An Algorithm for Control of Excessive Perioperative Bleeding and Ecchymosis in Rhinoplasty Patients Based on 4 Decades of Experience

Guyuron B, Cakmakoglu C, Avasarala V.

What this paper says

Guyuron's stepwise bleeding protocol (tranexamic acid, then desmopressin, then vitamin K) controlled bleeding in all 103 consecutive septorhinoplasties with no postoperative nosebleeds or clots.

Overview

Persistent bleeding, heavy bruising, nosebleeds and blood pooling above the tip compromise rhinoplasty results. Bahman Guyuron's 43-year experience produced an intraoperative algorithm, reviewed here in 103 consecutive patients with attention to coagulation disorders, medications, diet and drug use.

Sections of note

26 patients (25.2%) needed no haemostatic drug; 26 (25.2%) TXA only; 3 (2.91%) DDAVP only; 1 (0.97%) vitamin K only; 46 (44.7%) TXA plus DDAVP; 1 (0.97%) all three.
Sequence: 10 mg/kg intravenous TXA first, then DDAVP up to 0.3 micrograms if needed, then 10 mg vitamin K if bleeding persists.
Known type I or IIa von Willebrand patients received DDAVP preoperatively.
One factor XI-deficient patient was managed with TXA and DDAVP without plasma.
No postoperative epistaxis, thromboembolism or related complications. Level of Evidence IV.

What it means for a patient

Nearly three-quarters of patients in a leading practice received at least one drug to control bleeding during surgery.
Patients with known clotting disorders can still have rhinoplasty with planning.
Tell the surgeon about all medications, supplements and bleeding history; the algorithm depends on it.

Why this paper matters

It is a practical, dose-specified protocol from one of the most experienced rhinoplasty surgeons. Limits: retrospective, single surgeon, no comparison group.

Terms

Tranexamic acid (TXA): a clot-stabilising drug.
Desmopressin (DDAVP): a hormone analogue that raises clotting factor levels.
Vitamin K: a vitamin required to make several clotting factors.
Von Willebrand disease: the most common inherited bleeding disorder.
Epistaxis: nosebleed.

Summary written by rhinoplasty.cc from the abstract, 2026-09-08; not medical advice. The authors' own abstract follows.

From the abstract

“Persistent intraoperative bleeding, excessive postoperative ecchymosis, epistaxis, and blood collection in the supratip area increase the complexity of rhinoplasty, causing suboptimal outcomes. The authors present an intraoperative bleeding management algorithm, developed by the senior author (B.G.) based on 43 years…”

Excerpt; the full abstract is on PubMed.