Rhinoplasty is considered to be a popular and effective form of cosmetic surgery [1]. Nevertheless, its postoperative complications may include significant eyelid edema and ecchymosis [2]. Periorbital edema may cause difficulties in visual acuity in the early postoperative period, and ecchymosis may increase periorbital pigmentation and cause disruptions in the patient’s social activities. The main cause of eyelid edema and ecchymosis after rhinoplasty is soft tissue damage at the osteotomy site [2]. Careful and delicate surgical manipulation can help to reduce such damage, but it cannot be completely prevented.

External percutaneous osteotomy and the internal endonasal technique are the two most common approaches used in rhinoplasty. Considering the risk of periosteal injury and the manipulation of the surrounding soft tissue during osteotomy, lateral osteotomy can be done with or without periosteal elevation (subperiosteal tunneling) [3]. However, there is no consensus regarding which osteotomy method is more effective for reducing morbidity in rhinoplasty procedures. Since rhinoplasty remains a challenging procedure to this day, it is important for clinicians to follow the best practices for reducing postoperative complications. This review aimed to evaluate the efficacy of periosteal elevation. To assess the evidence for periosteal elevation prior to lateral osteotomy, we conducted a review of the literature to identify studies investigating eyelid edema, ecchymosis, and subconjunctival hemorrhage in patients undergoing lateral osteotomy with or without periosteal elevation.

Six studies with a total of 208 patients were included in this meta-analysis. Due to the incomplete reporting of patient variables in these studies, a clear comparison of patients’ overall characteristics could not be made. The characteristics of the included studies are shown in Table 1.

Eyelid edema (SMD, 0.45; 95% confidence interval [CI], 0.18 to 0.72; I²=35%) within 3 days postoperatively was significantly more common in the periosteal elevation group than in the preservation group. However, edema on postoperative day 7 (SMD, 0.21; 95% CI, –0.09 to 0.50; I²=0%) showed no significant difference between the two groups (Fig. 3). Eyelid ecchymosis was significantly more common in the periosteal elevation group than in the preservation group (within 3 days postoperatively: SMD, 0.48; 95% CI, 0.28 to 0.68; I²=0%; on postoperative day 7: SMD, 0.36; 95% CI, 0.07 to 0.65; I²=0%) (Fig. 4). There was no significant difference in subconjunctival hemorrhage on day 1 (SMD, 0.31; 95% CI, –0.09 to 0.72; I²=0%) (Fig. 5). No significant inter-study heterogeneity was found for these outcomes (I²<50%).

Repositioning or changing the location of the nasal bone is essential in most rhinoplasty procedures performed for external correction [9]. In particular, medial movement of the nasal bone via osteotomy allows the pyramid to be reconstructed to its normal condition [10]. Osteotomy is performed with the goals of straightening a deviated dorsum, narrowing the nasal dorsum, and opening the nasal vault [11]. Eyelid edema and ecchymosis, which are the most common postoperative complications of osteotomy, can be caused by damage to arteries or veins and soft tissue injuries during lateral osteotomy [5]. In lateral osteotomy, considerable force is delivered to the soft tissues and bones to mobilize the nasal bone. Thus, lateral osteotomy should be performed safely and accurately with minimal postoperative complications while producing aesthetically satisfactory results [12,13]. In order to minimize the complications of lateral osteotomy, various innovations have been made in surgical instruments, preoperative local infiltration, and intraoperative techniques [7,14,15].

Lateral osteotomy can be performed after periosteal elevation. A subperiosteal tunnel is formed by elevating the periosteum and upper layer from the bony cortex in the path of the osteotomy [5]. The goal of subperiosteal tunneling is to protect the blood vessels and to reduce periosteal injury during osteotomy [16]. This technique uses an elevator to make the subperiosteal tunnel wide enough for the osteotome to enter. This prevents the osteotome from damaging the soft tissue, resulting in a bloodless osteotomy [15,17,18]. The elevated periosteum also becomes a barrier that prevents blood from spreading into subcutaneous tissues [16]. However, several studies have suggested that periosteal elevation is more likely to cause damage to vessels [3,4,7]. In addition, subperiosteal tunneling can damage the lacrimal sac and the canthal ligament because the medial canthal ligament is just above the lacrimal sac [10,12]. Therefore, elevation of the periosteum may be unsafe because it can damage surrounding structures.

Edema and ecchymosis have been reported to reach maximum severity within 3 days postoperatively although they may persist until the 9th postoperative day [19]. Therefore, we used two time points to investigate changes in these outcomes over time. Periosteal elevation was found to be associated with more frequent edema and ecchymosis (postoperative edema within 3 days and postoperative ecchymosis at both time points), except for eyelid edema on postoperative day 7. In particular, the SMDs of the edema and ecchymosis outcomes within 3 days after surgery were near 0.5, with clinically medium effect sizes [20]. Because periosteal elevation requires more manipulation of the tissue, it may increase the risk of periorbital edema and ecchymosis [3]. Subperiosteal tunnels can also serve as a potential space for blood to accumulate and spread into the surrounding tissue [3,7]. Although periosteal elevation is designed to protect blood vessels, it can simultaneously provide a space for hematoma to spread more widely. Some studies have suggested that complications may be more frequent if the stabilization and functioning of the periosteum are completely stopped by elevation, rather than partial damage [21,22]. These possible explanations provide support for our results on postoperative edema and ecchymosis.

Periorbital ecchymosis is not limited to the subcutaneous tissue of the eyelids; instead, it sometimes continues through the orbital adipose tissue, resulting in subconjunctival ecchymosis [23]. Considering the positive effect of periosteal preservation on eyelid edema and ecchymosis, subconjunctival ecchymosis would be expected to be significantly less frequent in the periosteal preservation group than in the periosteal elevation group. In contrast to our expectations, postoperative ecchymosis on day 1 showed no significant difference between the two groups. However, this result was only based on two studies. Thus, the clinical implications of this result may not be meaningful, which is a limitation of our findings.

A limitation of our study is that surgical manipulations other than subperiosteal tunneling might also increase postoperative complications. In addition, when blood accumulates in surrounding tissues as a result of extensive bleeding during surgery, periorbital ecchymosis may be more likely. The results of our analysis could not distinguish these factors affecting complications that are distinct from subperiosteal tunneling. Nonetheless, in each of the studies that we included, there was no difference in the management of the two groups, enabling a meaningful comparison of the outcome measures. We considered that using the SMD to compare two groups under the same conditions was adequate from a methodological perspective. The spread of edema or bleeding could also vary depending on individual-level variations in skin thickness and the amount of subcutaneous fat [4,24]. If further studies are conducted on this issue, it may be possible to obtain more reliable results.