Accepted Manuscript Buccal sulcus versus intranasal approach for postoperative periorbital edema and ecchymosis in lateral nasal osteotomy Ali Ghazipour, Nadereh Alani, Shervin Ghavami Lahiji, Nader Akbari Dilmaghani PII:
S1010-5182(14)00133-4
DOI:
10.1016/j.jcms.2014.04.010
Reference:
YJCMS 1786
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 26 October 2013 Revised Date:
8 March 2014
Accepted Date: 22 April 2014
Please cite this article as: Ghazipour A, Alani N, Lahiji SG, Dilmaghani NA, Buccal sulcus versus intranasal approach for postoperative periorbital edema and ecchymosis in lateral nasal osteotomy, Journal of Cranio-Maxillofacial Surgery (2014), doi: 10.1016/j.jcms.2014.04.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Buccal sulcus versus intranasal approach for postoperative periorbital edema and ecchymosis in lateral nasal osteotomy
RI PT
ALI GHAZIPOUR1; NADEREH ALANI2; SHERVIN GHAVAMI LAHIJI 3 ;NADER AKBARI DILMAGHANI*1 1
Assistant professor of Otolaryngology, Shahid Beheshti Medical University, Loghman Hakim
2
SC
Hospital, Tehran, Iran
Resident of Otolaryngology, Shahid Beheshti Medical University, Loghman Hakim Hospital,
Tehran, Iran
Assistant professor of Otolaryngology, Ahwaz University of Medical Sciences, Ahwaz, Iran.
M AN U
3
*Corresponding Author: NADER AKBARI DILMAGHANI, MD, Assistant professor of Otolaryngology Email: [email protected]
Address: Loghman Hakim Hospital, Kargar St, Tehran, Iran
Mobile: +989123450082
TE D
Tel/Fax:+982155419005-11
AC C
EP
Keywords: rhinoplasty, osteotomy, edema, ecchymosis
ACCEPTED MANUSCRIPT
Abstract:
Background: Lateral Osteotomies are used in rhinoplasty to narrow the nasal bones, close the open roof deformity
RI PT
after hump removal, and achieve symmetry of an asymmetrical framework. But this procedure causes periorbital ooedema &ecchymosis. Different techniques have been described for lateral osteotomy.
Objective: To compare the post-operative ecchymosis and oedema after buccal sulcus lateral osteotomy versus intra nasal lateral osteotomy.
SC
Methods and Materials: In a prospective experimental study, buccal sulcus approach was performed on the right side and an intranasal approach performed on the left side of patients randomly. Then blind analysis of
M AN U
postoperative photographs was performed to determine the incidence of oedema and ecchymosis on each side. Results: fifty patients were enrolled in the study after exclusion of unfit patients. On the right side (buccal approach osteotomies), a significantly lower incidence of upper and lower eyelid oedema and upper eyelid th
ecchymosis was seen on both the 2nd day and after 7 day (P0.05) in
RI PT
intranasal group compare to buccal group. Based on our regression model using buccal approach decreased oedema and ecchymosis score significantly (p=0.002, p =0 .001, respectively).These data showed the significant benefit of buccal procedure in decreasing oedema and ecchymosis score compare to intranasal group. We did not see any postoperative bleeding in our in the site of osteotomies. There was a small amount of bloody oral
SC
secretions during first 6h postoperatively which was not annoying for patients. We did not see any infection or
M AN U
temporary numbness of face in our patients.
Discussion:
Lateral osteotomies are used in rhinoplasty to narrow the nasal bones and close the open roof deformity after
TE D
hump removal. Different techniques for doing a lateral osteotomy are available like internal or external lateral osteotomy .It has been discussed and approved that external lateral osteotomy causes less periorbital oedema and ecchymosis because the bone stump is more stable (Hashemi et al., 2005, Sinha et al., 2007)and damage to the intra nasal mucosa is much less(Rohrich et al., 1997) .Different methods have been introduced for reduction of
EP
post operative periorbital oedema and ecchymosis after rhinoplasty like cold compress, head elevation,
AC C
corticosteroid administration(Kara and Gökalan, 1999) or using thinner osteotomes (Becker et al., 2000).
Injection of lidocaine with epinephrine provides not only haemostasis but also some degree of hydrodissection, which may protect the intranasal mucosa and cause less post surgical oedema and ecchymosis(Becker, McLaughlin Jr et al., 2000) . Internal lateral osteotomy is preferred by many authors because it takes much less time and is easy to do in experienced hands. In this study for the first time we compared two different techniques for internal lateral osteotomy regarding oedema and ecchymosis. The upper buccal sulcus approach is a well-established method for surgical access to the middle third of the face in craniofacial and orthognathic surgery. The upper buccal sulcus approach for nasal surgery has been introduced by Kim, in which lateral nasal osteotomies of the
ACCEPTED MANUSCRIPT
frontal processes of the maxilla is performed endoscopically (Kortbus, Ham et al., 2006). Helel et al observed a measurable decrease in the nasal airway after lateral osteotomy in all their patients (Helal, El-Tarabishi et al., 2010). At the beginning of internal lateral osteotomy, surgeon has to make an incision superolateraly to inferior
RI PT
turbinate for insertion of lateral osteotomy. This incision may induce a later scar near internal valve area. In the buccal sulcus approach for lateral osteotomy no intranasal incision is made, so we do not see any scar formation near valve area. Kim et al found it necessary to use intranasal incisions in conjunction with the buccal approach, thereby violating the nasal valve and introducing intranasal scar(Kim and Kim, 2001). We decided to avoid the
SC
violation of the internal nasal valve and the introduction of internal nasal scarring, by using only the upper buccal sulcus approach. Gola described success with this manoeuvre, via endonasal incisions(Gola et al., 1989). Thus,
M AN U
successful skeletal correction of the nose in selected cases can be achieved with minimal disruption of the tipsupra-tip structures and no endonasal incision can minimize the associated morbidity (haemorrhage, oedema, and ecchymosis) in the rhinoplasty patient (Kortbus, Ham et al., 2006, Fettman et al., 2009).In our study buccal approach osteotomies induced a significant decrease in the incidence of upper and lower eyelid oedema and upper eyelid ecchymosis on both 2nd and 7th day post-operation follow-up that was statically significant . Buccal
TE D
osteotomy takes only approximately 2 minutes longer than intranasal osteotomy. The site of incision and osteotomy are two determining factors for the outcomes. It seems that buccal sulcus technique provides greater preservation of the periosteal support of the bony segments, supraperiosteal arteries, veins, and lymphatics than
EP
intranasal osteotomy, which may subsequently lead to decrease intra and post operative bleeding and less post op oedema and ecchymosis (Kortbus, Ham et al., 2006).In buccal sulcus technique there is a small drainage pathway
AC C
for blood, so accumulation and infiltration of blood inside the extracellular space is reduced. On the other hand, this technique causes preservation and improvement of the nasal airway by avoiding of any incision in lateral nasal wall adjacent to internal valve area.
The procedure is ideal for managing the bony nasal segment that needs lateralization, particularly in revision rhinoplasties or after trauma (Kortbus, Ham et al., 2006).
Conclusion:
ACCEPTED MANUSCRIPT
The buccal sulcus approach is an effective, safe, and reliable method for lateral osteotomy in rhinoplasty with an emphasis on decreasing post osteotomy oedema and ecchymosis .It is a less traumatic technique especially to the
AC C
EP
TE D
M AN U
SC
RI PT
internal nasal valve area.
ACCEPTED MANUSCRIPT
Conflict of Interest:
RI PT
The authors of this article declare no conflict of interest, no financial, consulting, and personal relationships with
AC C
EP
TE D
M AN U
SC
any other people or organizations that could influence (bias) the author’s work.
RI PT
ACCEPTED MANUSCRIPT
References:
SC
Becker DG, McLaughlin Jr RB, Loevner LA, Mang A: The lateral osteotomy in rhinoplasty: Clinical and radiographic rationale for osteotome selection. Plastic and reconstructive surgery 105(5): 1806-1816, 2000
M AN U
Byrne PJ, Walsh WE, Hilger PA: The use of inside-out lateral osteotomies to improve outcome in rhinoplasty. Archives of facial plastic surgery 5(3): 251-255, 2003
Fettman N, Sanford T, Sindwani R: Surgical management of the deviated septum: techniques in septoplasty. Otolaryngologic clinics of North America 42(2): 241-252, 2009
plastique et esthétique. 1989
TE D
Gola R, Nerini A, Laurent-Fyon C, Waller P: Conservative rhinoplasty of the nasal canopy. Annales de chirurgie
Hashemi M, Mokhtarinejad F, Omrani M: A Comparison between External versus Internal Lateral Osteotomy in Rhinoplasty. Journal of Research in Medical Sciences 10(1): 10-15, 2005
EP
Helal MZ, El-Tarabishi M, Sabry SM, Yassin A, Rabie A, Lin SJ: Effects of rhinoplasty on the internal nasal valve: a comparison between internal continuous and external perforating osteotomy. Annals of plastic surgery 64(5): 649-
AC C
657, 2010
Holt G, Garner E, McLarey D: Postoperative sequelae and complications of rhinoplasty. Otolaryngologic clinics of North America 20(4): 853-876, 1987 Kara COGökalan I: Effects of single-dose steroid usage on oedema, ecchymosis, and intraoperative bleeding in rhinoplasty. Plastic and reconstructive surgery 104(7): 2213-2218, 1999 Kargi E, Hosnuter M, Babucçu O, Altunkaya H, Altinyazar C: Effect of steroids on oedema, ecchymosis, and intraoperative bleeding in rhinoplasty. Annals of plastic surgery 51(6): 570-574, 2003
ACCEPTED MANUSCRIPT
Kim DWHwang HS: Traumatic Rhinoplasty in the Non-Caucasian Nose. Facial plastic surgery clinics of North America 18(1): 141-151, 2010 Kim JTKim SK: Endoscopically assisted, intraorally approached corrective rhinoplasty. Plastic and reconstructive
RI PT
surgery 108(1): 199-205, 2001 Kortbus MJ, Ham J, Fechner F, Constantinides M: Quantitative analysis of lateral osteotomies in rhinoplasty. Archives of facial plastic surgery 8(6): 369-373, 2006
Most SPMurakami CS: A modern approach to nasal osteotomies. Facial plastic surgery clinics of North America
SC
13(1): 85-92, 2005
Rohrich RJ, Minoli JJ, Adams WP, Hollier LH: The lateral nasal osteotomy in rhinoplasty: an anatomic endoscopic
M AN U
comparison of the external versus the internal approach. Plastic and reconstructive surgery 99(4): 1309-1312, 1997 Sinha V, Gupta D, More Y, Prajapati B, Kedia B, Singh SN: External vs. internal osteotomy in rhinoplasty. Indian Journal of Otolaryngology and Head & Neck Surgery 59(1): 9-12, 2007
Vacher C, Accioli de Vasconcellos JJ, Britto JA: The upper buccal sulcus approach, an alternative for post-trauma rhinoplasty. British journal of plastic surgery 56(3): 218-223, 2003
TE D
Zoumalan RA, Shah AR, Constantinides M: Quantitative comparison between microperforating osteotomies and
AC C
EP
continuous lateral osteotomies in rhinoplasty. Archives of facial plastic surgery 12(2): 92-96, 2010
ACCEPTED MANUSCRIPT
Table 1 : Grading of the severity of post rhinoplasty ecchymosis and oedema.
Oedema
Ecchymosis
1
cornea not covered by eyelids
limited to 1/3 nasal part of lower/ upper eyelid
2
cornea mildly covered by eyelids
limited to 1/3 medial part of lower/upper eyelid
3
cornea completely covered by eyelids
limited to 1/3 lateral part of lower/upper eyelid
4
complete closure of the eye
NA
AC C
EP
TE D
SC
M AN U
NA: not applicable
RI PT
Grade
SC
RI PT
ACCEPTED MANUSCRIPT
sides (intranasal versus buccal sulcus side).
M AN U
Table 2: Incidence and severity of post-operative oedema and ecchymosis on 2nd and 7th day after surgery in two
Intranasal side 2
Oedema grade 0
nd
TE D
Days
Buccal sulcus side
7
th
2
nd
7
th
86%
2%
86%
8%
10%
50%
10%
60%
4%
40%
4%
26%
3
0
6%
0
6%
4
0
2%
0
0
0
80%
0
90%
4%
1
20%
58%
10%
60%
2
0
32%
0
30%
3
0
10%
0
6%
4
0
0
0
0
1
AC C
EP
2
Ecchymosis grade
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
Sublabial osteotomy
intranasal osteotomy
RI PT
ACCEPTED MANUSCRIPT
SC
Photo.1: Second day after surgery, sublabial osteotomy on right side and intranasal lateral osteotomy on the left
AC C
EP
TE D
M AN U
side.
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
Photo 2: Buccal sulcus lateral osteotome insertion technique in left side
S1010-5182(14)00133-4
DOI:
10.1016/j.jcms.2014.04.010
Reference:
YJCMS 1786
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 26 October 2013 Revised Date:
8 March 2014
Accepted Date: 22 April 2014
Please cite this article as: Ghazipour A, Alani N, Lahiji SG, Dilmaghani NA, Buccal sulcus versus intranasal approach for postoperative periorbital edema and ecchymosis in lateral nasal osteotomy, Journal of Cranio-Maxillofacial Surgery (2014), doi: 10.1016/j.jcms.2014.04.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Buccal sulcus versus intranasal approach for postoperative periorbital edema and ecchymosis in lateral nasal osteotomy
RI PT
ALI GHAZIPOUR1; NADEREH ALANI2; SHERVIN GHAVAMI LAHIJI 3 ;NADER AKBARI DILMAGHANI*1 1
Assistant professor of Otolaryngology, Shahid Beheshti Medical University, Loghman Hakim
2
SC
Hospital, Tehran, Iran
Resident of Otolaryngology, Shahid Beheshti Medical University, Loghman Hakim Hospital,
Tehran, Iran
Assistant professor of Otolaryngology, Ahwaz University of Medical Sciences, Ahwaz, Iran.
M AN U
3
*Corresponding Author: NADER AKBARI DILMAGHANI, MD, Assistant professor of Otolaryngology Email: [email protected]
Address: Loghman Hakim Hospital, Kargar St, Tehran, Iran
Mobile: +989123450082
TE D
Tel/Fax:+982155419005-11
AC C
EP
Keywords: rhinoplasty, osteotomy, edema, ecchymosis
ACCEPTED MANUSCRIPT
Abstract:
Background: Lateral Osteotomies are used in rhinoplasty to narrow the nasal bones, close the open roof deformity
RI PT
after hump removal, and achieve symmetry of an asymmetrical framework. But this procedure causes periorbital ooedema &ecchymosis. Different techniques have been described for lateral osteotomy.
Objective: To compare the post-operative ecchymosis and oedema after buccal sulcus lateral osteotomy versus intra nasal lateral osteotomy.
SC
Methods and Materials: In a prospective experimental study, buccal sulcus approach was performed on the right side and an intranasal approach performed on the left side of patients randomly. Then blind analysis of
M AN U
postoperative photographs was performed to determine the incidence of oedema and ecchymosis on each side. Results: fifty patients were enrolled in the study after exclusion of unfit patients. On the right side (buccal approach osteotomies), a significantly lower incidence of upper and lower eyelid oedema and upper eyelid th
ecchymosis was seen on both the 2nd day and after 7 day (P0.05) in
RI PT
intranasal group compare to buccal group. Based on our regression model using buccal approach decreased oedema and ecchymosis score significantly (p=0.002, p =0 .001, respectively).These data showed the significant benefit of buccal procedure in decreasing oedema and ecchymosis score compare to intranasal group. We did not see any postoperative bleeding in our in the site of osteotomies. There was a small amount of bloody oral
SC
secretions during first 6h postoperatively which was not annoying for patients. We did not see any infection or
M AN U
temporary numbness of face in our patients.
Discussion:
Lateral osteotomies are used in rhinoplasty to narrow the nasal bones and close the open roof deformity after
TE D
hump removal. Different techniques for doing a lateral osteotomy are available like internal or external lateral osteotomy .It has been discussed and approved that external lateral osteotomy causes less periorbital oedema and ecchymosis because the bone stump is more stable (Hashemi et al., 2005, Sinha et al., 2007)and damage to the intra nasal mucosa is much less(Rohrich et al., 1997) .Different methods have been introduced for reduction of
EP
post operative periorbital oedema and ecchymosis after rhinoplasty like cold compress, head elevation,
AC C
corticosteroid administration(Kara and Gökalan, 1999) or using thinner osteotomes (Becker et al., 2000).
Injection of lidocaine with epinephrine provides not only haemostasis but also some degree of hydrodissection, which may protect the intranasal mucosa and cause less post surgical oedema and ecchymosis(Becker, McLaughlin Jr et al., 2000) . Internal lateral osteotomy is preferred by many authors because it takes much less time and is easy to do in experienced hands. In this study for the first time we compared two different techniques for internal lateral osteotomy regarding oedema and ecchymosis. The upper buccal sulcus approach is a well-established method for surgical access to the middle third of the face in craniofacial and orthognathic surgery. The upper buccal sulcus approach for nasal surgery has been introduced by Kim, in which lateral nasal osteotomies of the
ACCEPTED MANUSCRIPT
frontal processes of the maxilla is performed endoscopically (Kortbus, Ham et al., 2006). Helel et al observed a measurable decrease in the nasal airway after lateral osteotomy in all their patients (Helal, El-Tarabishi et al., 2010). At the beginning of internal lateral osteotomy, surgeon has to make an incision superolateraly to inferior
RI PT
turbinate for insertion of lateral osteotomy. This incision may induce a later scar near internal valve area. In the buccal sulcus approach for lateral osteotomy no intranasal incision is made, so we do not see any scar formation near valve area. Kim et al found it necessary to use intranasal incisions in conjunction with the buccal approach, thereby violating the nasal valve and introducing intranasal scar(Kim and Kim, 2001). We decided to avoid the
SC
violation of the internal nasal valve and the introduction of internal nasal scarring, by using only the upper buccal sulcus approach. Gola described success with this manoeuvre, via endonasal incisions(Gola et al., 1989). Thus,
M AN U
successful skeletal correction of the nose in selected cases can be achieved with minimal disruption of the tipsupra-tip structures and no endonasal incision can minimize the associated morbidity (haemorrhage, oedema, and ecchymosis) in the rhinoplasty patient (Kortbus, Ham et al., 2006, Fettman et al., 2009).In our study buccal approach osteotomies induced a significant decrease in the incidence of upper and lower eyelid oedema and upper eyelid ecchymosis on both 2nd and 7th day post-operation follow-up that was statically significant . Buccal
TE D
osteotomy takes only approximately 2 minutes longer than intranasal osteotomy. The site of incision and osteotomy are two determining factors for the outcomes. It seems that buccal sulcus technique provides greater preservation of the periosteal support of the bony segments, supraperiosteal arteries, veins, and lymphatics than
EP
intranasal osteotomy, which may subsequently lead to decrease intra and post operative bleeding and less post op oedema and ecchymosis (Kortbus, Ham et al., 2006).In buccal sulcus technique there is a small drainage pathway
AC C
for blood, so accumulation and infiltration of blood inside the extracellular space is reduced. On the other hand, this technique causes preservation and improvement of the nasal airway by avoiding of any incision in lateral nasal wall adjacent to internal valve area.
The procedure is ideal for managing the bony nasal segment that needs lateralization, particularly in revision rhinoplasties or after trauma (Kortbus, Ham et al., 2006).
Conclusion:
ACCEPTED MANUSCRIPT
The buccal sulcus approach is an effective, safe, and reliable method for lateral osteotomy in rhinoplasty with an emphasis on decreasing post osteotomy oedema and ecchymosis .It is a less traumatic technique especially to the
AC C
EP
TE D
M AN U
SC
RI PT
internal nasal valve area.
ACCEPTED MANUSCRIPT
Conflict of Interest:
RI PT
The authors of this article declare no conflict of interest, no financial, consulting, and personal relationships with
AC C
EP
TE D
M AN U
SC
any other people or organizations that could influence (bias) the author’s work.
RI PT
ACCEPTED MANUSCRIPT
References:
SC
Becker DG, McLaughlin Jr RB, Loevner LA, Mang A: The lateral osteotomy in rhinoplasty: Clinical and radiographic rationale for osteotome selection. Plastic and reconstructive surgery 105(5): 1806-1816, 2000
M AN U
Byrne PJ, Walsh WE, Hilger PA: The use of inside-out lateral osteotomies to improve outcome in rhinoplasty. Archives of facial plastic surgery 5(3): 251-255, 2003
Fettman N, Sanford T, Sindwani R: Surgical management of the deviated septum: techniques in septoplasty. Otolaryngologic clinics of North America 42(2): 241-252, 2009
plastique et esthétique. 1989
TE D
Gola R, Nerini A, Laurent-Fyon C, Waller P: Conservative rhinoplasty of the nasal canopy. Annales de chirurgie
Hashemi M, Mokhtarinejad F, Omrani M: A Comparison between External versus Internal Lateral Osteotomy in Rhinoplasty. Journal of Research in Medical Sciences 10(1): 10-15, 2005
EP
Helal MZ, El-Tarabishi M, Sabry SM, Yassin A, Rabie A, Lin SJ: Effects of rhinoplasty on the internal nasal valve: a comparison between internal continuous and external perforating osteotomy. Annals of plastic surgery 64(5): 649-
AC C
657, 2010
Holt G, Garner E, McLarey D: Postoperative sequelae and complications of rhinoplasty. Otolaryngologic clinics of North America 20(4): 853-876, 1987 Kara COGökalan I: Effects of single-dose steroid usage on oedema, ecchymosis, and intraoperative bleeding in rhinoplasty. Plastic and reconstructive surgery 104(7): 2213-2218, 1999 Kargi E, Hosnuter M, Babucçu O, Altunkaya H, Altinyazar C: Effect of steroids on oedema, ecchymosis, and intraoperative bleeding in rhinoplasty. Annals of plastic surgery 51(6): 570-574, 2003
ACCEPTED MANUSCRIPT
Kim DWHwang HS: Traumatic Rhinoplasty in the Non-Caucasian Nose. Facial plastic surgery clinics of North America 18(1): 141-151, 2010 Kim JTKim SK: Endoscopically assisted, intraorally approached corrective rhinoplasty. Plastic and reconstructive
RI PT
surgery 108(1): 199-205, 2001 Kortbus MJ, Ham J, Fechner F, Constantinides M: Quantitative analysis of lateral osteotomies in rhinoplasty. Archives of facial plastic surgery 8(6): 369-373, 2006
Most SPMurakami CS: A modern approach to nasal osteotomies. Facial plastic surgery clinics of North America
SC
13(1): 85-92, 2005
Rohrich RJ, Minoli JJ, Adams WP, Hollier LH: The lateral nasal osteotomy in rhinoplasty: an anatomic endoscopic
M AN U
comparison of the external versus the internal approach. Plastic and reconstructive surgery 99(4): 1309-1312, 1997 Sinha V, Gupta D, More Y, Prajapati B, Kedia B, Singh SN: External vs. internal osteotomy in rhinoplasty. Indian Journal of Otolaryngology and Head & Neck Surgery 59(1): 9-12, 2007
Vacher C, Accioli de Vasconcellos JJ, Britto JA: The upper buccal sulcus approach, an alternative for post-trauma rhinoplasty. British journal of plastic surgery 56(3): 218-223, 2003
TE D
Zoumalan RA, Shah AR, Constantinides M: Quantitative comparison between microperforating osteotomies and
AC C
EP
continuous lateral osteotomies in rhinoplasty. Archives of facial plastic surgery 12(2): 92-96, 2010
ACCEPTED MANUSCRIPT
Table 1 : Grading of the severity of post rhinoplasty ecchymosis and oedema.
Oedema
Ecchymosis
1
cornea not covered by eyelids
limited to 1/3 nasal part of lower/ upper eyelid
2
cornea mildly covered by eyelids
limited to 1/3 medial part of lower/upper eyelid
3
cornea completely covered by eyelids
limited to 1/3 lateral part of lower/upper eyelid
4
complete closure of the eye
NA
AC C
EP
TE D
SC
M AN U
NA: not applicable
RI PT
Grade
SC
RI PT
ACCEPTED MANUSCRIPT
sides (intranasal versus buccal sulcus side).
M AN U
Table 2: Incidence and severity of post-operative oedema and ecchymosis on 2nd and 7th day after surgery in two
Intranasal side 2
Oedema grade 0
nd
TE D
Days
Buccal sulcus side
7
th
2
nd
7
th
86%
2%
86%
8%
10%
50%
10%
60%
4%
40%
4%
26%
3
0
6%
0
6%
4
0
2%
0
0
0
80%
0
90%
4%
1
20%
58%
10%
60%
2
0
32%
0
30%
3
0
10%
0
6%
4
0
0
0
0
1
AC C
EP
2
Ecchymosis grade
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
Sublabial osteotomy
intranasal osteotomy
RI PT
ACCEPTED MANUSCRIPT
SC
Photo.1: Second day after surgery, sublabial osteotomy on right side and intranasal lateral osteotomy on the left
AC C
EP
TE D
M AN U
side.
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
Photo 2: Buccal sulcus lateral osteotome insertion technique in left side
