1. The effect of periosteum Elevation on Periorbital Ecchymosis in Rhinoplasty Accepted in journal of plastic reconstructive aesthetic surgery 2008 Ahmed Al-Arfaj,MD, Sami Al-Harethy,MD King Saud University Riyadh, Saudi Arabia

2. Aim of the Study The study goal was to determine whether creating a subperiosteal tunnel before lateral osteotomy had an effect on postoperative periorbital ecchymosis.

3. Patients and Methods Prospective study of seventy eight patients who underwent septorhinoplasty (March 2005 to March 2006) were included in the study. 31 females, 47 males Mean age 22 yrs (15-32) 53 closed technique, 25 Open technique.

4. Patients and Methods In all patients lateral osteotomies were carried out bilaterally, after elevating the periosteum on a randomly chosen side and without elevating the periosteum on the other side. Operations were carried out under GA Guided, curved 4-mm lateral osteotomes were used for the lateral osteotomies.

5. Patients and Methods Local anesthesia was achieved with 1% lidocain and 1:200,000 epinephrine solution infiltration. Steroids were not given, and only acetaminophen was administered for the post op analgesia. Nasal packing using size 8 slim Merocel was routinely used.

6. The patients were seen on the second postoperative day and ecchymosis grade determined. Grading system for evaluating periorbital ecchymosis. 0 point, none; 1 point, medial; 2 points, extending to the pupil; 3 points, extending past the pupil; 4 points, extending to the lateral canthus. Developed by Eksal Kargi et al 2003 Patients and Methods

7. Results THE DISTRIBUTION OF ECCHYMOSIS OF THE PATIENTS GROUPS Non-elevated Side Elevated Side Ecchymosis Grade 2 ( 50%) Grades 0 7 ( 63.3%)4 ( 36.7%) Grades 1 12 ( 80%)3 ( 20%) Grades 2 35 (50.7%)34 ( 49.3%) Grades 3 22 (38.6%)35 (61.4%) Grades 4

8. Results The increase in periorbital ecchymosis on the side with periosteal elevation was statistically significant( P=0.05)

9. Discussion Facial edema and ecchymosis after any surgical procedure at the face is normal, but especially in patients coming for cosmetic procedure is a very unpleasant experience.

10. Discussion Surgeons tried to compare external and internal lateral osteotomy in terms of post operative edema and ecchymosis, but the results were inconsistent, especially when using different instruments. Which Type of Osteotomy For Edema and Ecchymosis: external or Internal, O. Taskin Yucel Annals of Plastic surgery 2005 A comparison between External versus Internal Lateral Oseteotomy in rhinoplasty. M. Hashemi et al. Journal of research in medical scienses 2005.

11. Discussion Weather Elevating the periosteum on the side of the osteotomy or not will affect the degree of ecchymosis is a relatively controversial issue. (Huizing HG, de Groot JAM: Functional reconstructive Nasal surgery. Stuttgart, Germany, George Thieme Verlag, 2003, p201. Pastorek MJ: the large nose, in Gates GA(ed): current therapy in otolaryngology-Head and neck surgery. St Louis, MO, Mosbi, 1998, p 157 Daniel RK: the Osteocartilagenous Vault, in Daniel RK(ed): Rhinoplasty.Boston,MA,little,brown,1993pp 169-213 Sullvian PK, Harshbarger RJ,Adams WP(eds)Nasal osteotomy, Dallas Rhinoplasty St Louis, Quality Medical Publishing,2002, 595-611

12. Discussion Not only because the role of periosteal elevation is not well understood but also because other factors like, the level of the osteotomy, extent of surgery, vigerous rasping, may all affect the degree of ecchymosis. McCharthy JG, Wood Smith D: Rhinoplasty, in McCharthy JG(ed): Plastic Surgery. Philadelphia, PA, Saunders, 1990, pp 17851894 Kaschke O: Postoperative care and management, in Behrbohm H, Tardy ME Jr(eds): Essentials of septorhinoplasty.Stuttgart,Germany,Georg Thieme Verlag, 2004, pp 234-236

13. Discussion A recent study by Kara, et. al, showed the effect of subperiosteal tunnel creation on the periorbital edema and ecchymosis on 18 patients, and he concluded that creating subperiosteal tunnels before lateral osteotomy increases periorbital ecchymosis, subconjunctival ecchymosis and edema. Does Creating a subperiosteal Tunnel influence the Perorbital Edema and Ecchymosis in Rhinoplasty? J Oral Maxillofac Surg 63: 1088-1090, 2005

14. Discussion Our study investigate this finding in a larger group of patients (78 patient, 156 side studied), uses a different grading system and focussed mainly on the periorbital ecchymosis.

15. conclusion We suggest performing lateral osteotomy without elevating the periosteum.

16. THANKS