Application of dual‐frequency ultrasound for reduction of perilesional edema and ecchymosis after rhinoseptoplasty

Biological aspect and clinical research demonstrated that dual‐frequency ultrasound (local dynamic micro‐massage, LDM) waves of very high frequency can significantly modify cellular signaling providing anti‐inflammatory and anti‐fibrotic effects. During the recent past, these waves were successfully applied for the treatment of various inflammatory skin conditions, hypertrophic scars, and chronical wounds. Since the main complications after rhinoseptoplasty are caused by excessive inflammatory reactions and development of fibrosis along nasal implants which can lead to a revision rhinoseptoplasty, in this retrospective multicenter blinded study we have evaluated the efficacy of LDM ultrasound for the treatment of the postoperative perilesional ecchymosis and edema in patients after rhinoseptoplasty.

Rhinoseptoplasty is not only one of the most popular facial plastic surgery procedures but also one of the most challenging.1-3   The significant constriction of nasal passages that can occur after rhinoseptoplasty poses a serious concern.This often results from insufficient septal cartilage and the formation of thick, disorganized fibrotic skin, which compromises the effectiveness of surgical treatment. 1,2To avert complications following surgical procedures, treatments with agents are commonly employed.
These complications mainly arise due to excessive inflammatory reactions and fibrosis around nasal implants, often necessitating a revision rhinoseptoplasty. 3,4To achieve optimal surgical outcomes and concurrently diminish the risk of recurrent scarring, it is essential to minimize the duration of inflammatory reactions after rhinoseptoplasty.One potential approach to achieve this reduction involves appropriate pre-and/or postsurgical management. 4,5This approach can also decrease downtime, thereby enhancing patient satisfaction.The presence of swelling and bruising around the treated area after rhinoseptoplasty and revision rhinoseptoplasty indicates an ongoing inflammatory response, which is distressing for both surgeons and patients, as it leads to undesirable complications. 4,5merous strategies have been proposed to mitigate the post-rhinoseptoplasty swelling and bruising.These encompass the utilization of corticosteroids, inducing controlled low blood pressure during surgery, implementing cooling techniques to minimize bleeding resulting from bone and soft tissue trauma and incorporating halotherapy in the postoperative period. 6,7Very high-frequency dual-wave ultrasound (VHF-US) therapy can be an another interesting option for the management of the post-rhinoseptoplasty edema and ecchymosis.This therapy also known as local dynamic micro-massage (LDM) is based on the application of a very high-frequency ultrasound with frequencies of 10 MHz or higher as well as on a quick alternative application of ultrasound waves of two different frequencies.Previous research demonstrated strong anti-inflammatory and regenerative effects of this therapy in the skin and subcutaneous adipose tissue by different indications, among others in chronic wounds, 8,9 acne and rosacea, 10 injection lipolysis, 11 radiation-induced fibrosis, 12,13 postoperative wounds, 13 ulcerative necrobiosis lipoidica, 14 and breast reconstruction surgery. 15[18] It is well recognized that tissue injury, resulting among others in development of perilesional edema and ecchymosis, is associated with local accumulation of HA in damaged area. 19is accumulation leads to increased viscosity of the extracellular matrix and thus to a substantial reduction of transport rates in affected tissue.This is the reason for a broad application of hyaluronidase for the treatment of edema and hematoma. 20M of higher intensities can produce a thixotropic effect-transformation of the HA-bounded water into free water that is much less viscous and can be more easily removed from the tissue. 21,22Additionally, mathematical modeling revealed that high-frequency ultrasound waves produce sufficient temperature gradients in dermis and subcutis that can significantly enhance the transport rates in the skin. 23ese results point to the fact that LDM ultrasound may be effectively applied for reduction of the post-rhinoseptoplasty edema and ecchymosis.In this article, we present a retrospective study conducted across multiple medical centers, where a blinded cohort analysis was performed to assess the effectiveness and safety of LDM therapy in treating perilesional ecchymosis and edema that occur after rhinoseptoplasty or revision rhinoseptoplasty.Our primary focus in this research was to investigate the duration of postoperative edema and ecchymosis in patients treated with LDM, in comparison with a control group of individuals matched in age.

| Patients
In this retrospective study conducted across multiple medical centers, we examined a total of 48 Korean patients (26 men and 22 women) with a mean age of 29.5 ± 7.1 years (age range: 20-48 years).These patients had undergone either rhinoseptoplasty or revision rhinoseptoplasty at our clinic between May 2021 and January 2022.The study consisted of two groups: Group #1 comprised 24 patients (13 men and 11 women) with a mean age of 29.9 ± 6.7 years (age range: 20-46 years) who received daily LDM therapy for 5 days, while Group #2 included 24 patients (13 men and 11 women) with a mean age of 31.1 ± 8.

| Postoperative application of VHF-US therapy
Twenty-four patients from the Group #1 received daily five sessions of LDM (device LDM-MED®, Wellcomet, Karlsruhe, Germany).The protocol was set as 10 MHz with intensity of 1.5 W/cm 1 and 1.0 W/ cm 1 for 2 min each followed by a 3/10 MHz dual-frequency setting (LDM) with intensity of 1.0 W/cm 1 and 2.0 W/cm 1 for 3 min each.
The initial session was conducted on the first day after the surgery, followed by four subsequent sessions up to the fifth day after the surgery.The skin on the face and upper neck was cleansed using 70% ethanol without prior application of a topical anesthetic cream.
A standard ultrasound gel was evenly applied to the face and neck as a coupling medium (refer to Figure 1A).The applicator was continuously moved across both temples, cheeks, upper neck, and forehead at a speed of 5 mm/s (refer to Figure 1B-D).No post-treatment cooling or proactive administration of systemic or topical corticosteroids or antibiotics was implemented.In the control group, conventional ice packs were applied to the face and upper neck for 20 min per day over a span of 5 days.

| Statistical analysis
The findings were expressed as the mean ± SD, unless specified otherwise.The durations of ecchymosis and perilesional edema following rhinoseptoplasty were analyzed based on the anatomical region and patient satisfaction using Prism 8.0 software (GraphPad Software).Statistical significance was determined by p-values <0.05.Differences meeting this criterion were deemed to be statistically significant.5 individuals (20.8%) underwent revision rhinoseptoplasty.In control Group #2, out of the 24 patients, 20 individuals (83.3%) underwent rhinoseptoplasty, and 4 individuals (16.7%) underwent revision rhinoseptoplasty.There was no significant statistical difference between the two groups (p > 0.05).During these surgeries, lateral osteotomies were performed using an external perforating method with a 2-mm straight osteotome at the end of the procedure in 12 patients (50.0%) in Group #1, compared to 13 patients (54.2%) in Group #2.Again, there was no statistically significant difference between the two groups (p > 0.05).Other baseline patient characteristics, including sex and age, did not show statistically significant differences between the LDM-treated group and the control group (p > 0.05).

| Intragroup comparison of postoperative perilesional edema and ecchymosis
In both Group #1 and Group #2, the anterior cheeks exhibited the longest duration of postoperative edema and ecchymosis, followed by the lower eyelids and the upper eyelids.There were no statistically significant differences in the duration of edema and ecchymosis between the left and right sides of the face (p > 0.05), except for the anterior cheeks.This can be attributed to the fact that the majority of lateral osteotomies were performed unilaterally on the left side.In both groups, the duration of edema and ecchymosis in the anterior cheek area was significantly longer than in other areas (p < 0.0001).The duration of ecchymosis on the left/right lower eyelid was significantly longer than on the left/right upper eyelid (p < 0.05).

| Intergroup comparison of postoperative perilesional edema and ecchymosis
The utilization of LDM therapy following rhinoseptoplasty resulted in a significant reduction in the duration of edema and ecchymosis F I G U R E 3 Photographs of a 27-year-old female patient in the control group.Photographs were taken under normal light exposure at (A) 1, (B) 4, (C) 7, and (D) 14 days after first revision rhinoseptoplasty with bilateral osteotomy.across all facial areas examined.The average duration of perilesional edema after surgery was notably shorter in the LDM group (1.9 ± 0.9 days) in comparison with the control group (4.5 ± 2.1 days; p < 0.0001).Similarly, the mean duration of ecchymosis was significantly decreased in the LDM group (2.8 ± 1.4 days) compared with the control group (7.4 ± 2.8 days; p < 0.0001).Furthermore, the average durations of edema and ecchymosis in the lower and upper eyelids were also significantly reduced in the LDM group when compared to the control group.

| Patient satisfaction rate and adverse events
On the 28th day following the surgery, patients were asked to subjectively rate their satisfaction based on factors such as postoperative recovery time, pain, perilesional edema, and ecchymosis.The patient satisfaction score after receiving ultrasound treatment postoperatively was recorded as 3.1 ± 1.3, whereas the control group scored their satisfaction as 1.5 ± 0.7 (p < 0.005).No significant adverse effects were reported by any patients in the VHF-US group, including pain during and after the treatments, temporary redness, oozing, itching, bleeding, bacterial folliculitis or furunculosis, viral or fungal infections, ulceration, prolonged redness, changes in skin pigmentation, or scarring, throughout the follow-up period.

| DISCUSS ION
During rhinoplasty, various vascular structures in the nasal region can potentially be damaged or disrupted.These structures include:

| Nasal arteries
The nasal arteries are responsible for supplying blood to the nasal tissues.They consist of branches from the ophthalmic artery, ethmoidal arteries, and lateral nasal arteries.Surgical manipulation during rhinoplasty can inadvertently injure these arteries, leading to bleeding and potential ecchymosis.

| Septal perforating arteries
The septal perforating arteries are small vessels that pierce through the nasal septum to supply blood to both sides of the nasal lining.
When performing septoplasty or procedures involving the nasal septum, there is a risk of damaging these arteries, resulting in bleeding and possible hematoma formation.

| Columellar arteries
The columellar arteries are blood vessels located in the columella, the area of skin between the nostrils.They can be susceptible to injury during certain nasal tip procedures or when making incisions in the columellar area.

| Lateral nasal arteries
The lateral nasal arteries supply blood to the sidewalls of the nose.These arteries can be at risk during procedures involving the nasal bones or nasal sidewall modification.

| Angular artery
The angular artery is a branch of the facial artery that supplies blood to the sidewall of the nose, including the alar region and nasal tip.
Damage to the angular artery can lead to significant bleeding and potential complications during rhinoplasty.
Ultrasound treatment shown to improve wound repair by enhancing cellular proliferation and decreasing inflammatory chemokine production. 24,25Moreover, research has shown that stimulate endothelial cells to produce vascular endothelial growth factor (VEGF) receptor-2 and induce angiogenesis. 26Additional effects of ultrasound therapy include increased extracellular matrix deposition, decreased inflammatory responses, increased DNA and protein synthesis, regulation of insulin-like growth factor and tumor growth factor receptors, and antibacterial activity. 27 the present study, all of our patients experienced shorter durations of postoperative edema and ecchymosis along the upper eyelids, followed by the lower eyelids and anterior cheeks, regardless of treatment group.Accordingly, the resolution of postoperative edema and ecchymosis seems to be topographically associated with the lymphatic drainage system at the face and neck.Our patients in both groups showed significantly longer durations of edema and A previous in vivo human histopathologic study revealed that post-ultrasound specimens show decreased inflammatory cell infiltration, downregulation of metalloproteinase expression, and upregulation of VEGF expression. 26Additionally, research has shown that treatments employing ultrasound can reduce the production of proinflammatory mediators and enhance the growth rate of keratinocytes that promote wound repair. 28Moreover, one study has indicated that induction of lymphatic vasculature is correlated with the reduced severity of inflammatory reactions. 29,30 suggest that the observed improvements in the durations of postoperative edema and ecchymosis in our patients may be associated with increased angiogenesis and lymphangiogenesis and with inhibition of inflammatory reactions promoted by ultrasound-induced wound repair.
In this retrospective multicenter blinded cohort study, we compared the duration of postoperative perilesional edema and ecchymosis at 1-day intervals between the patients treated with LDM ultrasound and controls.Twenty-four patients in the LDM-treated group who underwent five sessions (10 min/session) of LDM treatment demonstrated significantly shorter durations of postoperative perilesional edema and ecchymosis in all three investigated facial areas compared with the 24 age-matched control patients who received conventional ice pack treatment.The LDM treatment offers several clinical advantages, including a painless procedure both during and after treatment, as well as no required downtime.
Additionally, minimal preparation is needed for this therapy, apart from applying a coupling medium.In this research, patients in both the LDM-treated and control groups demonstrated a shorter timeframe for postoperative swelling and bruising on the upper eyelids, followed by the lower eyelids and front cheeks.This finding indicates a strong correlation between the healing of postoperative swelling and bruising and the lymphatic drainage system in the neck and face.Interestingly, patients in both groups experienced noticeably longer durations of bruising and swelling on the left front cheek, which can be attributed to the fact that most of the lateral osteotomies were performed unilaterally on the left side.Nevertheless, there are evident constraints associated with conducting a retrospective study.Specifically, despite similarities in demographic characteristics among individual groups, asserting that all surgeries were conducted at an equivalent level of complexity becomes challenging.
Overall, our clinical study demonstrated that post-rhinoseptoplasty LDM ultrasound treatment effectively reduced the duration of postoperative ecchymosis and perilesional edema without any significant side effects.This approach to managing perilesional edema and ecchymosis after surgery resulted in reduced downtime and increased patient satisfaction.Hence, the utilization of LDM therapy can be seen as a viable and nonsurgical approach to effectively address the swelling and bruising around the surgical site following rhinoseptoplasty.As it was stated previously, application of LDM demonstrates a local effect with no improvement in a non-treated contralateral facial site. 10Further contralateral-controlled clinical cases will be needed to confirm this for the reduction of edema and ecchymosis post-rhinoseptoplasty.

ACK N OWLED G M ENTS
This study was conducted in compliance with the principles set forth in the Declaration of Helsinki.Consent was received from the families of the deceased patients before beginning the dissections.
The authors sincerely thank those who donated their bodies to science so that anatomical research could be performed.Results from such research can potentially increase mankind's overall knowledge, which can then improve patient care.Therefore, these donors and their families deserve our highest gratitude.

FU N D I N G I N FO R M ATI O N
There is nothing to declare.

CO N FLI C T O F I NTE R E S T S TATE M E NT
I acknowledge that I have considered the conflict of interest statement included in the "Author Guidelines."I hereby certify that, to the best of my knowledge, no aspect of my current personal or professional situation might reasonably be expected to significantly affect my views on the subject I am presenting.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.

E TH I C S S TATEM ENT
This study was conducted in compliance with the principles set forth in the Declaration of Helsinki.Consent was received from the participants of the patients.

R E FE R E N C E S
4 years (age range: 20-48 years) who were treated with conventional ice pack application daily for 5 days (control group).The study design incorporated blinding to ensure unbiased analysis.Two doctors can serve as an alternative option for the noninvasive management of postoperative perilesional ecchymosis and edema.K E Y W O R D S ecchymosis, edema, post-rhinoseptoplasty, rhinoseptoplasty, ultrasound assess the initial severity of both investigated parameters directly after surgery and then we compare the scores.All patients were administered systemic second-generation cephalosporins as a prophylactic antibiotic for 2 days after surgical intervention.No systemic corticosteroids were administered to any of the patients.Patients with a medical background involving conditions such as diabetes mellitus, chronic renal disease, chronic liver disease, hypertension, ischemic heart disease or stroke, peripheral artery disease, hemorrhagic disease, a high risk of cardio-embolism, predisposition to bleeding, current use of anticoagulants, blood clotting disorders, or concurrent smoking were excluded from the study.These factors have the potential to significantly impact the duration of postoperative edema and ecchymosis.It is important to note that all patients provided written informed consent prior to participating in the study.
Photographs were captured using consistent camera settings, lighting conditions, and patient positioning during each visit.These photographs were taken prior to ultrasound treatment or ice pack

| 833 AHN
et al. application and on the 7th, 14th, 21st, and 28th days after the operation.Blinded investigators analyzed both the photographs and medical records to assess the presence of perilesional edema and ecchymosis.The perilesional areas were divided into six modified regions, namely the right and left upper eyelids, right and left lower eyelids, and right and left anterior cheeks.On the 28th day postsurgery, patients were asked to rate their overall satisfaction on a 4-point scale (0-not satisfied, 1-somewhat satisfied, 2-quite satisfied, and 3-very satisfied) regarding postoperative recovery pain, time, perilesional edema, and ecchymosis.Additionally, patients were requested to report any other side effects experienced during the follow-up period, such as pain, temporary redness, prolonged redness, itching, bleeding, oozing, viral or fungal infections, bacterial folliculitis or furunculosis, ulceration, changes in skin pigmentation, and scarring.
Baseline characteristics: In the LDM Group #1, out of the 24 patients, 19 individuals (79.2%) underwent rhinoseptoplasty, while F I G U R E 2 Photographs of a 42-year-old female patient in the control group.Photographs were taken under normal light exposure at (A) 1, (B) 4, (C) 7, and (D) 14 days after a rhinoseptoplasty with unilateral (left) osteotomy.

Figures 2 -
Figures 2-5 illustrate the typical progressive reduction of postrhinoseptoplasty edema and ecchymosis for patients in both the control and LDM groups.

F I G U R E 4
Photographs of a 38-year-old female patient in the ultrasound-treated group.Photographs were taken under normal light exposure at (A) 1, (B) 4, (C) 7, and (D) 14 days after a rhinoseptoplasty with unilateral (left) osteotomy.

F I G U R E 5
Photographs of a 53-year-old female patient in the LDM group.Photographs were taken under normal light exposure at (A) 1, (B) 4, (C) 7 and (D) 14 days after a second revision rhinoseptoplasty with autologous costal cartilage graft.AHN et al. ecchymosis on the left anterior cheek.The reason thereof is likely that the most of the lateral osteotomies were performed unilaterally on the left side.