New rhinoplasty guidelines from the American Academy of Otolaryngology—Head and Neck Surgery provide data-driven advice on pre- and post-operative management of nose surgery patients.
The guidelines, which appear in the February 2017 issue of Otolaryngology–Head and Neck Surgery, come out against and routine nasal packing (with or without septoplasty) and the routine use of antibiotics for more than 24 hours preoperatively.
“There just isn’t evidence to support routine nasal packing to prevent hemostasis,” says guideline author Lisa Ishii, MD, an Associate Professor of Otolaryngology - Head and Neck Surgery at Johns Hopkins Medicine in Baltimore, tells AestheticsWire. “It is a feel-good for a surgeon but evidence does not support it.” For some rhinoplasty patients including those with epistaxis or complex unstable nasal fractures, nasal packing may make sense, the guidelines state.
“A lot of clinicans have prescribed prophylactic antibiotics for a week after rhinoplasty to be safe, but the literature does not support this,” she says. The risks outweigh the benefits after 24 hours in many cases. And “you don’t have to give any antibiotics at all,” she says.
There is a question mark surrounding the efficacy of perioperative steroids, and while they remain an option, more research is needed to better understand the benefits and risks associated with this practice.
The guidelines also encourage surgeons to assess rhinoplasty candidates for comorbid conditions that could modify or contraindicate surgery, including obstructive sleep apnea (OSA), body dysmorphic disorder, bleeding disorders, or chronic use of topical vasoconstrictive intranasal drugs. “Careful assessment preoperatively of expectations and motivations of our patents using a formal tool such as the Body Dysmorphic Disorder Questionnaire is easy to integrate even into very busy practices,” she says. “There are some patients who aren’t great candidates for rhinoplasty from a psychologiocal aspect and we must do due diligence.”
Surgeons and other healthcare providers should counsel OSA patients about the impact of surgery on nasal airway obstruction and how OSA might affect peri-operative management.
Realistic expectations about the procedure and what to expect afterward are also an important part of the consultation process. This includes a discussion about how surgery might affect the ability to breathe through the nose, potential complications, and the possible need for revision surgery, the guidelines state.
Clinicians should document patient satisfaction with their nasal appearance and with function at a minimum of 12 months after rhinoplasty. “Follow up to see how they are doing and determine, in a data-driven way, that the procedures perform you are making a difference.”
Waiting at least one year is optimal as it takes that long for swelling to fully abate after rhinoplasty, she says, noting that it can be a challenge to get a patient back to the office after a full year has elapsed.
The guideline is endorsed by American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), American Society of Plastic Surgeons (ASPS), American Academy of Sleep Medicine (AASM), American Rhinologic Society (ARS), Society of Otorhinolaryngology Head-Neck Nurses (SOHN), American Society for Aesthetic Plastic Surgery (ASAPS), American Academy of Pediatrics (AAP), and The Rhinoplasty Society.
"The Guidelines serve as the most complete evidence-based group of recommendations relating to the care and evaluation of the rhinoplasty patient available and will serve as a model for similar future endeavors," says Foley, AL-based facial plastic surgeon Fred Fedok, MD, president of AAFPRS.