Postoperative Ecchymosis and Edema After Creation of Subperiosteal Tunnels in Rhinoplasty: A Randomized Clinical Trial

Chan DS, Roskies M, Jooya AA, Samaha M.

PubMed 30589927 Publisher (DOI)Free full text (PMC)

What this paper says

In 34 patients each acting as their own control, creating subperiosteal tunnels before bone cuts on one randomly chosen side produced no clinically significant reduction in bruising or swelling on days 2 or 7.

Overview

Bruising and swelling around the eyes are the main reason people stay off work after rhinoplasty. One proposed remedy is lifting the vascular membrane over the bone into tunnels before cutting, protecting it from injury. This randomized blinded trial tested that within individual patients.

Sections of note

Randomized, blinded, matched-paired, prospective clinical trial between April 1 and August 30, 2015, at a private stand-alone clinic and surgical center.
All patients undergoing aesthetic rhinoplasty requiring bilateral lateral osteotomies were offered inclusion; all 34 enrolled completed follow-up.
Subperiosteal tunnels were created before lateral osteotomies on one randomly selected side, the other side serving as control.
Three blinded evaluators independently graded bruising and swelling on each side using a 0 to 10 visual analogue scale on days 2 and 7.
34 patients: 28 female, 6 male, mean age 27.3 years, SD 9.2.
Bruising difference between sides: day 2, -0.05 SD 1.94, 95% CI -0.43 to 0.33; day 7, -0.22 SD 1.23, 95% CI -0.47 to 0.02, both favoring the side without tunnels.
Swelling difference: day 2, -0.21 SD 1.66; day 7, -0.29 SD 1.11, 95% CI -0.51 to -0.07. Level of evidence 1. Trial registration ISRCTN42741475.

What it means for a patient

The technique did not reduce bruising or swelling; the small differences found slightly favored the untreated side.
Using each patient as their own control removes differences between people, making this a strong design for the question.
Bruising and swelling remain the limiting factor for returning to normal activity, and this approach does not shorten that.
Limits: 34 patients, one practice, and assessment only on days 2 and 7.

Why this paper matters

Subperiosteal tunneling has been recommended on the reasoning that protecting the periosteum reduces bleeding. This tests that reasoning directly with a within-patient randomized design and finds no benefit. A negative result of this quality removes a step without evidence behind it.

Terms

Subperiosteal tunnel: A channel lifted beneath the membrane covering the nasal bone before cutting it.
Periosteum: The living membrane wrapping bone, carrying its blood supply.
Lateral osteotomy: A bone cut along the side of the nose.
Matched-paired design: Comparing two treatments within the same patient.
Ecchymosis: Bruising under the skin.

Summary written by rhinoplasty.cc from the abstract, 2026-09-09; not medical advice. The authors' own abstract follows.

Abstract

Importance: Periorbital ecchymosis and edema are commonly associated with rhinoplasty and are the principal limiting factors for return to daily activities after rhinoplasty. Several methods have been evaluated to minimize these sequelae including creation of subperiosteal tunnels, which involves elevating the vascular periosteal layer, preserving it from trauma when creating osteotomies.

Objective: To assess the efficacy of the creation of subperiosteal tunnels prior to lateral osteotomies during rhinoplasty for reducing postoperative ecchymosis and edema.

Design, Setting, And Participants: A randomized, blinded, matched-paired, prospective, clinical trial took place between April 1 and August 30, 2015, in a private practice in a stand-alone clinic and surgical center. All patients who were undergoing aesthetic rhinoplasty requiring bilateral lateral osteotomies were offered inclusion in the trial. All 34 enrolled patients completed the follow-up requirements.

Intervention: Creation of subperiosteal tunnels prior to lateral osteotomies on 1 randomly selected side.

Main Outcomes And Measures: Three blinded evaluators independently graded the degree of ecchymosis and edema on a visual analog scale of 0 to 10 on each side of the nose on postoperative days 2 and 7. Each patient had 1 side that was randomly selected to undergo creation of subperiosteal tunnels. A difference in mean score between sides of the nose was calculated for each patient using a paired t test.

Results: Of the 34 patients (28 females and 6 males; mean [SD] age, 27.3 [9.2]), the mean (SD) difference in ecchymosis scores between sides on day 2 was -0.05 (1.94) (95% CI, -0.43 to 0.33) and on day 7 was -0.22 (1.23) (95% CI, -0.47 to 0.02), favoring the side without tunnels. The mean (SD) difference in edema scores on day 2 was -0.21 (1.66) (95% CI, 0.53-0.12) and on day 7 was -0.29 (1.11) (95% CI, -0.51 to -0.07). There were no clinically significant differences between sides in terms of postoperative ecchymosis and edema.

Conclusions And Relevance: Ecchymosis and edema can have significant postoperative practical, emotional, and financial effects on patients. Creation of subperiosteal tunnels prior to lateral osteotomies showed no clinically significant differences in edema and ecchymosis after the procedure.

Level Of Evidence: 1.

Trial Registration: isrctn.org Identifier: ISRCTN42741475.

Abstract as indexed by PubMed; the article is open access (PubMed Central).