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Frequency of acne vulgaris and its exacerbation in facial andperiorbital area after septorhinoplasty☆,☆☆

Shadman Nemati, MDa, Javad Golchay, MDb, Khosrow Iranfar, MDc,Arsalan Alizadeh, MDd,⁎a Otolaryngology-head and neck surgery Department and Research Center, Amiralmomenin Hospital. Guilan University of medical sciences,Rasht-Iranb Guilan University of medical sciences, Rasht-Iranc Otolaryngology-head and neck surgery, Kermanshah University of Medical Sciences. Kermanshah, Irand Otolaryngology–Head and Neck Surgery Research Center, Amiralmomenin Hospital. Rasht-Iran

A R T I C L E I N F O

☆ The Authors have no conflict of interest t☆☆A part of this work has been presented asHead and Neck Surgery, Tehran-Iran. Nov.01⁎ Corresponding author. Researcher at ENT-H

Amiralmomenin Hospital, 17-Shahrivar Ave.E-mail address: dr.alizadeh@ymail.com (A

0196-0709/$ – see front matter © 2013 Elsevihttp://dx.doi.org/10.1016/j.amjoto.2013.01.012

A B S T R A C T

Article history:Received 30 July 2012

Background: High prevalence of rhinoplasty, controversies about its cutaneouscomplications and lack of structured studies about relationship between acne vulgarisand rhinoplasty, point out the necessity for performing this study.Purpose: To determine the frequency of acne and its exacerbation after rhinoplasty.Materials and methods: In a longitudinal controlled study at a tertiary referral universityhospital, the degree of acne before and 1 and 3 months after surgery was measured in 110patients (30 Male, 80 Female, Mean age: 26.3±6.8) with rhinoplasty and 80 patients (35 Male,45 Female, Mean age: 24.5±4.6) with septoplasty, based on Global Acne Grading System(GAGS). The data were analyzed by SPSS 16 software.Results: The frequency of acne exacerbation in first post-surgical visit was 27% in case and3.5% in control subjects (P<0.007). In case group, 42.9% of those who had no acne beforesurgery, developedmild acne and 14.5% of those withmild acne, turned intomoderate acne.In second post-surgical visit 91.7% of those who hadmoderate acne in first visit, turned intomild acne and 80% of those with severe acne in first post-surgical visit changed intomoderate acne without any specific therapy (P<0.0001 and P<0.001, respectively).Conclusions: Rhinoplasty has significant relationship with acne exacerbation. The severityof acne decreases gradually during 3 months after surgery. For determining the exact courseand risk factors of this complication, further studies are needed.

© 2013 Elsevier Inc. All rights reserved.

Rhinoplasty is one of the most frequently performedfacial plastic surgeries [1]. Many patients undergo thisoperation in order to look and function better. According tothe American Society of Aesthetic Plastic Surgery, rhinoplas-

o declare.an oral presentation in Th.2010.NS Research Center. AdRasht-Iran. Tel.: +98 141. Alizadeh).

er Inc. All rights reserved

ty was among top five common aesthetic surgical proceduresin the United States and it was the most frequentlyperformed surgical procedure for teenagers in 2009 [2].However, similar to all surgical procedures, complications

e 12th International Congress of Iranian Society of Otolaryngology,

dress: Otolaryngology–Head and Neck Surgery Research Center,2243141, +98 9113415993.

.

Table 1 – The global acne grading system [9].

Location Factor

Forehead 2Right cheek 2Left cheek 2Nose 1Chin 1Chest and upper back 3

Note: Each type of lesion is given a value depending on severity: nolesions=0, comedones=1, papules=2, pustules=3 and nodules=4.The score for each area (Local score) is calculated using theformula: Local score=Factor × Grade (0–4). The global score is thesum of local scores, and acne severity was graded using the globalscore. A score of 1–18 is considered mild; 19–30, moderate; 31–38,severe; and >39, very severe.

379A M E R I C A N J O U R N A L O F O T O L A R Y N G O L O G Y – H E A D A N D N E C K M E D I C I N E A N D S U R G E R Y 3 4 ( 2 0 1 3 ) 3 7 8 – 3 8 1

may occur after rhinoplasty. Usually, rhinoplasty techniquesfocus on alteration of the structural framework of the nose.However, the aesthetic outcome, is the product of the nasalskeleton contour and the overlying skin-soft tissue envelope[3]. The psychological aspects of rhinoplasty have profoundimpacts on the postoperative course [4].

Affecting an estimated 40 to 50 million people in the UnitedStates, acnevulgaris ismost prevalent inadolescents andyoungadults. Left untreated, permanent scarring and psychologicalmorbidity may occur [5]. It is disfiguring and can be psycholog-ically devastating, as manifested by diminished self-esteem,social embarrassment, social withdrawal, and depression [6].The economic burdenof acne to the society is unknown, but it ispostulated to be high [7]. In our experience, we saw manypatients who suffered from acne exacerbation after septorhi-noplasty. Despite the importance of skin characteristics inrhinoplasty, and also, the high prevalence of minor complica-tions after this commonly performed surgical procedure [8],there are not enough structured studies about acne and itscourse after rhinoplasty. The aimof this studywas to determinefrequency of acne vulgaris (or any acneiform lesions) and itsexacerbation after rhinoplasty and septorhinoplasty.

1. Materials and methods

A longitudinal controlled studywas performed on 110 patients(80 females and 30 males) admitted for septorhinoplasty and80 patients (45 females, 35 males) admitted for septoplastyand/or turbinoplasty, in a tertiary referral university hospitalfrom October 2009 to June 2010. The proposal of the researchwas reviewed and approved by the Guilan University ofMedical Sciences Research Office Review Board and EthicsCommittee. Patients who had any of these conditions wereexcluded from the study: Using drugs that were known tocause or aggravate acne e.g. oral and topical corticosteroids,comedogenic compounds, vitamin B; receiving any treatmentfor acne; acne needed to be treated; any cutaneous disease likeatopic dermatitis and contact dermatitis prior to surgery andsystemic diseases e.g. systemic lupus erythematosus.

The severity of acne was determined preoperatively for allpatients by a dermatologist (JG) using Global Acne GradingSystem (GAGS). The GAGS is a clinical grading system for theclinical severity of acne that considers six locations on theface and chest/upper back, with a factor for each locationbased roughly on surface area, distribution, and density ofpilosebaceous units [9]. The borders on the face are delineatedby the hairline, jawline, and ears. No magnifying glass or skinstretching is allowed, and good lighting should be used. Thechest and upper back have been included because theirinvolvement is critical both in assessing the severity of acneand to decide upon treatment. Each of the six locations isgraded separately on a 0 (No acne) to, 4 (Nodules), scale, withthe most severe lesion within that location determining thelocal score. The global score is a summation of all local scores(for more details see Table 1) [9].

After initial examination, the operations were performedby a single surgeon (Sh. N.), with a constant method insimilar conditions under general anesthesia. Patients weredischarged the morning after the surgery. All of the patients

in case group had nasal cast for 5–7 days. Patients wereallowed to wash their face 5 days after the cast removal.They had adhesive tape for 3 to 4 weeks after removing thecast. The adhesive tape covered very limited area from theirnose to the nasofacial sulcus (from supratip to intercanthalline) and the tapes were changed every other day by thepatients. The control subjects underwent septoplasty and/orturbinoplasty in the same conditions, under general anes-thesia with the same drugs and postoperative cares exceptthat they had not any tape or cast on their nose after thesurgery. All the cases and controls were visited one and threemonths after the surgery for determining the severity of acneby dermatologist according to GAGS. Acne exacerbation wasdefined as any level of increase in grade of acne based onGAGS; e.g. from mild to moderate, moderate to severe, ormild to severe form.

Statistical analysis was performed by use of SPSS softwarever. 16 (SPSS, Inc., Chicago, IL). Cochran's Q and Friedman'stests were used for comparing related samples. Chi-squareand McNemar's test was used to compare different groups.The level of significance was determined to be 0.05.

2. Results

From 125 patients who entered in the case group, 110 patients(88%) including 30 male and 80 female attended both the firstand second post-surgical visits. Eighty subjects who under-went septoplasty and/or turbinoplasty enrolled in the controlgroup. The mean age (± Standard Deviation) of the cases was26.34±6.82 years whereas in the controls was 24.5±4.6.

2.1. Frequency of acne vulgaris

In pre-surgical visit, the frequency of any type of acneiformlesions based on the GAGS was 56.7% in males and 72.5% infemales of case group, and 51.5% of males and 68% of femalesin control group (P>0.11). Also the frequency was 76.6% in<25 year old age group, 62.5% in 25–35 year old age group, and57.1% in >35 year old age group.

In the first post-surgical visit, the frequency of acnevulgaris and other types of acneiform lesions was 70% inmales and 86.2% in females of case group and 54% of malesand 69.3% in females of control group (P>0.7). In the cases, the

Chart 2 – Between first and second post-surgical visit, 4.54%of patients experienced acne exacerbation (orange column)while in 24.5% the severity of acne decreased (Green column).In 70.9% of patients, there was no change in the severity ofacne vulgaris (red column). The changes of severity was notsignificant between these two visits.

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frequency was 85.9% in <25 year old age group, 78.1% in 25–35 year old age group and 71.4% in >35 year old age group (P=0.361). Thus the frequency of acneiform lesions in this visitamong females was higher than males and that wasstatistically significant (P<0.005).

In the second post-surgical visit, the frequency of acnevulgaris and other types of acneiform lesions was 66.7% inmales and 77.5% in females (P=0.245). The frequency was81.2% in <25 year old age group, 65.6% in 25–35 year old agegroup and 64.3% in >35 year old age group (P=0.162). So in thisvisit there was no significant difference between different sexand age groups and the difference in frequency in differentage groups had no relationship with the surgery. Also in thesecond visit, there was no significant difference in frequencyof acneiform lesions in control group.

2.2. Severity of acne

The frequency of exacerbation was 27% in first post-surgicalvisit in the cases. In comparison between pre-surgical and firstpost-surgical visits, the severity of acne increased significant-ly. In the cases, in first post-surgical visit 42.9% of those whohad no acne before surgery, developedmild acne and 14.5% ofthose who had mild acne, turned into moderate form (P=0.0001). Frequency of exacerbation was 4% in the controls(P>0. 21) (Chart 1).

Conversely, there was no significant relationship betweenthe severity of acne in pre-surgical and second post-surgicalvisit both in cases and controls (P=0.115).

In the case group the severity of acne decreasedbetween two post-surgical visits. Of those who hadmoderate acne in first visit, 91.7% turned into mild acneand 80% of those who had severe acne in first post-surgicalvisit changed into moderate acne without any specific

Chart 1 – Between presurgical and first post-surgical visit,27% of patients experienced acne exacerbation (orangecolumn) while in 3.6% the severity of acne decreased(Green column). In 69.1% of patients, there was no change inthe severity of acne vulgaris (red column). Increase inseverity between these two visits were statisticallysignificant (P=0.0001).

therapy (P=0.001) (Chart 2). Also through comparison be-tween all three visits, there was significant difference in theseverity of acne (Friedman Chi-Square=28.79, P-value<0.001).

3. Discussion and conclusions

Rhinoplasty is one of the most commonly performed facialplastic surgeries in thedevelopedworld [2]. It's alsoa commonlyperformed surgery for patients in their early adulthood or laterteenage years, the same ages in which acne vulgaris has itshighest prevalence [10]. Acne vulgaris is the most commonmajor dermatologic disorder which can cause psychologicalimpacts and considerable morbidity. [11] On the other hand,there is an unignorable lack of structured studies aboutfrequency of acne vulgaris and acneiform lesions and theirexacerbation in facial and periorbital area after rhinoplasty.

We saw a significant increase in acne severity afterseptorhinoplasty in our study (27%). This increase in severityhappened through the first month after the surgery and afterthat, the severity decreased between the first and thirdmonths after the procedure. These two sets of changes inthe severity were statistically significant (P=0.0001 and P=0.001 respectively).

Coban YK in 2007 postulated that decreasing in acnesymptoms could be used as a sign of surgical success afterrhinoplasty [12]. He believed that decrease in anxiety andneuroticism after cosmetic rhinoplasty in patients who weresatisfied with the surgical result was an important factor fordecreasing acne symptoms.

An increase in severity of acne can be related to somefactors such as psychological stress caused by surgicalprocedure, not washing the face efficiently because of pain

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or fear of spoiling the surgical result. As some studies suggestthat washing the face twice daily with a mild cleanser mayhelp reducing acne lesions [13] and stress caused by surgicalprocedure can be an exacerbating factor for acne vulgaris.Scientific research indicates that increased acne severity issignificantly associated with increased stress levels [14]. Astudy of adolescents in Singapore observed a statisticallysignificant positive correlation between stress levels andseverity of acne [15]; but in our study, the incidence of acneexacerbation in post-surgical period was not significant incontrol group and this means that the role of surgical stressmay be ignorable, although the quality and level of the stressmight not be the same in the case and control group.

As one of the other possible reasons, one can nameprobable skin reactions to adhesive tapes and cast. As thecontrol group of our study had no casts and tapes, skin tapingand occlusion of pilosebaceous units may be the reason forexacerbation of acne in the cases. Also alleviating the severityand frequency of the acne in second and third post-surgicalmonths in which taping the nose was less frequent may beanother evidence supporting this hypothesis. One reasonagainst this hypothesis might be the appearance and/orflaring of the acne in other parts and subunits of the faceand even in other areas of the body such as chest and upperback. In general, although we had a control group thatmatched many confounding factors such as age, sex, surgicalstress under general anesthesia, post operation drugs and soon, wemust be cautious in linking causality of the rhinoplastyto acne exacerbation because of variety of factors that cancause or exacerbate acne vulgaris.

In conclusion we can say, in this study acne vulgarisexacerbation was related to rhinoplasty however it's notobvious whether the cast or reaction to adhesive tapes arecausative, because the control group didn't wear a cast oradhesive tape. For clarification of this issue, especially inpathophysiological issues and risk factors and for the purposeof understanding how many patients will return to theirbaseline severity of acne, further studies with extendedfollow-up periods are needed.

Acknowledgment

Special thanks to Maryam Shakiba Msc. of biostatistics whoaided us in the analysis of the data, also with special thanks to

the Research Office of Guilan University of Medical Sciencesfor the financial support of this project.

R E F E R E N C E S

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[13] Mimi Choi J, Lew VK, Kimball AB. Asingle-blinded, ran-domized, controlled clinical Trial evaluating the effect offace washing on acne vulgaris. Pediatr Dermatol 2006;23:421–7.

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