DISCUSSION
Septorhinoplasty is an effective cosmetic surgery widely applied and
accepted around the world. In this procedure, complications involving
skin and soft tissues may occur due to the force applied to reshape the
nose and these complications significantly affect patient satisfaction
[21-23].
Edema and ecchymosis can be distressing for patients in the early
postoperative period. Of note, edema in the first postoperative 24 hours
may affect visual acuity and ecchymosis may lead to disruption of
patients’ social activities due to increased pigmentation
[24].
Although numerous techniques have been developed to reduce edema and
ecchymosis since years, post-rhinoplasty care remains controversial
[25,26].
As rhinoplasty remains a demanding and popular operation, it is
important to ensure that clinicians follow best practices to reduce
morbidity
[26,27].
To the best of our knowledge, this is the first study in the literature
to investigate the effect of topically usage of bromelain and arnica gel
combination on periorbital edema and ecchymosis following
septorhinoplasty.
A previous study evaluated the effect of arnica and bromelain
combination on ecchymosis after blepharoplasty. A total of 130 patients
received the tablet forms of arnica and bromelain for a total of two
weeks, one week before surgery and another week after surgery, while the
control group received no treatment. The authors concluded that no
significant difference was found between the two groups with regard to
ecchymosis
[28].
But, in this study, we applied bromelain-arnica gel combination
topically to the patients’ ecchymosis and edema around their eyes, and
we also observed that topical application of bromelain-arnica gel
combination was effective to significantly decrease patients’ both
ecchymosis and edema.
Another study evaluated the effect of topical application of arnica and
mucopolysaccharide polysulphate in open rhinoplasty on periorbital edema
and ecchymosis and divided the patients into three groups: group I
received postoperative arnica cream treatment, group II received
postoperative mucopolysaccharide polysulphate cream treatment, and Group
III (control group) included patients who received no postoperative
treatment. The authors found a significant difference between groups I
and II and the control group with regard to periorbital edema and
ecchymosis, while there was no significant difference between groups I
and II. The authors proposed that a rapid regression of edema and
ecchymosis could be achieved by local treatments of arnica and
mucopolysaccharide polysulphate cream
[29].
Sakallioglu et al. examined the effect of tranexamic acid and
methylprednisolone on periorbital edema and ecchymosis in patients that
underwent open septorhinoplasty. The authors divided patients into three
groups: group I (control group) received no postoperative treatment,
group II received oral tranexamic acid, and group III received
intravenous methylprednisolone therapy. Groups II and III had
significantly lower periorbital edema and ecchymosis scores compared to
the control group, while no significant difference was found between
groups II and III
[30].
A prospective, randomized triple-blinded study examined the effect of
dexamethasone and tranexamic acid on post-rhinoplasty periorbital edema
and ecchymosis and divided the patients into four groups: group D
received dexamethasone, group T received tranexamic acid, group DT
received dexamethasone and tranexamic acid, and group P (control group)
received no medication. All the drugs were administered intravenously.
The results indicated that the periorbital edema and ecchymosis scores
were significantly lower in groups D, T, and DT, compared to the control
group, whereas no significant difference was found among groups D, T,
and DT
[31].
Totonchi et al. investigated the effect of steroids and arnica following
rhinoplasty and divided the patients into three groups: group P received
steroids, group A received arnica, and group C (control group) received
no medication. The results demonstrated that both steroids and arnica
could be effective in reducing edema during the early postoperative
period
[32].
Literature indicates that preoperative steroid administration could be a
preventive measure to reduce edema and ecchymosis in rhinoplasty
[1,33,34].
A previous meta-analysis reported that perioperative administration of
repeated doses of steroids was more effective in reducing periorbital
edema and ecchymosis than single-dose steroid administration
[35].
Combined use of lidocaine and adrenaline reduces intraoperative bleeding
and postoperative pain in patients undergoing rhinoplasty while it may
not lead to reduction in postoperative edema and ecchymosis
[36].
In a prospective randomized controlled double-blinded study, Chaiet et
al. evaluated the efficacy of perioperative use of Arnica montana on
post-rhinoplasty ecchymosis and found that Arnica montana led to a
significant reduction in ecchymosis compared to the control group
[37].
Kara et al. found that the subperiosteal tunnel created before lateral
osteotomy led to a significant increase in periorbital ecchymosis and
also increased subconjunctival ecchymosis though insignificantly. Based
on these findings, the authors recommended that the creation of a
subperiosteal tunnel before lateral osteotomy should be avoided
[38].
Another study by Sakallioglu et al. compared the effect of open and
closed septorhinoplasty procedures on periorbital edema and ecchymosis
and found no significant difference between the two techniques
[39].
Kelles et al. investigated the efficacy of local heparinoids in the
reduction of periorbital edema and ecchymosis and found that local
administration of heparinoids following rhinoplasty had no significant
effect on the prevention of periorbital edema and ecchymosis
[40].
A recent systematic review indicated that favorable outcomes were
obtained in terms of edema, ecchymosis, and pain control in surgical
operations using arnica and bromelain, including not only rhinoplasty
but also orthopedic surgeries. Based on these findings, the authors
suggested that arnica and bromelain could be used not only in
rhinoplasty but also in surgical operations that are suitable in terms
of edema, ecchymosis, and pain control
[41].
Septorhinoplasty is highly popular and the number of patients undergoing
this procedure is growing worldwide. But, periorbital edema and
ecchymosis following septorhinoplasty can cause to significant increase
in morbidity and a significant decrease in patient satisfaction.
Although, there are numerous studies investigating the reduction of
periorbital edema and ecchymosis, and post-rhinoplasty care remains
controversial. In this study, we investigated the efficacy of topical
administration of bromelain and arnica gel combination in the reduction
of periorbital edema and ecchymosis following septorhinoplasty, and we
compared the results with those of control group in a randomized
fashion. In conclusion, this study indicated that topical administration
of bromelain and arnica gel combination lead to a significant reduction
in periorbital edema and ecchymosis following septorhinoplasty.
Conflict of interest: There is no conflict of interest for any
authors.
Financial disclosure: There is no
financial assistance