Reverse Trendelenburg Positioning in Open Rhinoplasty: A Systematic Review of Clinical outcomes

Reverse Trendelenburg Positioning in Open Rhinoplasty: A Systematic Review of Clinical outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Reverse Trendelenburg Positioning in Open Rhinoplasty: A Systematic Review of Clinical outcomes Waleed Burhamah, Daniel Madarshahian, Nimeshan Chandra-Segaran This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8663766/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Rhinoplasty, a frequently performed facial plastic surgery procedure, often associated with challenges such as intraoperative bleeding and postoperative periorbital odema and/or ecchymosis, which can prolong recovery and reduce patient satisfaction. This systematic review investigates the impact of intraoperative patient positioning, in reverse Trendelenburg positioning (RTP), on bleeding and postoperative outcomes in open rhinoplasty. The included studies comprised of randomized and observational studies comparing reverse Trendelenburg position (RTP) with varying degrees of head elevation, and reporting outcomes such as blood loss, surgical field visibility, and postoperative odema or ecchymosis. Three studies met the inclusion criteria, proving that reverse Trendelenburg position (RTP) at angles between 10° and 20° being effective in reducing intraoperative bleeding and enhancing clarity of the surgical field compared to supine or lesser degrees of elevation. The largest trial demonstrated a decrease in bleeding with increasing tilt, with no significant advantage beyond 15°. Reverse Trendelenburg position (RTP) has also been shown to decrease postoperative periorbital odema and ecchymosis, especially at 20°, with these effects lasting through the first week following surgery. Surgeon satisfaction improved with Reverse Trendelenburg position (RTP), while operative time and physiological parameters remained stable, the later proving its safety. This review is the first to comprehensively assess the role of reverse Trendelenburg position (RTP) in open rhinoplasty and supports its adoption as a straightforward, safe, and effective technique to reduce bleeding and postoperative complications. Due to its simplicity and proven benefits, the reverse Trendelenburg position (RTP) at about 10° to 20° should be considered a valuable addition to rhinoplasty practice for optimizing surgical conditions and enhancing recovery. Level of evidence: Level II open rhinoplasty reverse Trendelenburg peri orbital odema open rhinoplasty post operative bleeding Figures Figure 1 Figure 2 Summary Bleeding and ecchymosis is a common complication in open rhinoplasty. The evidence on the effect of Intraoperative patient positioning on outcomes is summarised in this review. Reverse Trendelenburg Position (RTP) is a safe and effective method of reducing intra operative bleeding and postoperative ecchymosis, independent of pharmacological interventions. Introduction Rhinoplasty is a widely performed facial plastic surgery procedure, commonly associated with perioperative challenges such as intraoperative bleeding, postoperative periorbital oedema, and/or ecchymosis. [ 1 ] These complications can significantly influence patients’ recovery and surgical outcome. [ 1 ][ 2 ] With a prolonged recovery time and a delay in return to normal social and occupational activities, it is inevitable that patient satisfaction and perceived success of the procedure will be negatively impacted.[ 3 ][ 4 ] To mitigate these issues, many surgeons have integrated minimally invasive techniques and adjunctive perioperative strategies aimed at reducing trauma, inflammation, bleeding, oedema and/or ecchymosis.[ 5 ] With the ultimate goal being optimizing recovery and improving the overall patient satisfaction. With a varying degree of success, these measures include the perioperative use of pharmacologic agents (e.g., corticosteroids [ 3 ][ 4 ] tranexamic acid or desmopressin [ 5 ]), modifications in surgical technique, permissive hypotension [ 6 ], and adjustments in intra-operative patient positioning.[ 7 ][ 9 ] In rhinoplasty, one commonly used strategy is placing the patient in a reverse Trendelenburg position (RTP) intraoperatively. This involves elevating the head above the heart level to reduce venous return and, consequently, perfusion pressure at the surgical site and hence the amount of intra operative bleeding. [ 7 ][ 8 ][ 9 ] This has shown to be extremely beneficial in a number of endoscopic nasal procedures [ 7 ][ 9 ], with paucity in the literature in describing it’s role, safety and efficacy as a primary haemostatic modality in rhinoplasty. This review aims to summarize the existing evidence on the effect of intraoperative patient positioning—particularly the reverse Trendelenburg position (RTP)—on intraoperative bleeding and postoperative outcomes in patients undergoing an open rhinoplasty. To the best of our knowledge, this is the first systematic review to exclusively evaluate the aforementioned. Methods Design and Study selection This systematic review was conducted in accordance with a pre-specified review protocol, which has been registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD420251056743). The review was designed and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Eligible studies were identified based on predefined inclusion and exclusion criteria, and the selection process, data collection, and outcome synthesis were performed systematically to ensure methodological rigor [ 16 ]. Eligibility Criteria Inclusion Criteria Studies were considered eligible for inclusion if they involved patients undergoing rhinoplasty procedures, including both primary and revision surgeries, where intraoperative reverse Trendelenburg positioning (RTP) (any degree of head-up tilt) was compared to supine (flat) positioning or head-up flexed body positioning. Studies were required to report at least one relevant outcome, such as intraoperative blood loss (measured as volume or graded by surgical field visibility), surgeon satisfaction with the operative field, or postoperative periorbital oedema or ecchymosis. Both randomized controlled trials (RCTs) and observational studies (prospective or retrospective cohort studies) were eligible for inclusion to capture the full range of available evidence on this topic. Exclusion Criteria Studies were excluded if they were non-comparative in design, such as case series without a control group and case reports. Studies not involving open rhinoplasty (e.g., isolated septoplasty, closed rhinoplasty or endoscopic sinus surgery) were also excluded, as were studies where intraoperative patient positioning was not clearly described or was not a studied variable of interest. Additional exclusions included reviews, commentaries, letters, conference abstracts without full-text data, non-original research, animal studies, cadaveric studies, and purely anatomical or experimental studies without live surgical outcomes. Rationale for inclusion and exclusion criteria These inclusion and exclusion criteria were applied to ensure that the review focused specifically on assessing the impact of intraoperative patient positioning during open procedures on clinically relevant outcomes. Both RCTs and observational studies were considered eligible to ensure a comprehensive evaluation of the existing literature. However, during the selection process, all of the included studies were randomized controlled trials, reflecting the limited amount of research currently available on this specific aspect of rhinoplasty surgery. Outcome measures Based on these eligibility criteria, the primary outcomes of interest for this systematic review were identified as follows: intraoperative bleeding, assessed either by direct measurement of blood loss volume (mls) or by visual estimation; postoperative periorbital oedema, reflecting the degree of odema around the eyes; postoperative periorbital ecchymosis, representing the extent of ecchymosis in the periorbital region; and surgical field evaluation scores, assessing the clarity of the operative field from the surgeon’s perspective. These outcomes were selected as they directly reflect both the intraoperative challenges and postoperative morbidity associated with rhinoplasty procedures and are critical indicators of the potential clinical impact of intraoperative patient positioning. Literature Search Strategy Comprehensive search of the available literature was conducted to identify relevant studies. Searches were performed across electronic databases including PubMed, Cochrane library, and Google Scholar, using combinations of keywords such as “rhinoplasty,” “reverse Trendelenburg,” “supine position,” “head-up position,” “table tilt,” “intraoperative bleeding,” “postoperative oedema,” and “postoperative ecchymosis.” In addition to database searches, manual screening of reference lists from the included articles and related reviews was undertaken to capture any additional eligible studies. No restrictions were placed on publication date, language, or country of origin. Both peer-reviewed articles and grey literature sources, including dissertations and conference proceedings, were considered. The selection process involved screening titles and abstracts for relevance, followed by full-text review against the inclusion and exclusion criteria outlined above. Although both randomized controlled trials and observational studies were eligible for inclusion, the final set of included studies consisted exclusively of randomized controlled trials that specifically compared different patient positioning strategies during open rhinoplasty and reported on the predefined outcomes of interest. The search was conducted on the 08/05/2025, yielding 60 results from Google Scholar, 4 results from PubMed, and 3 results from Cochrane Library. Data collection and data extraction Data extraction was performed using a standardized template specifically developed for this review. Extracted data included study characteristics such as first author, year of publication, country of origin, journal, and study design. Patient demographic information was also collected, including the number of patients undergoing each intervention, mean age, sex distribution, body weight, body mass index (BMI), American Society of Anaesthesiologists (ASA) physical status classification, operative time, heart rate, and mean arterial pressure. Outcome data relevant to intraoperative bleeding, postoperative morbidity, and secondary outcomes were reviewed and narratively synthesized within the Results section. Any discrepancies during data extraction were resolved through discussion, and efforts were made to ensure the consistency and completeness of the extracted information across all included studies. Screening and data extraction was performed by 2 authors individually. Risk of Bias Assessment Risk of bias was assessed independently for each included study using the Cochrane Risk of Bias (RoB 2.0) tool, which is specifically designed for randomised controlled trials. The assessment evaluated potential bias across key domains, including the randomization process, deviations from intended interventions, missing outcome data, measurement of outcomes, and selection of reported results [ 17 ]. Each domain was rated as having a low, high, or unclear risk of bias according to the guidance provided in the RoB 2.0 tool. Any disagreements between reviewers during the assessment process were resolved through discussion. Overall judgments regarding the risk of bias were incorporated into the interpretation of the review findings. Summary of Outcomes and Data Synthesis Given the small number of included studies, the clinical and methodological heterogeneity, a formal meta-analysis did not yield presentable results. As a result, a narrative synthesis approach was adopted. Study findings were summarized qualitatively, with particular attention to patterns and trends across the reported outcomes, including intraoperative bleeding, periorbital oedema, periorbital ecchymosis, and surgical field evaluation scores. The results were organized in structured tables to facilitate comparison between studies, and differences in study design, interventions, and outcome measurement methods were considered in the interpretation of findings. Results The initial search across multiple electronic databases yielded a total of 67 records (Figure 1). After removing six duplicate entries, 61 records remained for title and abstract screening. Of these, 57 were excluded for being irrelevant to the objectives of this review. The full texts of the remaining four articles were assessed for eligibility. One study was excluded at this stage as it was a narrative review and did not constitute an original observational study or randomized controlled trial. Ultimately, three studies met the predefined inclusion criteria and were included in the final systematic review. Details about each study, study design and year publication, is presented in table 1. Baseline demographic and clinical characteristics of the study populations – including the number of patients undergoing each intervention, mean age, sex distribution, body weight, body mass index (BMI), American Society of Anaesthesiologists (ASA) physical status classification, operative time, heart rate, and mean arterial pressure – are reported in table 2. Baseline characteristics were generally comparable across groups, with no statistically significant differences observed. Table 3 summarises the interventions performed by each author. Assessment of risk of bias in included studies. Risk of bias was assessed for each of the three included studies using the Cochrane Risk of Bias 2.0 (RoB 2) tool, which is specifically designed for randomized controlled trials. The results of the risk of bias assessments are presented in Figure 2. Intraoperative Bleeding and Surgical Field Visibility All three included studies assessed the effect of intraoperative patient positioning on the volume of blood loss during open rhinoplasty. While each study used slightly different positioning protocols and comparator groups, a consistent trend emerged favouring reverse Trendelenburg positioning (RTP) in reducing intraoperative bleeding and improving surgical field conditions. (Table 4) In the largest of the three studies, Koc et al. [10] compared three different degrees of reverse Trendelenburg positioning (RTP)—5°, 10°, and 20°—in patients undergoing open rhinoplasty. They reported a progressive reduction in mean intraoperative blood loss with increasing tilt: 109.1 mL in the 5° group, 73.3 mL in the 10° group, and 70.2 mL in the 20° group. Statistically significant reductions in bleeding were observed between the 5° group and both the 10° (p = 0.004) and 20° (p = 0.001) groups, while the difference between 10° and 20° was not significant. In addition to blood loss volume, the study also evaluated surgical field visibility using the Fromme-Boezaart grading scale, where lower scores indicate better operative conditions. The mean surgical field scores were significantly lower in the 10° and 20° groups compared to the 5° group (p = 0.013 and p = 0.014, respectively), indicating that moderate head elevation not only reduces bleeding but also improves the visual clarity of the operative field. Similarly, Ozkose et al. [12] compared the supine position (Group 1) to 15° (Group 2) and 20° (Group 3) reverse Trendelenburg positioning (RTP). The mean blood loss was highest in the supine group (96.7 mL) and markedly lower in both reverse Trendelenburg position (RTP) groups—25.6 mL and 28.3 mL for 15° and 20°, respectively. The reduction in bleeding was statistically significant when comparing both reverse Trendelenburg position (RTP)groups to the supine group (p = 0.001 and p = 0.002), but no significant difference was found between the 15° and 20° angles (p = 0.392). These findings align with those of Koc et al. [10], indicating that reverse Trendelenburg positioning (RTP) substantially reduces intraoperative bleeding, and that increasing the tilt beyond 15° may offer no further statistically significant advantage. In contrast, the study by Nooraei et al. [13] did not find a statistically significant difference in bleeding volume between two head-elevated positions: a reverse Trendelenburg position (RTP)group (30° tilt with the head above pelvis and feet lowered) and a head-up group (30° incline with head and shoulders elevated but hips and legs in line). The reverse Trendelenburg position (RTP) group experienced a slightly lower mean blood loss (77.0 ± 13.2 mL vs. 83.3 ± 21.2 mL), but the difference was not statistically significant (p = 0.233). In addition to this quantitative blood loss measurement, the authors assessed intraoperative surgical field clarity using an endoscopic grading system. The reverse Trendelenburg position (RTP) group had a higher proportion of favourable scores (Grades I–II: 19.3%) and fewer poor visibility scores (Grades III–IV: 17.4%) compared to the head-up group (Grades I–II: 15.3%; Grades III–IV: 11.7%), though no statistical analysis was reported for these visibility scores. This qualitative grading offers additional support for the use of reverse Trendelenburg positioning (RTP) in improving operative field conditions. Taken together, the findings from these studies suggest that reverse Trendelenburg positioning (RTP) during open rhinoplasty—particularly at angles of 10° to 20°—is associated with a meaningful reduction in intraoperative bleeding and improved surgical field visibility compared to flat or non-RT positions. The optimal angle appears to lie between 10° and 15°, beyond which no consistent additional benefit has been demonstrated. Periorbital Oedema Koc et al. [10] evaluated the effect of different degrees of reverse Trendelenburg positioning (RTP) on postoperative periorbital oedema in patients undergoing open rhinoplasty. Ninety patients were randomized into three groups based on table tilt angle: Group 5 (5° RTP), Group 10 (10° RTP), and Group 20 (20° RTP), with 30 patients in each group. Postoperative eyelid oedema was assessed on postoperative days 1, 3, and 7 using standardized photographic evaluations, rated on a 5-point scale (0–4) by independent observers blinded to the group allocation. The findings demonstrated that patients in Group 20 experienced significantly less periorbital oedema compared to Group 5 on all three postoperative days (Day 1: p = 0.001; Day 3: p = 0.006; Day 7: p = 0.001). Additionally, oedema was significantly lower in Group 20 compared to Group 10 on postoperative day 7 ( p = 0.004). No significant differences in oedema were reported between Groups 5 and 10 on Days 1 and 3. These results suggest that increasing the degree of reverse Trendelenburg positioning (RTP) to 20° during open rhinoplasty can lead to a significant reduction in postoperative periorbital oedema, especially in the early recovery period, with a measurable benefit persisting to day 7.(Table 4) Periorbital Ecchymosis Koc et al. [10] assessed periorbital ecchymosis in patients undergoing open rhinoplasty under different degrees of reverse Trendelenburg positioning (RTP) (5°, 10°, and 20°), using a standardized 5-point photographic scale (0–4) on postoperative days 1, 3, and 7. The findings demonstrated that patients in the 20° group experienced significantly less ecchymosis than those in the 5° group on both postoperative day 1 (p = 0.001) and day 3 (p = 0.003). Furthermore, ecchymosis scores in the 20° group were also significantly lower than those in the 10° group on day 1 (p = 0.001), though this difference was not observed on later days. By day 7, no statistically significant differences in ecchymosis were detected among the groups (p = 0.254), suggesting that most echymosis had resolved across all positions. These results support the use of 20° reverse Trendelenburg positioning (RTP) to minimize early postoperative periorbital ecchymosis following open rhinoplasty. (Table 4) Secondary Outcomes Two of the included studies reported additional perioperative and postoperative outcomes beyond intraoperative bleeding and postoperative morbidity, namely operation time, surgeon satisfaction, and systemic physiological and haematological parameters. Nooraei et al. [13] assessed the effect of patient positioning on the duration of surgery by comparing two head-elevated techniques: reverse Trendelenburg position (RTP) (30° tilt with head above pelvis and feet lowered) and a head-up flexed position (30° tilt with head and shoulders elevated, but legs level with the pelvis). The mean operation time was 1.35 ± 0.43 hours in the reverse Trendelenburg position (RTP) group and 1.28 ± 0.55 hours in the head-up group. This difference was not statistically significant (p = 0.571), suggesting that intraoperative positioning did not affect the overall duration of the procedure in this cohort. In contrast, Ozkose et al. [12] evaluated surgeon satisfaction, measured using a 5-point ordinal scale (1 = excellent, 5 = very poor), across three positioning groups: Group 1 (supine), Group 2 (15° reverse Trendelenburg position (RTP)), and Group 3 (20° reverse Trendelenburg position (RTP)). The proportion of "excellent" ratings increased markedly in the reverse Trendelenburg position (RTP) groups, with 40% in Group 2 and 39% in Group 3, compared to 17% in Group 1. Similarly, "good" ratings were reported in 48% of Group 2 and 55% of Group 3, versus 52% in the supine group. Statistical analysis demonstrated significantly greater surgeon satisfaction in both reverse Trendelenburg position (RTP) groups when compared to the supine group (Group 1 vs. Group 2: p = 0.045; Group 1 vs. Group 3: p = 0.048), with no significant difference between the two reverse Trendelenburg position (RTP) angles (p = 0.959). These findings suggest that even moderate table tilt improves surgical conditions and perceived ease of the operation without requiring greater elevation beyond 15°. Nooraei et al. [13] also assessed postoperative systemic physiological and haematological variables to determine whether patient positioning had broader physiological effects. These included systolic and diastolic blood pressure, heart rate, haemoglobin concentration, platelet count, and international normalized ratio (INR). No significant differences were observed between the two groups in vital signs or INR. However, statistically significant differences were reported for haemoglobin and platelet count, with higher values observed in the reverse Trendelenburg position (RTP) group (Hb: 13.57 ± 1.66 g/dL vs. 11.94 ± 0.82 g/dL; p = 0.004, and platelets: 198.5 ± 49.7 ×10³/µL vs. 162.0 ± 43.2 ×10³/µL; p = 0.020). Despite statistical significance, the authors deemed these differences to be not clinically significant, and concluded that reverse Trendelenburg positioning (RTP) did not adversely impact postoperative hematologic or hemodynamic stability. Taken together, these secondary outcomes reinforce the practical benefits of reverse Trendelenburg positioning (RTP) in open rhinoplasty. While it does not appear to reduce operative time, it is associated with significantly improved surgeon satisfaction and no adverse physiological effects. (Table 4) Discussion Rhinoplasty is one of the fundamental procedures in facial plastic surgery, performed to enhance nasal aesthetics. Due to the complex and highly vascular anatomy of the nasal region, these procedures carry a risk of perioperative bleeding and ecchymosis [ 1 ]. Excessive bleeding can not only prolong operative time but also impair surgical visualization, potentially affecting precision and increases intraoperative difficulty. [ 12 ] Additionally post operative odema and periorbital ecchymosis, can compromise aesthetic outcomes, patient perception and can delay recovery [ 1 – 4 ]. In light of these concerns, numerous approaches have been explored in an attempt to reduce intraoperative and postoperative complications of rhinoplasty, including pharmacological agents, surgical technique modifications, and intraoperative positioning strategies. [ 3 ][ 5 ][ 14 ][ 15 ] Among the pharmacological agents evaluated is the use of tranexamic acid (TXA), an antifibrinolytic agent.[ 5 ] [ 15 ] A recent meta-analysis by Khajuria et al. demonstrated that the use of TXA, particularly via intravenous or oral administration, is effective in reducing intraoperative blood loss during rhinoplasty and septoplasty. This reduction in bleeding has been associated with improved surgical field visibility and increased surgeon satisfaction. However, despite its efficacy in minimizing blood loss, the review noted that TXA had no significant effect on operative duration. [ 15 ] Interestingly, a randomized controlled trial conducted by Akbarpour et al. investigated the use of intranasal desmopressin in patients undergoing open septorhinoplasty. The study demonstrated a significant reduction in intraoperative blood loss, with the haemostatic effect being dose-dependent. Notably, desmopressin did not cause any significant alterations in hemodynamic parameters, suggesting a favourable safety profile. However, similar to findings with tranexamic acid, the reduction in bleeding did not correlate with a decrease in operative time. [ 14 ] The intraoperative use of the reverse Trendelenburg position (RTP) is a well-established practice among rhinoplasty surgeons, intended to reduce surgical bleeding and improve visualization. Notably, this systematic review represents the first focused synthesis of evidence on the role of reverse Trendelenburg positioning (RTP) as a standalone perioperative intervention in open rhinoplasty. Our review has identified consistent evidence supporting the benefits of reverse Trendelenburg position (RTP) during open rhinoplasty procedures. Across the included studies, the reverse Trendelenburg position (RTP) was shown to significantly reduce intraoperative blood loss, post operative odema, and ecchymosis, while also contributing to higher levels of surgeon satisfaction. The trials conducted by Mehmet et al. and Koc et al. employed robust methodologies, with comparable patient groups and standardized interventions. All patients underwent standardized open septorhinoplasty procedures including osteotomies, with a consistent anaesthetic protocol to ensure a stable mean arterial pressure (Table 3 ) [ 10 ][ 12 ]. Mehmet et al. found that reverse Trendelenburg position (RTP) at 15° and 20° offered a significant reduction in bleeding and enhanced surgeon satisfaction compared to the supine position. However, an angle of 15° did not yield a significant benefit when compared to 20°.[ 12 ] Koc et al observed that angles of 10° and 20° were significantly more effective in controlling bleeding when compared to 5°. Interestingly, no significant difference was found between 10° and 20° [ 10 ]. We conclude the findings of the above trials may indicate that the optimal benefit may occur between 10° and 15° of reverse Trendelenburg position (RTP) compared to either supine or 5°. In the studies reviewed, no adjunctive pharmacologic agents such as tranexamic acid (TXA), corticosteroids, or desmopressin were employed, (as summarised in Table 3 ) although local epinephrine infiltration was uniformly used across all patient groups. This highlights that the observed haemostatic effect was attributable almost solely to patient positioning, thereby strengthening the case for reverse Trendelenburg position (RTP) as a simple, safe and effective intervention. Despite the multifactorial nature of intraoperative blood loss, current evidence consistently supports the effectiveness of the reverse Trendelenburg position (RTP) in reducing bleeding during surgery, despite the scarcity of published evidence. Furthermore, reverse Trendelenburg position (RTP) at angles up to 20 degrees has been shown to be safe from an anaesthetic perspective, with no significant alterations in hemodynamic parameters reported across the studies.[ 10 ][ 12 ][ 13 ] While reduced intraoperative blood loss was consistently observed, no significant reduction in operative duration was noted. [ 10 ][ 12 ][ 13 ] These findings were also observed in studies investigating the use of desmopressin [ 14 ] and TXA [ 5 ][ 15 ]. This is likely due to the inherently multifactorial nature of surgical time, which is influenced by factors such as surgeon experience, complexity of the case, and intraoperative decision-making and interruptions—variables that are difficult to standardize or control. Our review has several limitations to be considered, a number of confounding variables such as surgeon technique, operative expertise, and intraoperative interruptions are inherently difficult to control for, and may influence outcomes like operative time and bleeding. Additionally, despite the consistent benefit observed with the reverse Trendelenburg position (RTP), the sample sizes in the included studies were relatively small, which may limit the generalizability and statistical power of the conclusions. Furthermore, adherence to postoperative care protocols, particularly head elevation, could not be strictly monitored across all studies, potentially affecting the evaluation of outcomes such as post operative odema and ecchymosis. Future research should focus on incorporating patient-reported outcome measures (PROMs) to provide a more comprehensive assessment of recovery and satisfaction. Larger, multicentre randomized trials with standardized surgical protocols and enhanced monitoring of perioperative variables would further strengthen the evidence base. From a statistical perspective, the absence of a meta-analysis limits the ability to provide pooled effect estimates or confidence intervals, which would have strengthened the overall precision and reliability of the findings. We were un able to present a meta-analysis due to the included studies being heterogeneous in terms of outcome measures, follow-up time points, and intraoperative positioning protocols, making quantitative synthesis inappropriate. Additionally, the small sample sizes of the included trials and the inconsistent reporting of statistical parameters — such as confidence intervals — reduce the overall strength and interpretability of the evidence. Without access to original trial protocols, selective outcome reporting cannot be ruled out. Conclusion Intraoperative bleeding remains a key complication in open rhinoplasty that surgeons strive to minimize. Various interventions have been explored with differing degrees of success. Among the most widely studied are tranexamic acid (TXA), corticosteroids, and desmopressin, all of which have shown effectiveness in reducing intraoperative blood loss. However, none have demonstrated a consistent impact on reducing operative time. This review consolidates the current evidence on the role of the reverse Trendelenburg position (RTP) during open rhinoplasty. The findings support its effectiveness in reducing intraoperative bleeding, as well as postoperative odema and ecchymosis, while maintaining a favourable safety profile. Given its simplicity, safety, and effectiveness of reverse Trendelenburg positioning (RTP) represents a valuable adjunct in optimizing surgical outcomes in open rhinoplasty with an optimal angle of no more than 20 degrees. Declarations Author Contribution WB- Conceptualization, literature review, data extraction, analysis, writing, editing DM- Conceptualization, data extraction, analysis, editing. NC- analysis, editing. Acknowledgments: • This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors. • The authors declare that they have no conflicts of interest to disclose. • For this type of study informed consent is not required. • This article does not contain any studies with human participants or animals performed by any of the authors. • Clinical trial number: not applicable. Data Availability International Prospective Register of Systematic Reviews (PROSPERO; CRD420251056743) References American Society of Plastic Surgeons (2014) plastic surgery statistics report. Available at: http://www.plasticsurgery.org/Documents/news-resources/statistics/2014-statistics/ plastic-surgery-statsitics-full-report.pdf . Accessed October 26, 2015 Rohrich RJ, Ahmad J (2011) Rhinoplasty. 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Int J Prev Med 4(12):1438–1441 PMID: 24498500; PMCID: PMC3898450 Akbarpour M, Jalali MM, Akbari M, Nasirmohtaram S, Haddadi S, Habibi AF, Azad F (2023) Investigation of the effects of intranasal desmopressin on the bleeding of the patients during open septorhinoplasty: A randomized double-blind clinical trial. Heliyon 9(7):e17855 PMID: 37455992; PMCID: PMC10344754 Khajuria A, Khademi Mansour HR, Muhammad I, Asare A, Tammasse I, Suresh J, Leiberman C, Pacheco-Barrios N, Brown S, Dogan T, Rohrich R (2024) Tranexamic Acid in Rhinoplasty and Septoplasty: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Plast Reconstr Surg Glob Open 12(11):e6275. 10.1097/GOX.0000000000006275 PMID: 39507311; PMCID: PMC11537566 Liberati A, Altman DG, Tetzlaff J et al (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700 Higgins JP, Altman DG, Gøtzsche PC et al (2019) Assessing risk of bias in a randomized trial. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (eds) Cochrane Handbook for Systematic Reviews of Interventions, 2nd edn. Wiley-Blackwell, Chichester (UK), pp 205–228 Gurlek A, Fariz A, Aydogan H, Ersoz-Ozturk A, Eren AT (2006) Effects of different corticosteroids on edema and ecchymosis in open rhinoplasty. Aesthetic Plast Surg 30:150–154. https://doi.org/10.1007/s00266-005-0158-1 Tables Table 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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03:10:12","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":17390,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8663766/v1/58077842e0a5939f9836f703.docx"},{"id":101274361,"identity":"c4614aa8-26e9-483c-8bc4-3369d69ad84a","added_by":"auto","created_at":"2026-01-28 03:10:08","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":15522,"visible":true,"origin":"","legend":"","description":"","filename":"interventionstable3.docx","url":"https://assets-eu.researchsquare.com/files/rs-8663766/v1/b2413e5f75970aef2d376361.docx"},{"id":101274375,"identity":"0f6414c8-57d6-40e8-acdf-4322b8487ecd","added_by":"auto","created_at":"2026-01-28 03:10:11","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":20519,"visible":true,"origin":"","legend":"","description":"","filename":"table4outcomemeasurestable.docx","url":"https://assets-eu.researchsquare.com/files/rs-8663766/v1/bf2a21f6a6c23154b9dbc8b9.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Reverse Trendelenburg Positioning in Open Rhinoplasty: A Systematic Review of Clinical outcomes","fulltext":[{"header":"Summary","content":"\u003cul\u003e\n \u003cli\u003eBleeding and ecchymosis is a common complication in open rhinoplasty.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThe evidence on the effect of Intraoperative patient positioning \u0026nbsp; on outcomes is summarised in this review.\u003c/li\u003e\n \u003cli\u003eReverse Trendelenburg Position (RTP) is a safe and effective method of reducing intra operative bleeding and postoperative ecchymosis, independent of pharmacological interventions.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eRhinoplasty is a widely performed facial plastic surgery procedure, commonly associated with perioperative challenges such as intraoperative bleeding, postoperative periorbital oedema, and/or ecchymosis. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] These complications can significantly influence patients\u0026rsquo; recovery and surgical outcome. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e][\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] With a prolonged recovery time and a delay in return to normal social and occupational activities, it is inevitable that patient satisfaction and perceived success of the procedure will be negatively impacted.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eTo mitigate these issues, many surgeons have integrated minimally invasive techniques and adjunctive perioperative strategies aimed at reducing trauma, inflammation, bleeding, oedema and/or ecchymosis.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] With the ultimate goal being optimizing recovery and improving the overall patient satisfaction. With a varying degree of success, these measures include the perioperative use of pharmacologic agents (e.g., corticosteroids [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] tranexamic acid or desmopressin [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]), modifications in surgical technique, permissive hypotension [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and adjustments in intra-operative patient positioning.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn rhinoplasty, one commonly used strategy is placing the patient in a reverse Trendelenburg position (RTP) intraoperatively. This involves elevating the head above the heart level to reduce venous return and, consequently, perfusion pressure at the surgical site and hence the amount of intra operative bleeding. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e][\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] This has shown to be extremely beneficial in a number of endoscopic nasal procedures [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], with paucity in the literature in describing it\u0026rsquo;s role, safety and efficacy as a primary haemostatic modality in rhinoplasty.\u003c/p\u003e \u003cp\u003eThis review aims to summarize the existing evidence on the effect of intraoperative patient positioning\u0026mdash;particularly the reverse Trendelenburg position (RTP)\u0026mdash;on intraoperative bleeding and postoperative outcomes in patients undergoing an open rhinoplasty. To the best of our knowledge, this is the first systematic review to exclusively evaluate the aforementioned.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign and Study selection\u003c/h2\u003e \u003cp\u003e This systematic review was conducted in accordance with a pre-specified review protocol, which has been registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD420251056743). The review was designed and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Eligible studies were identified based on predefined inclusion and exclusion criteria, and the selection process, data collection, and outcome synthesis were performed systematically to ensure methodological rigor [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEligibility Criteria\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eInclusion Criteria\u003c/h2\u003e \u003cp\u003eStudies were considered eligible for inclusion if they involved patients undergoing rhinoplasty procedures, including both primary and revision surgeries, where intraoperative reverse Trendelenburg positioning (RTP) (any degree of head-up tilt) was compared to supine (flat) positioning or head-up flexed body positioning. Studies were required to report at least one relevant outcome, such as intraoperative blood loss (measured as volume or graded by surgical field visibility), surgeon satisfaction with the operative field, or postoperative periorbital oedema or ecchymosis. Both randomized controlled trials (RCTs) and observational studies (prospective or retrospective cohort studies) were eligible for inclusion to capture the full range of available evidence on this topic.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eExclusion Criteria\u003c/h3\u003e\n\u003cp\u003eStudies were excluded if they were non-comparative in design, such as case series without a control group and case reports. Studies not involving open rhinoplasty (e.g., isolated septoplasty, closed rhinoplasty or endoscopic sinus surgery) were also excluded, as were studies where intraoperative patient positioning was not clearly described or was not a studied variable of interest. Additional exclusions included reviews, commentaries, letters, conference abstracts without full-text data, non-original research, animal studies, cadaveric studies, and purely anatomical or experimental studies without live surgical outcomes.\u003c/p\u003e\n\u003ch3\u003eRationale for inclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003eThese inclusion and exclusion criteria were applied to ensure that the review focused specifically on assessing the impact of intraoperative patient positioning during open procedures on clinically relevant outcomes. Both RCTs and observational studies were considered eligible to ensure a comprehensive evaluation of the existing literature. However, during the selection process, all of the included studies were randomized controlled trials, reflecting the limited amount of research currently available on this specific aspect of rhinoplasty surgery.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eOutcome measures\u003c/h2\u003e \u003cp\u003eBased on these eligibility criteria, the primary outcomes of interest for this systematic review were identified as follows: intraoperative bleeding, assessed either by direct measurement of blood loss volume (mls) or by visual estimation; postoperative periorbital oedema, reflecting the degree of odema around the eyes; postoperative periorbital ecchymosis, representing the extent of ecchymosis in the periorbital region; and surgical field evaluation scores, assessing the clarity of the operative field from the surgeon\u0026rsquo;s perspective. These outcomes were selected as they directly reflect both the intraoperative challenges and postoperative morbidity associated with rhinoplasty procedures and are critical indicators of the potential clinical impact of intraoperative patient positioning.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eLiterature Search Strategy\u003c/h3\u003e\n\u003cp\u003eComprehensive search of the available literature was conducted to identify relevant studies. Searches were performed across electronic databases including PubMed, Cochrane library, and Google Scholar, using combinations of keywords such as \u0026ldquo;rhinoplasty,\u0026rdquo; \u0026ldquo;reverse Trendelenburg,\u0026rdquo; \u0026ldquo;supine position,\u0026rdquo; \u0026ldquo;head-up position,\u0026rdquo; \u0026ldquo;table tilt,\u0026rdquo; \u0026ldquo;intraoperative bleeding,\u0026rdquo; \u0026ldquo;postoperative oedema,\u0026rdquo; and \u0026ldquo;postoperative ecchymosis.\u0026rdquo; In addition to database searches, manual screening of reference lists from the included articles and related reviews was undertaken to capture any additional eligible studies. No restrictions were placed on publication date, language, or country of origin. Both peer-reviewed articles and grey literature sources, including dissertations and conference proceedings, were considered. The selection process involved screening titles and abstracts for relevance, followed by full-text review against the inclusion and exclusion criteria outlined above. Although both randomized controlled trials and observational studies were eligible for inclusion, the final set of included studies consisted exclusively of randomized controlled trials that specifically compared different patient positioning strategies during open rhinoplasty and reported on the predefined outcomes of interest. The search was conducted on the 08/05/2025, yielding 60 results from Google Scholar, 4 results from PubMed, and 3 results from Cochrane Library.\u003c/p\u003e\n\u003ch3\u003eData collection and data extraction\u003c/h3\u003e\n\u003cp\u003e Data extraction was performed using a standardized template specifically developed for this review. Extracted data included study characteristics such as first author, year of publication, country of origin, journal, and study design. Patient demographic information was also collected, including the number of patients undergoing each intervention, mean age, sex distribution, body weight, body mass index (BMI), American Society of Anaesthesiologists (ASA) physical status classification, operative time, heart rate, and mean arterial pressure. Outcome data relevant to intraoperative bleeding, postoperative morbidity, and secondary outcomes were reviewed and narratively synthesized within the Results section. Any discrepancies during data extraction were resolved through discussion, and efforts were made to ensure the consistency and completeness of the extracted information across all included studies. Screening and data extraction was performed by 2 authors individually.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eRisk of Bias Assessment\u003c/h2\u003e \u003cp\u003eRisk of bias was assessed independently for each included study using the Cochrane Risk of Bias (RoB 2.0) tool, which is specifically designed for randomised controlled trials. The assessment evaluated potential bias across key domains, including the randomization process, deviations from intended interventions, missing outcome data, measurement of outcomes, and selection of reported results [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Each domain was rated as having a low, high, or unclear risk of bias according to the guidance provided in the RoB 2.0 tool. Any disagreements between reviewers during the assessment process were resolved through discussion. Overall judgments regarding the risk of bias were incorporated into the interpretation of the review findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSummary of Outcomes and Data Synthesis\u003c/h2\u003e \u003cp\u003eGiven the small number of included studies, the clinical and methodological heterogeneity, a formal meta-analysis did not yield presentable results. As a result, a narrative synthesis approach was adopted. Study findings were summarized qualitatively, with particular attention to patterns and trends across the reported outcomes, including intraoperative bleeding, periorbital oedema, periorbital ecchymosis, and surgical field evaluation scores. The results were organized in structured tables to facilitate comparison between studies, and differences in study design, interventions, and outcome measurement methods were considered in the interpretation of findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe initial search across multiple electronic databases yielded a total of 67 records (Figure 1). After removing six duplicate entries, 61 records remained for title and abstract screening. Of these, 57 were excluded for being irrelevant to the objectives of this review. The full texts of the remaining four articles were assessed for eligibility. One study was excluded at this stage as it was a narrative review and did not constitute an original observational study or randomized controlled trial. Ultimately, three studies met the predefined inclusion criteria and were included in the final systematic review.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDetails about each study, study design and year publication, is presented in table 1. Baseline demographic and clinical characteristics of the study populations \u0026ndash; including the number of patients undergoing each intervention, mean age, sex distribution, body weight, body mass index (BMI), American Society of Anaesthesiologists (ASA) physical status classification, operative time, heart rate, and mean arterial pressure \u0026ndash; are reported in table 2. Baseline characteristics were generally comparable across groups, with no statistically significant differences observed. Table 3 summarises the interventions performed by each author.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment of risk of bias in included studies.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRisk of bias was assessed for each of the three included studies using the Cochrane Risk of Bias 2.0 (RoB 2) tool, which is specifically designed for randomized controlled trials. The results of the risk of bias assessments are presented in Figure 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntraoperative Bleeding and Surgical Field Visibility\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll three included studies assessed the effect of intraoperative patient positioning on the volume of blood loss during open rhinoplasty. While each study used slightly different positioning protocols and comparator groups, a consistent trend emerged favouring reverse Trendelenburg positioning (RTP) in reducing intraoperative bleeding and improving surgical field conditions. (Table 4)\u003c/p\u003e\n\u003cp\u003eIn the largest of the three studies, Koc et al. [10] compared three different degrees of reverse Trendelenburg positioning (RTP)\u0026mdash;5\u0026deg;, 10\u0026deg;, and 20\u0026deg;\u0026mdash;in patients undergoing open rhinoplasty. They reported a progressive reduction in mean intraoperative blood loss with increasing tilt: 109.1 mL in the 5\u0026deg; group, 73.3 mL in the 10\u0026deg; group, and 70.2 mL in the 20\u0026deg; group. Statistically significant reductions in bleeding were observed between the 5\u0026deg; group and both the 10\u0026deg; (p = 0.004) and 20\u0026deg; (p = 0.001) groups, while the difference between 10\u0026deg; and 20\u0026deg; was not significant. In addition to blood loss volume, the study also evaluated surgical field visibility using the Fromme-Boezaart grading scale, where lower scores indicate better operative conditions. The mean surgical field scores were significantly lower in the 10\u0026deg; and 20\u0026deg; groups compared to the 5\u0026deg; group (p = 0.013 and p = 0.014, respectively), indicating that moderate head elevation not only reduces bleeding but also improves the visual clarity of the operative field.\u003c/p\u003e\n\u003cp\u003eSimilarly, Ozkose et al. [12] compared the supine position (Group 1) to 15\u0026deg; (Group 2) and 20\u0026deg; (Group 3) reverse Trendelenburg positioning (RTP). The mean blood loss was highest in the supine group (96.7 mL) and markedly lower in both reverse Trendelenburg position (RTP) groups\u0026mdash;25.6 mL and 28.3 mL for 15\u0026deg; and 20\u0026deg;, respectively. The reduction in bleeding was statistically significant when comparing both reverse Trendelenburg position (RTP)groups to the supine group (p = 0.001 and p = 0.002), but no significant difference was found between the 15\u0026deg; and 20\u0026deg; angles (p = 0.392). These findings align with those of Koc et al. [10], indicating that reverse Trendelenburg positioning (RTP) substantially reduces intraoperative bleeding, and that increasing the tilt beyond 15\u0026deg; may offer no further statistically significant advantage.\u003c/p\u003e\n\u003cp\u003eIn contrast, the study by Nooraei et al. [13] did not find a statistically significant difference in bleeding volume between two head-elevated positions: a reverse Trendelenburg position (RTP)group (30\u0026deg; tilt with the head above pelvis and feet lowered) and a head-up group (30\u0026deg; incline with head and shoulders elevated but hips and legs in line). The reverse Trendelenburg position (RTP) group experienced a slightly lower mean blood loss (77.0 \u0026plusmn; 13.2 mL vs. 83.3 \u0026plusmn; 21.2 mL), but the difference was not statistically significant (p = 0.233). In addition to this quantitative blood loss measurement, the authors assessed intraoperative surgical field clarity using an endoscopic grading system. The reverse Trendelenburg position (RTP) group had a higher proportion of favourable scores (Grades I\u0026ndash;II: 19.3%) and fewer poor visibility scores (Grades III\u0026ndash;IV: 17.4%) compared to the head-up group (Grades I\u0026ndash;II: 15.3%; Grades III\u0026ndash;IV: 11.7%), though no statistical analysis was reported for these visibility scores. This qualitative grading offers additional support for the use of reverse Trendelenburg positioning (RTP) in improving operative field conditions.\u003c/p\u003e\n\u003cp\u003eTaken together, the findings from these studies suggest that reverse Trendelenburg positioning (RTP) during open rhinoplasty\u0026mdash;particularly at angles of 10\u0026deg; to 20\u0026deg;\u0026mdash;is associated with a meaningful reduction in intraoperative bleeding and improved surgical field visibility compared to flat or non-RT positions. The optimal angle appears to lie between 10\u0026deg; and 15\u0026deg;, beyond which no consistent additional benefit has been demonstrated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePeriorbital Oedema\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKoc et al. [10] evaluated the effect of different degrees of reverse Trendelenburg positioning (RTP) on postoperative periorbital oedema in patients undergoing open rhinoplasty. Ninety patients were randomized into three groups based on table tilt angle: Group 5 (5\u0026deg; RTP), Group 10 (10\u0026deg; RTP), and Group 20 (20\u0026deg; RTP), with 30 patients in each group. Postoperative eyelid oedema was assessed on postoperative days 1, 3, and 7 using standardized photographic evaluations, rated on a 5-point scale (0\u0026ndash;4) by independent observers blinded to the group allocation.\u003c/p\u003e\n\u003cp\u003eThe findings demonstrated that patients in Group 20 experienced significantly less periorbital oedema compared to Group 5 on all three postoperative days (Day 1: \u003cem\u003ep\u003c/em\u003e = 0.001; Day 3: \u003cem\u003ep\u003c/em\u003e = 0.006; Day 7: \u003cem\u003ep\u003c/em\u003e = 0.001). Additionally, oedema was significantly lower in Group 20 compared to Group 10 on postoperative day 7 (\u003cem\u003ep\u003c/em\u003e = 0.004). No significant differences in oedema were reported between Groups 5 and 10 on Days 1 and 3.\u003c/p\u003e\n\u003cp\u003eThese results suggest that increasing the degree of reverse Trendelenburg positioning (RTP) to 20\u0026deg; during open rhinoplasty can lead to a significant reduction in postoperative periorbital oedema, especially in the early recovery period, with a measurable benefit persisting to day 7.(Table 4)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePeriorbital Ecchymosis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKoc et al. [10] assessed periorbital ecchymosis in patients undergoing open rhinoplasty under different degrees of reverse Trendelenburg positioning (RTP) (5\u0026deg;, 10\u0026deg;, and 20\u0026deg;), using a standardized 5-point photographic scale (0\u0026ndash;4) on postoperative days 1, 3, and 7. The findings demonstrated that patients in the 20\u0026deg; group experienced significantly less ecchymosis than those in the 5\u0026deg; group on both postoperative day 1 (p = 0.001) and day 3 (p = 0.003). Furthermore, ecchymosis scores in the 20\u0026deg; group were also significantly lower than those in the 10\u0026deg; group on day 1 (p = 0.001), though this difference was not observed on later days. By day 7, no statistically significant differences in ecchymosis were detected among the groups (p = 0.254), suggesting that most echymosis had resolved across all positions. These results support the use of 20\u0026deg; reverse Trendelenburg positioning (RTP) to minimize early postoperative periorbital ecchymosis following open rhinoplasty. (Table 4)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSecondary Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo of the included studies reported additional perioperative and postoperative outcomes beyond intraoperative bleeding and postoperative morbidity, namely operation time, surgeon satisfaction, and systemic physiological and haematological parameters.\u003c/p\u003e\n\u003cp\u003eNooraei et al. [13] assessed the effect of patient positioning on the duration of surgery by comparing two head-elevated techniques: reverse Trendelenburg \u0026nbsp;position (RTP) (30\u0026deg; tilt with head above pelvis and feet lowered) and a head-up flexed position (30\u0026deg; tilt with head and shoulders elevated, but legs level with the pelvis). The mean operation time was 1.35 \u0026plusmn; 0.43 hours in the reverse Trendelenburg position (RTP) group and 1.28 \u0026plusmn; 0.55 hours in the head-up group. This difference was not statistically significant (p = 0.571), suggesting that intraoperative positioning did not affect the overall duration of the procedure in this cohort.\u003c/p\u003e\n\u003cp\u003eIn contrast, Ozkose et al. [12] evaluated surgeon satisfaction, measured using a 5-point ordinal scale (1 = excellent, 5 = very poor), across three positioning groups: Group 1 (supine), Group 2 (15\u0026deg; reverse Trendelenburg position (RTP)), and Group 3 (20\u0026deg; reverse Trendelenburg position (RTP)). The proportion of \u0026quot;excellent\u0026quot; ratings increased markedly in the reverse Trendelenburg position (RTP) groups, with 40% in Group 2 and 39% in Group 3, compared to 17% in Group 1. Similarly, \u0026quot;good\u0026quot; ratings were reported in 48% of Group 2 and 55% of Group 3, versus 52% in the supine group. Statistical analysis demonstrated significantly greater surgeon satisfaction in both reverse Trendelenburg position (RTP) \u0026nbsp;groups when compared to the supine group (Group 1 vs. Group 2: p = 0.045; Group 1 vs. Group 3: p = 0.048), with no significant difference between the two reverse Trendelenburg position (RTP) angles (p = 0.959). These findings suggest that even moderate table tilt improves surgical conditions and perceived ease of the operation without requiring greater elevation beyond 15\u0026deg;.\u003c/p\u003e\n\u003cp\u003eNooraei et al. [13] also assessed postoperative systemic physiological and haematological variables to determine whether patient positioning had broader physiological effects. These included systolic and diastolic blood pressure, heart rate, haemoglobin concentration, platelet count, and international normalized ratio (INR). No significant differences were observed between the two groups in vital signs or INR. However, statistically significant differences were reported for haemoglobin and platelet count, with higher values observed in the reverse Trendelenburg position (RTP) group (Hb: 13.57 \u0026plusmn; 1.66 g/dL vs. 11.94 \u0026plusmn; 0.82 g/dL; p = 0.004, and platelets: 198.5 \u0026plusmn; 49.7 \u0026times;10\u0026sup3;/\u0026micro;L vs. 162.0 \u0026plusmn; 43.2 \u0026times;10\u0026sup3;/\u0026micro;L; p = 0.020). Despite statistical significance, the authors deemed these differences to be not clinically significant, and concluded that reverse Trendelenburg positioning (RTP) did not adversely impact postoperative hematologic or hemodynamic stability.\u003c/p\u003e\n\u003cp\u003eTaken together, these secondary outcomes reinforce the practical benefits of reverse Trendelenburg positioning (RTP) in open rhinoplasty. While it does not appear to reduce operative time, it is associated with significantly improved surgeon satisfaction and no adverse physiological effects. (Table 4)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eRhinoplasty is one of the fundamental procedures in facial plastic surgery, performed to enhance nasal aesthetics. Due to the complex and highly vascular anatomy of the nasal region, these procedures carry a risk of perioperative bleeding and ecchymosis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Excessive bleeding can not only prolong operative time but also impair surgical visualization, potentially affecting precision and increases intraoperative difficulty. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Additionally post operative odema and periorbital ecchymosis, can compromise aesthetic outcomes, patient perception and can delay recovery [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn light of these concerns, numerous approaches have been explored in an attempt to reduce intraoperative and postoperative complications of rhinoplasty, including pharmacological agents, surgical technique modifications, and intraoperative positioning strategies. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e][\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e][\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Among the pharmacological agents evaluated is the use of tranexamic acid (TXA), an antifibrinolytic agent.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] A recent meta-analysis by Khajuria et al. demonstrated that the use of TXA, particularly via intravenous or oral administration, is effective in reducing intraoperative blood loss during rhinoplasty and septoplasty. This reduction in bleeding has been associated with improved surgical field visibility and increased surgeon satisfaction. However, despite its efficacy in minimizing blood loss, the review noted that TXA had no significant effect on operative duration. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eInterestingly, a randomized controlled trial conducted by Akbarpour et al. investigated the use of intranasal desmopressin in patients undergoing open septorhinoplasty. The study demonstrated a significant reduction in intraoperative blood loss, with the haemostatic effect being dose-dependent. Notably, desmopressin did not cause any significant alterations in hemodynamic parameters, suggesting a favourable safety profile. However, similar to findings with tranexamic acid, the reduction in bleeding did not correlate with a decrease in operative time. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe intraoperative use of the reverse Trendelenburg position (RTP) is a well-established practice among rhinoplasty surgeons, intended to reduce surgical bleeding and improve visualization. Notably, this systematic review represents the first focused synthesis of evidence on the role of reverse Trendelenburg positioning (RTP) as a standalone perioperative intervention in open rhinoplasty. Our review has identified consistent evidence supporting the benefits of reverse Trendelenburg position (RTP) during open rhinoplasty procedures. Across the included studies, the reverse Trendelenburg position (RTP) was shown to significantly reduce intraoperative blood loss, post operative odema, and ecchymosis, while also contributing to higher levels of surgeon satisfaction.\u003c/p\u003e \u003cp\u003eThe trials conducted by Mehmet et al. and Koc et al. employed robust methodologies, with comparable patient groups and standardized interventions. All patients underwent standardized open septorhinoplasty procedures including osteotomies, with a consistent anaesthetic protocol to ensure a stable mean arterial pressure (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e][\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Mehmet et al. found that reverse Trendelenburg position (RTP) at 15\u0026deg; and 20\u0026deg; offered a significant reduction in bleeding and enhanced surgeon satisfaction compared to the supine position. However, an angle of 15\u0026deg; did not yield a significant benefit when compared to 20\u0026deg;.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Koc et al observed that angles of 10\u0026deg; and 20\u0026deg; were significantly more effective in controlling bleeding when compared to 5\u0026deg;. Interestingly, no significant difference was found between 10\u0026deg; and 20\u0026deg; [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. We conclude the findings of the above trials may indicate that the optimal benefit may occur between 10\u0026deg; and 15\u0026deg; of reverse Trendelenburg position (RTP) compared to either supine or 5\u0026deg;.\u003c/p\u003e \u003cp\u003eIn the studies reviewed, no adjunctive pharmacologic agents such as tranexamic acid (TXA), corticosteroids, or desmopressin were employed, (as summarised in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e) although local epinephrine infiltration was uniformly used across all patient groups. This highlights that the observed haemostatic effect was attributable almost solely to patient positioning, thereby strengthening the case for reverse Trendelenburg position (RTP) as a simple, safe and effective intervention.\u003c/p\u003e \u003cp\u003eDespite the multifactorial nature of intraoperative blood loss, current evidence consistently supports the effectiveness of the reverse Trendelenburg position (RTP) in reducing bleeding during surgery, despite the scarcity of published evidence. Furthermore, reverse Trendelenburg position (RTP) at angles up to 20 degrees has been shown to be safe from an anaesthetic perspective, with no significant alterations in hemodynamic parameters reported across the studies.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e][\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e][\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWhile reduced intraoperative blood loss was consistently observed, no significant reduction in operative duration was noted. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e][\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e][\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] These findings were also observed in studies investigating the use of desmopressin [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and TXA [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e][\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This is likely due to the inherently multifactorial nature of surgical time, which is influenced by factors such as surgeon experience, complexity of the case, and intraoperative decision-making and interruptions\u0026mdash;variables that are difficult to standardize or control.\u003c/p\u003e \u003cp\u003eOur review has several limitations to be considered, a number of confounding variables such as surgeon technique, operative expertise, and intraoperative interruptions are inherently difficult to control for, and may influence outcomes like operative time and bleeding. Additionally, despite the consistent benefit observed with the reverse Trendelenburg position (RTP), the sample sizes in the included studies were relatively small, which may limit the generalizability and statistical power of the conclusions. Furthermore, adherence to postoperative care protocols, particularly head elevation, could not be strictly monitored across all studies, potentially affecting the evaluation of outcomes such as post operative odema and ecchymosis. Future research should focus on incorporating patient-reported outcome measures (PROMs) to provide a more comprehensive assessment of recovery and satisfaction. Larger, multicentre randomized trials with standardized surgical protocols and enhanced monitoring of perioperative variables would further strengthen the evidence base. From a statistical perspective, the absence of a meta-analysis limits the ability to provide pooled effect estimates or confidence intervals, which would have strengthened the overall precision and reliability of the findings. We were un able to present a meta-analysis due to the included studies being heterogeneous in terms of outcome measures, follow-up time points, and intraoperative positioning protocols, making quantitative synthesis inappropriate. Additionally, the small sample sizes of the included trials and the inconsistent reporting of statistical parameters \u0026mdash; such as confidence intervals \u0026mdash; reduce the overall strength and interpretability of the evidence. Without access to original trial protocols, selective outcome reporting cannot be ruled out.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIntraoperative bleeding remains a key complication in open rhinoplasty that surgeons strive to minimize. Various interventions have been explored with differing degrees of success. Among the most widely studied are tranexamic acid (TXA), corticosteroids, and desmopressin, all of which have shown effectiveness in reducing intraoperative blood loss. However, none have demonstrated a consistent impact on reducing operative time.\u003c/p\u003e \u003cp\u003eThis review consolidates the current evidence on the role of the reverse Trendelenburg position (RTP) during open rhinoplasty. The findings support its effectiveness in reducing intraoperative bleeding, as well as postoperative odema and ecchymosis, while maintaining a favourable safety profile. Given its simplicity, safety, and effectiveness of reverse Trendelenburg positioning (RTP) represents a valuable adjunct in optimizing surgical outcomes in open rhinoplasty with an optimal angle of no more than 20 degrees.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eWB- Conceptualization, literature review, data extraction, analysis, writing, editing DM- Conceptualization, data extraction, analysis, editing. NC- analysis, editing.\u003c/p\u003e\u003ch2\u003eAcknowledgments:\u003c/h2\u003e \u003cp\u003e\u0026bull; This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors.\u003c/p\u003e \u003cp\u003e\u0026bull; The authors declare that they have no conflicts of interest to disclose.\u003c/p\u003e \u003cp\u003e\u0026bull; For this type of study informed consent is not required.\u003c/p\u003e \u003cp\u003e\u0026bull; This article does not contain any studies with human participants or animals performed by any of the authors.\u003c/p\u003e \u003cp\u003e\u0026bull; Clinical trial number: not applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eInternational Prospective Register of Systematic Reviews (PROSPERO; CRD420251056743)\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Society of Plastic Surgeons (2014) plastic surgery statistics report. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.plasticsurgery.org/Documents/news-resources/statistics/2014-statistics/ plastic-surgery-statsitics-full-report.pdf\u003c/span\u003e\u003cspan address=\"http://www.plasticsurgery.org/Documents/news-resources/statistics/2014-statistics/ plastic-surgery-statsitics-full-report.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed October 26, 2015\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRohrich RJ, Ahmad J (2011) Rhinoplasty. Plast Reconstr Surg 128(2):49e\u0026ndash;73e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKargi E, Hoşnuter M, Babuc.u O, Altunkaya H, Altinyazar C (2003) Effect of steroids on edema, ecchymosis, and intraoperative bleeding in rhinoplasty. Ann Plast Surg 51:570\u0026ndash;574\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaskin U, Yigit O, Bilici S, Kuvat SV, Sisman AS, Celebi S (2011) Efficacy of the combination of intraoperative cold saline soaked gauze compression and corticosteroids on rhinoplasty morbidity. Otolaryngol Head Neck Surg 144:698\u0026ndash;702\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOng AAMD, Farhood, Zachary MD, Kyle ARBS, Patel KGMD Ph.D. Interventions to Decrease Postoperative Edema and Ecchymosis after Rhinoplasty: A Systematic Review of the Literature. Plastic and Reconstructive Surgery 137(5):p 1448\u0026ndash;1462, May 2016. | \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/PRS.0000000000002101\u003c/span\u003e\u003cspan address=\"10.1097/PRS.0000000000002101\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhetpal S, Dahoud F, Partownavid P et al (2023) Permissive Hypotension in Rhinoplasty: A Literature Review of Therapeutics and Associated Outcomes. Aesth Plast Surg 47:2632\u0026ndash;2638. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00266-023-03298-y\u003c/span\u003e\u003cspan address=\"10.1007/s00266-023-03298-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKo MT, Chuang KC, Su CY (2008) Multiple analyses of factors related to intraoperative blood loss and the role of reverse Trendelenburg position in endoscopic sinus surgery. Laryngoscope 118:1687\u0026ndash;1691\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTankisi A, Rasmussen M, Juul N, Cold GE (2006) The effects of 10 degrees reverse Trendelenburg position on subdural intracranial pressure and cerebral perfusion pressure in patients subjected to craniotomy for cerebral aneurysm. J Neurosurg Anesthesiol 18:11\u0026ndash;17\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGan EC, Habib AR, Rajwani A, Javer AR (2014) Five-degree, 10-degree, and 20-degree reverse Trendelenburg position during functional endoscopic sinus surgery: a double-blind randomized controlled trial. Int Forum Allergy Rhinol 4(1):61\u0026ndash;68\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoc EK, Besir A, Tugcugil E, Livaoğlu M (2022) Mar-Apr;43(2):103311 The effects of 5-degree, 10-degree and 20-degree reverse Trendelenburg positions on intraoperative bleeding and postoperative Edemea and ecchymosis around the eye in open rhinoplasty. Am J Otolaryngol. doi: 10.1016/j.amjoto.2021.103311. Epub 2021 Dec 3. PMID: 34894451\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFromme GA, MacKenzie RA, Gould ABJr, Lund BA, Offord KP (1986) Controlled hypotension for orthognatic surgery. Anesth Analg 65:683\u0026ndash;686\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOzkose M, Baykan H, Coşkuner İ (2016) The Effect of Patient Positioning on Amount of Intraoperative Bleeding in Rhinoplasty: A Randomized Controlled Trial. Aesthetic Plast Surg 40(4):453\u0026ndash;457. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00266-016-0653-6\u003c/span\u003e\u003cspan address=\"10.1007/s00266-016-0653-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2016 May 25. PMID: 27225876\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNooraei N, Dabbagh A, Niazi F, Mohammadi S, Mohajerani SA, Radmand G, Hashemian SM (2013) The Impact of Reverse Trendelenburg Versus Head-up Position on Intraoperative Bleeding of Elective Rhinoplasty. Int J Prev Med 4(12):1438\u0026ndash;1441 PMID: 24498500; PMCID: PMC3898450\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkbarpour M, Jalali MM, Akbari M, Nasirmohtaram S, Haddadi S, Habibi AF, Azad F (2023) Investigation of the effects of intranasal desmopressin on the bleeding of the patients during open septorhinoplasty: A randomized double-blind clinical trial. Heliyon 9(7):e17855 PMID: 37455992; PMCID: PMC10344754\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhajuria A, Khademi Mansour HR, Muhammad I, Asare A, Tammasse I, Suresh J, Leiberman C, Pacheco-Barrios N, Brown S, Dogan T, Rohrich R (2024) Tranexamic Acid in Rhinoplasty and Septoplasty: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Plast Reconstr Surg Glob Open 12(11):e6275. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/GOX.0000000000006275\u003c/span\u003e\u003cspan address=\"10.1097/GOX.0000000000006275\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 39507311; PMCID: PMC11537566\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiberati A, Altman DG, Tetzlaff J et al (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiggins JP, Altman DG, G\u0026oslash;tzsche PC et al (2019) Assessing risk of bias in a randomized trial. In: Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (eds) Cochrane Handbook for Systematic Reviews of Interventions, 2nd edn. Wiley-Blackwell, Chichester (UK), pp 205\u0026ndash;228\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGurlek A, Fariz A, Aydogan H, Ersoz-Ozturk A, Eren AT (2006) Effects of different corticosteroids on edema and ecchymosis in open rhinoplasty. Aesthetic Plast Surg 30:150\u0026ndash;154. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00266-005-0158-1\u003c/span\u003e\u003cspan address=\"10.1007/s00266-005-0158-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"open rhinoplasty, reverse Trendelenburg, peri orbital odema, open rhinoplasty, post operative bleeding","lastPublishedDoi":"10.21203/rs.3.rs-8663766/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8663766/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eRhinoplasty, a frequently performed facial plastic surgery procedure, often associated with challenges such as intraoperative bleeding and postoperative periorbital odema and/or ecchymosis, which can prolong recovery and reduce patient satisfaction. This systematic review investigates the impact of intraoperative patient positioning, in reverse Trendelenburg positioning (RTP), on bleeding and postoperative outcomes in open rhinoplasty. The included studies comprised of randomized and observational studies comparing reverse Trendelenburg position (RTP) with varying degrees of head elevation, and reporting outcomes such as blood loss, surgical field visibility, and postoperative odema or ecchymosis.\u003c/p\u003e\n\u003cp\u003eThree studies met the inclusion criteria, proving that reverse Trendelenburg position (RTP) at angles between 10° and 20° being effective in reducing intraoperative bleeding and enhancing clarity of the surgical field compared to supine or lesser degrees of elevation. The largest trial demonstrated a decrease in bleeding with increasing tilt, with no significant advantage beyond 15°. Reverse Trendelenburg position (RTP) has also been shown to decrease postoperative periorbital odema and ecchymosis, especially at 20°, with these effects lasting through the first week following surgery. Surgeon satisfaction improved with Reverse Trendelenburg position (RTP), while operative time and physiological parameters remained stable, the later proving its safety.\u003c/p\u003e\n\u003cp\u003eThis review is the first to comprehensively assess the role of reverse Trendelenburg position (RTP) in open rhinoplasty and supports its adoption as a straightforward, safe, and effective technique to reduce bleeding and postoperative complications. Due to its simplicity and proven benefits, the reverse Trendelenburg position (RTP) at about 10° to 20° should be considered a valuable addition to rhinoplasty practice for optimizing surgical conditions and enhancing recovery.\u003c/p\u003e\n\u003cp\u003eLevel of evidence: Level II\u003c/p\u003e","manuscriptTitle":"Reverse Trendelenburg Positioning in Open Rhinoplasty: A Systematic Review of Clinical outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-28 03:08:51","doi":"10.21203/rs.3.rs-8663766/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9e642bc7-766d-4946-bc94-0766a8aac97d","owner":[],"postedDate":"January 28th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-30T13:41:07+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-28 03:08:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8663766","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8663766","identity":"rs-8663766","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}