Tumescent Steroid Infiltration Reduces Postoperative Eye Closure after Craniofacial Surgery

Sir: Craniofacial surgery results in postoperative swelling. Elevation of a coronal scalp flap and subsequent bony remodeling leads to significant edema and ecchymosis. This is frequently severe enough to prevent eye opening for a number of days postoperatively. In pediatric patients, this adds to the distress suffered by patients and their caregivers, and makes postoperative monitoring difficult. Evidence for systemic steroids in reducing this postoperative swelling is mixed,1 but this has not prevented their common use in craniomaxillofacial surgery.2 This study aims to confirm the beneficial effect of tumescent steroid infiltration of the scalp in reducing postoperative eyelid swelling. From January of 2001 to February of 2006, 20 consecutive patients undergoing fronto-orbital advancement for craniosynostosis without preoperative tumescent steroid infiltration were compared with 20 subsequent patients undergoing the same operation with infiltration of triamcinolone acetonide (Kenacort-A 10; Bristol-Myers Squibb Pharmaceuticals, New York, N.Y.). The historic control group had a solution containing ropivacaine with 1:200,000 adrenaline infiltrated in the region of the incision only. In the treatment group, the tumescent solution was made up to a total volume of 7 ml/kg body weight and contained triamcinolone, 0.1 mg/ml; ropivacaine, 3 to 5 mg/kg body weight; hyaluronidase, 3 units/ml; and adrenaline, 5 to 10 μg/kg body weight, in normal saline.3 This solution was administered in a subgaleal plane by means of a 23-gauge needle beneath the planned incision and then anteriorly over most of the forehead except for the inferiormost 1 cm of the supraorbital bar to avoid inadvertent injection into the supraorbital and supratrochlear vessels. Intravenous dexamethasone was given to all patients at induction and 6 hours postoperatively for its antiemetic effect.4 Data for total intraoperative transfusion requirement (crystalloid, colloid, and blood products), length of surgery, postoperative eyelid closure, length of stay, and postoperative complications both local and systemic were collected and compared between the two groups. Data for the first control group were collected retrospectively. A scale for grading postoperative eyelid swelling is proposed (Table 1).Table 1: Grade of Eye ClosureA significant reduction in postoperative eyelid closure on the second postoperative day was shown with tumescent steroid infiltration (75 percent of patients in the steroid infiltration group had eyes open compared with 9.5 percent of the control group; p < 0.0005). This was carried out using bivariate analyses with each of the variables of duration of operation, volume of fluid transfused, age, and steroid infiltration using t tests and chi-square analysis. This difference occurred despite an average 510 ml more fluid transfused intraoperatively in the treatment group (p = 0.0003). No complications of the surgery or steroid infiltration were observed in the median follow-up period of 29 months (range, 3 to 62 months). In particular, there was no effect on wound healing5 or dermal or soft-tissue atrophy. There was no significant difference in the length of hospital stay after the operation. In the steroid infiltration group, the average grade of closure at each postoperative day is charted in Figure 1.Fig. 1.: Average grade of eyelid closure in the steroid infiltration group.Tumescent infiltration of triamcinolone into the scalp before raising scalp flaps in pediatric craniofacial surgery reduces postoperative eyelid swelling and has been a welcome addition to our operative protocol. Wai-Ting Choi, M.B., B.S. Andrew L. Greensmith, F.R.A.C.S. Chalermpong Chatdokmaiprai, M.D. Anthony D. Holmes, F.R.A.C.S. John G. Meara, M.B.A., F.R.A.C.S. Department of Plastic and Maxillofacial Surgery Royal Children’s Hospital Melbourne, Australia ACKNOWLEDGMENT Dr. Susan Donath of the Department of Biostatistics and Epidemiology, University of Melbourne, Royal Children’s Hospital, performed the statistical analysis. DISCLOSURES No financial support or benefits have been received by any author, or by any member of our existing families or any individual or entity with whom or with which we have a significant relationship from any commercial source that is related directly or indirectly to the scientific work reported on in the article.