Outcomes of a Treatment Protocol for Compromised Nasal Skin in Primary and Revision Open Rhinoplasty

Abstract

Importance:

This is the first study to review the incidence of nasal skin compromise after open rhinoplasty surgery and outcomes of treatment.

Objectives:

To determine whether risk of skin compromise after open rhinoplasty surgery can be predicted and whether our treatment protocol led to acceptable outcomes.

Design, Setting, and Participants:

This is a retrospective chart review of the senior author's private patients. In total, 384 rhinoplasty cases were reviewed and all cases with signs of vascular compromise requiring treatment were analyzed.

Main Outcomes and Measures:

Descriptive statistics were used to evaluate characteristics of patients who developed intra- and postoperative skin compromise, and unpaired two-tailed t-test was used to compare the characteristics of patients with and without compromised nasal skin when possible. Overall satisfaction results and complications in the skin compromise group were reported.

Results:

A total of 384 open rhinoplasties were performed by the senior author between October 1, 2015, and December 31, 2018. Of them, 109 were primary rhinoplasties and 275 were revision rhinoplasties. Of the 384 rhinoplasties, 27 (7%) had skin compromise leading to unplanned postoperative treatment. Two of the patients in the skin compromise group underwent primary surgeries (7.4%) and 25 underwent revision procedures (92.6%). Advanced age (p < 0.0001), prior or current history of smoking (p = 0.027), and greater number of prior rhinoplasty surgeries (p = 0.0002) were significantly correlated with risk of skin compromise. The average time to last follow-up in the skin compromise group was 392 days (range 15–1057 days). At their last follow-up, 12 patients had complete resolution of all signs of nasal skin compromise with no further treatment required (44.4%). The revision rate for patients experiencing skin compromise was 22.2%. One patient underwent revision surgery directly related to a complication of skin compromise and one is considering revision directly related to skin breakdown.

Conclusions and Relevance:

The rate of skin compromise after open rhinoplasty is low. Older patients and patients with more prior rhinoplasty surgeries may be at increased risk. Prompt treatment of compromised nasal blood supply after rhinoplasty surgery can salvage skin in most patients.

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References

Rohrich

, Muzaffar

, Gunter

. Nasal tip blood supply: confirming the safety of the transcolumellar incision in rhinoplasty. Plast Reconstr Surg. 2000; 106(7):1640–1641.

Toriumi

, Mueller

, Grosch

, Bhattacharyya

, Larrabee

Jr . Vascular anatomy of the nose and the external rhinoplasty approach. Arch Otolaryngol Head Neck Surg. 1996; 122(1):24–34.

Saban

, Andretto Amodeo

, Bouaziz

, Polselli

. Nasal arterial vasculature: medical and surgical applications. Arch Facial Plast Surg. 2012; 14(6):429–436.

Yessenow

, Maves

. The effects of pentoxifylline on random skin flap survival. Arch Otolaryngol Head Neck Surg. 1989; 115(2):179–181.

Harbison

, Kriet

, Humphrey

. Improving outcomes for composite grafts in nasal reconstruction. Curr Opin Otolaryngol Head Neck Surg. 2012. 20(4):267–273.

Beer

, Downie

, Beer

. A treatment protocol for vascular occlusion from particulate soft tissue augmentation. J Clin Aesthet Dermatol. 2012; 5(5):44–47.

Chao

, Raveendran

, Sauerhammer

, Rogers

, Oh

, Boyajian

. Columellar reconstruction after nasal continuous positive airway pressure associated necrosis. J Craniofac Surg. 2017; 28(4):928–930.

Jayaratne

, Zwahlen

, Htun

, Bütow

. Columella pressure necrosis: a method of surgical reconstruction and its long-term outcome. BMJ Case Rep. 2014; 2014:bcr2013203132.

Maruccia

, Fanelli

, Ruggieri

, Onesti

. Necrosis of the columella associated with nasal continuous positive airway pressure in a preterm infant. Int Wound J. 2014; 11(3):335–336.

10.

Robertson

, McCarthy

, Hamilton

, Moss

. Nasal deformities resulting from flow driver continuous positive airway pressure. Arch Dis Child Fetal Neonatal Ed. 1996; 75(3):F209–F212.

11.

Sherris

, Fuerstenberg

, Danahey

, Hilger

. Reconstruction of the nasal columella. Arch Facial Plast Surg. 2002; 4(1):42–46.

12.

Kerolus

, Nassif

. Treatment protocol for compromised nasal skin. Facial Plast Surg Clin North Am. 2019; 27(4):505–511.

13.

Kashima

, Ikemura

, Hayashi

. Regional differences in facial skin blood flow responses to the cold pressor and static handgrip tests. Eur J Appl Physiol. 2013; 113(4):1035–1041.

14.

Kleydman

, Cohen

, Marmur

. Nitroglycerin: a review of its use in the treatment of vascular occlusion after soft tissue augmentation. Dermatol Surg. 2012; 38(12):1889–1897.

15.

Elyassi

, Terres

, Rowshan

. Medicinal leech therapy on head and neck patients: a review of literature and proposed protocol. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013; 116(3):e167–e172.

16.

Pannucci

, Nelson

, Chung

, et al. Medicinal leeches for surgically uncorrectable venous congestion after free flap breast reconstruction. Microsurgery. 2014; 34(7):522–526.

17.

Kruer

, Barton

, Roberti

, Gilbert

, McMillian

. Antimicrobial prophylaxis during Hirudo medicinalis therapy: a multicenter study. J Reconstr Microsurg. 2015; 31(3):205–209.

18.

Moffat

, Weaver

, Tettelbach

. Compromised breast flap treated with leech therapy, hyperbaric oxygen, pentoxifylline and topical nitroglycerin: a case report. Undersea Hyperb Med. 2015; 42(3):281–284.

19.

Davis

, Wachholz

, Jassir

, Perlyn

, Agrama

. Comparison of topical anti-ischemic agents in the salvage of failing random-pattern skin flaps in rats. Arch Facial Plast Surg. 1999; 1(1):27–32.

20.

Kerrigan

. Skin flap failure: pathophysiology. Plast Reconstr Surg. 1983; 72(6):766–777.

21.

Rohrich

, Cherry

, Spira

. Enhancement of skin-flap survival using nitroglycerin ointment. Plast Reconstr Surg. 1984; 73(6):943–948.

22.

Gdalevitch

, Van Laeken

, Bahng

, et al. Effects of nitroglycerin ointment on mastectomy flap necrosis in immediate breast reconstruction: a randomized controlled trial. Plast Reconstr Surg. 2015; 135(6):1530–1539.

23.

Aker

, Mancoll

, Lewis

, Colen

. The effect of pentoxifylline on random-pattern skin-flap necrosis induced by nicotine treatment in the rat. Plast Reconstr Surg. 1997; 100(1):66–71.

24.

Ward

, Clissold

. Pentoxifylline. A review of its pharmacodynamic and pharmacokinetic properties, and its therapeutic efficacy. Drugs., 1987; 34(1):50–97.

25.

Ahmadi

, Khalili

. Potential benefits of pentoxifylline on wound healing. Expert Rev Clin Pharmacol. 2016; 9(1):129–142.

26.

Daoudi

, Labeyrie

. Guillerm S, et al. Multimodal strategy for the management of sphenoid osteoradionecrosis: preliminary results. Laryngosc Investig Otolaryngol., 2020; 5(1):19–23.

27.

Lucca

, Brasolin

, Feitosa

, Simoes e Silva Enokihara

, Gomes

, Ferreira

. Histological modification in TRAM flap in rats treated with pentoxifylline. Acta Cir Bras. 2014; 29(Suppl 2):34–37.

28.

Monteiro

, Santamore

, Nemir

Jr . The influence of pentoxifylline on skin-flap survival. Plast Reconstr Surg. 1986; 77(2):277–281.

29.

Sig

, Guney

, Uskudar Guclu

, Ozmen

. Medicinal leech therapy—an overall perspective. Integr Med Res. 2017; 6(4):337–343.

30.

Jose

, Varghese

, Babu

. Salvage of venous congestion using medicinal leeches for traumatic nasal flap. J Maxillofac Oral Surg. 2015; 14(Suppl 1):251–254.

31.

Frodel

Jr , Barth

, Wagner

. Salvage of partial facial soft tissue avulsions with medicinal leeches. Otolaryngol Head Neck Surg. 2004; 131(6):934–939.

32.

Lozano

, Stephenson

, Zamboni

. Effect of hyperbaric oxygen and medicinal leeching on survival of axial skin flaps subjected to total venous occlusion. Plast Reconstr Surg. 1999; 104(4):1029–1032.

33.

Utley

, Koch

, Goode

. The failing flap in facial plastic and reconstructive surgery: role of the medicinal leech. Laryngoscope. 1998; 108(8 Pt 1):1129–1135.

34.

Ardehali

, Hand

, Nduka

, Holmes

, Wood

. Delayed leech-borne infection with Aeromonas hydrophilia in escharotic flap wound. J Plast Reconstr Aesthet Surg. 2006; 59(1):94–95.

35.

Nguyen

, Crosby

, Skoracki

, Hanasono

. Outcomes of flap salvage with medicinal leech therapy. Microsurgery. 2012; 32(5):351–357.

36.

Patel

, Svestka

, Sinkin

, Ruff P

. Ciprofloxacin-resistant Aeromonas hydrophila infection following leech therapy: a case report and review of the literature. J Plast Reconstr Aesthet Surg. 2013; 66(1):e20–e22.

37.

Francis

, Baynosa

. Hyperbaric oxygen therapy for the compromised graft or flap. Adv Wound Care (New Rochelle). 2017; 6(1):23–32.

38.

Sheffield

PJ.

Tissue oxygen measurements. In: Davis

, Hunt

, eds. Problem Wounds: The Role of Oxygen. New York: Elsevier; 1988: pp. 17–51.

39.

Xiao

, Liu

, Li

, et al. Hyperbaric oxygen preconditioning inhibits skin flap apoptosis in a rat ischemia-reperfusion model [published correction appears in J Surg Res. 2016 May 1;202(1):111]. J Surg Res. 2015; 199(2):732–739.

40.

Kang

, Hai

, Liang

, Gao

, Liu

. Preconditioned hyperbaric oxygenation protects skin flap grafts in rats against ischemia/reperfusion injury. Mol Med Rep. 2014; 9(6):2124–2130.

41.

, Gao

, Wang

, et al. Effects of hyperbaric oxygen preconditioning on ischemia-reperfusion inflammation and skin flap survival. Chin Med J (Engl). 2013; 126(20):3904–3909.

42.

Liu

, Yang

, Li

, et al. Hyperbaric oxygen preconditioning promotes neovascularization of transplanted skin flaps in rats. Int J Clin Exp Pathol. 2014; 7(8):4734–4744.

43.

Larson

, Steensma

, Flikkema

, Norman

. The application of hyperbaric oxygen therapy in the management of compromised flaps. Undersea Hyperb Med. 2013; 40(6):499–504.

44.

Weber

, Silver

, Williams

, et al. Random flap survival with hyperbaric oxygen: daily versus twice-daily treatments. Undersea Hyperb Med. 2018; 45(2):157–164.

45.

Polfer

, Zimmerman

, Tefera

, Katz

, Higgins

, Means

Jr . The effect of skin pigmentation on determination of limb ischemia. J Hand Surg Am. 2018; 43(1):24–32.e1.

46.

Kamer

, McQuown

. Revision rhinoplasty. Analysis and treatment. Arch Otolaryngol Head Neck Surg., 1988; 114(3):257–266.

47.

Parkes

, Kanodia

, Machida

. Revision rhinoplasty. An analysis of aesthetic deformities. Arch Otolaryngol Head Neck Surg., 1992; 118(7):695–701.

48.

Bagheri

, Khan

, Jahangirnia

, Rad

, Mortazavi

. An analysis of 101 primary cosmetic rhinoplasties. J Oral Maxillofac Surg. 2012; 70(4):902–909.

49.

Neaman

, Boettcher

, Do

, et al. Cosmetic rhinoplasty: revision rates revisited. Aesthet Surg J. 2013; 33(1):31–37.

50.

Virdis

, Bacca

, Colucci

, et al. Endothelial dysfunction in small arteries of essential hypertensive patients: role of cyclooxygenase-2 in oxidative stress generation. Hypertension. 2013; 62(2):337–344.

51.

Gronkjaer

, Eliasen

, Skov-Ettrup

, et al. Preoperative smoking status and postoperative complications: a systematic review and meta-analysis. Ann Surg. 2014; 259(1):52–71.

52.

Gelber

, Babushkin

, Schattner

. Stubborn creatures: Dormant Staphylococcus aureus. Am J Med. 2017; 130(3):e101–e102.

53.

Handler

, Bloom

, Goldberg

. IPL vs PDL in treatment of facial erythema: a split-face study. J Cosmet Dermatol. 2017; 16(4):450–453.

54.

Mohamed

, Mohamed Tawfik

, Hassan Ahmad

. Successful treatment of facial vascular skin diseases with a 577-nm pro-yellow laser. J Cosmet Dermatol. 2019; 18(6):1675–1679.

55.

Ponticorvo

, Taydas

, Mazhar

, et al. Evaluating visual perception for assessing reconstructed flap health. J Surg Res. 2015; 197(1):210–217.

56.

Whitaker

, Pratt

, Rozen

, et al. Near infrared spectroscopy for monitoring flap viability following breast reconstruction. J Reconstr Microsurg. 2012; 28(3):149–154.

57.

Engel

, Huang

, Tsao

, et al. Remote real-time monitoring of free flaps via smartphone photography and 3G wireless Internet: a prospective study evidencing diagnostic accuracy. Microsurgery. 2011; 31(8):589–595.

58.

Russell

, Conforti

, Connor

, Hartig

. Cutaneous tissue flap viability following partial venous obstruction. Plast Reconstr Surg. 2006; 117(7):2259–2266; discussion 2267–2258.