Triamcinolone acetonide is commercially available as an injectable suspension in concentrations of 10 and 40 mg/mL, but it can be diluted to lesser concentrations with either 1% lidocaine hidrochloride or normal saline. The package insert states that triamcinolone acetonide at a concentration of 10 mg/mL (Kenalog-10; Bristol-Myers Squibb Co, Princetonm, NJ) is intended for intradermal and intra-articular use. Intradermal applications include treatment of a wide range of disorders, including keloid scars, discoid lupus erythematosus , necrobiosis lipoidica diabeticorum, lichen simplex chronicus. Triancinolone acetonide at a concentration of 40 mg/mL (Kenalog-40; BristolMyers Squibb Co) is intended for intframuscular and intraarticular use. We describe herein subcutaneous intralesional rather than intradermal injection of triamcinolone acetonide at concentration doses of up to 40 mg/mL.
Intralesional injection of keloid and hypertrophic scars with triamcinolone was first described in the 1965 by Maguire.11 Triamcinolone is used in hypertrophic and keloid scars as both a primary tratment and prophylatically after surgical scar excision to prevent recurrence.12,13 Significant action of the agent is discernible in tissues for up to 6 weeks.14 Darzi et all12 reported symptomatic relief in 72% and complete flattering in 64% of keloid and hypertropic scars injected with triamcinolone. It has therefore been recommended as a first-line treatment for small keloids.
The exact mechanism by wich steroids reduce scaring has not been fully elicidated. Corticosteroids decrease fibroplast proliferation and inflammatory responses.13 Thus action results in decreased collagen and glycosaminogly can synthesis with decreased tissue fibrosis.15 Corticosteroids also inhibit collagenase inhibitors, resulting in increased collagen degradation.13,15 Prophylactic and early trestments associated with both decreased scar proliferation and increased degradation. Later, revision treatment may have less effect, because it takes place after the period of scar proliferation and is associated with increased scar degradation before scar proliferation, early injection requires less agent. Out method therefire requires a lower concentration (10 mg/mL) of triamcinolone acetonide for intraoperative and early postoperative tratments and a higher concentration (40 mg/mL) for revision cases with curative rather than preventive intent.
The major risk of treatment with triamcinolone injections is subcutaneous atrophy.12 The rate of subcutaneous atrophy in hypertrophic and keloid scar treatment reported by Dazi et al12 was 4%. Because triamcinolone remains active in the tissue for 4 to 6 weeks, reinjection should probably not take place before this period because there may be a higher accumulation of corticosteroid than desired. Other potential complications include depigmentation, telangectasia formation, necrosis, and ulceration.13,14,16 Rarely, symptons of Cushing syndrome have been reportad but are ussually reversible.17,18 A recent report described an ocurrrence of complete and irreversible blindness was caused by a microembolous of injected suspension that led to the oclusion of retinal or choroidal vessels. To ouer knowledge, there have been described as a complication of nasal turbinate steroid injection.19
We know of no studies that have quantitatively evaluated the systemic effects of intralesional injection of triamcinolone for the pollybeak deformity. Mabry20 found that slight systemic absorption was evident 3 days after intraturbinal injection with 40 mg of triamcinolone acetonide for nasal turbinate hypertrophy, with some depression of plasma cortisol lasting up to 1 week in 4 (30%) of the 14 patients studied. Cortisol values, however, were not lower than normal limits at any time, and no adrenal suppression was apparent after repeated injections.
If steroid injections do not fully correct the pollybeak deformity, revision surgery can be performed. The scar tissue is excised, and a compressive tape should be maintained for at least 3 weeks. If the cartilaginous septum or the dorsal borders of the upper lateral cartilages are too high, they can also be trimmed during surgical revision. Augmentation of the upper dorsum may be needed in patients with very thick supratip skiin in order to cereate a straight-appearing dorsal line. Tip grafts may also be used to refine and protect the tip above a thick supratip taht will not respond to therapphy.
Dorsal autologus grafts can also be used when the illusion of supratip fullness is caused by excesive high dorsal resection when the remaining nasal skin does not shrink down. Prophylactic triamcinolone iinjections can be administered at the time of surgery and during the recovery parios according to the protocol we have outlined. Revision surgery should be delayed for at least 6 moths after the initial surgery.
It is preferable, however, to avoid surgery if possible. Subdermal dissection with resection of scar tissue in revision surgery is difficult to perform and may lead to complications.. Irregular thinning, adhesions, telangiectasias, vertical grooves, furrows, and possible skin loss may result.2 In general subcutaneous triamcinolone injection into the scar tissue is the preferred first-line tratment for soft tissue pollybeak, as it is well tolerated and has minimal risk of exacerbating the deformity. If the triamcinolone injections are not effective, surgical revision remains a possibility for correction the deformity.
Systemic steroids, such as dexamethasone, are used by some rhinoplastic surgeons to decrease postoperative eyelid and nasal edema as well as discomfort or pain.21,22 It is not known whether use the systemic steroids at the time of surgery may reduce the incidence of the pollybeak deformity. Several other modulators of the wound healing process are also currently being explored as intralesional or systemic treatment for keloids and hypertrophiv scars. These modulators include isotretinoin, interferion gamma, interferon alfa, and tamoxifen citrate.23-25 For example, isotretinoin combined with triamcinolone appears to significantly inhibit the growth of keloid fibroblasts in cell culture.23 Wether these tratments alone or in combination with triamcinolone injection will prove to be effective tratment for the postrhinoplasty pollybeak remains to be seen.
