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

[BACKGROUND] 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 of experience, and assess its efficacy in achieving hemostatic control through 103 consecutive cases.

[METHODS] A retrospective chart review was conducted on 103 consecutive patients who had undergone septorhinoplasty performed by a single surgeon. The authors reviewed patient demographics; coagulopathies; medications; diet; intraoperative use of tranexamic acid (TXA), deamino-8- d -arginine vasopressin (DDAVP), and vitamin K; and postoperative complications.

[RESULTS] Twenty-six patients (25.2%) did not receive intraoperative hemostatic agents. Twenty-six patients (25.2%) required TXA only, 3 patients (2.91%) were given DDAVP only, 1 patient (0.97%) received vitamin K only, and 46 patients (44.7%) required both TXA and DDAVP. One patient (0.97%) needed TXA, DDAVP, and vitamin K. Intraoperative bleeding was controlled in all patients. One patient with known factor 11 deficiency received both TXA and DDAVP intraoperatively but did not require fresh frozen plasma. Intraoperative bleeding was controlled by first administering 10 mg/kg of TXA intravenously, followed by DDAVP with a maximum dose of 0.3 µg if needed, and 10 mg of vitamin K if bleeding persisted. Patients with known type I or IIa von Willebrand disease received DDAVP preoperatively. No patient experienced postoperative epistaxis, thromboembolism, or other associated complications.

[CONCLUSION] The algorithm of TXA, DDAVP, and vitamin K is effective in controlling excessive intraoperative bleeding, postoperative ecchymosis, and epistaxis.

[CLINICAL QUESTION/LEVEL OF EVIDENCE] Therapeutic, IV.