Steroid Injection After Rhinoplasty

The Use of Local Steroids After Nose Aesthetic Surgery

Steroid Injection After Rhinoplasty
Nasal cortisone injection should be considered as an important tool for any rhinoplasty or revision surgery that undergoes rhinoplasty surgery. In the next patient, in the patient who underwent 3rd (tertiary) revision nose surgery, and after the operation, and the nose tip view after 3 months, the "ball-shaped" appearance at the tip of the nose and the areas where cortisone injection was required were examined.

Do not confuse corticosteroids with anabolic steroids!

When we use the term steroid in the world  and nose surgery, we are talking about a very specific type of steroids. The word of anabolic steroid is a hormone that is used for increased muscle growth in bodybuilders and actually refers to a different type of steroid called an anabolic steroid used to create this body mass. Rinoplasty and revision rhinoplasty after the "cortisone needle" as the nose used as the hormone that we call the type of steroids is called corticosteroid. They are also sometimes called glucocorticoids. Corticosteroids are a particular steroid class with a very strong anti-inflammatory effect on the tissues of our body. This is almost the opposite effect of anabolic steroids, because the primary effect of corticosteroids is to reduce the volume of soft tissue. Many corticosteroids come in pill form, while others are used as an injectable solution. In either case, the main goal is to reduce inflammation when using such steroids. When injected into the body, for example, in the nose following the nose, the steroids can help reduce scar tissue and swelling.

The aim of cortisone injection in the nose is to "reduce unwanted swelling"!

The main indication for using steroid injections in the nose remodeling is to reduce unwanted swelling. After each patient undergoes a rhinoplasty or revision rhinoplasty procedure, a degree of swelling (edema) inevitably occurs. In rhinoplasty patients, nasal edema occurs in various degrees depending on the type of skin and what is done during the nose remodeling process. Most rhinoplasty patients have an initial edema stage that resolves within 10-14 days. Depending on the type of skin, usually in the first 6 months edema more than 90% is eliminated.

A rhinoplasty or revision procedure has a secondary edema phase that will last for months or years after the rhinoplasty procedure. Normally, this type of permanent edema is targeted by steroid injection after rhinoplasty. Most of the edema that can be seen months after nose aesthetics typically resolves spontaneously. However, some patients with rhinoplasty prefer not to wait 6-24 months for this process to occur. In such cases, a steroid injection into the nose may be beneficial.

Nasal cortisone injection, ethnic features, thick skin noses, rhinoplasty can be more after!
In order to prevent the formation of unwanted scar tissues and permanent edema, intraperitoneal steroid injections can be performed, especially after abdominal rhinoplasty operations. Some rhinoplasty patients are moderately thick (or thicker) who are more likely to leave intense scar tissue between cartilage or bone to skin. ) has a soft texture. This population includes more patients with ethnic rhinoplasty (eg Spanish rhinoplasty, Asian rhinoplasty, Middle East rhinoplasty, African-American rhinoplasty patients). In these ethnic noses, the thicker soft tissue is more prone to leave traces in some areas, such as the supratip region. If this scarring process is excessive, it will prevent the nasal skin from sitting down to the desired shape of the underlying cartilage and / or bone. If this occurs, the desired aesthetic shape and recovery may not occur in the nose (camouflage effect of thick and edematous skin on cartilages). In these patients with ethnic rhinoplasty, a strategically applied steroid injection may be used to prevent the formation of unwanted scar tissue. The benefit is that the patient has as much chance as possible to achieve the best possible rhinoplasty result.

Selection of Steroids That Used in Rhinoplasty

There are many different steroids that can be chosen to reduce inflammation. Cortisone is probably the most popular example of corticosteroids used in medicine, but rhinoplasty and revision is not the preferred option for rhinoplasty. Various depot cortisone needles may be used, including triamcinolone or methylprednisolone acetate. These products are synthetic corticosteroids which are commercially available in various concentrations. The higher the concentration, the stronger the steroid injection. Injection of a higher volume will also have a greater effect in terms of the anti-inflammatory effect.

Timing of Steroid Injections After Nasal Surgery

The timing of steroid injections after nasal surgery is a controversial issue in rhinoplasty and revision rhinoplasty. The following information is based on our own personal experience as a rhinoplasty specialist and revision rhinoplasty specialist.

Some rhinoplasty specialists think that if you are going to use steroid shots or injections, you should do it within the first 1-2 months to be effective on their noses. This is based on the fact that the body leaves most of the new collagen in the first two months of healing following the remodeling of the nose. Finally, this collagen is a scar tissue. These experts believe that steroids are best used during early recovery because this is the beginning of the scar tissue development process. Obviously, I'm not involved in this philosophy. The most swelling you've seen in the first few months is the self-edging. In addition, it is prone to recover from the multiplicity of scar tissue formed in the first few months. Note that not all wound tissue is bad. If you prevent this good scar tissue from being injected by a very early steroid injection, it can actually endanger a good rhinoplasty result. There are rare cases in which you may need to inject a steroid into the nose within the first 1-2 months of nose aesthetics, but I have no experience with this.

Before considering a steroid injection into the nose, I would normally prefer to wait at least 3-4 months for aesthetic nose surgeries. With this point in the healing process, most rhinoplasty patients are actually beginning to see the change in the nose contour. At the same time, thin nasal changes can be better understood. Steroid injections work here in a great way to further contour your nose. At this point, waiting to be injected is also considered safer, because you are less likely to endanger the formation of normal healing tissue.

Interestingly, there are those who have reported a decrease in subcutaneous edema after steroid injections in rhinoplasty patients years after surgery. They are all about what steroid concentration you are using and how much you use. In the hands of a rhinoplasty specialist, steroid injection can be a great tool to further refine the nose even after scar tissue is formed.

Where to Inject Cortisone Nose?

After a rhinoplasty, some patients may have a greater amount of swelling or tend to form a nasal scar tissue. This may be caused by both closed (endonasal) and open (external) rhinoplasty procedures. The area where most of the swelling occurs is the supratip and the tip of the nose. If this area remains swollen or scar tissue develops, patients may appear in the supratip region called pollybeak (bird beak). Especially in patients with two fingers (with the index finger and thumb) down the nose of the nose, a significant difference in the thickness of the skin and supratip thick, different subcutaneous feeling in patients; In patients with frequent comedones as a sign of oily skin features at the nasal tip, there is a greater risk of long expansive edema and exaggerated snow development.

Steroid Injections Series

In many rhinoplasty patients, steroid injections are performed as part of a series of steroid injections. Patients with a single injection and adequate results are available. More commonly, however, a series of steroid injections are performed over time to achieve the desired result. In fact, 6-8 weeks can be expected between steroid injections in the nose.

When does the effect begin after steroid injection in the nose? 

Most patients begin to experience some effect within 2 weeks after injection.

Potential Complications and Risks of Steroid Injections

One of the possible complications of steroid shots in the nose is the development of a collapse in the injection site. Similar to the mechanism of reducing the scar tissue of steroids; they can also cause the normal soft tissue to melt. This process, in which the soft tissue shrinks, is also known as atrophy. This may cause the soft tissue to cause atrophy if the steroid solution enters the skin and oil around it. In this case, we normally wait a few weeks and observe the tissues. In most cases, the tissue lost by healing is recovered on its own, and it takes back some, if not all, of the lost soft tissue volume. The main risks of making a nose with cortisone are the discoloration (called hypopigmentation), abnormal blood vessel formation and thinning of the skin, except for a depression in the skin. Fortunately, undesirable soft tissue atrophy after a steroid injection is not very common, especially when a more conservative approach is chosen with the choice of steroid concentration and volume. Injection sites may occasionally become bruised and swollen. Infection is a small risk as with any injection and is treated with antibiotics. Injection into the skin or the oil below may cause fat loss. The main risk of treatment with intralesional steroids is subcutaneous atrophy. Depigmantation and telangiectasia may also occur.

Although the dangerous condition of a complete and irreversible blindness following local steroid injection on the nose of the nose has been reported only once in the literature; however, it emphasizes the importance of care and attention, requiring the path and ratio of the injection. The cause of this complication is probably the obstruction of retinal or choroidal vessels by suspended particles of Triamcinolone injection. Since blindness is defined as a complication after local steroid injection into turbinate for the treatment of turbinate hypertrophy, steroid injection into turbinate is now completely prohibited.

Why are some patients more at risk of scarring and permanent edema?

There are many theories about why some patients develop scar. Some theories show that excessive scar formation is a result of excessive collagen formation by fibroblasts, a type of cell present in the body. A growth factor thought to induce fibroblasts in excessive collagen production is thought to be TGF-β. Intranasal cortisone injection inhibits collagen production and fibroblast formation by decreasing TGF-β.

Are cortisone injections to the nose painful?

Each patient has a variable response. Most patients reported minimal discomfort. In general, adrenaline and lidocaine-containing painkillers should be mixed with the pain relief effect and can lead to prolonged duration of action.

Should the tape be used immediately after the cortisone injection to the nose?

Generally, it is recommended this  for 1-2 weeks after injection.

Can you repeat swelling after cortisone injection in the nose?

Yes, the swelling may repeat. Typically, a stronger dose of cortisone or additional applications may be necessary.

Should I have a cortisone injection after a nose job?

Each patient has a variable healing response and depends on the surgeon's recommendation based on this swelling amount. No matter how careful or careful your surgeon is, there will still be some swelling. Your nose may not be exactly the same as the pre-operative photographic analysis done with computer animation. It will take some time to wrap your skin into the new structure underneath to give your nose really much definition. Of course, the goal is to make you feel good about your nose as soon as possible. Therefore, patients with thick and oily skin specificities may need to use steroid medication both during and after surgery to accelerate postoperative nares and improve healing.

There are many studies showing that it can reduce the use of steroids, swelling, bruising and surgery. After the first two months, it is extremely beneficial to reduce the swelling in some stubborn areas of the nose, just as the skin is thicker than the steroid injections that are extremely useful (source: Correction of the Soft Tissue Pollybeak Using Triamcinolone Injection).

What are the benefits of cortisone injection after nose aesthetics?

Rhinoplasty is a unique form of cosmetic surgery with the removal or tightening of the skin with most plastic surgery. With rhinoplasty, the cartilage and bone are reshaped and the skin needs to wrap it over this new bony cartilaginous frame. This can occur very quickly in thin skin patients. However, this process may last longer in patients with thick skin. In addition, it may take 2 years or longer for the skin to be completely narrowed, which is the thickest skin. Sometimes, scar tissue can cause scarring between the skin and cartilage. This occurs most frequently in the supra type region and the nasal tip (nose end) region. Patients who continue to swell in the supratip area are good candidates for steroid injection after rhinoplasty in this region. Along with the massage this will help the healing process.

Nasal cortisone injection for pollybeak deformity

Septorinoplasty surgery is considered one of the most common surgical procedures in all medical centers around the world. Nowadays, although the likelihood of side effects of this type of surgery has decreased, depending on the incredibly subtle level of surgery; however, special complications are reported in all centers after this operation. In this respect, perhaps due to the individual dermal properties of each individual, we encounter the most common postoperative soft tissue problem in the supratip region. Problems in the supratip region are considered to be one of the most common complications especially in patients with thick nasal skin. In these patients, the profile of 2/3 of the nose is similar to that of a parrot; in these cases, the term pollybeak (defect nose) deformity is used. You can read detailed article about Pollybeak deformity at >> Pollybeak Deformity - Definition, Causes, Classification, Treatment

About permanent and temporary edema after nasal aesthetic surgery

It is important to know that there is a temporary edema in the supratip region, which usually disappears spontaneously after a few days or weeks. This edema is temporary and therefore the term beak-nose deformity is not used here. The etiology of this deformity is different. Sometimes this can be caused by insufficient removal of the cartilage structures in the supratip region during the rhinoplasty operation and sometimes by soft tissue edema in the supratip region due to this nasal tip problem. For example, inadequate removal of the caudal portion of the nasal dorsal septal cartilage may cause a visible supratip swelling. Sometimes the problems of surgical removal of the cephalic part of the lower lateral cartilage may cause this deformity. On the other hand, if the protective mechanisms for protecting and reinforcing the end support mechanisms during the first support are not maintained, a postoperative nasal tip drop may facilitate the emergence of the pollybeak nasal deformity.

In patients with thick skin, the most common cause of this complication, which may occur after nasal aesthetics, is to create dead space in the supratip region, avoiding the creation of this dead space during the first operation or not being properly treated can effectively prevent the occurrence of this problem. In other words, the key to preventing this complication is to provide a complete and appropriate connection between the skin and the supratip underlying cartilage after the surgical procedure. For this purpose, it has been proposed in some cases to use a supratip stich or to apply a pressure dressing in the supratip region before placing the splint (source: Supratip excision in rhinoplasty).

How is cortisone injection performed on the nose?

For injection into the area on the nose, it is better to use a small gauge needle (30 gauge) or insulin syringes to reduce pain in the injection site and also to have more control over the amount deposited in the supratip region. Products containing injectable cortisone in the form of an injectable suspension should be shaken well before use. The depth of the injection into the supratip region is very important. This should be done correctly in the subcutaneous tissue. If the injection is done in the dermis, the possibility of complications including skin necrosis increases considerably. Therefore, in the case of burning during injection, the needle should be directed to deeper tissues. Before starting the injection, it should ensure that the needle tip is correct. Injection of only 0.1-0.2cc triamcinolone solution in the supratip area appears to be sufficient in most cases to treat and prevent soft tissue beak nasal deformity. In general, the pain is reduced by the use of lidocaine-containing painkillers. Since triamcinolone remains active in the tissue for four to six weeks on an average basis, it is important to avoid possible complications if a re-injection is needed between injections over this period of 4-6 weeks.

Steroid injection after rhinoplasty

Steroid injection after rhinoplasty

Steroid injection after rhinoplasty

Steroid injection after rhinoplasty

Steroid injection after rhinoplasty

Steroid injection after rhinoplasty

In the above photographs, the nose photographs of the patient, who has a very thick skin structure, are seen after steroid injection. When looked closely from the front, the presence of dense comedones in the nasal tip and supratip area, the presence of an angulation in the supratip region when viewed from the side, and edema at the tip of the nose and a drooping nasal tip appearance are present. After applying the local anesthetic cream on the nasal tip and the skin of the supratip area, it was waited for 5-10 minutes and the mixture of cortisone - lidocaine - adrenaline was injected externally on the skin of the nose. Injected areas (marked with an arrow) appear swollen and white. There is usually edema at the injection site for a few days after the injection. The effect of cortisone begins within a few weeks and continues for 3-4 months. The second cortisone injection can be planned at the end of this period.

Is Cortisone Injection Beneficial in Patients Who Haven't Had No Nasal Surgery and In Thick-Skinned Noses?

In the internet environment, although no nose operation has been performed; There may be comments that it is possible to narrow the nasal volume, shrink the tip of the nose or shape the nose with cortisone injection into the nose. This information would be unscientific. Although no nasal surgery is performed, cortisone injection into the nose means that a chemical product is injected into the patient unnecessarily. In fact, this situation may lead to the interpretation that the nasal skin can be thinned by repeatedly applying cortisone before the operation, unfortunately, the thick skin features are genetic and it is not possible to thin the nasal skin with a simple drug injection. Cortisone should be used to relieve nasal edema in patients who have undergone nasal surgery.

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul

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