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.
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