A 1-mL tuberculin syringe with a 30-gauge needle is used. The triamcinolone should be shaken well, as it comes in suspension rather than as a solution. The technique of administering triamcinolone can be performed as 2 separate lateral supratip injections or as a single midline supratip injection in which the needle is redirected to the left and right sides (Figure 1).
The depth of injection should be in the subcutaneous tissue. If blanching is seen, the injection is in the dermis, and the tip of a needle should be directed deeper. Injection of triamcinolone into the dermis can result in cutaneous atrophy. As is standard practice in intralesional injection technique, the surgeon should attempt aspiration with the syringe first to ensure that the needle tip is not within a blood vessel. This cannot be overemphasized, as injection of triamcinolone into a blood vessel can have hazardous consequences for the patient (see the "Comment" section). Aspiration before injection may also facilitate the diagnosis and tratment of a seroma that is masquerding as a soft tissue pollybeak in the early popsoperative phase.
A splint may be placed back on the nose in thickskinned individuals after the first injection and left in place for aproximately 1 week. The splint should fit well with adequate pressure over the supratrip but should not extend onto the domal area or cover the tip region. Patients should be informed that the supratip are may look swolen for several days. They are assessed every 4 weeks after injection, and a subsequent injections are administered based on the tissue response. Restraint must be used in the decision to repeat an injection to prevent overtreatment and the consequent atrophy that may prduce a saddle nose or irregular skin deformity. Generally, no more than 4 to 6 injections are administered over time.
The amount of triamcinolone use varies depending on wether the intent is preventative or curative. In the patient with thick nasal skin and a cartilaginous pollybeak deformity who is at risk for developing a soft tissue pollybeak, triamcinolone acetonide at a concentration of 10 mg/mL is tipically used at the conclusion of surgeryas a preventive measure. Such an injection is not administered when the technique of open rhinoplasty is used to prevent spread of triamcinolone over the entire dorsal region of the nose. One of us (R.W.H.K)assesses patients at 2 weeks after surgery for potential soft tissue pollybeak deformity and, if evident, will inject 0.1 to 0.2 mL of triamcinolone acetonide at a concentration of 10 mg/mL (1 to 2 mg).Subsequent injections in the same quantity are then administered every 4 weeks as needed using either the 10 or the 40 mg/mL suspensions, based on the response to the prior injection. The total amount of triamcinolone used is guided by the response of the deformity, wich varies from patient to patient. In referral cases in wich varies from patient to patient. In referral cases in wich a soft tissue pollubeak has already formed from previous surgery, 0.1 to 0.2 mL of triamcinolone acetonide at a concentration of 40 mg/mL (4-8 mg) is injected (Figure 2).
Another one of us (N.J.P.) begins injections earliier in the postoperative course to address incipient formation of the soft tissue pollybeak. evaluation of the supratip area is performed 1 week after surgery. At that time, supratip fullness is visually assessed and the supratrip fullness is vissually assessed and the supratip area is palpated. If there appears to be fullness or if there is a blottable edema of the supratip, a small amount of triamcinolone acetonoide, 0.1 mL of a 10-mg/mL suspension (1mg), is injected subcutaneously. The patient is seen again at 1 month after surgery and another injection is administered at that time if residual fullness is present.
Tha Table summarizes the regimens used by several authors. Note that more recent reports have recomended smaller dosages than those used by Rees6 and Mahe et al,7 who were among the first to describe the technique in detail and had very succesful results. Also, Holt et al1recommend an injection of 5mg of triamcinolone acetonide into the supratip region every 3 to 6 weeks until the edema is resolved. cook and Guida4 recommend treating the soft tissue pollybeak with 10-mg/mL triamcinolone acetonide injections monthly beginning 1 month after surgery until the deformity resolves.
