Part B – Case Study Portfolio: Students will need to work through the 2 case scenarios given.
Rhinoplasty can be performed in two ways using the external perforated method and the internal continuous method. As the patient wants a quick recovery and the least amount of swelling the latter was used. Within the case it also mentions in this case that sutures are internal so the latter was most likely. Lymphedema (swelling) around the eyes at least in the first few days up to a month is a common side effect and may persist up to a month. However, the internal perforated method may lead to increased internal mucosal tearing as opposed to the external perforated method (Rohrich, 1997). Although a closed rhinoplasty may seem like it gives a faster recovery these kind of complications actually may take longer because of these complications. This likely could be by there was increased swelling within this area.
If the nose, eyes are jaw are swollen the nodes affected are the pertinent nasal lymphatic system. This system comes from the superficial mucosa. It drains posteriorly to the retropharyngeal nodes. It can either drain to 1. the cervical nodes 2. submandibular glands 3. nodes and glands in the neck and jaw.
Infections are quite rare in rhinoplasty operations (1-3%) (Millman, 2002) however there are complications and bacterial infections that can occur (Holt, 1987). Care must be taken in order to make sure there is not an infection around these lymph regions.
In the head the watershed divide the two lymphatic drainage regions. This is shown in a cone shape starting from the eyebrows down laterally to the nose to the end of the mandible. The lymph from the upper part of the face will drain outward and downward to the perotid lymph nodes then into the cervical lymph chain to sub-mandibular lymphatic nodes. The patient can be instructed manual lymphatic drainage is a massage. This can be done at home up to five times a day. If the lymph is drained from here then the swelling should go down in time.
References
Millman, B., & Smith, R. (2002). The potential pitfalls of concurrent rhinoplasty and endoscopic sinus surgery. The Laryngoscope, 112(7), 1193-1196.
Holt, G. R., Garner, E. T., & McLarey, D. (1987). Postoperative sequelae and complications of rhinoplasty. Otolaryngologic clinics of North America, 20(4), 853-876.
Rohrich, R. J., Minoli, J. J., Adams, W. P., & Hollier, L. H. (1997). The lateral nasal osteotomy in rhinoplasty: an anatomic endoscopic comparison of the external versus the internal approach. Plastic and reconstructive surgery, 99(5), 1309-1312.
Clinical Scenario – NUMBER 2 - Tattoo Removal
Laser tattoo removal is common for getting rid of tattoos. In the tattoo process ink penetrates the skin and binds to keratinocytes and phagocytes dying them and then penetrates into deeper layers concentrated along the epidermal-dermal junction and then a basement layer is formed where ink is not lost. Ink however can also penetrate the regional lymph nodes and care must be taken in order to avoid them during making the tattoo. Some tattoo inks may be worst than others Specifically, black tattoos affect the lymph nodes more (Lehner, 2014). If the patient has a tattoo on the calf, as per this case, the lymph nodes affected would be the popliteal lymph nodes. The popliteal lymph nodes are small lymph nodes and consist of only about six or seven in total. Laser tattoo removal breaks the particles of the tattoo that can be then absorbed by the body. After laser removal there will be crusting in the first days and after the crusting is resolved the tattoo will continue to fade over the course of several weeks. However, there may be particular risks or complications if these broken ink particles are taken up by white blood cells.
Within this case as the area affected is near the calf it lymph nodes that will be affected are called the popliteal lymph nodes. These are likely to be the ones impacted if there is swelling in the area. This could be caused by tattoo ink causing inflammation that is localized lymphadenopathy (lymph nodes that are abnormal in size). Tattoo lymphadenopathy is likely a specific case whereby a foreign substance (ink) causes an allergy (Zirkin, 2001)
Precaution should be taken that this swelling is caused by the tattoo removal itself and not some lymphadenopathy-associated virus like HIV. If there is swelling at the site there could also be a lot of swelling in the area. This may decrease mobility. However, as there is currently no swelling the patient should not be concerned about this until there is.
Their are six or seven popliteal lymph nodes. A watershed running through the middle of the buttocks and the posterior thigh to the popliteal fossa separates both territories. The popiteal will drain upwards if the patient is lying with their legs up. The patient should be in the prone position for the manual lymphatic drainage massage. A doctor or someone else can start at the gluteal position at the iliac crest applying compression movements covering the entire buttocks and posterior leg the go from hip to heal. Light pressure could be applied a the popiteal space and the superficial efflearage. The other leg can also be performed (Kerchner, 2008) in similar manner to make sure there is no build up there.
The patient can do these massage treatments at home with a partner or perhaps consult a physiotherapist or a doctor if there persistent swelling. If there is a larger edema or lymphadenopathy a biopsy and potential removal may need to be undertaken. However, drainage of the area would be most appropriate, easier and more cost effective if possible.
References
Lehner, K., Santarelli, F., Vasold, R., Penning, R., Sidoroff, A., König, B., & Bäumler, W. (2014). Black Tattoos Entail Substantial Uptake of Genotoxicpolycyclic Aromatic Hydrocarbons (PAH) in Human Skin and Regional Lymph Nodes. PloS one, 9(3), e92787.
Zirkin, H. J., Avinoach, I., & Edelwitz, P. (2001). A tattoo and localized lymphadenopathy: a case report. CUTIS-NEW YORK-, 67(6), 471-472.
Kerchner, K., Fleischer, A., & Yosipovitch, G. (2008). Lower extremity lymphedema: Update: Pathophysiology, diagnosis, and treatment guidelines. Journal of the American Academy of Dermatology, 59(2), 324-331.
