Correcting the nasal bone deformities in the rhinoplasty operations is the most important part of the surgery. The nasal dorsum is reshaped by hump excision, lateral and median osteotomy with the help of chisel and hammer.1 One of the major problems after surgery is the unwanted outcomes such as edema, ecchymosis, and endurance as a result of tissue damage after bone surgery, in addition to routine surgical trauma.2–6 In order to reduce the damage to the soft tissue during osteotomies, however, saw blades and more recently piezosurgery have been preferred by nasal surgeons as an alternative to osteotomes.6,7
Piezosurgery is a technique that enables safe and effective osteotomies using piezoelectric ultrasonic vibrations.8–10 The piezosurgical device comprises a platform with a powerful piezoelectric hand piece and an irrigation system for cooling. Ultrasonic osteotomies were first described by Horton et al.11 Although it was defined by Horton et al,11 the technique was not implemented widely until Vercellotti12 initiated the routine use of this method in 2000.
The first study on the use of piezosurgery in osteotomies in septorhinoplasty operations is the study of Robiony et al9 where they reported a lower rate of postoperative hemorrhage, edema, and ecchymosis. In the following studies, the information about the superiority of piezosurgery in shaping the bone along with the reduced postoperative edema, hemorrhage, and ecchymosis was reported.6,10,13 Although it is claimed that piezoelectric surgery does not cut the mineralized tissue and traumatize the soft tissue, there are very few studies evaluating the effects of the procedure on soft tissue histopathologically most of which being in the experimental animals.14–17
The aim of this study was to histopathologically compare the soft tissue damage in hump resection and osteotomies performed by piezosurgery to the classical method in the patients with open septorhinoplasty.
Thirty patients who underwent open septorhinoplasty between January 2019 and February 2019 were included in our study. Exclusion criteria were the previous nasal surgery, use of anticoagulant drugs, hypertension, bleeding diathesis with chronic disease, chronic skin allergy, or inflammatory skin disease. The study was approved by the Ethics and Research Committee of the institution, under protocol 2019/45. All patients individually provided written informed consent.
Patients were randomly divided into 2 groups: The classic group (n = 15) and piezo group (n = 15). Routine preoperative and preanesthesia exams were carried out. All operations were performed under general anesthesia. The surgical procedure was performed by the same surgeon for all patients. In order to assist in elevation and hemostasis at the beginning of the operation, 3 ampoules (6 mL) of Jetosel (Lidocaine HCl 40 mg, adrenaline 0.025 mg in 1 ampoule) were injected into the nasal dorsum on both sides of the septum mucosa.
Ten minutes after the injection, the midcolumellar reverse V incision was combined with the marginal incision of the bilaterally alar. A skin flap was dissected in a relatively bloodless subpericondrial and subperiostial plane in a way that the soft tissue remains as far as possible to maintain the viability of the lateral cruses, after the perichondrium is exposed. In this way, the lower and upper lateral cartilages and bone dorsum were exposed to the nasofrontal angle. At this stage, 1 mm3 punch biopsy was performed from the under skin tissue of the nose bridge radix of all of our patients.
After correction of septum deformities in the classical group (n = 15) cartilage hump was resected with a number 15 scalpel and bone hump with the help of a chisel. The lateral and median osteotomies were conducted with the 4 mm sharp osteomes applied from the endonasal route. Bone dorsum rasping was performed to correct bone deformities in the dorsum. Then, 1 mm3 punch biopsy was taken from the skin tissue of the nasal back near the radix.
In the piezo group (n = 15), hump excision and osteotomies were performed with 20 mL/min irrigation under the Woodpecker Piezosurgery unit SDT-E702, (Guangxi, China). A 1 mm3 punch biopsy was taken from the under the skin tissue of the nasal back near the radix.
Subcutaneous tissue samples taken from the nasal dorsum were fixed in 4% paraformaldehyde in 0.1 M phosphate buffer, pH 7.4. After dehydration through a graded series of ethanol solutions, samples were embedded in paraffin. Sections 5 μm thick were cut and processed for hematoxylin-eosin (H-E) staining. Sections were examined by a single pathologist under the light microscope (Olympus BX-50 Olympus Optical, Japan) without knowledge of the groups. Thus, the study was designed to be a single-side blinded. Edema, inflammation, and necrosis in the cross-sectional areas were scored. The score for edema was scaled as absent: 0, mild: 1+, moderate: 2+ (between scores 1 and 3), intense: 3+. Similarly, the inflammation scores were set as absent: 0, mild: 1+, moderate: 2+, and intense: 3+. For necrosis the quantification scale was set as absent: 0, mild: 1+ (a few muscle fibers), moderate: 2+ (between scores 1 and 3), intense: 3+ (many muscle fibers).
Descriptive statistics for categorical variables obtained in our study are expressed as Number (N) and Percent (%). In calculating the sample width (magnitude) of the study, power was determined to be at least 0.80 and Type-I error rate was 0.05. χ2 test was used to determine the relationship between classical group and piezo group in terms of edema and necrosis formation. The statistical package program SPSS (IBM SPSS for Windows, Ver.24) was used for the analyses.
Of the 30 patients presented in this series, 21 were female and 9 were male. There was an average age of 29.16 ± 8.17, ranging from 18 to 43 years. The average age of patients in the piezo group was 28.46 ± 8.08 (9 female and 6 male patients) and 29.86 ± 8.47 in classic group (12 female and 3 male patients). Neither age nor gender distributions of either group showed any significant difference (P > 0.05).
Histopathological examination revealed no inflammation before and after intervention in both the piezo group and the classical group (0%–0%).
In the classical group, none of the 15 patients had edema (0%) before the osteotomy, and 13 (86.7%) had soft tissue edema at the 1+ level after osteotomy. In the piezo group, none of the 15 patients had a pre-piezosurgery edema (0%), and 4 patients (26.7%) had a soft tissue edema (1+) after piezosurgery. Edema rate was significantly lower when the piezo surgery group compared to the classical osteotomy group (P < 0.05). Histopathological findings in classical group are presented in Figure 1 and Table 1 (SDC, http://links.lww.com/SCS/A519). Severe necrosis at the (2+) and (3+) levels was not observed in any group.
In the classical group, none of 15 patients had necrosis before osteotomy (0%), and 2 patients (13.3%) had necrosis in the soft tissue after osteotomy at the (1+) level. In the piezo group, none of the 15 patients had necrosis prior to piezosurgery (0%), and 10 patients (66.7%) had necrosis in the soft tissue (1+) after piezosurgery. Necrosis was significantly higher in the piezo surgery group compared to the classical osteotomy group (P < 0.05). Histopathological findings in the piezo group are presented in Figure 2 and Table 2 (SDC, http://links.lww.com/SCS/A519). Severe necrosis at the (2+) and (3+) levels was not observed in any group.
Postoperative pain, edema, ecchymosis, delayed tissue healing, step deformities that may occur at osteotomy sites, and inverted V deformities that may occur at the osteocartilaginous junction can be counted as the factors affecting patient morbidity in aesthetic nose surgery operations.18,19 In addition to techniques such as rhinoplasty with complete subperiosteal degloving of nasal bone and endonasal osteotomy to minimize these undesirable consequences, innovation technologies have also been utilized.4–7 In the surgical approach, traumatizing the tissues should be avoided and the mucosa, cartilage, and bones should be protected as much as possible while correcting nasal anatomic deformities.19,20
Particularly for bone surgery such as otology and skull base surgery, piezoelectric technology is a more reliable method than conventional instruments such as drill that traumatize soft tissue. Short learning time, ease of use, and providence of the sufficient visibility can be considered other advantages. On the other hand, the high cost, the length of the operation time, and the insufficient proof of the success are disadvantages of the technique.21
Nasal osteotomy using piezoelectric surgery was first described by Robiony et al in 2007 and the superiority of the technique was reported by Pribitkin et al.9,10 Piezoelectric surgery uses ultrasonic vibrations to cut or erode bones without damaging the soft tissue.8–10,22–24 Piezoelectric osteotomes vibrate at a frequency of 24 to 29 kHz and an amplitude of 60 to 200 μm.8 As reported in the literature, these micro-vibrations allow selective cutting of inelastic mineralized structures without damaging the soft tissues. The device does not damage even if it accidentally runs into the soft tissue. Micro-vibrations provide an exact cutting motion and a bloodless operation area.22–26 Piezoelectric surgery is used for maxillofacial surgery and rhinoplasty for lateral, median osteotomy, hump excision, and filing.9–10,21 Tirelli et al27 reported significantly less complications in piezosurgery than traditional osteotomy.
Soft tissue damage due to osteotomies is the main cause of postoperative edema and ecchymosis.3,19,20 Ilhan et al6 reported that piezoelectric surgery reduces postoperative edema and ecchymosis whereas Taşkin et al5 reported that there was no difference between piezoelectric surgery and the classical method for postoperative edema and ecchymosis. Gerbault et al13 mentioned superiority in the predominantly revision based bone shaping and widen surgical field in a series of 185 cases piezosurgery. In experimental studies conducted by Ma et al,28 piezosurgery is indicated to have lower bone debris that allows a quicker recovery compared with the other methods.
In most studies reporting the superiority of piezosurgery, the evaluations are mostly based on clinical observations. There are very few studies targeting histopathological effects. Some of these studies show the effects of piezosurgery on bone and periosteum. Horton et al11 demonstrated that osteotomy with osteotome led to more osteocytic damage to the bone than to ultrasonic surgery. In a study of the caprine animal model, microscopical mucosal damage after piezo osteotomy has been shown to be significantly less than both endonasal and percutaneous osteotomy.17 Stoetzer et al16 immunohistochemically and histologically compared the piezoelectric elevation method to the classical periosteal elevators in rats. They reported less damage in peripheral tissue and periosteum in the piezoelectric method than the classical periosteal elevation.16
Otake et al conducted incision in the rat tibia and tongue with classical drilling and piezosurgery. They compared cut-off times and histopathological effects and reported longer cut-off time of the tibia in piezoelectric surgery compared to the drill. Nonetheless, soft tissue damage was not observed in piezoelectric surgery. The piezosurgery reported not being able to cut the tongue, and not to damage the epithelium and lingual papillae. The study by Otake et al14 was the first to prove the clinical advantage of piezosurgery in the soft tissue.
The human body maintains its integrity with a number of healing mechanisms in spite of different injuries. After tissue damage, platelets and inflammatory cells are the first to come to the damaged region and the healing process begins. Normal tissue healing occurs in ordinary and consecutive phases. These phases can be expressed as hemostasis, inflammation, proliferation, and remodeling.29 Cell injury usually occurs as a result of physical violence. In the acute phase, there is enlargement in the cell, bleeding, and swelling in the organelles followed by loss of continuity in the cell membrane, serious damage in the organelles, especially in the nucleus, deterioration of cell regeneration mechanisms, necrosis, and ultimately apoptosis. The degree of structural deterioration determines the tissue damage.30
In our study, no inflammation was observed in both groups before and after osteotomy. No preoperative edema or necrosis was detected in any of our patients. In the classical group, the rate of the postoperative edema was 86.7% and in the piezo group the rate was 26.7%. This difference is statistically significant (P < 0.05). The significantly lower ratio of edema in the piezo group can explain lower ratio of postoperative edema and ecchymosis in piezo applications in the previous studies.6,14,22,26
In classical group, necrosis was observed in 13.3% of cases after osteotomy whereas the rate was 66.7% in piezo group and was significantly higher (P < 0.05). Pathological assessment reveals that the molecules released from necrotic tissue cause inflammation. After inflammation, tissue regeneration may occur or alternatively the event may become chronic and develop chronic inflammation. In this case, fibrosis or scar can develop.30 In this respect, the pathological process may cause a delay in the healing of piezosurgery.
Low edema can be explained by isotonic irrigation during piezosurgery and low acute tissue trauma. However, a significant increase in necrosis can be explained by long-term soft tissue trauma caused by piezoelectric vibrations. We think that high rate of necrosis may cause problems in late periods, especially in patients with thin skin.
We planned this study as a prospective single-side blind study that evaluated the edema, ischemia, and necrosis related to surgery in the pre and postoperative tissues. The results indicated that histopathological edema was significantly lower in the piezo group compared to the conventional osteotomy group whereas necrosis was significantly higher in the piezo group. Piezosurgery is not completely harmless to soft tissue.
The authors thank Ahmet Cemil Kaur, Pathologist in e-patoloji Laboratory.
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