The Effects of Vibration and Pressure Treatments in the Early Postoperative Period of Rhinoplasty — Suleyman Tas PubMed

Rhinoplasty DOI: 10.1093/asj/sjz226 www.aestheticsurgeryjournal.com © 2019 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals. permissions@oup.com The Effects of Vibration and Pressure Treatments in Early Postoperative Period of Rhinoplasty Süleyman Taş, MD, FEBOPRAS Abstract Background: The early postoperative period can be distressing for the patients undergoing rhinoplasty since edema and ecchymosis are commo n complications. Objectives: To analyze the effects of the vibration and pressure treatments in the early postoperative period of rhinoplasty. Methods: Sixty patients, who had undergone rhinoplasty, were randomized into 3 groups: group 1 (control group, n = 20) received classic nasal casting, group 2 (n = 20) received nasal cast with an elastic bandage to hold it on the face, and group 3 (n = 20) received vibration treatment in addition to that in group 2 following the rhinoplasty. They were evaluated preoperatively and postoperatively at 3 and 7 days in a prospective study. The postoperative edema and ecchymosis were scored by 2 independent surgeons. The postoperative pain was measured using the visual analog scale, and the necessity of anti-inflammatory medication (and the dose needed) and the cast comfort was questioned. The sebaceous activity of the nose skin was examined. A preoperative and postoperative seventh day sonographic study was performed to evaluate the tissue edema objectively. Results: The pressure treatment decreased the edema and ecchymosis significantly compared with the control group. The vibration treatment minim- ized edema, ecchymosis, sebaceous activity of the nose skin, pain score, and the need for anti-inflammatory medication, and increased the cast comfort significantly compared with the other groups (P < 0.0001). Conclusions: Rapid regression of edema and ecchymosis may be achieved using the vibrating nasal cast technique that may minimize patient di s- comfort, pain, and sebaceous activity following rhinoplasty. Level of Evidence: 1

Editorial Decision date: July 31, 2019; online publish-ahead-of-print August 13, 2019. The issue of postoperative edema and ecchymosis (post- operative discoloration and bruising) is significant and distressing for patients following rhinoplasty. Their physi- ological and psychological effects often lead to the annul- ment and delay of the operative procedures, complicating the goals of rhinoplasty, which constitute imp rovement of the nasal function and aesthetic appearance. 1 In spite of meticulous surgical dissection and hemostasis, edema, and ecchymosis may occur.2 Steroids, herbal supplements, and specific surgical techniques, such as dissection planes and osteotomies have been employed to eliminate these complications. Although these methods helped in reducing swelling and bruising, they did not help resolve these issues. 3 The vibration treatment facilitates lymph and blood flow and induces acute analgesia, which are crucial to the practice of physiotherapy.4-8 Dr Taş is a plastic surgeon in private practice in Istanbul, Turkey. Corresponding Author: Dr Süleyman Taş, Hakkı Yeten Cad, No: 11, Terrace Fulya, Center: 1, Apt: 97 Şişli, Istanbul 34349, Turkey. E-mail: drsuleymantas@live.com; Twitter: drsuleymantas Aesthetic Surgery Journal 2019, 1–11 Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjz226/5549327 by kyleigh@surgery.org on 09 December 2019

In addition, recent studies concluded that low- magnitude, high-frequency vibration (LMHFV) therapy induces the mesenchymal stem cells to rebuild the soft tissue, activates osteoblasts, and decreases the osteoclastic activity to increase the bone healing. 9-14 To resolve the discomfort of edema and maximize the immediate as well as long-term postoperative healing pro- cess, tapes, splints, and massage techniques are commonly used. However, many patients are unable to perform such therapy completely and effectively due to postoperative pain and sensitivity.15,16 In this study, the effects of the vibration and pressure treatments which are novel approaches were analyzed in the early postoperative period of rhinoplasty patients. METHODS Study Design and Patient Selection Sixty consecutive patients (48 female, 12 male), who under- went primary rhinoplasty performed by the author, from Feb 2018 to May 2018, were evaluated in the prospective randomized controlled trial. This study was approved by the ethics committee of Taksim Research and Training Hospital (decision no: 2018/71) and was conducted in ac- cordance with the guidelines in the Declaration of Helsinki. Preoperatively, all patients received detailed information about the study and provided written informed consent for the surgery and publication of their photographs for educational purposes. Participants were randomized into 3 groups: group 1 (control group, n = 20) received classic casting, group 2 (n = 20) received nasal cast with an elastic bandage to hold it on the face and apply pressure in the naso-maxillary region, and group 3 (n = 20) received vibration treatment for 3 days (between the fourth and seventh postoperative days) in addition to the procedure for group 2 following the rhinoplasty. Randomization was performed by using a software program (www.randomlists.com). The follo wing were excluded from the study: smokers, those with chronic dermatologic or rheumatic diseases, those who did not undergo osteotomy, which is the most traumatic part of the rhinoplasty and change of edema and ecchymosis, and those who received incisional or ex- cisional procedure externally during rhinoplasty, such as alar reduction, in patients where the skin integrity was protected for an objective evaluation. Detailed medical re- cords were obtained for each patient, including bleeding diathesis. Patients were screened preoperatively for coag- ulation by evaluating the prothrombin time, partial throm- boplastin time, and bleeding/coagulation time. Patients with values outside the reference ranges were excluded from the study. The patients who were informed and ap- proved to be a part of this study were included. None of the patients had received herbal supplements, such as arnica, steroid treatments, and cool application intraoperatively and postoperatively to exactly measure the effect of the pressure and vibration. All patients underwent closed rhinoplasty under general anesthesia. Hypotensive anesthesia was applied to achieve an average arterial blood pressure of approximately 60 mm Hg. Lidocaine with 1:100,000 adrenaline was administered close to the incision sites before start to the operation. Study Groups Regular tape and thermoplastic external nasal cast were used in all patients. Group 1: The classic nasal casting was applied with a tape and thermoplastic cast. Following the application of the tape for dorsum and tip area, the thermoplastic cast was inserted into the dorsum to stabilize the nose. Group 2: The thermoplastic cast with an elastic head bandage was inserted to stabilize the nasal framework and the tape was applied to only the tip area. Group  3: The vibration treatment was applied from fourth postoperative day to seventh postoperative day in addition to the procedure for group 2. Preparation of the Nasal Cast With an Elastic Bandage The elastic bandage was prepared with a 1 cm width and sutured to a regular thermoplastic cast. A Velcro tape was sutured to the tips of the elastic bandage to allow their linking at the back of the head (Supplemental Figure 1). Application of the Vibration In this study, a portable micro motor was used to admin- ister low-magnitude, high frequency vibration (LMHFV) therapy as found in common electric toothbrushes. The approximate frequency of the micro motor is 14,000 times per minute and weight is 1.2 gr. The micro motor was posi- tioned on the dorsal portion of the cast using a double sided-adhesive. Centralization of the vibration device in the nose aims equally distributing of the vibration over the nose. The vibration was not recommended for first 3  days to avoid any bleeding complications. At the fourth day, LMHFV therapy was started with vibration for 3 × 30 min- utes in a day (morning, afternoon, evening) until the sev- enth day. Totally, the vibration treatment was applied for 1.5 hour in a day for 3 days (Supplemental Figure 2). 2 Aesthetic Surgery Journal Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjz226/5549327 by kyleigh@surgery.org on 09 December 2019

Taş 3 Evaluation Method The patients were photographed by the author with a standard 50-mm lens and paraflash system (Canon700D, Tokyo, Japan; and Golden Eagle Flash JY-180, Yuyao Co Ltd., Shenzhen, China, respectively) from the front view preoperatively and on postoperative days 3 and 7.  The images were reviewed by 2 board certified independent plastic surgeons (S.C., R.K.) who were blinded to the vi- bration application. These examiners rated the extent of ecchymosis on a scale of 0 to 5, the color density of ecchymosis on a scale of 0 to 4, and the severity of the edema on a scale of 0 to 3 (Table 1). 17 The data was collected on postoperative day 7, at which time the patient was asked to rate the comfort of the cast as fair, good, or excellent on a scale of 0 to 2 (0, fair; 1, good; 2, excellent), for the first 3 days and between the fourth and seventh days, separately. 15 All the casts were removed on postoperative day 7. No complications were reported during the study. The visual analog scale (V AS) was used to measure pain severity for the first 3 days and between the fourth and seventh days, separately. A linear scale marked 0-10 shows the extent of pain. No pain is defined as 0; whereas, max- imum pain is 10. Moreover, the use and frequency of the anti-inflammatory medication was analyzed. The surgeon investigated the sebaceous activity of the nose skin on the seventh day following the removal of the cast, and scored it as 0 to 2 (0, dry skin with no seba- ceous activity; 1, oily skin with no pimple; 2, oily skin with pimples). The sonographic study was performed preoperatively and on the seventh postoperative day to objectively eval- uate the edema. The thickness of the soft tissue envelop was measured in the nasolabial region from the medial canthus to the alar base using 3 points (Samsung RS80A Ultrasound Machine, with LA2-9A probe) ( Figure 1). The per centage of change between the preoperative and post- operative sonographic measurements for each patient was used for statistical analyses. Statistical Analyses Statistical analyses were performed using the SPSS (Statistical Package for Social Sciences) for Windows 22.0. The descriptive statistics, including mean, standard devi- ation, and percentage were calculated. The 1-way analysis of variance test was used to compare the quantitative con- tinuous data between more than 2 independent groups. Scheffe test was used as a complementary post-hoc ana- lysis to determine the differences after the analysis of vari- ance test. The difference between the intragroup repeated Table 1. Scoring System for Ecchymosis, Edema, Cast Comfort, and Sebaceous Activity Rating Edema Extent of ecchymosis Intensity of ecchymosis Cast comfort Sebaceous activity 0 No edema No ecchymosis No color change Fair Dry skin with no sebaceous activity 1 Mild edema Up to medial 1/3 of the lower and /or upper eyelid Yellowish color change Good Oily skin with no pimple 2 Moderate edema Medial 1/2 of upper and/or lower eyelid Light purple Excellent Oily skin with pimples 3 Severe edema Entire upper and/or lower eyelid Dark purple — — 4 — Entire part of the lower and upper eyelid and/or conjunctiva Very dark purple — — 5 — Extension of ecchymosis below malar bone — — — Figure 1. A preoperative planning for ultrasonographic evaluation is demonstrated in this 24-year-old woman. The ultrasound probe was inserted in the nasolabial region to measure the soft tissue thickness from the medial canthus to the alar base as 3 points; proximal nasolabial point was in the medial chantal level, middle nasolabial point was in the middle portion of the nasolabial region, and distal nasolabial point was in the alar base. The location of the probe was marked as a red frame. Numbers 1, 2, and 3 mark the level of the proximal, middle, and distal nasolabial regions, respectively. Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjz226/5549327 by kyleigh@surgery.org on 09 December 2019

measurements was analyzed using the paired t test. Statistical significance was defined as P < 0.05. Power analysis was performed to ensure sufficient power to be able to extrapolate the statistical analysis re- sults to the overall population. To determine the power of the study for exceeding 95%, it was determined that 51 patients should be enough in total and 17 patients for each group with 5% significance level and 0.50 effect size (df = 2; F = 3.190). Interrater reliability between the examiners was as- sessed using weighted kappa statistics. The mean scores of the examiners were used for statistical analysis. RESULTS In total, 60 patients (48 female, 12 male) were enrolled in the study. The average age was 24.2  years (range, 18-32  years). The follow-up period for patients in this study was 7  days. The distributions of mean scores for edema and ecchymosis on postoperative days 3 and 7, and cast comfort, V AS score, sebaceous activity are presented in Table 2. The results of the sonographic evaluation are pr esented in Table 3. The results indicated moderate to v ery good agreement (weighted kappa [κ]  =  0.474; P = 0.028 <0.05) between the examiners (κ = 0.421 for severity of the edema, κ = 0.542 for extent of the ecchym- osis, and κ = 0.459 for intensity of the ecchymosis). The severity of the edema scores on the third post- operative day were significantly lower for patients who underwent pressure treatment (group 2, 1.775  ±  0.472; group 3, 1.700 ± 0.470) than those in the control group (group 1, 2.575  ±  0.438). The edema scores decreased significantly from day 3 to day 7 for all groups. The edema scores were significantly the lowest for the vibration treat- ment group (group 3, 0.425 ± 0.467), followed by group 2 (1.275 ± 0.525) and the control group (1.750 ± 0.380) on the seventh postoperative day (P < 0.001) (Figure 2). The e xtent and intensity of the ecchymosis scores on the third postoperative day were significantly higher for group 1 (2.775 ± 1.303 and 2.550 ± 0.930, respectively) than those for groups 2 (1.650 ± 1.204 and 1.275 ± 0.866, respectively) and 3 (1.800  ±  1.409 and 1.225  ±  0.819, respectively). The scores for the extent and intensity of ecchymosis decreased from day 3 to day 7 in all groups. The scores for the extent and intensity of ecchymosis were significantly lower for vibration treatment group 3 (0.350 ± 0.540 and 0.150 ± 0.286, respectively), followed by group 2 (1.100 ± 0.868 and 0.825 ± 0.467, respectively) and the control group (1.775 ± 0.850 and 1.675 ± 0.568, respectively) (P < 0.001) (Figures 3-7). The changes in the e xtent and intensity of ecchymosis from group 1 and group 3 were statistically significant, on the other hand, the slope patterns appears to be very similar. The patients reported their comfort of the cast as 1  ±  0.45 and 1  ±  0.46 for the first 3  days and next 4  days, respectively, in the control group; 1.05  ±  0.51 and 1 ± 0.45, respectively, in group 2; and 0.90 ± 0.55 and 1.95  ±  0.22, respectively, in group 3.  The vibra- tion treatment increased the patient comfort significantly (P  <  0.001); however, the other comparisons were not significant (P  > 0.05) (Figure 8). The V AS for the first 3  days was 5.050  ±  0.686, 4.950 ± 0.945, and 4.900 ± 0.968, and for the next 4 days 3.400 ± 0.821, 3.450 ± 0.999, and 1.450 ± 0.945 in the groups 1, 2, and 3, respectively. V AS scores decreased sig- nificantly from day 3 to day 7 for all the groups. The vi- bration treatment decreased the V AS scores significantly (P < 0.001), and the other comparisons were not signifi- cant (P > 0.05) (Figure 9). In gr oups 1 and 2, all patients except a couple expressed that they used the antiinflammatory medication routinely twice per day for 1 week. In group 3, all patients expressed that they did not need to use the antiinflammatory medica- tion after the fifth day. The vibration treatment decreased the sebaceous activity significantly (1.150  ±  0.587 in Table 2. Mean Scores of the Groups: Mean ± SD Group number Edema at 3rd day Edema at 7th day Extent of ecchymosis at 3rd day Extent of ecchymosis at 7th day Intensity of ecchymosis at 3rd day Intensity of ecchymosis at 7th day Cast comfort at 3rd day Cast comfort at 7th day VAS score at 3rd day VAS score at 7th day Sebaseus activity 1 2.575 ± 0.438 1.750 ± 0.380 2.775 ± 1.303 1.775 ± 0.850 2.550 ± 0.930 1.675 ± 0.568 1 ± 0.45 1 ± 0.46 5.050 ± 0.686 3.400 ± 0.821 1.150  ± 0.587 2 1.775 ± 0.472 1.275 ± 0.525 1.650 ± 1.204 1.100 ± 0.868 1.275 ± 0.866 0.825 ± 0.467 1.05 ± 0.51 1 ± 0.45 4.950 ± 0.945 3.450 ± 0.999 1.050  ± 0.605 3 1.700 ± 0.470 0.425 ± 0.467 1.800 ± 1.409 0.350 ± 0.540 1.225 ± 0.819 0.150 ± 0.286 0.9 ± 0.55 1.95 ± 0.22 4.900 ± 0.968 1.450  ± 0.945 0.250  ± 0.444 SD, standard deviation. Table 3. Sonographic Evaluation Group no. NL proximal NL middle NL distal 12 2 2 4 4 0 2 151 73 0 3 6 11 16 The mean percentage of change (%) between the preoperative and postoperative sonographic measurements are demonstrated. NL, nasolabial. 4 Aesthetic Surgery Journal Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjz226/5549327 by kyleigh@surgery.org on 09 December 2019

Taş 5 group 1, 1.050 ± 0.605 in group 2, and 0.250 ± 0.444 in group 3; P < 0.001) (Figure 10). The pr eoperative and postoperative sonographic eval- uation could be performed in 6 patients from group 1, 8 from group 2, and 9 from group 3. The mean percent of change between the preoperative and postoperative son- ographic measurements is demonstrated in Table 3. The ultr asonography findings were compatible with the edema scores statistically (P < 0.001) (Figure 11). DISCUSSION Edema and ecchymosis are the most notable concerns for patients seeking rhinoplasty. Ecchymosis is attributed to the subcutaneous bleeding or any blood spreading to the subcutaneous area. Submembranous dissection and drainage of bleeding are the known recommendations to decrease this complication. 18 On the other hand, edema is unavoidable because of the nature of the human body and also the mechanism of the healing process, which in- volves high-volume cell migration and cytokine degrad- ation. However, uncontrolled edema and healing reaction are undesirable, so they must be under control not only in rhinoplasty but also in all fields of medicine. The following have been used to control the edema in rhinoplasty; lo- cally: many types of cast, tape, and massage; systemic- ally: steroids, decongestants, and herbal supplements; and surgically: various surgical techniques, including different approaches to lateral osteotomies. 3,15 Casting the cartilaginous and bony components fol- lowing the operation is as crucial as the surgical procedure itself.19,20 Proper postoperative care is integral for the suc- cess of the surgeries, yet currently there is a lack of suit- able casting materials that can provide sufficient support for the postoperative nose and aid the healing process. 21,22 Vibration is a new medical application, which appears to solve these problems. It has demonstrated an acute analgesic effect and an increased level of lymphatic and blood flow, which reduces swelling. 4-8,23 In physiotherapy, the acute analgesic effect of vibration reduces chronic musculoskeletal pain, thus alleviating delayed-onset muscle soreness and recovering range of motion. 4-7,23 It has found application in a range of different procedures, such as during venipuncture in infants 24 and to treat di- abetic peripheral neuropathy. 25 It has been employed in injection-associated pain during dental and cosmetic sur- gical treatment as well as during incision and drainage for reducing needle phobia. 26-32 The mechanics of the acute analgesic affect are explained by the gate control theory of pain,33 which states that the somatic stimuli can closes the “gate.” This gate must be sufficiently stimulated or “triggered” to transmit impulses to the brain. Neural fi- bers carry information to the central nervous system via the dorsal horn of the spinal cord. The neural fibers are classified as small diameter (A- δ and C fibers) and large diameter (A-β fibers). Pain is transmitted to the brain via the small fibers, whereas the vibration itself is transmitted Figure 2. The mean differences of the regression of edema between the groups are demonstrated. Figure 3. The mean differences of the extent of ecchymosis between the groups are demonstrated. Figure 4. The mean differences of the intensity of ecchymosis between the groups are demonstrated. Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjz226/5549327 by kyleigh@surgery.org on 09 December 2019

AB C Figure 5. (A) This 24-year-old woman, who was also featured in Figure 1, displays left external deviated, humpy, and droopy tip. The pr eoperative patency score was 5 of 10. The surgical procedure included hump removal, alignment of the nose following the separation of the upper lateral cartilages and lateral nasal bones from the septum, asymmetric low to low lateral and medial osteotomies, and reconstruction with bilateral asymmetric spreader flaps with septoplasty. Tipplasty with lateral crural steal and medial crural overlapping, interdomal and cephalic intradomal sutures, and strut grafting through the delivery technique. Deep superficial musculoaponeurotic system (SMAS) layer suture to suspend and relocate the tip on the nasal dorsum was performed. (B) Moderate edema and no ecchymosis were seen in postoperative 3rd day. (C) Moderate edema, no ecchymosis, and oily skin with pimples were seen in postoperative 7th day. In this example of the classic casting group (group 1, control group), although there was moderate edema and no ecchymosis, we can see that there is almost no regression between the 3rd and 7th day. 6 Aesthetic Surgery Journal Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjz226/5549327 by kyleigh@surgery.org on 09 December 2019

Taş 7 AB C Figure 6. (A) This 26-year-old woman displayed left external deviation, humpy and droopy nose, and alar base asymmetry as well as nostrils. The preoperative patency score was 6 of 10. The surgical procedure included hump elimination, alignment of the nasal framework with asymmetric lateral and medial osteotomies, and roof reconstruction with septoplasty. Tip surgery included superior-based transposition flaps and strut grafting. Nostril and alar base asymmetry were treated with rim graft and dissection of the levator alaque nasi muscle in the right side. (B) Moderate edema and 2 points of extent and intensity of the ecchymosis were seen on postoperative 3rd day. (C) Mild edema, no ecchymosis, and dry skin were seen on postoperative 7th day. In this example of the pressure group (Group 2), the regression between the 3rd and 7th day was satisfying. Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjz226/5549327 by kyleigh@surgery.org on 09 December 2019

AB C Figure 7. (A) This 34-year-old woman displayed right external deviation, humpy and droopy nose, and alar base asymmetry. The preoperative patency score was 4 of 10. The surgical procedure included hump elimination, alignment of the nasal framework with asymmetric lateral and medial osteotomies, and roof reconstruction with septoplasty. Tip surgery included superior-based transposition flaps and strut grafting. Alar base asymmetry was treated with releasing the pyriform ligament in the left side. (B) Severe edema and 3 points of extent and intensity of the ecchymosis were seen on postoperative 3rd day. (C) Mild edema, no ecchymosis, and dry skin were seen on postoperative 7th day. In this example of the vibration group (Group 3), although the severe edema and ecchymosis, a significant regression between the 3rd and 7th day was observed. 8 Aesthetic Surgery Journal Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjz226/5549327 by kyleigh@surgery.org on 09 December 2019

Taş 9 to the brain via the large fibers that can inhibit the small fibers.34 Moreover, recent studies about the effect of LMHFV therapy were very exciting. It was demonstrated that vi- bration therapy induced an anabolic effect on the mesen- chymal stem cell and osteoblast activity and decelerated the catabolic effects with osteoclastic activity, thus decreasing bone resorption and increasing bone formation and there- fore bone strength. It also stimulates collagen synthesis and increases the tendon and muscle strength by differentiation of the mesenchymal stem cells. Because of these effects, vi- bration therapy is employed even in the treatment of sarco- penia. 9-14 Because the nasal bones are small and heal very slowly, utilizing vibration treatment may be helpful in pro- viding more stable nasal bones; however, this requires fur- ther study. On the other hand, there is no consensus about the effects, side effects, and regimen of LMHFV therapy in the literature, and all existing studies investigated the effect of whole-body vibration. Thus, the applied regimens of the vibration therapy were high enough to induce muscle con- tractions, which obviously cause poor bone healing. 35,36 The moment of cast removal is very exciting for pa- tients, because they are anxious about seeing their new nose. These expectations make this moment very dif- ficult, although we inform the patients in a detailed manner and perform a psychological therapy before the surgery. Thus, we still need to find a solution to make this first week more comfortable for patients. In modern rhinoplasty, we commonly use the thermo- plastic cast and sterile strips at the end of the surgery to protect the shape of the nose, on which we have spent a lot of effort and have performed difficult maneuvers to shape it. However, this application has some risk and scope for improvement. In case of uncontrolled edema, the cast may drop down. In addition, because of the coverage of the nose and the effects of the edema, sebaceous activity and Figure 8. The mean differences of cast comfort between the groups are demonstrated. Figure 9. The mean differences of the visual analog scale score between the groups are demonstrated. Figure 10. The mean differences of the sebaceous activity between the groups are demonstrated. Figure 11. The mean percent of changes between the preoperative and postoperative sonographic measurements between the groups are demonstrated. NL, nasolabial area. Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjz226/5549327 by kyleigh@surgery.org on 09 December 2019

pimples increase, especially in oily skin, causing unaes- thetic and unpleasant results during the removal of the cast and a more difficult psychological period for these pa- tients. Here, the presented casting technique utilizes pres- sure and vibration treatment, which decrease edema and ecchymosis, prevent the risk of the cast dropping out, and reduce sebaceous activity. This elastic bandage did not dis- turb the patient. On the contrary, the patients expressed that they felt safe with it. In this comparative randomized prospective clinical trial, the patients underwent rhinoplasty by the same surgeon utilizing the closed technique. Previously val- idated scales, 15,17 sonographic evaluation, physical find- ings, and photographs were utilized in the presented study to analyze the edema, ecchymosis, pain, cast com- fort, and sebaceous activity. The vibration and pressure treatment group was found to be more superior than the normal casting group based on discomfort, edema, pain, and sebaceous activity as per the evaluation by the inde- pendent reviewer, patients, and the author. The need for antiinflammatory medications was discontinued with the vibrating cast. The idea of a vibrating nasal cast occurred to me in 2013, and I have employed this application in many pa- tients with satisfying results. Based on my experience, I  started to recommend this novel cast to patients for 1 hour at night for an additional 2  months following cast removal. With this application, the patients felt relief and massage application could be eliminated. A future study is planned to examine the long-term effects of this novel ap- plication; the present study is a preliminary report of this innovative application. The limitation of this study was that the preparation of this novel cast needed more time and a vibrating device was necessary. The vibrating device, which can be pro- cured from the internet easily, is cost-effective (1-3 USD). The casts were prepared before surgery by the nurse to limit the duration of the surgery. In the future, the au- thor hopes that the emerging medical firms provide the vibrating nasal cast to make it easier and more accessible for colleagues. To prevent any possible bleeding compli- cation caused by the vibration, the author advises to start the vibration on the fourth day of the surgery. Moreover, a toothbrush vibration motor was used to apply the vi- bration treatment; however, different options are available on the internet. Another limitation was that this random- ized comparative case series considered the experience of a single surgeon. The presented innovative method should be compared with other methods to p revent edema and ecchymosis and larger case series should be involved. On the other hand, we should not forget that individual differ- ences are one of the most important determinant factors in edema and ecchymosis. CONCLUSION Herein, an innovative casting technique, which has a vi- bration device and elastic bandage, was demonstrated and compared with the classic cast and taping method. The vibrating nasal cast technique may solve the problems of postoperative edema, patient discomfort, pain, and seba- ceous activity following rhinoplasty. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The vibrating nasal cast (a thermoplastic cast with elastic bandage and vibrating motor) were designed by the author and patented by the Turkish Patent Institute (No: TR 2016 14675 B). This invention is not commercially available. 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