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Rhinoplasty surgery is fundamentally about changing the osteocartilaginous anatomy of the nose. The end result is a function of those structural changes and the overlying skin’s ability to shrink down and contact around the modified support to show it. It is well known by plastic surgeons and even many patients that the thicker the skin is the less likely some changes of the nose will be seen. Thick skin is truly the ‘enemy’ of the desired aesthetic result in some patients.

In managing after surgery swelling, particularly in the thicker-skinned nose, early injectable treatments have known effectiveness. Historically this was always injected steroid (Kenalog or triamcinolone) and more recently it has been 5-FU. (5-fluorouracil) While 5-FU and steroids work by different mechanism, their use individually or as a combined injection early after surgery in the first few months can work synergistically with the natural healing process. While it is always hard to determine when given early on as to the absolute merits of the injections as opposed to healing time, in the thicker skinned nose it is best to be aggressive.

An alternative approach to postoperative steroids/5-FU is to apply it during the surgery. If getting on the swelling is important as easily as possible, and it is, one can not do so any sooner than right when it starts. This requires a different delivery method than an injection which requires a closed and somewhat healed wound. The delivery approach is to apply the liquid agent to a thin dissolvable collagen membrane, like Surgicel, and lay it over the tip or in the supra tip area. In this way there is some concentration and release of the agent beginning right at wound closure.

While I currently use 0.1cc of Kenalog 40 in the very thick-skinned nose, I reduce that in noses that appear to have less risk for adverse or prolonged swelling. I avoid doing it at all in normal skin or thin skinned rhinoplasty patients.

Dr. Barry Eppley

Indianapolis, Indiana

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