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Correction of the Soft Tissue Pollybeak Using Triamcinolone Injection
Matthew M. Hanasono, MD;
Russell W. H. Kridel, MD;
Norman J. Pastorek, MD;
Mark J. Glasgold, MD;
R. James Koch, MD
Arch Facial Plast Surg. 2002;4:26-30.
ABSTRACT
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Objective To describe the technique for correction of the soft tissue pollybeak
deformity using intralesional injection of triamcinolone acetonide.
Methods We discuss our philosophy, regimen, and technique for treatment of the
soft tissue pollybeak using triamcinolone injection. We include results from
a series of 173 patients who underwent rhinoplasty performed by one of us
(N.J.P.).
Results Triamcinolone was injected at 1 week after surgery in 127 patients (73%).
A second injection was performed in 92 (72%) of the 127 patients at 4 weeks
after surgery. One hundred eight (85%) of the 127 patients had an acceptable
result, as judged by the surgeon, with good supratip definition. Nineteen
(15%) of the 127 patients had a less than optimal result, with residual supratip
fullness, as judged by the surgeon. There were no complications caused by
triamcinolone injection.
Conclusions Because revision surgery is difficult and may be associated with complications,
intralesional triamcinolone injection is the first-line treatment for the
soft tissue pollybeak deformities caused by subdermal scarring. Should intralesional
steroid injection fail to satisfactorily treat the deformity, revision rhinoplasty
can subsequently be performed.
INTRODUCTION
THE POLLYBEAK deformity is one of the most common complications of rhinoplasty.1-3 It is a
convexity of the nasal supratip relative to the rest of the nose. This deformity
is colloquially known as pollybeak because the lower
two thirds of the nose takes on the convex profile of a parrot's beak. The
pollybeak is not due to transient postoperative edema but represents a persistent,
unattractive fullness that distorts the dorsal profile and obscures the tip.
While the pollybeak may be the result of technique, it may also be an
unpredictable complication for even the most experienced surgeons. The causes
of pollybeak include inadequate resection of supratip structures, most commonly
the dorsal septal cartilage or the cephalic margins of the lower lateral cartilages;
loss of tip support; or, paradoxically, excessive cartilage resection in the
supratip region that results in subcutaneous scar tissue formation, often
in conjuction with thick nasal tip skin.1-5
If excess cartilage is the cause, the condition is called a cartilaginous pollybeak, and simple trimming of this cartilage will
solve the problem. With loss of tip support, a cartilage strut or tip graft
can be placed to correct or disguise the deformity.
A more difficult problem is the pollybeak deformity that occurs paradoxically
as a result of overresection of the lower dorsal cartilaginous septum and/or
the cephalic margins of the lower lateral cartilages in the area of the supratip.
This deformity usually occurs in combination with thick nasal skin, resulting
in inadequate skin contraction and excessive dead space between the skin and
the septal border, which fills with scar tissue and results in a supratip
fullness. The patient who requires revision rhinoplasty with major alar and
septal cartilage resections to correct a cartilaginous pollybeak deformity
is also at risk for formation of dead space that may fill with scar tissue
and result in a soft tissue pollybeak.1
For this soft tissue type of pollybeak, revision rhinoplasty with resection
of the scar and debulking of the supratip subcutaneous tissue is often followed
by taping and splinting to prevent recurrence. However, this technique may
be ineffective in thick-skinned individuals and must be performed with utmost
care so as not to perforate through the skin or devascularize the dermis from
below and cause tissue necrosis. Many rhinoplastic surgeons have successfully
been able to avoid such revision surgery by sequential injection of the corticosteroid
triamcinolone acetonide into the supratip scar tissue.6-10
The literature, however, contains only brief mention of the use triamcinolone,
and to date there has been little comparison or quantification of the treatment
regimens used by various surgeons.
TECHNIQUE
A 1-mL tuberculin syringe with a 30-gauge needle is used. The triamcinolone
should be shaken well, as it comes in suspension rather than as a solution.
The technique of administering triamcinolone can be performed as 2 separate
lateral supratip injections or as a single midline supratip injection in which
the needle is redirected to the left and right sides (Figure 1).
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Figure 1. Placement of subcutaneous intralesional
triamcinolone acetonide injection for soft tissue pollybeak deformity.
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The depth of injection should be in the subcutaneous tissue. If blanching
is seen, the injection is in the dermis, and the tip of the needle should
be directed deeper. Injection of triamcinolone into the dermis can result
in cutaneous atrophy. As is standard practice in intralesional injection techniques,
the surgeon should attempt aspiration with the syringe first to ensure that
the needle tip is not within a blood vessel. This cannot be overemphasized,
as injection of triamcinolone into a blood vessel can have hazardous consequences
for the patient (see the "Comment" section). Aspiration before injection may
also facilitate the diagnosis and treatment of a seroma that is masquerading
as a soft tissue pollybeak in the early postoperative phase.
A splint may be placed back on the nose in thick-skinned individuals
after the first injection and left in place for approximately 1 week. The
splint should fit well with adequate pressure over the supratip but should
not extend onto the domal area or cover the tip region. Patients should be
informed that the supratip area may look swollen for several days. They are
assessed every 4 weeks after injection, and subsequent injections are administered
based on the tissue response. Restraint must be used in the decision to repeat
an injection to prevent overtreatment and the consequent atrophy that may
produce a saddle nose or irregular skin deformity. Generally, no more than
4 to 6 injections are administered over time.
The amount of triamcinolone used varies depending on whether the intent
is preventative or curative. In the patient with thick nasal skin and a cartilaginous
pollybeak deformity who is at risk for developing a soft tissue pollybeak,
triamcinolone acetonide at a concentration of 10 mg/mL is typically used at
the conclusion of surgery as a preventive measure. Such an injection is not
administered when the technique of open rhinoplasty is used to prevent spread
of triamcinolone over the entire dorsal region of the nose. One of us (R.W.H.K.)
assesses patients at 2 weeks after surgery for potential soft tissue pollybeak
deformity and, if evident, will inject 0.1 to 0.2 mL of triamcinolone acetonide
at a concentration of 10 mg/mL (1 to 2 mg). Subsequent injections in the same
quantity are then administered every 4 weeks as needed using either the 10-
or the 40-mg/mL suspension, based on the response to the prior injection.
The total amount of triamcinolone used is guided by the response of the deformity,
which varies from patient to patient. In referral cases in which a soft tissue
pollybeak has already formed from previous surgery, 0.1 to 0.2 mL of triamcinolone
acetonide at a concentration of 40 mg/mL (4-8 mg) is injected (Figure 2).
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Figure 2. A, Presurgical photograph of a
22-year-old woman who underwent rhinoplasty, chin augmentation, and submental
liposuction. B, Photograph taken 7.5 weeks after surgery demonstrates early
formation of a soft tissue pollybeak, which was treated with triamcinolone
acetonide at that time. C, Photograph taken 7 months after surgery. D, Posttreatment
photograph taken 9.5 months after surgery shows resolution of the soft tissue
pollybeak.
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Another one of us (N.J.P.) begins injections earlier in the postoperative
course to address incipient formation of the soft tissue pollybeak. Evaluation
of the supratip area is performed 1 week after surgery. At that time, supratip
fullness is visually assessed and the supratip area is palpated. If there
appears to be fullness or if there is blottable edema of the supratip, a small
amount of triamcinolone acetonide, 0.1 mL of a 10-mg/mL suspension (1 mg),
is injected subcutaneously. The patient is seen again at 1 month after surgery
and another injection is administered at that time if residual fullness is
present.
Table 1 summarizes the regimens
used by several authors. Note that more recent reports have recommended smaller
dosages than those used by Rees6 and Mahe et
al,7 who were among the first to describe the
technique in detail and had very successful results. Also, Holt et al1 recommend an injection of 5 mg of triamcinolone acetonide
into the supratip region every 3 to 6 weeks until the edema is resolved. Cook
and Guida4 recommend treating the soft tissue
pollybeak with 10-mg/mL triamcinolone acetonide injections monthly beginning
1 month after surgery until the deformity resolves.
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Triamcinolone Regimens Recommended by Various Authors for Treatment
of the Soft Tissue Pollybeak
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RESULTS
A retrospective review of the experience of one of us (N.J.P.) with
rhinoplasty was performed. One hundred seventy-three rhinoplasties were performed
over a 13-month period. The patients (139 women and 34 men) ranged in age
from 15 to 78 years. One hundred nineteen patients underwent primary rhinoplasty
(91 women and 28 men), and 54 patients underwent revision rhinoplasty (48
women and 6 men). These rhinoplasties were performed with the cartilage delivery
technique in patients who demonstrated adequate tip support before surgery.
An external splint was placed at the conclusion of surgery and was removed
in 1 week, at which time the supratip was visually assessed and palpated.
Postoperative follow-up lasted a minimum of 6 weeks.
Triamcinolone acetonide (10 mg/mL) was injected subcutaneously into
the supratip region per the author's protocol at 1 week after surgery in 127
patients (73%). The group included 84 (70%) of 119 primary rhinoplasties and
43 (80%) of 54 revision rhinoplasties. Ninety-two (72%) of the 127 patients
required a second injection with triamcinolone acetonide at a concentration
of 25 mg/mL at 4 weeks after surgery. The decision to treat with triamcinolone
was made by the surgeon (N.J.P.).
One hundred eight (85%) of the 127 patients who received injections
had an acceptable result, with good supratip definition, as judged by the
surgeon. Nineteen (15%) of the 127 patients had a less than optimal result,
with residual supratip fullness, as judged by the surgeon. There were no permanent
complications from the injections in any of the patients in this series.
COMMENT
Triamcinolone acetonide is commercially available as an injectable suspension
in concentrations of 10 and 40 mg/mL, but it can be diluted to lesser concentrations
with either 1% lidocaine hydrochloride or normal saline. The package insert
states that triamcinolone acetonide at a concentration of 10 mg/mL (Kenalog-10;
Bristol-Myers Squibb Co, Princeton, NJ) is intended for intradermal and intra-articular
use. Intradermal applications include treatment of a wide range of disorders,
including keloid scars, discoid lupus erythematosus, necrobiosis lipoidica
diabeticorum, lichen planus, psoriatic plaques, granuloma annulare, and lichen
simplex chronicus. Triamcinolone acetonide at a concentration of 40 mg/mL
(Kenalog-40; Bristol-Myers Squibb Co) is intended for intramuscular and intra-articular
use. We describe herein subcutaneous intralesional rather than intradermal
injection of triamcinolone acetonide at concentration doses of up to 40 mg/mL.
Intralesional injection of keloid and hypertrophic scars with triamcinolone
was first described in the 1965 by Maguire.11
Triamcinolone is used in hypertrophic and keloid scars as both a primary treatment
and prophylactically after surgical scar excision to prevent recurrence.12-13 Significant action of the agent is
discernible in tissues for up to 6 weeks.14
Darzi et al12 reported symptomatic relief in
72% and complete flattening in 64% of keloid and hypertrophic scars injected
with triamcinolone. It has therefore been recommended as a first-line treatment
for small keloids.
The exact mechanism by which steroids reduce scarring has not been fully
elucidated. Corticosteroids decrease fibroblast proliferation and inflammatory
responses.13 This action results in decreased
collagen and glycosaminoglycan synthesis with decreased tissue fibrosis.15 Corticosteroids also inhibit collagenase inhibitors,
resulting in increased collagen degradation.13, 15
Prophylactic and early treatments should therefore have a greater clinical
effect, as they are associated with both decreased scar proliferation and
increased degradation. Later, revision treatment may have less effect, because
it takes place after the period of scar proliferation and is associated with
increased scar degradation alone. Because of the dual activity of triamcinolone
before scar proliferation, early injection requires less agent. Our method
therefore requires a lower concentration (10 mg/mL) of triamcinolone acetonide
for intraoperative and early postoperative treatments and a higher concentration
(40 mg/mL) for revision cases with curative rather than preventive intent.
The major risk of treatment with triamcinolone injections is subcutaneous
atrophy.12 The rate of subcutaneous atrophy
in hypertophic and keloid scar treatment reported by Darzi et al12
was 4%. Because triamcinolone remains active in the tissue for 4 to 6 weeks,
reinjection should probably not take place before this period because there
may be a higher accumulation of corticosteroid than desired. Other potential
complications include depigmentation, telangiectasia formation, necrosis,
and ulceration.13-14,16
Rarely, symptoms of Cushing syndrome have been reported but are usually reversible.17-18 A recent report described an occurrence
of complete and irreversible blindness resulting from steroid injection into
the dorsum of the nose to treat subcutaneous scarring.18
Presumably, the blindness was caused by a microembolus of injected suspension
that led to the occlusion of retinal or choroidal vessels. To our knowledge,
there have been no other reports of blindness associated with steroid injection
of the nasal dorsum, but blindness has been described as a complication of
nasal turbinate steroid injection.19
We know of no studies that have quantitatively evaluated the systemic
effects of intralesional injection of triamcinolone for the pollybeak deformity.
Mabry20 found that slight systemic absorption
was evident 3 days after intraturbinal injection with 40 mg of triamcinolone
acetonide for nasal turbinate hypertrophy, with some depression of plasma
cortisol lasting up to 1 week in 4 (30%) of the 14 patients studied. Cortisol
values, however, were not lower than normal limits at any time, and no adrenal
suppression was apparent after repeated injections.
If steroid injections do not fully correct the pollybeak deformity,
revision surgery can be performed. The scar tissue is excised, and a compressive
tape and nasal dorsal splint are applied. The compressive tape should be maintained
for at least 3 weeks. If the cartilaginous septum or the dorsal borders of
the upper lateral cartilages are too high, they can also be trimmed during
surgical revision. Augmentation of the upper dorsum may be needed in patients
with very thick supratip skin in order to create a straight-appearing dorsal
line. Tip grafts may also be used to refine and protect the tip above a thick
supratip that will not respond to therapy.
Dorsal autologous grafts can also be used when the illusion of supratip
fullness is caused by excessive high dorsal resection when the remaining nasal
skin does not shrink down. Prophylactic triamcinolone injections can be administered
at the time of surgery and during the recovery period according to the protocol
we have outlined. Revision surgery should be delayed for at least 6 months
after the initial surgery.
It is preferable, however, to avoid surgery if possible. Subdermal dissection
with resection of scar tissue in revision surgery is difficult to perform
and may lead to complications. Irregular thinning, adhesions, telangiectasias,
vertical grooves, furrows, and possible skin loss may result.2
In general, subcutaneous triamcinolone injectioninto the scar tissue is the
preferred first-line treatment for soft tissue pollybeak, as it is well tolerated
and has minimal risk of exacerbating the deformity. If the triamcinolone injections
are not effective, surgical revision remains a possibility for correction
of the deformity.
Systemic steroids, such as dexamethasone, are used by some rhinoplastic
surgeons to decrease postoperative eyelid and nasal edema as well as discomfort
or pain.21-22 It is not known
whether use of systemic steroids at the time of surgery may reduce the incidence
of the pollybeak deformity. Several other modulators of the wound healing
process are also currently being explored as intralesional or systemic treatment
for keloids and hypertrophic scars. These modulators include isotretinoin,
interferon gamma, interferon alfa, and tamoxifen citrate.23-25
For example, isotretinoin combined with triamcinolone appears to significantly
inhibit the growth of keloid fibroblasts in cell culture.23
Whether these treatments alone or in combination with triamcinolone injection
will prove to be effective treatment for the postrhinoplasty pollybeak remains
to be seen.
CONCLUSIONS
Because revision surgery is difficult and may result in complications,
subcutaneous intralesional triamcinolone injection is the first-line treatment
for the soft tissue pollybeak deformity. The technique is straightforward,
and good results may be achieved. Subcutaneous injection into the scar tissue
may be accompanied by infrequent adverse effects, most commonly subcutaneous
atrophy; therefore, injections should be administered only in the subcutaneous
level of the supratip, where the overlying skin is thick. Should intralesional
steroid injection fail to satisfactorily treat the deformity, revision rhinoplasty
can still be performed 6 months after the initial surgery.
AUTHOR INFORMATION
Accepted for publication August 23, 2000.
This study was presented in part at the spring meeting of the American
Academy of Facial Plastic and Reconstructive Surgery (Combined Otolaryngological
Spring Meetings), Orlando, Fla, May 13, 2000.
Corresponding author and reprints: Russell W. H. Kridel, MD, Facial
Plastic Surgery Associates, 6655 Travis St, Suite 900, Houston, TX 77030-1336
(e-mail: rkridel{at}todaysface.com).
From the Division of Otolaryngology–Head and Neck Surgery, Stanford
University Medical Center, Stanford, Calif (Drs Hanasono and Koch); the Department
of Otolaryngology–Head and Neck Surgery, Division of Facial Plastic
Surgery, University of Texas Health Science Center, Houston (Dr Kridel); the
Department of Otolaryngology–Head and Neck Surgery, Cornell University
Medical Center, New York, NY (Dr Pastorek); and The Glasgold Group, Highland
Park, NJ (Dr Glasgold).
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