Permissive Hypotension in Rhinoplasty: A Literature Review of Therapeutics and Associated Outcomes

Khetpal S, Dahoud F, Partownavid P, Roostaeian J.

PubMed 36877227 Publisher (DOI)Free full text (PMC)

What this paper says

A systematic review of ten studies found that deliberately holding blood pressure low during rhinoplasty reduced bleeding during surgery and bruising and swelling afterward.

Overview

Permissive hypotension means keeping mean arterial pressure at 60 to 70 mm Hg during an operation so the surgical field bleeds less and can be seen clearly. Several drugs are used to achieve it, and how they compare has been unclear. The authors searched the literature following PRISMA reporting guidelines, recorded treatment modality and outcomes, and graded each article by American Society of Plastic Surgeons evidence levels.

Sections of note

Design: systematic review. Level of evidence III as assigned by the journal.
The initial search returned 65 articles; 10 met inclusion criteria after title, abstract and full text screening.
Drugs identified across the studies: dexmedetomidine, dexamethasone, gabapentin, labetalol, nitroglycerine, remifentanil, magnesium sulfate, clonidine and metoprolol.
Outcomes collected included bleeding during surgery, postoperative swelling and bruising, adverse events, complications and satisfaction.
Overall finding: bleeding during surgery and bruising and swelling afterward were reduced when mean arterial pressure was controlled.
The review states no funding was required. Conflicts between reviewers were settled by discussion and full text review.
No pooled numbers, effect sizes or head to head ranking of the drugs appear in the abstract.

What it means for a patient

Anesthetic management, not only surgical technique, affects how bruised and swollen a nose is after rhinoplasty.
Nine different drugs are in use for this purpose, and the review does not identify which is safest or most effective.
Ten studies is a small evidence base, and the abstract reports no adverse event rates from lowering blood pressure.
The authors state that future work should examine how a patient's other medical conditions should shape the drug choice.

Why this paper matters

Bruising and swelling drive much of the recovery experience after rhinoplasty and can obscure the result for weeks. Controlled hypotension is one of the few levers that acts on both the operation and the recovery. Which agent to use, at what target pressure, and in which patients, remains unsettled.

Terms

Permissive hypotension: deliberately maintaining a lower than normal blood pressure during surgery.
Mean arterial pressure: the average pressure in the arteries across one heartbeat cycle.
Ecchymosis: bruising, the discoloration from blood under the skin.
Edema: swelling caused by fluid collecting in tissue.
Systematic review: a structured search and appraisal of all studies meeting set criteria.
PRISMA: a checklist governing how systematic reviews are searched and reported.

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

Abstract

Background/Purpose: Permissive hypotension, defined as mean arterial pressure (MAP) of 60-70 mm Hg, has been regarded as favorable among surgeons performing rhinoplasty. Furthermore, management of blood pressure has been shown to promote greater visualization of the surgical field and decrease postoperative complications, such as ecchymosis and edema. While multiple therapies have been utilized to achieve permissive hypotension, it remains unclear how modalities compare in terms of safety and efficacy. The purpose of this study was to conduct a systematic review to better understand the specific modalities and associated outcomes in managing blood pressure during rhinoplasty.

Methods: A systematic literature review was conducted in order to identify and assess therapeutics utilized in achieving permissive hypotension during rhinoplasty. Variables collected included year of publication, journal, article title, organization of study, patient sample, treatment modality, associated outcomes (i.e., intraoperative bleeding, edema, and ecchymosis), adverse events, complications, and satisfaction. Articles were then categorized by the level of evidence as set forth by the American Society of Plastic Surgeons. Any conflicts were resolved through discussion and full-text review among co-authors. Of note, the search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. No funding was required to conduct this review of the literature.

Results: Initial review yielded sixty-five articles. Title and abstract review followed by standardized application of inclusion and exclusion criteria resulted in a total of ten studies for analysis. Articles discussed multiple therapies for management of blood pressure during rhinoplasty, including dexmedetomidine, dexamethasone, gabapentin, labetalol, nitroglycerine, remifentanil, magnesium sulfate, clonidine, and metoprolol. Overall, intraoperative bleeding, as well as postoperative ecchymosis and edema were reduced when MAP was controlled.

Conclusion: Given its intra- and postoperative benefits, permissive hypotension can be leveraged to improve outcomes in rhinoplasty. This study presents an updated comprehensive review of various modalities used to achieve permission hypotension in rhinoplasty. Future studies should explore how comorbidities may impact choice of treatment regimen among patients undergoing rhinoplasty.

Level Of Evidence Iii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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