Septorhinoplasty surgery is considered as one of the most common surgical procedure in all medical centers around the world. Although today the possibility of side effects from this type of surgery has decreased due to an unbelievable level of sophisticated finesse of the surgery, but still we can see specific complications after this type of surgery in all centers. In this regard perhaps due to the specific dermal characteristics of each individual we come across the occasional post-operative soft-tissue problem which of course is most commonly seen in the supratip area. Now, Problems in the supratip area are considered as one of the most frequent complications especially in patients with thick nasal skin. Supratip deformity is generally referred to as any fullness located immediately cephalic to the nasal tip after rhinoplasty surgery. Since the profile of the lower 2/3 of the nose in these patients resembles that of a parrot hence the term Polly beak deformity is used in these cases (1).
It is important to know that, often post operatively a temporary edema is seen in the immediate supratip area which usually disappears spontaneously after a few days or weeks. This edema is transitory and therefore the term Polly beak deformity is not applied to it. . In fact, in a supratip deformity a permanent unsightly bulge in the supratip region is encountered which may need revision surgery as treatment. (Figure A)
The etiologic causes of this deformity are different. Sometimes the cause of this type of complication is due to lack of properly applied anatomical knowledge and scientific principles during initial surgery. As inadequate removal of cartilaginous structures in the area of the supratip during the rhinoplasty can lead to this post-operative complication. For example, inadequate removal of the caudal part of nasal dorsal septal cartilage can lead to a visible supratip bulging. Sometimes the lack of precision in the surgical removal of the cephalic portion of the lower lateral cartilage is the culprit in this occurrence of this complication. . On the other hand, if the protective mechanisms to maintain and strengthen the tip support mechanisms are not preserved during the initial surgery, a gradual postoperative tip ptosis is gradually seen revealing the same profile as a Polly beak appearance . Sometimes the condition is caused by a congenital mal positioning of the lower lateral cartilage (LLC) in a cephalic orientation and lack of recognition and proper treatment of this condition causes the postoperative supratip fullness. Needless to state that in some cases a combination of any one of these causes can lead to this dreaded complication. Since the main pathology in these cases is the existence of specific anatomical problems in this area, treatment of this group of patients is therefore a mandatory revision surgery. (2-5).
For example, if the cause of the patient’s condition, is excessive cartilage tissue, septum or LLC, so, removal of the excess amount of cartilage causing this problem will correct the deformity .on the other hand , if deficiency of the tip support mechanisms is the cause of this complication , restoring the tip support and increasing nasal tip projection using necessary struts and grafts in the treatment of such patients can be useful (6).
As the main pathology in all of these cases, is presence of excess cartilage tissue in the supratip area, so we can consider this type of patients as cartilaginous Polly beak deformity group.
In 1979, Sheen (6) published an article stating that the main pathology in supratip deformity in most cases is not the presence of inappropriate cartilage tissue but in fact the main cause is due to over resection of the caudal dorsal tissue during initial surgery. Based on this hypothesis, the use of a tip graft with dorsal augmentation cephaled to the supratip deformities introduced for a successful treatment of pollybeak deformity. Since that year, numerous articles have been published in this regard (2- 5-8) and in all of them, the authors have defended the concept that the cause of the polly beak deformity is the removal of too much cartilage in this region, followed by scar tissue proliferation, causing the convexity in the supratip area, which is accentuated in thick-skinned individual (15). Therefore, given that the main pathology in these patients is inappropriate, excessive scar tissue in the supratip area, we can label this group of patients as the soft tissue polly beak deformity group.
So, according to the mentioned etiologic factors we can divide patients with pollybeak deformity to the following major groups:
- Patients with Cartilaginous Polly beak deformity: which the main pathology causing the permanent deformity of the supratip in these patients is the existence of excessive amount of the cartilage (septum and/or LLC) in supratip region.
- Patients with Soft tissue Polly beak deformity : which the main pathology in these patients is excessive amount of scar tissue formation following the created dead space after removing too much amount of cartilage from supra tip area.
Since the undelaying pathology in these two groups of patients are quite different from each other, so the treatment modalities must be different Therefore the need for placing patients in one of the two groups before any treatment modality is essential.
In recent years the major cause of the Polly beak deformity in most patients is the creation of abundant scar tissue in the supratip area , which is due to the creation of dead space following inappropriate removal of cartilage, especially in thick skin patients (10-13).In this regard , until recently the main method to treat this common complication was re-operation and removal of the fibrotic tissue in hope of achieving an aesthetically pleasing supratip contour. during removal of scar tissue from this area , the subdermal capillary plexus may become damage & skin necrosis in the tip & supratip area will be likely making the patient ‘s problem worse than it was before. . Although applying the scientific principles necessary to remove scar tissue from this region can prevent vascular network damage, but on the other hand, the removal of scar tissue from this area in some cases re-creates again the dead space & abundant scar tissue formation. Therefore In recent years, many surgeons have been opposed to treating this condition surgically and have proposed other methods to correct this condition (1, 12, 13, 17,18 and 19).
Since, the most common cause of this common complication is the creation of dead space in supratip area, avoidance of the creation or proper treatment of that dead space during initial surgery can effectively prevent the occurrence of this problem. In other words, the key in the prevention of this complication is maintaining a full and proper connection between the skin and underlying cartilages of supratip area after the completion of the surgery. To this end, in some cases the use of a supratip stich or applying pressure dressings in the supratip region before placing the splint has been recommended (1).
In some cases, although all scientific principles necessary during surgery to prevent this complication has been observed, but we are occasionally still have some patients with soft tissue pollybeak deformity. Therefore, for the treatment of this problem in recent years the use of local steroids in the supratip is has aroused a great interest and attention of many surgeons.
For the first time in 1965, Maguire used local steroid injections for the treatment of hypertrophic scar and keloid tissue (20). Since that time, local use of steroid injections (Triamiciolone) for the treatment of hypertrophic scars and keloid tissues has been intensely popular (21, 22).
Although the use of local triamcinolone injection is very popular for the treatment of small hypertrophic & keloid scars, the exact mechanism of action of this medication for the treatment of such lesions has not yet been properly identified.
Steroids decrease the overall proliferation of fibroblast cells and inflammatory mediator responses (22) so, collagen and glycosaminoglycan synthesis following steroid injection decreases. This action results in decreased tissue fibrosis (24). On the other hand the impact of steroids on collagenase enzyme activity levels causes an increased activity and ensuing accentuation in tissue collagen degradation (22, 24). This action results in increased scar degradation also. So, early injection of steroid in the hypertrophic or keloid tissue will be more effective for the treatment. (16)
The major risk of treatment with intralesional steroid is subcutaneous atrophy (21). Other possible complications of local steroid injection in the skin includes: Depigmentation Telangectasia formation, skin necrosis & ulceration (22, 23 and 25), the rare instance of Cushing’s syndrome symptom (26-27)
Although the dangerous condition of a complete and irreversible blindness following local steroid injection in the nasal dorsum has been only once reported in literature (27), but it highlights the importance of great care and consideration required the route and rate of the this injection in the nasal area . The cause of this complication has been stated to probably be the occlusion of retinal or choroidal vessels by the suspended particles of the Triamcinolone injection. (16). In this regard, blindness has been described as a complication after local steroid injection for treatment of turbinate hypertrophy into the inferior turbinate so that today steroid injection into the nasal turbinate is completely prohibited (28).
Today, Triamcinolone injection for to treatment and prevention of soft tissue pollybeak deformity in the supratip area is now advocated by many surgeons. . In most countries Triamcinolone acetonide is presented as a suspension with concentrations of 10 and 40 mg per Ml.. In many centers concentrations of 10 mg / ml of this drug for intradermal injection to treat such cases as keloid scar, discoid lupus erythematosis, lichen plan plaque, psoriasis and….are used, while the injection of 40mg / ml is used for intra-muscular or intra-articular injections.
For the treatment of soft tissue Polly beak deformity, triamcinolone at a concentration of 10 mg/ml of the drug should be used. If the 40 mg/ml is available, we can dilute that concentration to 10mg/ml with either 1% lidocaine hydrochloride or injectable normal saline solution.
For injection into the region it is better to use a small-gauged needle (30 gauge) or insulin syringes to reduce the pain at the injection site and also have a more control over the deposited amount in the supratip region . Since the injectable triamcinolone is in suspension form it should probably be well shaken before use (Figure Two)
Based on surgeon’s experience and skill triamcinolone solution can be injected in one of two ways in the supra tip area:
- using two separate injections in the upper side of the nasal tip (two lateral supratip injections) (figure three)
- use of a single injection in the middle area of supratip region (single midline supratip injection) (16) (Figure Four)
Of much importance is the depth of the injection into the supratip region. This must correctly be done at the subcutaneous tissue. if blanching is seen during injection , it means that the injection is the dermis . If the injection is done in the dermis the probability of complications including skin necrosis increases considerably.so, In the case of blanching occurring during the injection, the needle must be redirected into deeper tissues .Aspirating before initiating the injection ensured that the needle tip is not within a vessel.(Figure Five)
In most cases injecting only 0.1-0.2cc of the triamcinolone solution at a concentration of 10 mg / ml at the supratip area seems to be enough to treat and prevent s soft tissue polly beak deformity .
Since triamcinolone remains active for an average four to six weeks in the tissue (16), if a re-injection is needed observing this period of 4-6 weeks between injections, to avoiding possible complications is very important.
After injection the appropriate amount of drug in the supratip area, using adhesive tape and even splint for at least one week is recommended by most surgeons. But even longer use of adhesives in the injection area (for 4 to 6 weeks) to create the necessary pressure, can help significantly in the treatment of this complication, especially in thick skin patients (Figures Six and Seven).
It is essential to note that it is best to avoid trimcinolone injection immediately after surgery or during surgery, since, due to the surgical disruption of the tissues; the drug may be widely dispersed in all areas of the nose causing undesirable complications.
It is recommended that the patient be examined within 2- 4 weeks after surgery by the surgeon. During this examination, supratip area must be carefully observed for any signs of the formation of soft tissue Polly beak deformity. If any signs of this deformity were observed, injection of Triamcinolone at the appropriate concentration and volume in the supratip area is recommended.
After injection, the patient is advised of the proper use of adhesive tape at supratip area for at least 4 weeks to create the appropriate pressure at the site of injection to treat the dead space also. Patient is re-examined about 4 weeks after injection. IN most of the cases, the problem is resolved. But if after this period of treatment, the edema of the supratip has not subsided, a re-injection may be done at the supratip area with applying the same principals of injection . Sometimes the surgeon may increase the concentration of the injectable drug to concentrations of even up to 40 mg / ml in these cases .After the second injection, the patient must be examined after 4 weeks. If no appropriate response has been detected, the surgeon may again inject triamcinolone to help in the treatment of this complication. with consideration the adequate time interval between injections ( 4-6 weeks ) ,multiple injection is possible to treat of these patients , But no more than a total of 4-6 injections, in a patient should be done.
Most cases of soft tissue Polly beak deformity are treated favorably with triamcinolone injection with using the above mentioned principles. But if the patient is of the cartilaginous Polly beak deformity, then the underlying pathology of the patient must be treated by appropriate surgical procedures and injection of the drug in this group of patients is not only helpful but also may cause other problems. So, exact diagnosis of soft tissue pollybeak deformity is very important to consider this treatment modality.
Although in rare cases, some patients with soft tissue pollybeak deformity dose not respond appropriately to this treatment modality although all of the principles mentioned for the triamcinolone injection were considered by the surgeon, in these rare cases, removal of excessive scar in the supratip region by surgery after 6-12 months may be helpful. This type of surgery is often problematic and may cause other complications such as: uneven irregularity in the supratip skin area, adhesion ,telangiectasia formation, deep skin grooves and even supratip skin loss (2).During this surgery ,after the removal of scar tissue from supratip area, a dead space again may be recreated in place of the removed scar , causing a vicious cycle in the patient . Therefore, in these cases to eliminate this dead space, different methods are recommended including the proper use of cartilage grafts in the right area or use of a suitable suture to create a strict attachment of skin to the underlying caudal part of the septum (1).
Although, hypertrophic scars and keloid tissue in different parts of the body are treated today with other topical medications and substances such as; tamoxifen citrate, interferon alpha, interferon gamma and isotretinoin, but use of such substances and drugs alone or in combination with triamcinolone to treat complications soft tissue polly beak deformity has not been mentioned yet (29-31).
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