A meta-analysis of pre-and postoperative corticosteroids for reducing the complications following facial reconstructive and aesthetic surgery

Aldhabaan, Saud A.; Hudise, Jibril Y.; Obeid, Amani A.

doi:10.1016/j.bjorl.2020.05.015

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Brazilian Journal of Otorhinolaryngology

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Sumário

Original article • Braz. j. otorhinolaryngol. 88 (01) • 2022 • https://doi.org/10.1016/j.bjorl.2020.05.015 copy

A meta-analysis of pre-and postoperative corticosteroids for reducing the complications following facial reconstructive and aesthetic surgery

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction

Edema and ecchymosis after facial plastic surgery are a troublesome concern for both patients and surgeons. Corticosteroid administration is thought to shorten the recovery period and reduce these sequelae. Data regarding the efficacy of corticosteroid administration remains controversial among surgeons.

Objective

We conducted this systematic review and meta-analysis to determine the effect of preand postoperative corticosteroids on postoperative complications in patients undergoing facial reconstructive surgery supported with different subgroup analysis.

Methods

A comprehensive literature search of articles was conducted in PubMed, Cochrane Central, SCOPUS, and EBSCO through October 2019. We included all clinical trials in which patients underwent any type of facial plastic surgery to study the effect of corticosteroids on postoperative complications. We performed subgroup analysis according to the types and doses of corticosteroid preparation, in addition to a subgroup analysis of preor postoperative corticosteroid usage. All statistical analysis was performed using the RevMan software.

Results

Nineteen studies were included in this systematic review, but only 10 of them were eligible for meta-analysis. The periorbital edema and ecchymosis scores were significantly reduced in the corticosteroids group compared to placebo −0.82, 95% CI (−1.37, −0.26), and -0.95, 95% CI (−1.32, −0.57), respectively. However, these significant differences were not maintained at day 3 and 7. Smaller doses of corticosteroid (8 mg and 10 mg) were associated with smaller differences in the mean score of upper and lower eyelid edema and ecchymosis, while the higher doses were associated with greater differences. Furthermore, preoperative corticosteroid usage significantly reduced the intraoperative bleeding when compared to placebo for higher doses > 50 mg per day (p < 0.0001), but not for 8 mg corticosteroid (p = 0.06). Adding postoperative steroid dose to the preoperative one was associated with less edema and ecchymosis than preoperative administration alone.

Conclusion

This comprehensive meta-analysis confirms a statistically significant benefit of preoperative corticosteroids. Furthermore, continuing the steroids postoperatively is associated with long-term reduction of complications. Higher doses of corticosteroids are associated with a more significant reduction in edema and ecchymosis, but further studies are recommended to determine the postoperative side effects, including surgical site infection and delayed healing.

Keywords
Corticosteroid; Edema; Ecchymosis; Facial plastic surgery; Rhinoplasty

Study ID		Sitting	Study design		Sample size		Intervention Peri/Intraoperative dose	Postoperative dose	Control		Age, Year		Gender	Type of surgery	Duration of surgery, minutes		Outcome measurement (edema and ecchymosis)	Follow-up visits	Findings
Studies included in the meta-analysis
Griffies et al. 1989		USA	Prospective Randomized, double-blind study		30		Immediate preop: Dexamethasone 10 mg IV	No	Placebo (saline)		Median (range), 23 (18-45)		Male 23 (76.7%), Female 7 (23.3%)	Rhinoplasty with osteotomy	NR		Periorbital ecchymosis and edema were evaluated separately using a 4 point graded scale	Day 1	Edema and ecchymosis were significantly reduced in the steroid group.
Gurlek et al. 2006		Turkey	Prospective randomized placebo-controlled double-blind study		40		Immediate preop: betamethasone 8 mg (Group 1), dexamethasone 8 mg (Group 2), methylprednisolone 40 mg (Group 3), tenoxicam 20 mg (Group 4)	Postop: same as peri ×3 days	Placebo (Group 5)		Range; 22-30		NR	Open rhinoplasty with osteotomies	NR		Digital photographs of each patient were taken and scoring was performed separately for eyelid swelling and ecchymosis by using a graded scale from 0-4.	Days 1, 3, and 7	No differences in the levels of ecchymosis or edema among the steroid groups, the tenoxicam group, and the control groups were observed. Steroids used in these doses were not effective in preventing or reducing edema and ecchymosis after open rhinoplasty with osteotomies.
Gurlek et al. 2009		Turkey	Prospective randomized placebo-controlled double-blind study		40		Immediate preop: single dose methylprednisolone 250 mg (Group 1), single dose methylprednisolone 500 mg (Group 2), 4 doses methylprednisolone 250 mg (Group 3), 4 doses methylprednisolone 5000 mg (Groups 4)	In groups (3 and 4), 250 and 500 mg daily ×3 days	Placebo		Mean 24.5 (range 19-35)		Male 26 (76.7%), Female 14 (23.3%)	Open rhinoplasty with osteotomy	NR		Digital photographs of each patient were taken and scoring was performed separately for eyelid swelling and ecchymosis by using a graded scale from 0 to 4.	Days 1, 3 and 7	Clinically and statistically significant difference was observed regarding ecchymosis and edema, between the placebo and high dose methylprednisolone group.
Hoffmann et al. 1991		USA	Prospective randomized placebo-controlled double-blind study		49		Intraop: Dexamethasone 10 mg IV	Postoper: 5 day taper, 50 mg prednisone by 10 mg daily	Placebo		Range; 15-70		NR	Closed or Open Rhinoplasty	NR		Upper and lower eyelid edema and periorbital ecchymosis were evaluated using a graded scale from 0-4. Paranasal edema was graded from 0-4 visually and by palpating the soft tissue of the cheek. Intranasal edema was evaluated by anterior rhinoscopic examination and graded from 0-4 by determining the amount of septal and turbinate edema and the patency of the airway.	1,4,7 days	less postoperative eyelid edema, para/intra-nasal edema and ecchymosis was recorded in patients receiving steroids
Kargi et al. 2003		Turkey	Prospective randomized controlled double-blind study		60		1 h preop: single dose dexamethasone 8 mg IV (Group 1 and 3); Immediate preop: dexamethasone 8 mg IV (Group 2 and 4)	Postop: dexamethasone 8 mg IV 24, 48 h (Group 3 and 4); Immediate postop: dexamethasone 8 mg IV, 24 and 48 h (Group 5)	Nothing (Group 6)		NR		NR	Closed Rhinoplasty	NR		Periorbital ecchymosis and edema were evaluated separately using a 4-point scale	Days 1, 2, 5, 7, 10	Triple-dose administration was found to be more effective in decreasing edema and ecchymosis during the first 5-7 days. Edema and ecchymosis were significantly lower in the steroid groups during the first 2 days compared with the control group. On day 5, edema and ecchymosis were significantly lower in groups 3 and 4 compared with other groups, but there was no difference between them. Group 5 had a significantly higher level of edema and ecchymosis compared with groups 1 through 4 at 24 h and at days 2, 5, and 7.
Koc et al. 2011		Turkey	Prospective randomized controlled trial		40		Preop: single dose of 1 mg/kg IV methylprednisolone (Group I), single dose of 3 mg/kg IV methylprednisolone (Group II)	No	Nothing		NR		Male 22 (55%), Female 18 (45%)	Open Rhinoplasty with Osteotomy	NR		Eyelid edema and periorbital soft-tissue ecchymosis were evaluated separately using a scale of 0-4.	Days 1, 3, and 7	Periorbital edema and ecchymosis were significantly lower in the dexamethasone groups compared with the control group. No significant differences were seen clinically or statistically in preventing or reducing either the periorbital ecchymosis or the periorbital edema between groups I and II.
Mehdizadeh et al. 2017		Iran	Prospective randomized triple-blinded clinical trial		60		Preop: Group D (dexamethasone 8 mg), Group T (tranexamic acid 10 mg/kg), Group DT (dexamethasone 8 mg + tranexamic acid 10 mg/kg)	Postop: three doses every 8 h of corresponding treatments	Nothing (Group P)		Mean 27.35 ± 6		Male 27 (45%), Female 33 (55%)	Primary open rhinoplasty	NR		Photographs were taken after surgery and examined by an independent plastic surgeon for edema and ecchymosis using a scale 0-4	Days 1, 3, and 7	In tranexamic acid, dexamethasone, and tranexamic acid plus dexamethasone groups, edema and ecchymosis were lower; no difference comparing tranexamic acid, dexamethasone, and dexamethasone plus tranexamic acid on any postoperative day; no difference in duration of surgery between any group.
Owsley et al. 1996		USA	Randomized, double-blind study		30		Preop: 500 mg methylprednisolone	Postop: a 6 day oral tapering dose of methyl-prednisone	Nothing		NR		NR	Face lift surgery	NR		Facial swelling was evaluated using a full-face frontal and oblique 35 mm 3 × 5-inch photographic prints taken of every participant preoperatively and on postoperative days 1, 4 (or 6), and 10 on a scale graded 1-4)	Days 1, 4 (or 6), 10	No significant differences in facial swelling between the study group was recorded on any occasion
Ozdel et al. 2006		Turkey	Prospective Randomized, double-blind study		30		Immediate preop: Dexamethasone 10 mg IV	No	Nothing		Study group (23.73 ± 4.58), Control group (25.46 ± 8.70)		Male 15 (50%), Female 15 (50%)	Rhinoplasty with hump removal and bilateral lateral osteotomies	NR		Periorbital edema and ecchymosis were graded, and psychological well-being was measured on a standard visual analog scale. Edema and ecchymosis of the upper and lower eyelids were evaluated separately on a graded scale from 0 to 4 (0 indicates none; 1+, medial; 2+, to pupil; 3+, past pupil; 4+, to lateral canthus)	Days 1, 2	Periorbital edema was significantly reduced on the first 2 postoperative days, and upper eyelid ecchymosis in the dexamethasone group compared with the control. Preoperative steroid administration had no influence on ecchymosis of the lower eyelid
Tuncel et al. 2013		Turkey	Retrospective randomized study		60		Preop: dexamethasone 10 mg/kg IV administered in Group I (single dose), II (2 doses) and III (3 doses).	Postop: (Group II), dexamethasone 10 mg/kg after 24 h; (Group III), same dose dexamethasone immediately before osteotomy and after 24 h	Nothing (Group IV)		Mean 29 (range 23-35)		Male 28 (46.7%), Female 32 (53.3%)	Open rhinoplasty with hump removal and bilateral osteotomies	Group I (87.40 ± 11.65) min, Group II (84.67 ± 10.90) min, Group III (84.40 ± 11.18) min, Group IV (116.67 ± 14.84) min		Degree of eyelid edema and periorbital soft tissue ecchymosis were evaluated separately using a scale of 0−4. Intraoperative blood loss was recorded for each patient. All patients in groups I, II and III were operated under controlled hypotension which was achieved by remifentanil infusion of 0.1-0.5 microg/kg/min, following a bolus of 1 microg/kg.	Days 1, 2, 5, 7, 10	In the three study groups, eyelid edema and periorbital ecchymosis were significantly decreased at days 7, 10 compared with the control group. There was a statistically significant difference between Group III and other groups at days 5 and 7 regarding lower eyelid edema, upper and lower eyelid ecchymosis. Intraoperative bleeding was more decreased in the study groups compared with the control group.
Studies not included in the meta-analysis
Abukawa et al. 2017	Japan			Prospective randomized double-blind controlled study	24	Preop: dexamethasone 8 mg (Group I), 16 mg (Group II)		No		Nothing administered		Control Group (24.0 ± 6.0), Group I (27.3 ± 8.7), Group II (28.6 ± 9.7)	Men 5 (20.8%), Women 19 (79.1%)	Bilateral sagittal split osteotomies (BSSOs)		Control Group (263.1 ± 34.9), Group I (262.0 ± 30.7), Group II (226 ± 30.4)	CT measurements in masseter muscle thickness and buccal soft tissue, maximum incisal opening, sensation of the chin and lower lip region were recorded. Blood examinations, and types of complications were also.	Day 1, 2 and 2 years	In the 16 mg group, rate of increase in the thickness of masseter muscle was lower than the control group. Preoperative levels in the number of lymphocytes were maintained after surgery; whereas there was a reduced number of lymphocytes in the control group.
Alajami, 2009	Kuwait			Prospective randomized placebo-controlled trial	84	Intraop: Dexamethasone 10 mg		Postop: dexamethasone 10 mg given 12 h after surgery		Placebo (5 mL saline)		Study Group (28.1 ± 5.7), Control Group (28.9 ± 6)	Male 28 (33.3%), Female 56 (66.7%)	Open rhinoplasty with hump removal and bilateral lateral osteotomies		NR	Patients were evaluated postoperatively for periorbital edema ± subconjunctival ecchymosis. Absence of edema was graded as 0, edema of lower eyelid alone was graded 1, edema of lower and upper eyelids was graded 2 and edema all around the orbit spreading to face ± subconjunctival ecchymosis was graded 3	Days 1, 2, 5, 7, 10 and 2nd and 3rd week	Preoperative and a 12 h’ postoperative dose of 10 mg of dexamethasone significantly reduced postoperative periorbital edema given during rhinoplasty compared to the control group
Berinstein et al. 1998	USA			Prospective Randomized, double-blind study	20	Preop: dexamethasone 10 mg		No		Nothing		Range; 18-45	NR	Rhinoplasty		Control Group (Average 135 M in., Study Group (Average 120 Min)	Pre and postoperative magnetic resonance imaging scans were obtained and postoperative edema was quantified as the difference in soft tissue thickness (mm) between the pre and postoperative scans.	-	On the contrary, the rhinoplasty patients who received dexamethasone had increased postoperative edema when compared to controls.
Semper-Hogg et al. 2017	Germany			Randomized controlled clinical trial	38	Preop: single dose of dexamethasone 40 mg (The patients involved were divided into three subgroups)		No		Nothing		Mean 27.63 (range 16-61)	Male 27 (71.1%), Female 11 (28.9%)	Orthognathic surgery (LeFort I osteotomy (subgroup I), BSSO (subgroup II), bimaxillary osteotomy (subgroup III)		Group I (97.16 ± 41.29), Group II (142.56 ± 29.24), Group II (285 ± 6356)	Postoperative Facial edema was measured using 3D surface scans and neurosensory disturbances were investigated by thermal stimulation.	Days 1, 2, 5, 14 and 90	Facial edema significantly decreased in the study group compared to the control group. The influence of dexamethasone on neurosensory disturbances was not significant for the inferior alveolar nerve or the infraorbital nerve.
Lin et al. 2017	Taiwan			Prospective Randomized controlled, double-blind study	56	Immediate preop: dexamethasone 15 mg IV		No		Immediate preop: dexamethasone 5 mg IV (Group I)		Control Group (20.9 ± 4.8), Study Group (23.2 ± 4.2).	Male 28 (50%), Female 28 (50%)	Orthognathic Surgery		NR	Facial swelling was assessed by 3D images that were recorded at 5 time points: preoperative (T0) and postoperative at 48 ± 6 h (T1), 1 week (T2), 1 month (T3), and 6 months (T4). Facial swelling at T1, T2, and T3 and the reduction in swelling at T2 and T3 compared with that at the baseline (T4) were calculated.	2^nd day, 1^st week, 1^st month, 6^th month	The effect of 5 and 15 mg of dexamethasone on facial swelling reduction as well as on nausea and vomiting after orthognathic surgery was not significantly different between study groups.
Sanober et al. 2018	Pakistan			Randomized controlled trial	60	Preop: dexamethasone 8 mg IV (Group I)		Postop: Dexamethasone 8 mg 4 h after surgery		Nothing (Group II)		Mean 26.48 ± 6.07	Male 14 (23.3%), Female 46 (76.6%)	Open Rhinoplasty		NR	Periorbital edema was assessed in terms of on first postoperative day and frontal view pictures were taken and compared on follow up on the 7^th day and scores were measured.	Days 1 and 7	Preoperative Dexamethasone decreased periorbital edema by 50% while in control group by 33.3%. The overall by the 7^th day control group 13.3% patients had Grade III edema as compared to 3.33% in dexamethasone group.
Totonchi et al. 2007	USA			Randomized controlled trial	48	Intraop: Group P, dexamethasone 10 mg IV; Group A arnica three times a day for 4 days.		Group P: a 6 day oral tapering dose of methyl-prednisone		Nothing (Group C)		Range; 15-65	Male 11 (22.9%), Female 37 (77.1%)	Primary rhinoplasty with osteotomy		NR	Intensity of ecchymosis, and severity of edema were graded by 3 blinded panelists on days 2 and 8. The panelists rated the extent of ecchymosis on a scale of 0-5, the color density of ecchymosis on a scale of 0-4, and the severity of edema on a scale of 0-3.	Days 2 and 8	Both arnica and corticosteroids reduced edema during the early postoperative period and Arnica did not provide any benefit with regard to extent and intensity of ecchymosis. No significant differences in the ratings of extent and intensity of ecchymosis among the groups on postoperative day 2 but there was a significant difference for the edema rating, with group C demonstrating more swelling compared with groups A and P. On postoperative day 8, group P demonstrated a larger extent and higher intensity of ecchymosis compared with groups A and C and there were no differences in the magnitude of edema by postoperative day 8 among the three groups
Valente et al. 2015	Brazil			Randomized, Double-blind, Placebo-Controlled Clinical Trial	42	Preop: dexamethasone 4 mg/mL IV		No		Preop: 2.5 mL placebo (saline)		Mean 23.12 ± 5.09	Male 3 (7.1%), Female 39 (92.9%)	Rhinoplasty		Mean ± SD (50.17 ± 6.62)	Edema and ecchymosis were assessed using Kara and Gökalan scale by 5 authors. Ecchymosis was assessed according to the affected area as follows: 0 for none, 1 for medium, 2 for to the line of the center of the pupil, 3 for passed the line of the center of the pupil, and 4 for to the lateral corner of the eye. Edema was as follows: 0 for none, 1 for minimum, 2 for to the iris, 3 for reaches the pupil, and 4 for closes the eyes.	Day 7	Dexamethasone significantly reduced the rates of postoperative ecchymosis and edema compared to the controls
Weber et al. 1994	USA			Randomized, Double-blind, Placebo-Controlled Clinical Trial	23	Immediate preop: dexamethasone, 16 mg IV (Group II), dexamethasone, 16 mg IV (Group III)		Postop: 3 IV placebo doses (Group II), 3 doses 8 mg IV dexamethasone (Group III)		Immediate prop: single IV placebo postop: 3 IV placebo doses at 6 h intervals (Group I)		Range; 15-49	NR	Bilateral Sagittal Split Osteotomies (BSSOs)		186 min (Group I), 164 min (Group II), and 175 min (Group III)	Facial edema was quantified by computer scanning of standardized photographs taken of each patient with a. Five sets of photographic and laboratory data were obtained for each patient: preoperative, day of surgery, and postoperative days 1, 2 and 3. The underlying inflammatory process also was measured using C-reactive protein, erythrocyte sedimentation rate, and complete blood counts.	Days 1, 2, and 3	Dexamethasone administration significantly reduced postoperative edema only on postoperative Day 1 when measured photographically. C-reactive protein was significantly reduced on postoperative days 1,2 and 3 in both dexamethasone groups and no significant difference was found between the two dexamethasone groups.

Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Sede da Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico Facial, Av. Indianópolia, 1287, 04063-002 São Paulo/SP Brasil, Tel.: (0xx11) 5053-7500, Fax: (0xx11) 5053-7512 - São Paulo - SP - Brazil
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[1] Peer Review under the responsibility of Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial.