Effects of Perioperative Remifentanil With Controlled Hypotension on Intraoperative Bleeding and Postoperative Edema and Ecchymosis in Open Rhinoplasty Mu ¨ge Kos ¸ucu, MD,* S ¸ahin O ¨ mu ¨r, MD,* Ahmet Bes ¸ir, MD,* Muhammet Uralog ˘ lu, MD,Þ Murat Topbas ¸, MD,þ and Murat Livaog ˘ lu, MDÞ Background: This randomized, double-blind study was designed to assess the effect of perioperative remifentanil with controlled hy- potension on intraoperative bleeding, postoperative edema, and ecchymosis. Methods: Fifty-two patients undergoing rhinoplasty were divided into 2 groups. The remifentanil group received 1 Hg I kg j1 intrave- nously as a bolus before induction of anesthesia, 0.5 to 1 Hg I kg j1 I h j1 by continuous intravenous infusion during the operation. After anesthesia induction with propofol (2Y3 mg I kg j1 ) and fentanyl (1Y15 Hg I kg j1 ), muscle relaxation was achieved with rocuronium (0.45Y0.90 mg I kg j1 ). Mean arterial pressure was maintained at 50 to 60 mm Hg in controlled hypotensive anesthesia achieved using remifentanil infusion. Perioperative hemodynamics and bleeding; early postoperative pain and agitation scale; postoperative first, third, and seventh day edema; and ecchymosis were evaluated. Edema and ec- chymosis were evaluated using graded scale from 0 to 4. Results: Remifentanil reduced mean arterial pressure during the entire operative period and the first 30 minutes postoperatively (P G 0.05 for these comparisons). Intraoperative bleeding also decreased (P G 0.001). There was a significant decrease in edema in both upper and lower eyelid edema on the first and third days in the remifentanil group, although this difference was not detected on the seventh day (P 1upper = 0.000, P 1lower = 0.000, P 3upper = 0.008, and P 3lower = 0.002). Ecchymosis decreased significantly in both upper and lower eyelids on the first, third, and seventh days in the remifentanil group (P 1upper = 0.000, P 3upper = 0.000, P 3upper = 0.002, P 3lower = 0.002, P 7upper = 0.049, and P 7lower = 0.038). There were no differences in postoperative pain and agitation between 2 groups. Conclusions: Remifentanil with controlled hypotension may re- duce edema and ecchymosis of the upper and lower eyelids, by re- ducing mean arterial pressure and amount of bleeding in rhinoplasty. Key Words: Rhinoplasty, controlled hypotension, remifentanil, edema, ecchymosis, bleeding (J Craniofac Surg 2014;25: 471Y475) N o matter how careful and gentle the surgeon performs an op- eration, trauma and inflammation inevitably develop in the tissues. Inflammation and bleeding of the soft tissue result in peri- orbitaledema and ecchymosis. This is very significant and a cause of separate anxiety for patients, especially in operations performed for cosmetic purposes involving the facial region. Various agents have been used to reduce edema and ecchymosis developing around the eyes after rhinoplasty, 1Y5 such as corticosteroids, arnica, lidocaine, and adrenaline combination and Melilotus extract. The most fre- quently investigated subjects are steroids administered in different doses and for different periods. 1Y3,6Y8 However, there is no consensus on their efficacy. 8 Intraoperative controlled hypotensive drugs such as sodium nitroprusside, calcium-channel blockers, volatile anesthetics, and remifentanil have been experimented to provide a bloodless operative field, which is especially needed for head and neck operations. 1,9,10 Remifentanil has been used to induce mild to moderate hypotension for various kinds of surgery, including middle ear surgery and cranioplasty. 11,12 Remifentanil produces a decrease in heart rate (HR), systolic blood and common carotid arterial blood flow, and maxillo- facial tissue blood flow. 13,14 In this study, we investigated whether remifentanil with con- trolled hypotension could be used to achieve better results for intraoperative bleeding and postoperative edema and ecchymosis after rhinoplasty for the first week. MATERIALS AND METHODS The protocol was approved by the Institutional Medical Board (2012/72), and patients gave written informed consent. Fifty-two American Society of Anesthesiologists physical status I patients were included. Exclusion criteria included a history of any chronic disease (carotid stenosis; peripheral vasculopathy; hypertension; atrioventricular block; hepatic, renal, or hematological disorders), psychiatric problems, morbid obesity, any other chronic drug use, and allergy to opioid or other drugs. All the study patients had nearly the same nasal deformities. Open rhinoplasty was performed under general anesthesia by the same surgical team with the same surgical instruments. Epinephrine 1:10,000 and 5% lidocaine were injected into the septum, and all parts of the nose. Lateral osteotomy and hump reduction were given to all of the patients repeatedly. External nasal splints (Rinofix; Rinomed tıbbi u ¨ru ¨nler, Istanbul, Turkey) and CLINICAL STUDY The Journal of Craniofacial Surgery & Volume 25, Number 2, March 2014 471 From the Departments of *Anesthesiology, †Plastic and Aesthetic Surgery, and ‡Public Health, Medical School of Karadeniz Technical University, Trabzon, Turkey. Received February 18, 2013. Accepted for publication November 17, 2013. Address correspondence and reprint requests to Mu ¨ge Kos ¸ucu, MD, Department of Anesthesiology, KTU Farabi Hospital, 61080, Trabzon, Turkey; E-mail: mugekk73@hotmail.com The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000603 Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.