Nasal tip edema is may occur after rhinoplasty. Persistent nasal tip edema is edema that lasts greater than one month and is a common complaint after an extensive surgical dissection of the nasal tip and placement of various grafts particularly in secondary rhinoplasty. It requires patience on the part of the patient and the physician. The patient must avoid certain inciting culprits such as excess sodium intake and excessive overheating. Additional interventions may be necessary to expedite the healing process.
Excessive dietary sodium may result in sustained swelling in the postoperative rhinoplasty patient. Sodium draws water intravascularly due to its osmotic forces. Nasal blood vessels are leaky after surgery due to local damage, tissue factors, and cytokines. The excess fluid drawn in by the sodium will now gather in the extravascular spaces in the healing tissues. This is a commonly observed finding in postoperative patients after digesting a meal high in sodium content. Although it will likely not impact the final result of the patient, avoidance of sodium can expedite the healing process.
Avoidance of heat and exercise is not well described in the literature, but has also been found to be a factor in resolution of nasal tip swelling. Increase body temperature will lead to peripheral vasodilatation in the dermis. The increase in blood flow in the dermis of the postoperative rhinoplasty patient can potentially contribute to persistence of swelling in the nasal tip. This is often observed in our postoperative rhinoplasty patients.
If the swelling persists for a prolonged time and is bothersome to the patient, intervention may be considered by the surgeon. In patients with thick skin or excess nasal skin, intervention may be performed even earlier. Nasal taping consists of placing non-reactive skin-colored tape nightly across the nasal supratip. (Figure 3) The tape serves to reduce some of the edema and may be effective in reducing the dead space in patients with thick skin.
Steroid injections may be beneficial in patients with persistent nasal swelling. Hanasono et al described their experience using triamcinolone injection as a first line of therapy in patients with a soft tissue pollybeak with an acceptable aesthetic outcome achieved in 85% without any significant sequelae.10 Their recommendations included injecting intralesionally and avoiding intradermal injections. Rohrich et al described their postoperative regimen that includes the combination of triamcinolone injections, nasal taping, and silastic sheeting.11
The senior author’s postoperative regimen depends on the healing course of the patient. In a patient with thick skin or in which excess nasal tip skin remains, nasal steroid injections can be done as early as two weeks postoperatively. Because an infection in a patient with nasal tip grafts is a potentially devastating consequence, nasal steroids injections are generally not used earlier. In a patient with residual swelling, the senior author employs a conservative concentration of 10mg/cc of triamcinolone acetonide directly into the area of swelling and generally injects less than 0.2cc. It is prudent to avoid intradermal injection to avoid thinning of the epidermis. The triamcinolone injections complemented with the nasal taping is especially effective in treating postoperative thick-skin patients. This combination of interventions may help to expedite the resolution of edema in postoperative rhinoplasty patients.