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Comparison of clinical outcomes using a Piezosurgery device vs. a conventional osteotome for lateral osteotomy in rhinoplasty.


Our aim for this study was to evaluate and compare the clinical outcomes in patients who underwent lateral osteotomy with a Piezosurgery device or a conventional osteotome in open-technique rhinoplasty. This cohort trial involved 65 patients (36 women and 29 men; average age: 23.6 [+ or -] 5.71 yr) who underwent surgery between May 2015 and January 2016. Piezosurgery was used for lateral osteotomy in 32 patients, whereas 33 patients underwent conventional external osteotomy. These 2 groups were compared for duration of surgery, perioperative bleeding, postoperative edema, ecchymosis, pain, and patient satisfaction on the first and seventh postoperative days. The Piezosurgery group revealed significantly more favorable outcomes in terms of edema, ecchymosis, and hemorrhage on the first day postoperatively (p < 0.001 for all). Similarly, edema (p = 0.005) and ecchymosis (p < 0.001) on the seventh postoperative day also were better in the Piezosurgery group. Hemorrhage was similar in both groups on the seventh postoperative day (p = 0.67). The Piezosurgery group not only experienced less pain on the first postoperative day (p < 0.001), but these patients also were more satisfied with their results on both the first and seventh postoperative days. Results of the present study imply that Piezosurgery may be a promising, safe, and effective method for lateral osteotomy, a critical step in rhinoplasty. The time interval necessary for the learning curve is counteracted by the comfort and satisfaction of both patients and surgeons.


Achievement of surgical success in rhinoplasty is closely related to accomplishing the desired sculpting of the nasal bony framework and soft tissue. For this purpose, osteotomy constitutes a critical step, and various osteotomy techniques have been described for achievement of targeted aesthetic and functional results. Incorporation of new instruments in rhinoplasty has provided easier interventions with reliable, controllable, and reproducible results. (1,2)

Each osteotomy technique has both advantages and limitations. Soft-tissue injury, irregularities of bony structures, postoperative edema, ecchymosis, and nasal obstruction may occur as a result of osteotomy. Soft-tissue trauma in particular may lead to prolonged edema and ecchymosis, as well as apparent irregularities in nasal bone owing to the thin overlying skin.

Lateral osteotomy is indicated for closing the dorsal open roof, narrowing the nasal pyramid, and straightening the nasal bones. Mobilization of nasal bones and maintenance of the aesthetic contour are the main goals of lateral osteotomy. (3) Selection of the type and approach for osteotomy is mostly dependent on the comfort and experience of the surgeon. (1,4)

The use of ultrasonic vibrations for cutting tissues has recently become popular for several clinical applications in various surgical fields. (5) It decreases the risk of damage to surrounding soft tissues and critical structures (nerves, vessels, and mucosa), particularly during osteotomy. (6) Horton et al suggested that Piezosurgery, which uses piezoelectric vibrations, was a safe and gentle method for cutting bone indentai surgery. (7) Robiony et al adapted this method for nasal osteotomy by adjusting the power and frequency employed. (8) Only a few reports in the literature describe the use of Piezosurgery in rhinoplasty.

The aim of this report is to compare the early clinical outcomes and perioperative morbidity after lateral percutaneous osteotomies performed via standard chisel or a Piezosurgery device.

Patients and methods

This cohort study was implemented in the Otolaryngology Department of our tertiary care center between May 2015 and January 2016. A total of 65 patients (36 women and 29 men) who were scheduled for open-technique rhinoplasty were enrolled after the approval of the Baskent University Institutional Review Board (KA10/45). The average age of the study population was 23.6 [+ or -] 5.71 years (range: 18 to 38). Exclusion criteria included a history of smoking, presence of systemic diseases (such as cardiac disease, diabetes mellitus, hypertension, bronchial asthma, neurologic diseases), and use of any medications. The patients did not know to which study group they were assigned.

Open-technique rhinoplasty was performed in all patients by the same surgeon under general anesthesia. Patients were randomly assigned into 2 groups according to the use of a Piezosurgery medical device or a standard chisel for percutaneous lateral osteotomy. Descriptive data (age, sex) and duration of the surgical procedure (in minutes) were noted.

Evaluation for postoperative edema, ecchymosis, hemorrhage, pain, and patient satisfaction with the outcome was made on the first and seventh days postoperatively. Before and after photographs of the patients were taken in the same examination room under the same light. Edema, ecchymosis, and hemorrhage (oozing from the nostrils through nasal packs) were graded as follows: 0 = absent; 1 = mild (restricted to zygomatic region); 2 = moderate (extending slightly beyond zygomatic region); 3 = severe (extended edema and "raccoon eyes").

Two study-blind surgeons evaluated the patients' photographs, and mean scores were obtained for every patient for the grading of edema and ecchymosis. Patient satisfaction and pain were assessed with a visual analog scale (VAS). (9)

Piezosurgery medical device. In the present study, the Piezosurgery Flex medical device ([PMD]; Mectron Medical Technology; Carasco, Italy) was used. This instrument transforms electric current into ultrasonic waves through a special transducer. These are transmitted to a specific hand piece, resulting in the vibration of cutting scalpels. The device exerts its cutting action only on mineralized tissues and allows the execution of ostetotomy beside delicate tissues such as nerves, vessels, and mucosa. Ultrasonic resonance frequencies (ranging from 24.7 to 29.5 kHz) in low-frequency amplitude are selected by the operator. Therefore, usage of modulated ultrasonic waves in variable duty cycles allows for a precise and safe cut of the bone by the hammer effect of the tip and ultrasonic vibration.

Piezosurgery allows the preservation of the integrity of surfaces undergoing osteotomy and avoids the overheating of mineralized tissues. The electronic generator automatically regulates the working frequency, and the insert tip at the hand piece functions at optimal resonance. Control of the device by the operator is executed via a graphic user interface, and settings for the insert tip, vibration level, irrigation level, and bone quality are shown on a flat monitor. Thereby, operation can be carried out without interruption for substitution of insert tips.

Surgical technique. Open-technique rhinoplasty under general anesthesia was uniformly performed. Infiltration of the local anesthetic solution (2% lidocaine and 1:100,000 epinephrine) was made intranasally and at the level of the lateral nasal walls. Subsequent to removal of the dorsal hump and median nasal osteotomy, an incision of 2 mm was made 10 mm medially and downward from the medial canthus. This incision passed through the skin, superficial musculoaponeurotic system, and the periosteum.

The narrow and curved tip of the PMD scalpel was applied to the bony surface through this incision. The scalpel was located in accordance with the ideal osteotomy line without creation of a frank subperiosteal tunnel. After activation of the PMD, the vibrating scalpel was moved continuously along the osteotomy line with a gentle pressure (figure 1). The osteotomy was performed starting from the access point, and a greenstick fracture occurred with minimal manual pressure at the canthal level after execution of the osteotomy on the opposite side (figure 2).

In the conventional osteotomy group, an osteotomy of 2-mm width, as described in relevant literature, was used. (10) After each operation, nasal splints were placed intranasally. An external plaster cast was applied for protection of the nasal pyramid.

Postoperative care and follow-up. Postoperative management was also standardized. All patients were instructed to remain in the semi-seated position; cold compresses were applied to the eyes and continuously changed during the first 24 hours. All patients were hospitalized for 1 night. The nasal splints and the plaster cast were removed on the seventh day after surgery. Photographs of all patients were taken preoperatively and at the first and seventh days at their postoperative visits. Figure 3 shows one of the patients in her preoperative and postoperative days 1 and 7 photographs.

Statistical analysis

Data were analyzed by means of the IBM Statistical Package for the Social Sciences. The normal distribution of variables was tested with the Kolmogorov-Smirnov test. Parametric tests were used for variables with normal distribution, and nonparametric tests were used for variables that do not display normal distribution. Two independent groups were compared with the Mann-Whitney U test. The Pearson chisquare test was used for categorical variables. Quantitative variables under investigation were expressed as mean and standard deviation or median, minimum, maximum, and interquartile range (IQR). Confidence interval was 95%, and level of significance was set at p < 0.05.


There was no significant difference between the 2 groups with respect to age (p = 0.86) and sex distribution (p = 0.89). The duration of surgery for the both groups combined was 100 to 195 minutes. The duration of surgery was significantly longer in the Piezosurgery group (p = 0.002; 153.75 minutes vs. 136.06 minutes).

Notably, the Piezosurgery group had significantly more favorable outcomes in terms of edema, ecchymosis, and hemorrhage on the first day postoperatively (p < 0.001 for all). Similarly, edema (p = 0.005) and ecchymosis (p < 0.001) on the seventh postoperative day were better in the Piezosurgery group. Hemorrhage was similar in both groups on the seventh day postoperatively (p = 0.67).

Comparison of VAS outcomes regarding pain and patient satisfaction indicated that not only did the Piezosurgery group experience less pain on the first postoperative day (p < 0.001), but they also were more satisfied with their results on both the first and seventh postoperative days. The two groups exhibited similar scores for pain on the seventh day after surgery (p = 0.42).


The current study was implemented to evaluate and compare the clinical outcomes with a Piezosurgery device vs. a conventional osteotome for lateral osteotomy in open-technique rhinoplasty. Our results demonstrated that Piezosurgery reduces edema, pain, ecchymosis, and hemorrhage after surgery and improves patient satisfaction.

Conventional methods of osteotomy may require mechanical energy, and prolonged postoperative ecchymosis and edema may occur due to trauma to the nasal mucosa. (11) Although the method used for lateral osteotomy must preserve the integrity of the nasal mucosa, the ideal method and approach for lateral osteotomy are controversial. (3)

With results similar to those of our study, Robiony et al reported that the use of Piezosurgery did not lead to soft-tissue injury and was associated with less hemorrhage and ecchymosis in the postoperative period. (8) To reduce edema and swelling, they recommended the dissection of a narrow subperiosteal tunnel. It has also been reported that preservation of an unlacerated nasal mucosa may prevent collapse of the lateral nasal wall after osteotomy. (12)

A precise and reproducible lateral osteotomy is mandatory for successful rhinoplasty. A percutaneous approach allows the surgeon to perform the osteotomy in a controlled fashion. Moreover, ease of the procedure, consistent and predictable outcomes, and quicker recovery are important advantages. (13)

Since the thickness of the bone is less than 3 mm throughout the osteotomy line, and because cutting the bone completely across the whole thickness is not necessary, Piezosurgery can be an ideal tool for performing lateral osteotomy. (14) Also, other osteotomies, as well as hump resection, can be accomplished safely and effectively with this technique. A newly designed, more delicate, and more ergonomie scalpel, appropriate for use in an endonasal approach, may eliminate the risk of scar formation from percutaneous surgery. As with any other new technique, a learning curve is required, but Piezosurgery is a safe and straightforward technique. (13)

Shaping the nasal bones constitutes an integral part of the rhinoplasty procedure. Selection of the mode of lateral osteotomy mostly depends on the experience and preference of the surgeon. (1,11) In our study, the surgeon preferred the external perforating technique. In the external technique, perforations created on the nasal bone are connected with application of digital pressure. In case perforations are not uniformly performed or a thicker bony area is encountered, greater pressure may be required for achievement of appropriate infracture. The greater the pressure, the more likely it is that unfavorable aesthetic and functional outcomes will occur.

With conventional chisels, a noteworthy amount of force is applied to the bone and soft tissues over the osteotomy line. (8) Since the unguarded chisels are blindly used, nasal soft tissues and vessels may be lacerated, and risk of hemorrhage and ecchymosis is increased. In contrast, Piezosurgery requires minimal external pressure after lateral osteotomy. It acts in a gentle fashion without the need for hammer hits. Labanca et al suggested that Piezosurgery provides an easier method of cutting the bone, especially in complex anatomic areas. (5) It induces the release of bone morphogenetic proteins with a controlled inflammatory process and triggers the bone remodeling earlier.

Results of the current study suggest that avoidance of morbidity and improvement of patient satisfaction can be achieved by the use of Piezosurgery for lateral osteotomy in rhinoplasty. Tirelli et al also have shown that Piezosurgery may reduce some of the complications associated with rhinoplasty. (3) Other advantages include the selective cutting of mineralized structures, which avoids soft-tissue injury and achieves more precise greenstick fractures, preservation of soft tissue, and maintenance of nasal function. Patients who have undergone rhinoplasty with Piezosurgery have reported less pain, ecchymosis, and edema; thus, this novel method provides comfort for both the surgeon and the patient.

Aside from the longer duration of surgery, most parameters under investigation in our study were significantly more favorable in the Piezosurgery group. This method may become more popular with increased publication regarding its advantages; and its disadvantages will be assessed more accurately, as well.

Perforating intranasal osteotomies were not attempted during our study because this procedure can be unsafe due to the long distance between the access point and the end point of osteotomy. Therefore, all of our patients underwent external perforation osteotomies.

Drawbacks of our study include the fact that our follow-up period was too short to evaluate cosmetic and functional outcomes in the long term. Therefore, larger, prospective, controlled trials are required. Furthermore, the subjectivity of our evaluation criteria, e.g., VAS and grading, limit us from generalizing our results to larger populations.

The relatively longer duration of surgery in the Piezosurgery group can be linked to the learning curve associated with this technique. We believe that this difference may disappear as soon as surgeons become familiar with the its use. Sophistication with and improvement in the Piezosurgery technique may allow application of the device through the intranasal route without causing any skin scars.

To conclude, we suggest that Piezosurgery can be a safe, practical, and effective method for performing lateral osteotomy in rhinoplasty. Popularization of Piezosurgery's use in rhinoplasty and more published reports on this procedure will aid in the establishment of more accurate conclusions. The time interval necessary for the learning curve is counteracted by comfort and satisfaction of both the patients and surgeons. Patient comfort is important in aesthetic procedures, and patient satisfaction enhances the surgeon's motivation to use novel methods. We hope that our results with Piezosurgery in rhinoplasty will encourage its use by surgeons who perform rhinoplasty.


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Bulent Koc, MD; Eltaf Ayca Ozbal Koc, MD; Selim Erbek, MD

From the Rhinoplasty Center, Goztepe, Istanbul, Turkey (Dr. B. Koc); and the Department of Otorhinolaryngology, Baskent University, Istanbul, Turkey (Dr. E.A.O. Koc and Dr. Erbek).

Corresponding author: Eltaf Ayca Ozbal Koc, MD, Department of Otorhinolaryngology, Baskent University, Istanbul Hospital, Mahir Iz caddesi No: 43 Altunizade Istanbul, Turkey. Email: ozbalayca@

Caption: Figure 1. This photo shows the osteotomy line being marked.

Caption: Figure 2. Osteotomy is performed with the piezoelectric device.

Caption: Figure 3. Photos show a patient preoperatively (A) and 1 day (B) and 7 days (C) postoperatively.
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Author:Koc, Bulent; Koc, Eltaf Ayca Ozbal; Erbek, Selim
Publication:Ear, Nose and Throat Journal
Article Type:Report
Date:Aug 1, 2017
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