investigated perioperative management practices in patients undergoing sinus surgery, with 52% reporting routine packing. However, significantly fewer nasal experts reported engaging in packing, once again suggesting decreased packing among nasal specialists. 4 Although previous studies of surgeon practices have yielded interesting information with regard to the postoperative management of rhinoplasty, no survey to date has specifically addressed postoperative management by aesthetic plastic surgeons. This article describes the results of a survey sent to plastic surgeons across the United States, inquiring about surgical techniques and preferences for postoperative management with respect to rhinoplasty. Packing, splinting, and postoperative management preferences are described, as well as common postoperative complications as reported by the surgeons themselves. Methods In March 2009, members of the American Society for Aesthetic Plastic Surgery were sent an online survey regarding their personal rhinoplasty practices (SurveyMonkey.com, Portland, Oregon; The survey focused on surgical training, techniques, and postoperative management of rhinoplasty patients (see appendix). Surgeons were also asked to report common patient complications. Of 1550 members originally contacted, 127 responded (8.2%). One respondent s survey was disregarded because the surgeon logged in but did not answer any questions, thus leaving a total of 126 respondents (8.1%). Respondents were asked to classify their practice type as private, academic, or other. Those who answered both private and academic (n = two) were coded as other. Members were also queried about their main training background and were allowed to choose more than one of the following: plastic surgery, plastic surgery with fellowship, ear/nose/ throat (ENT), ENT with facial plastic surgery fellowship, or other (for which they were asked to specify). Those who answered both plastic surgery and plastic surgery with fellowship (n = two) were coded as plastic surgery with fellowship. One respondent who answered craniofacial surgery was also coded as plastic surgery with fellowship. One respondent answered plastic surgery with fellowship and ENT with facial plastic surgery fellowship was coded as plastic surgery with fellowship. Any respondent who gave a response mentioning a training background in ENT was coded as yes on a separate ENT training variable. Respondents were asked to classify the number of rhinoplasties they performed in the previous 12 months: zero-10, 11-20, 21-30, 31-40, 41-50, more than 50. Due to low rates in some groups, the categories were collapsed to more than zero-20, 21-40, and more than 40 during data analysis. Surgeons were asked whether they routinely pack the nasal cavity after rhinoplasty and what type of material they employ (the latter of which was an open-ended question). Respondents were also asked what type of nasal splinting they prefer and how long they prefer to leave splints in place (both open-ended). Because several surgeons specified different preferences for external versus internal splinting, we examined them separately. Length of splint placement was categorized postsurvey, given the distribution of surgeons responses: less than five days, five to seven days, greater than seven days, or other. If a surgeon specified different responses for external and internal splint duration, only the external splinting duration was coded. The other category included two answers that were ambiguous about the duration of splinting (ie, depending on whether nose was broken, degree of septal deformity ). Surgeons were asked a series of open-ended questions regarding their management of postoperative complications, including instances of ecchymosis and supratip deformities. Postoperative ecchymosis management was coded as follows: ice pack alone, ice pack plus other modalities (perioperative steroids, vitamins, head elevation, arnica, SinEcch [Alpine Pharmaceuticals, Inc., San Rafael, California], bromelain, and Swiss Therapy [Inovtec International, Inc., Jacksonville, Florida]), and other alone. Management of supratip deformities was classified as follows: taping/external manipulation alone, steroid administration (with or without other modalities), reoperation/early intervention, observation, or other. When steroids were mentioned in conjunction with reoperation/early intervention, the response was coded for the latter only. Surgeons were also asked about the three most common complications/morbidities experienced by their patients, in order from most to least frequent and categorized as follows: general medical issues, surgical site complications (septal deviation, breathing difficulty, suture problems, edema, bleeding, etc), aesthetic issues (asymmetry, palpable dorsal irregularities, tip issues, inadequate dorsum excision, etc), and other (patient dissatisfaction). Aesthetic issues were further classified as such: bone and cartilage (all answers involving osteotomy or cartilage), tip, ala, columella, supratip, and general aesthetic (all answers that did not fit into the above categories). All statistical analyses were performed with Minitab 15 (Minitab, Inc., State College, Pennsylvania). The frequency of each response was examined. Additionally, bivariate analyses (χ 2 tests) were performed to examine whether training background (plastic surgery vs plastic surgery with fellowship) or rhinoplasty volume in the past year was associated with packing and splinting practices or with postoperative complications and their management.

3 186 Aesthetic Surgery Journal 31(2) Table 1. Training, Practice Type, and Annual Experience by Packing Preference Results Overall Packing No Packing n (%) n (%) n (%) P a Respondents 126 (100) 41 (33) 66 (53) Training Plastic surgery 102 (81) 34 (83) 53 (80).74 Plastic surgery with fellowship 24 (19) 7 (17) 13 (20) Ear/nose/throat training 10 (8) 2 (2) 5 (5).58 Other b 5 (4) Practice type Private practice 108 (86) 33 (81) 58 (89).18 Academic 13 (10) 7 (17) 4 (4) Other c 4 (3) 1 (1) 3 (3) Past-year rhinoplasty experience (68) 33 (81) 42 (64) (19) 5 (12) 15 (23) 40 < 16 (13) 3 (7) 9 (14) 0-20 vs (32) 8 (19) 24 (37).06 a χ 2 test. b Surgical dentistry/oral and Maxillofacial Surgery (OMFS) (n = three), general surgery (n = one), both ear/nose/throat and facial plastics (n = one). c Both private and academic (n = three), multispecialty practice (n = one), missing (n = one). Respondents were grouped according to their description of training type, practice type, and number of rhinoplasties performed in the past year (Table 1). Of the 126 respondents, 81% reported training in plastic surgery without a further fellowship. The majority of respondents (86%) reported being in private practice aesthetic surgery practice, with only 10% reporting an academic base. Finally, most practitioners (68%) reported performing fewer than 20 rhinoplasty procedures per year. A much smaller proportion performed between 21 and 40 rhinoplasties in the past year (19%), and only 13% of respondents reported performing more than 40 rhinoplasties in the past year. There was no significant difference noted in terms of packing practices with respect to surgeon training or number of rhinoplasty operations performed in the past year (Table 1). However, surgeons performing 21 or more rhinoplasties per year were less likely to pack routinely (P =.06). Surgeons reported a variety of preferred packing materials. Forty-one surgeons reported packing; of these, 40 responded about their preferred packing material. Two respondents who denied routine packing reported packing materials for only those times when hemostasis could not be achieved through standard means. The largest percentage of respondents (38%) preferred a petrolatum jelly impregnated gauze, including Vaseline (Unilever, Inc., Atlanta, Georgia) and Adaptic (Johnson and Johnson, Inc., New Brunswick, New Jersey). The next-most popular packing material was Merocel (Medtronic, Inc., Jacksonville, Florida) polyvinyl alcohol gauze (17%). Other packing materials mentioned included Tefla (Covidien, Inc., Mansfield, Massachusetts), Xeroform (Covidien, Inc.), and Gelfoam (Pfizer, Inc., New York, New York), each representing 9.5% of respondents. Three respondents listed Doyle splints (Doyle Medical Devices; various manufacturers) as their preferred packing material, while two other respondents listed gauze without additional remark of preference. Seventy-five percent of surgeons reported frequent splinting, with internal, external, or combined internalexternal splinting. The majority of surgeons who frequently splint reported applying only internal splinting (91%). An additional 8% reported combined internalexternal splinting, while only one respondent reported external splinting alone. This respondent also reported having performed zero to 10 rhinoplasties in the past year and frequently packed with Merocel. No significant difference was noted when comparing postoperative duration of splinting with regard to training background, past-year rhinoplasty volume, or packing practices (Table 2). The majority of respondents reported their most frequent complications as being either surgical site (23%) or aesthetic (48%) in nature. A further 27% declined to offer any response (Table 2). Aesthetic complications were further divided into anatomic nasal regions or general aesthetic complaints (Table 3). Respondents most frequently reported complications with their results in the region of bone and cartilage (45%). Most often, this referred to mismanagement of the nasal dorsum, with either too little resection or a postoperative dorsal irregularity. Respondents also frequently reported nonspecific general aesthetic complaints (30%), which included statements such as unsatisfactory cosmetic result. Surgeons who reported performing more than 40 rhinoplasties in the past year were significantly less likely to report tip deformities (P =.01; Table 3). Furthermore, those surgeons reporting tip complications were less likely to pack more frequently (P =.06). Interestingly, supratip deformities were more likely to be reported by surgeons who had performed more than 20 operations in the past year (P =.06). It is also worth noting that all five surgeons reporting either columellar or alar deformities as complications performed less than 20 rhinoplasties per year. Surgeons with the most rhinoplasty experience in the past year (more than 40 operations) were significantly less likely than we expected to specify ice packs alone as an option for managing postoperative ecchymoses (P =.03; Table 2). Surgeons with greater rhinoplasty case numbers were more likely to place ice packs in combination with another therapy (steroids, arnica, etc). There was no significant difference in the management of ecchymoses with

4 Kelley et al 187 Table 2. Postoperative Management Preferences by Training and Recent Rhinoplasty Experience Length of splinting, days c Overall n (%) b Training P a Rhinoplasty Experience Packing < 5 2 (2) (59) 7 < 19 (15) Missing 28 (22) Postoperative ecchymoses management d Ice pack alone 58 (46) Ice pack and other 38 (30) Other alone 5 (4) Missing 25 (20) Most frequent complication e Surgical site 29 (23) Aesthetic 60 (48) Other 3 (2) Missing 34 (27) Next most frequent complication e Surgical site 26 (21) Aesthetic 46 (37) Other 5 (4) Missing 49 (39) Least frequent complication e Surgical site 25 (20) Aesthetic 21 (25) Other 4 (3) Missing 66 (52) Supratip deformity management f Taping/external manipulation 23 (18) Reoperation/early intervention 5 (4) Steroid (+/ additional therapy) 35 (28) Observation 24 (19) Missing 39 (31) a χ 2 test. b Percentage of total sample (N = 126). c For P values, < 5 grouped with 5-7 to achieve adequate cell sizes for analysis. d For P values, excludes other alone to achieve adequate cell sizes for analysis. e For P values, other and aesthetic combined to achieve adequate cell sizes for analysis. f For P values, reoperation/early intervention combined with taping/external manipulation to achieve adequate cell sizes for analysis. respect to training background of the surgeon. Notably, although those with greater rhinoplasty case volume advise their patients to apply multimodal therapy to prevent postoperative ecchymoses, they do not report significantly different rates of surgical site complication than do those who do not perform rhinoplasties as frequently. A subset of surgeons (n = 87) reported on their management of supratip deformities. The management of these complications appears to be somewhat controversial in this group, as no majority opinion was evident. The three most common management plans were steroid injections, observation, and taping/external manipulation (28%, 19%, 18%, respectively); however, this was not a significant trend (P =.21). Discussion Our data indicate that among the 126 surgeons responding to the survey, there are a few significant differences in postoperative practices. Despite controversies in rhinoplasty recommendations, 33% of respondents engage in postoperative packing of some sort. The responses suggest that surgeons performing more than 20 rhinoplasty operations per year are less likely to pack (P =.06), but this finding is not statistically significant. This is interesting in comparison with similar studies abroad, which also suggested that experienced rhinologists are significantly less likely to practice packing. 2,3 Although rhinoplasties are clearly common among the surgeons we polled, the total number of operations performed seems to be lower than those in similar surveys. Only 16 surgeons in our poll reported performing more than 40 rhinoplasties per year. This information is useful given that modern aesthetic plastic surgeons practice a variety of procedures including but not limited to rhinoplasty. Therefore, we speculate that the increased rates of packing practices may be related to the decreased operative experience in our surveyed population. Packing materials do not vary greatly between our group and reports from previous studies. Petrolatum-impregnated gauze and other nonstick packing materials remain popular among US-based surgeons polled. Packing has been justified by the belief that it decreases postoperative complications such as bleeding, adhesion formation, and septal hematomas. 5 However, research has suggested that not only can packing fail to prevent complications, but it may actually precipitate them. 6 Furthermore, packing has been shown to be directly associated with postoperative pain, discomfort, soft palate laceration, septal perforation, nasopulmonary reflex (a life-threatening vagal response that can lead to hypoxia and bradycardia), and even toxic shock. 7,8 A few large case series have questioned the utility of packing in nasal surgeries, with predominantly unfavorable results. In one series of 50 patients undergoing septorhinoplasty, Guyuron et al 3 reported a higher rate of septal deviations postoperatively in unpacked patients (p <.05) and subjective breathing improvement

5 188 Aesthetic Surgery Journal 31(2) Table 3. Aesthetic Complications and Recent Rhinoplasty Experience Past-Year Rhinoplasty Experience, n (%) b Packing n (%) a P c P c General aesthetic 38 (30) 27 (71) 7 (18) 4 (11) Bone and cartilage 45 (36) 30 (67) 10 (22) 5 (11) Ala 4 (3) 4 (100).58 Columella 1 (1) 1 (100) Tip 29 (23) 14 (48) 11 (38) 4 (14) Supratip 4 (3) 1 (25) 3 (75).06 f.86 f a Percentage of total sample (N = 126). b Percentage of column. c χ 2 test. Dashes ( ) indicate that the test was not performed due to small cell sizes. f Less than 20 versus 21 or greater past-year rhinoplasty experience. (p <.01) in patients packed with polysporin-impregnated gauze. 9 In contrast, an examination of 59 patients undergoing septal surgery by Nunez et al 4 demonstrated no significant difference in complication rates (adhesions, crusting/mucosal atrophy, or granuloma formation) between patients packed with Vaseline gauze versus those without packing. 10 In addition, Nunez et al reported higher pain on postoperative day 1 in the Vaseline gauze group (p <.05). Von Schoenberg et al 5 discussed similar findings in a series of 95 patients undergoing routine nasal procedures, with higher pain being reported by patients packed with Bismuth iodoform paraffin paste or Tefla (p <.001). Furthermore, a higher rate of complications was observed in the packed group. 11 Postoperative ecchymosis management also varied greatly among polled surgeons. Surgeons with fewer annual rhinoplasties were found to be significantly more likely to utilize ice packs alone to prevent postoperative bruising. In contrast, surgeons performing more rhinoplasties often paired ice packs with other forms of antiinflammation tools. These items in the other category varied widely and ranged from common pharmaceuticals to homeopathic therapies. However, although these surgeons reported additional measures to prevent postoperative ecchymosis, there was no statistical significance in the types of most frequent complications reported by this group as compared to others who performed fewer rhinoplasties (P =.34). We are unable to identify a clear reason for the addition of secondary therapies in concert with ice packs among these surgeons. However, we speculate that since this is noted in surgeons performing more annual rhinoplasty operations, this addition is a learned defense in light of their greater operative experience. The frequently reported complications following rhinoplasty suggest interesting trends. We unexpectedly found that the majority of self-reported complications were not significant when correlated with surgeons annual rhinoplasty volume, which suggests that similar complications are reported regardless of a surgeon s past-year experience. We cannot speculate on the frequency of these complications, but we do expect more experienced rhinologists to have lower rates of postoperative complications. Of interest, surgeons with fewer operations reported significantly more tip complications postoperatively (P =.01) and were more likely to practice packing, although not significantly (P =.06). Although we do not believe that packing is responsible for these complications (ie, the relationship is not direct), these data show that US surgeons with lower annual rhinoplasty volumes experience increased packing and tip difficulties as a result of their infrequent cases. Finally, it is intriguing that surgeons with increased annual rhinoplasty specialization mentioned supratip deformities as a common complication. We speculate that this may be partially due to their difficulty in recognizing and discerning more subtle postoperative cosmetic defects. Surgeons with increased expertise may be able to distinguish these deformities more easily. This study is limited by a relatively low response rate (8.2%). Furthermore, the majority of respondents reported being in private practice and having been trained in plastic surgery without a fellowship. We recognize that the results represent a narrow representation of practicing aesthetic surgeons in the United States. However, given the interest in aesthetic rhinoplasty in the United States and the case volumes achieved by these surgeons, we believe that the results are important to understanding the rhinoplasty case management characteristics in this population. Conclusions The implications of this study suggest that packing is still prominent in a subset of US surgeons. Certainly, plastic surgeons in this country encounter a variety of patient needs and may have a broad focus rather than a concentration in one area of aesthetics, such as rhinoplasty. It is interesting that these surgeons continue to utilize such a controversial postoperative management practice in rhinoplasty. Future studies may need to address this activity and examine patient outcomes in this population. Disclosures The authors declared no conflicts of interest with respect to the authorship and publication of this article. Funding The authors received no financial support for the research and authorship of this article.

6 Kelley et al 189 Appendix: Online Survey As distributed to members of the American Society for Aesthetic Plastic Surgery in March What is your training background? A) Plastic surgery B) Plastic surgery with fellowship C) ENT D) ENT with fellowship E) Other What type of practice do you have? A) Private B) Academic C) Other (please specify) Approximately how many rhinoplasty procedures have you completed in the past 12 months? A) 0-10 B) C) D) E) F) >50 Do you routinely pack the nasal cavity after rhinoplasty? A) Yes B) No References 1. American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank: statistics. Published Accessed December 17, Warner J, Gutowski K, Shama L, Marcus B. National interdisciplinary rhinoplasty. Aesthet Surg J 2009;29(4): Guyuron B. Is packing after septorhinoplasty necessary? A randomized study. Plast Reconstr Surg 1989;84(1): Nunez DA, Martin FW. An evaluation of post-operative packing in nasal septal surgery. Clin Otolaryngol Allied Sci 1991;16(6): von Schoenberg M, Robinson P, Ryan R. Nasal packing after routine nasal surgery: is it justified? J Laryngol Otol 1993;107(10): What type of nasal splinting do you prefer? How long do you prefer for nasal splints to be in place? What do you recommend to decrease postoperative ecchymosis? A) Ice pack B) Heating pad C) Other (please specify) If you utilize post-operative steroids, what steroid do you use, and what is your regimen? What are your three most common complications/ morbidities, in order from most to least frequent? How do you manage an early postoperative supratip deformity? 6. Repanos C, McDonald SE, Sadr AH. A survey of postoperative nasal packing among UK ENT surgeons. Eur Arch Otorhinolaryngol 2009;266(10): Sindwani R, Wright ED, Janzen VD, Chandarana S. Perioperative management of the sinus patient: a Canadian perspective. J Otolaryngol 2003;32(3): Stucker FJ, Ansel DG. A case against nasal packing. Laryngoscope 1978;88(8): Fairbanks DN. Complications of nasal packing. Otolaryngol Head Neck Surg 1986;94(3): Jacobs JR, Levine LA, Davis H, et al. Posterior packs and the nasopulmonary reflex. Laryngoscope 1981;91(2): Jacobson JA, Kasworm EM. Toxic shock syndrome after nasal surgery: case reports and analysis of risk factors. Arch Otolaryngol Head Neck Surg 1986;112(3):