In line with the modern trend toward minimally invasive surgery, the use of ultrasonic waves for cutting bone has recently been introduced in oral and maxillofacial surgery. This generally results in no visible injury to the adjacent soft tissues from the generated micromovements.1,2 In rhinoplasty, the lateral osteotomy technique should not only be precise, reproducible, and safe but also minimize postoperative sequelae, including ecchymosis and edema.
The goal of this surgical step is to mobilize the nasal bones while simultaneously maintaining an esthetic contour. The use of ultrasound in rhinoplasty has the coincident aim of minimizing the surgical approach and overcoming many of the complications of this procedure.3,4
We present our own experience with a piezosurgery approach for nasal osteotomies, emphasizing the advantages of this method. We also suggest an innovative approach based on the navigation of the piezosurgery device.5
MATERIALS AND METHODS
In this study, we used ultrasonic piezosurgery to perform sharp osteotomies in 183 patients via a percutaneous approach, without a subperiosteal tunnel. The osteotomy was continuous rather than perforating.
All patients were evaluated for ecchymosis, bleeding, edema, and scarring, immediately and at 1 and 2 weeks postoperatively. In addition, a prospective randomized pilot study6 compared the outcome of post-traumatic rhinoplasty performed with 2 different external techniques: ultrasound osteotomy using the piezosurgery medical device (Mectron, Carasco, Italy) and traditional external osteotomy. A reduction in postoperative pain and local sequelae was demonstrated with the piezosurgery device. Three patients undergoing piezo-navigated rhinoplasty are presented.
Using ultrasound piezosurgery, we observed reduced bleeding during surgery and immediately postoperatively, minor edema and periorbital ecchymosis, and no visible scarring. Compared with a traditional external osteotomy, there was considerably less trauma, postoperative edema, and ecchymosis. In addition, a navigation system attached to the piezosurgery device provided a 3-dimensional view during the nasal bone osteotomy procedure.
During osteotomies, the piezosurgery device decreases the risk of damage to surrounding soft tissues and to the most critical structures, such as nerves, vessels, and mucosa.7 Our experience using ultrasound for osteotomies in rhinoplasty started with a 2002 cadaver study that demonstrated a rapid linear cut, minimal or no internal mucosal damage, minimal periosteal detachment, and technical feasibility (Fig. 1).
Gerbault et al8 claim that extensive exposure allows the surgeon to analyze and surgically correct deformities of the osseocartilaginous vault more accurately. However, when used in this way, the technique is too aggressive and the advantages imparted by the use of piezosurgery are not guaranteed.
Our results support a relationship between minor surgical trauma and improved soft and hard tissue behavior during healing with piezosurgery. As such, this innovative technique represents a true revolution in bone surgery, opening a new era for delicate surgical approaches involving facial aesthetic bone.
The authors are developing an innovative navigation-guided piezosurgery rhinoplasty technique (Fig. 2) in which the possibility of performing osteotomies under navigational control permits a less invasive approach. The accuracy and reproducibility of surgery conducted in this manner are presently under evaluation.
1. Robiony M, Polini F, Costa F, et al. Piezoelectric bone cutting in multipiece maxillary osteotomies. J Oral Maxillofac Surg. 2004;62:759761.
2. Robiony M, Costa F, Politi M. Ultrasound endoscopic bone cutting for rapid maxillary expansion. J Oral Maxillofac Surg. 2014;72:980990.
3. Robiony M, Polini F, Costa F, et al. Ultrasound piezoelectric vibrations to perform osteotomies in rhinoplasty. J Oral Maxillofac Surg. 2007;65:10351038.
4. Robiony M, Toro C, Costa F, et al. Piezosurgery: a new method for osteotomies in rhinoplasty. J Craniofac Surg. 2007;18:10981100.
5. Bianchi A, Badiali G, Piersanti L, et al. Computer-assisted piezoelectric surgery: a navigated approach toward performance of craniomaxillofacial osteotomies. J Craniofac Surg. 2015;26:867872.
6. Tirelli G, Tofanelli M, Bullo F, et al. External osteotomy in rhinoplasty: Piezosurgery vs osteotome. Am J Otolaryngol. 2015;36:666671.
7. Ford CN, Battaglia DG, Gentry LR. Preservation of periosteal attachment in lateral osteotomy. Ann Plast Surg. 1984;13:107111.
8. Gerbault O, Daniel RK, Kosins AM. The role of piezoelectric instrumentation in rhinoplasty surgery. Aesthet Surg J. 2016;36:2134.