CRANIOMAXILLOFACIAL DEFORMITIES/COSMETIC SURGERY

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Osteotomy of the Nasal Wall Using a NewlyDesigned Piezo Scalpel—A Cadaver Study

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rmany.

Alireza Ghassemi, MD, DDS, PhD,* Andreas Prescher, MD, PhD,yMohammad Talebzadeh, DDS,z Frank H€olzle, MD, DDS, PhD,x and

Ali Modabber, MD, DDS, PhDk

Purpose: Achieving the desired outcome in rhinoplasty depends on many factors. Osteotomy and

adjustment of the lateral nasal wall are important steps that necessitate careful planning and execution.

A cadaver study was performed to evaluate the osteotomy result obtained with a newly designedpiezoelectric-based scalpel.

Materials and Methods: Twenty lateral osteotomies of the nasal wall were performed in 10 human

cadaver noses. The osteotomies were conducted in 6 female and 4 male cadavers (age range, 65 to 83yr; mean age, 74.8 yr). A specially designed Piezosurgery-based scalpel was used endonasally to perform

the lateral osteotomy. Cutting of the bony nasal wall was performed subperiostally along the planned

osteotomy route under tactile control. Digital infracturing was accomplished by applying gentle pressure.

After completing the osteotomy, the osteotomy line and nasal mucosawere examined endoscopically. The

skin cover was removed to examine the lateral bony nasal wall for the shape and amount of bone

fragments, the osteotomy path, and mucosa involvement.

Results: Using the Piezosurgery-based scalpel required a learning curve, but the handling was easy.

It allowed an exact performance of the osteotomy and caused no mucosal tearing. If excessive force

was used, the piezo tip stopped working. There was no comminuted fracture pattern and the lateral nasal

wall remained in 1 piece. The duration of the osteotomy was 5 to 10 minutes on each side.

Conclusion: The piezoelectric-based scalpel is a useful tool, which can be used to perform osteotomy of

the nasal wall. In addition, this specifically designed tool tip allows an endonasal approach, is easy to han-dle, and allows effective irrigation of the osteotomy region.

� 2013 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg -:e1-e6, 2013

A significant yet difficult contributor to operative suc-

cess in rhinoplasty is shaping the underlying nasal

bony structures.1,2 Depending on the deformities

presented, different osteotomy techniques—lateral,

medial, and transverse—can be indicated to achieve

the desired esthetic and functional outcome.3 Two dif-ferent approaches—endonasal and percutaneous—

with corresponding instruments have been developed

nt Professor, Department of Oral, Maxillofacial, and

ial Surgery, University Hospital RWTH-Aachen, Aachen,

nt Professor, Institute of Anatomy, Medical Faculty of

hen, Aachen, Germany.

nt, Department of Oral, Maxillofacial, and Plastic Facial

niversity Hospital RWTH-Aachen, Aachen, Germany.

and Chairman, Department of Oral, Maxillofacial, and

ial Surgery, University Hospital RWTH-Aachen, Aachen,

e1

tomake this steppredictable, less traumatic, easy toper-

form, and controllable.2,4-7 Nevertheless, every tech-

nique has its advantages and disadvantages, and

osteotomy can cause soft tissue injury, irregularity of

the bony lateral wall, a comminuted fracture pattern,

and, as sequels, prolonged postoperative edema andecchymosis and functional nasal obstruction with an

undesired esthetic and functional outcome.2,5-7 Soft

kSenior Resident, Department of Oral, Maxillofacial, and Plastic

Facial Surgery, University Hospital RWTH-Aachen, Aachen, Germany.

Address correspondence and reprint requests to Dr Ghassemi:

Pauwelsstr 30, 52074 Aachen, Germany; e-mail: aghassemi@

ukaachen.de

Received June 18 2013

Accepted July 26 2013

� 2013 American Association of Oral and Maxillofacial Surgeons

0278-2391/13/00939-7$36.00/0

http://dx.doi.org/10.1016/j.joms.2013.07.028

e2 PIEZO SURGERY FOR OSTEOTOMY OF NASAL WALL

tissue trauma may contribute to destabilization,

hemorrhage, and prolonged postoperative ecchymosis

and edema. The nasal skin is very thin and any nasal

wall irregularity from a comminuted fracture and

irregular-shaped bony fragments will be apparent.8,9

Horton et al10,11 introduced piezo surgery in alveolar

bone surgery in 1975, using thepiezoelectric ultrasonic

vibration for gentle cutting of the bone. They reportedbetter bone healing of the bony fragments when using

piezo surgery. Subsequently, additional uses were

introduced, such as cutting a bony window in the

maxillary sinus wall to perform sinus augmentation or

to perform orthognathic surgery.10-16 In 2007,

Robiony et al17 suggested this technique for nasal os-

teotomy. This device cuts the bone micrometrically us-

ing ultrasonic piezoelectric vibration, and it can beadjusted by changing the frequency and cutting power.

It has proved a useful tool for cutting thin bone with

precision, causing minimal damage to soft tissue and

avoiding osteonecrosis.18 Since then, the technique

has improved rapidly and has extended its indication.12

This anatomic study was undertaken to perform

osteotomy of the nasal wall with a newly designed

piezo scalpel. The degree of difficulty of performingosteotomy was evaluated using this scalpel through

an endonasal approach. In addition, the effectiveness

of the cooling capacity, the condition of the osteotomy

path, the amount and shape of bony fragments, and

mucosal injuries were examined.

Materials and Methods

Ten human cadaver heads were used for performing

lateral osteotomy (age range, 65 to 83 yr; mean age,

74.8 yr; gender distribution, 4 male and 6 female).

One experienced rhinoplasty surgeon, who was famil-

iar in applying the Piezosurgery device (Mectron Med-

ical Technology, Carasco, Italy), performed theosteotomies through an endonasal approach. A spe-

cially designed piezo scalpel was used to dissect a tun-

nel and to perform the osteotomy (Figs 1, 2). In

FIGURE 1. Working insert for soft periosteal elevation. Th

Ghassemi et al. Piezo Surgery for Osteotomy of Nasal Wall. J Oral Maxil

addition, irrigation with internal cooling and a flow

of 40 mL/min was used to avoid heating the bone.

The coolant was transferred to the osteotomy area

through a hole at the end of the tool tip (Fig 2).

The mucosa was incised along the lower edge of the

pyriform aperture for about 3 mm to access the bony

lateral wall. A special tool tip was used as a periosteal

elevator to create a subperiosteal tunnel around thepyriform aperture along the planned osteotomy

path, as marked on the skin (Fig 3). The piezo scalpel

was inserted into this tunnel and the osteotomy was

performed along the osteotomy path under digital con-

trol. After accomplishing the endonasal cutting of the

bony lateral nasal wall, 3 independent examiners (ex-

cluding the surgeons) who were blinded to the tech-

nique inspected the intranasal cavities of all cadaverson each side with a 4-mm 30� rigid endoscope (Karl

Storz GmbH & Co KG, Tuttlingen; Germany). They

looked for lacerations of the nasal mucosa. Then, the

nasal pyramid was infractured digitally on each ca-

daver. The soft tissue envelope was removed after in-

fracturing to evaluate the condition of the osteotomy

line and the size, shape, and amount of the bony frag-

ments. Special inspection was performed for contourirregularities, bony spur or spicules generated, and

greenstick infracture characteristics. This step was fol-

lowed by an intranasal examination to explore the

nasal mucosa.

Results

Altogether, 20 lateral osteotomies were performed

in human cadaver specimens. The osteotomy path

was marked on the skin (Fig 3). It was easy to cut

through the bony wall all the way along the osteotomy

line by digitally controlling the piezo inset (Figs 1, 2).

Because of the learning curve, 10 minutes was re-

quired for the first nose and 7 minutes was requiredfor the second nose. For the next 8 noses, approxi-

mately 5 minutes was required. For continuous cut-

ting, the scalpel should be moved along the bone

e cooling hole (arrow) is in the shaft near the handle.

lofac Surg 2013.

FIGURE2. The cutting working tip with the hole close to the tip. The cooling hole (arrow) and the pathway along the shaft, where the irrigationhas to flow to reach the tip (2-headed arrow), are depicted.

Ghassemi et al. Piezo Surgery for Osteotomy of Nasal Wall. J Oral Maxillofac Surg 2013.

GHASSEMI ET AL e3

surface by applying gentle pressure. This is sufficient

to cut partly or completely through the bone, as indi-cated. As soon as any extensive force was exerted,

the piezo stopped working. Near the nasal root, cut-

ting the bone required more time. At the end of piezo

FIGURE 3. Osteotomy course marked on the skin of the cadavernose. This was used continuously to control the tip of the piezo scal-pel while performing the osteotomy.

Ghassemi et al. Piezo Surgery for Osteotomy of Nasal Wall. J Oral

Maxillofac Surg 2013.

surgery, digital infracturing could be performed by ap-

plying gentle pressure and no forceful manipulationwas necessary.

All examiners independently recorded identical

findings from their separate endoscopic examinations

FIGURE 4. Endoscopic inspection of nasal mucosa after osteot-omy. No injury to the mucosa is observed.

Ghassemi et al. Piezo Surgery for Osteotomy of Nasal Wall. J Oral

Maxillofac Surg 2013.

FIGURE 5. Osteotomy course after removal of soft tissue cover. Avery tiny tooth mark along the osteotomy path, caused by the tipof the piezo scalpel, is depicted. The osteotomy course is regular,which corresponds exactly to the path marked on the skin. Thereis only 1 bony fragment without any comminuted fracture pattern.

Ghassemi et al. Piezo Surgery for Osteotomy of Nasal Wall. J Oral

Maxillofac Surg 2013.

e4 PIEZO SURGERY FOR OSTEOTOMY OF NASAL WALL

and from the condition of the lateral nasal wall. None

of the cadavers exhibited perforation of the nasal mu-

cosa (Fig 4). The examiners recorded 1 complete nasal

wall on each side, with small irregularities resemblingthe tooth of the piezo scalpel. There was minimal loss

of bone material along the osteotomy line (Fig 5).

Discussion

Successful rhinoplasty is the result of controlled

changes in the nasal framework and its soft tissue cover.Alterations and shapingof the nasal bony structure pres-

ent an ongoing challenge in esthetic and reconstructive

surgery.1 Numerous lateral osteotomy techniques

evolved in the previous century, incorporating the use

of different instruments from the saw to the chisel to

the diamond.2-7,19-21 Various modifications of available

techniques have been introduced to rhinoplasty

surgery to increase ease of performance, precision,controllability, and reliability, on the one hand, and

reproducibility with low morbidity, on the other.

Despite the many previously described methods, it

remains difficult to perform osteotomies in such

away as to provide esthetically pleasing and reliable re-

sults. Lateral osteotomy is associatedwith an increase in

hemorrhage, edema, and ecchymosis. This has been

substantiatedbyother studies andcancontribute signif-

icantly to postoperativemorbidity after rhinoplasty.2,5-9

Perforated lateral osteotomy preserves the support of

the periosteum and is supposed to decrease lateral

nasal wall collapse and minimize hemorrhages andedema.5-7 However, this method is suspected of

causing comminuted fractures with irregular bony

fragments, which can cause postoperative esthetic

deformity.4 The perforating technique is reliable only

in thehandsof anexperienced surgeon, because it is dif-

ficult to direct and may need repeated passes.2,9

Murakami and Larrabee4 found more irregular osteoto-

mies and more soft tissue trauma when using the per-cutaneous approach, and they preferred building

a subperiosteal tunnel andusing an adequate technique

to ensure proper stability. In a cadaver study, Kuran

et al19 evaluated fracture line and mucosal injuries.

They found that a wide osteotome causes significantly

more mucosal injuries.

The piezo scalpel allows the cutting of a bony win-

dow into the maxilla without any laceration of the del-icate mucosa of the maxillary sinus.13 Robiony et al17

introduced the piezo technique in rhinoplasty and em-

phasized the advantages of this method. They used an

external approach to insert the piezo scalpel. Although

soft tissue probably will not be lacerated by slight

touches, continuous irrigation would be difficult using

this approach. Robiony et al reported decreased bleed-

ing during surgery, minor edema, and periorbital ec-chymosis immediately after surgery. The Piezosurgery

device offers effortless handling and requires very little

manual pressure.22 Moreover, it is an optimal tech-

nique for selectively cutting mineralized tissue.10 It al-

lows the exact placement and control of the tool tip

to cut along the desired path using micrometric move-

ment, and the piezo scalpel is armed with a peristaltic

pump for irrigation.14,16,22 Although this instrumentwas originally developed for augmentation surgery in

the dentoalveolar field, there are different working

tips for currently available indications.11-17,22

The main purpose of this cadaver study was to

evaluate the quality of osteotomy when using the Pie-

zosurgery device. The newly designed piezo scalpel

allowed the osteotomy from an endonasal approach

and irrigation of the bone through a hole close tothe tip of the scalpel (Fig 2). Lateral osteotomy was

performed in 10 human cadaver noses (20 lateral

walls) according to the technique described earlier.

A 3-mm incision in the mobile mucosa of the pyri-

form aperture and narrow exposure of the osteotomy

site were sufficient to easily access the lateral nasal

wall. A short learning curve was necessary to become

familiar with the procedure. The exposure of bone

GHASSEMI ET AL e5

surface at the osteotomy site was less extensive than

with other methods. The line of osteotomy, which

had been marked on the skin along the nasofacial

crease, could be palpated and followed exactly

through the skin (Fig 3). The hand piece stopped

moving if any excessive force was used.22 It should

just be guided over the bone gently, as in piezo sur-

gery generally. It does not involve the risk of acciden-tal dislocation of the osteotome and the course of

osteotomy can always be followed exactly as

planned.22 The sound of the cutting also can help

as acoustic feedback to guide the applied force.

The infracturing of the bony lateral wall can be ac-

complished with gentle pressure. The endoscopic ex-

amination along the osteotomy line showed a bone

ridge with spikes, similar to the tip of the scalpel,but no major irregularity or comminuted fracture

(Fig 5). No tear of nasal mucosa was apparent

(Fig 4). The average time for incision and preparation

was 5 minutes after a learning curve in the first 2 os-

teotomies. No residual deformity, such as a bony

spur, was observed. The lateral nasal wall was ob-

served as a whole bone fragment, with some irregu-

larities of the bone edge caused by the tooth of thepiezo tool tip. The osteotomy part of the bone

showed signs of adequate irrigation and no sign of

heat development. The irrigation flowed through

the shaft of the scalpel to the tip. This had an addi-

tional cooling effect on the surrounding soft tissue

coverage (Fig 2). In some noses, the osteotomy

path was osteotomized incompletely. Nevertheless,

the infracturing could be performed easily. The re-sulting osteotomy gap was approximately 0.5 mm.22

Because the use of piezo surgery does not cause any

soft tissue injury, minimal hemorrhage and ecchymosis

are expected postoperatively, as was shown clinically

by Robiony et al.17 The dissection of a narrow subper-

iosteal tunnel, combined with healthy and unlacerated

nasal mucosa, will hinder the collapse of the osteotom-

ized lateral nasal wall and thus decrease postoperativeedema and swelling.9 Aprecise and reproducible lateral

osteotomy can be performed,which is the requirement

for successful rhinoplasty. It can be controlled transcu-

taneously toperform theosteotomy in anexact planned

course. It makes this step easier to perform and more

controllable, with a predictable and consistent result.

This promotes faster healing and shortens postopera-

tive hospital stay.9 Because the bone thickness doesnot exceed 3 mm at any point on the osteotomy lines,

piezo surgery is optimal for this procedure.19,23 In

addition, there is no need to cut through the entire

thickness of the nasal bone to infracture the nasal wall.

All kinds of osteotomies, such as transverse, median,

paramedian, and hump removal, also can be performed

as required. Although there is limited scarring from the

percutaneous approach, the concept of an external

incision conjures debate when an internal option

exists.2This speciallydesignedpiezoscalpel allowsanen-

donasal approach and thus avoids any risk of possible

scar formation.

The optimal technique for osteotomy should be safe,

precise, and reproducible, withminimal postoperative

ecchymosis and edema, and deliver a predictable re-

sult. The piezo scalpel is easy to handle and does notcause any mucosa laceration; the osteotomy can be

performed exactly in the planned osteotomy track

and does not result in any comminuted fractures. It is

a nontraumatic and controllable alternative to known

osteotomy techniques. A learning curve may be neces-

sary, but it is a straightforward method to learn.

References

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e6 PIEZO SURGERY FOR OSTEOTOMY OF NASAL WALL

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