Volume 135, Number 5 • Letters references 1. Wheble GA, Tan EK, Turner M, Durrant CA, Heppell S. Surgeon-administered, intra-operative transversus abdominis plane block in autologous breast reconstruction: A UK hospital experience. J Plast Reconstr Aesthet Surg. 2013;66:1665–1670. 2. Zhong T, Ojha M, Bagher S, et al. Transversus abdominis plane block reduces morphine consumption in the early postoperative period following microsurgical abdominal tissue breast reconstruction: A double-blind, placebo-controlled, randomized trial. Plast Reconstr Surg. 2014;134:870–878. 3. Zhong T, Wong KW, Cheng H, et al. Transversus abdominis plane (TAP) catheters inserted under direct vision in the donor site following free DIEP and MS-TRAM breast reconstruction: A prospective cohort study of 45 patients. J Plast Reconstr Aesthet Surg. 2013;66:329–336.
Use of the Ultrasonic Bone Aspirator for Lateral Osteotomies in Rhinoplasty Sir:
T
he article entitled “Use of the Ultrasonic Bone Aspirator for Lateral Osteotomies in Rhinoplasty” by Cochran and Roostaeian1 claims that the ideal osteotomy technique delivers precise control, consistent results, low complication rates, and minimal postoperative sequelae. The technique offers a new approach to nasal osteotomies in rhinoplasty using ultrasonic vibrations. This was first described by us2,3; however, it is not mentioned by Cochran and Roostaeian, who falsely claim that “no previous studies have examined the role of the ultrasonic bone aspirator in performing lateral osteotomies in rhinoplasty.” In 2007,2,3 we published a new nasal osteotomy technique using piezoelectric ultrasonic vibrations instead of the standard chisel to minimize postoperative sequelae. Cochran and Roostaeian report only five consecutive cases (August to October of 2011) in a retrospective analysis of preoperative and postoperative photographs. Some technical aspects, such as insert tip thickness, are omitted. They suggest creating a subperiosteal tunnel along the planned lateral osteotomy path to the intercanthal line anterior to the lacrimal crest. Their results are as follows: “Intraoperatively, we noted minimal mechanical force required to make the osteotomies and no bleeding following the osteotomy. No patients had visible or palpable stepoff deformities, irregularities, or asymmetries. There were no open-roof or inverted-V deformities, or revision procedures. All patients had minimal pain and minimal-tono bruising at 5 to 7 days postoperatively. No patients reported worsening of their nasal breathing.” They conclude that ultrasonic bone aspiration is feasible for lateral osteotomies in rhinoplasty. Our ultrasound experience for osteotomies in rhinoplasty started with a 2002 cadaver study in which a rapid linear cut, minimal or absent internal mucosal damage, minimal periosteal detachment, and technical feasibility were noted (Fig. 1). The osteotomy was
Fig. 1. (Above) Osteotomy course marked on the skin of the cadaver nose. This was used continuously to control the tip of the piezo scalpel while performing the osteotomy. (Below) Osteotomy course after removal of soft-tissue cover. The osteotomy course is regular, which corresponds exactly to the path marked on the skin. There is only one bony fragment without any comminuted fracture pattern.
Fig. 2. External percutaneous osteotomy.
continuous rather than perforating. Our technique has been performed in 175 patients with a percutaneous approach (Fig. 2) without a subperiosteal tunnel using
921e
Plastic and Reconstructive Surgery • May 2015 an ultrasonic piezosurgical instrument to perform sharp osteotomies (Mectron Medical Technology, Carrasco, Italy). It allows efficient cutting of mineralized tissues with minimal soft-tissue trauma. The insert tip is 0.5 or 0.3 mm thick, allowing an effective cut that preserves osteotomized surface integrity and avoids overheating of mineralized tissue. Previous histologic examination of the cut surfaces of bony segments confirmed the lack of coagulative necrosis and identified live osteocytes.4 In our study, all patients were evaluated for ecchymosis, bleeding, edema, and scarring immediately and at 1 and 2 weeks postoperatively. Reduction of bleeding during surgery, minor edema, periorbital ecchymosis, and no visible scarring were noted immediately postoperatively. Considerable reduction of trauma, postoperative edema, and ecchymosis was noted. These results were confirmed by previous histologic findings that support the relationship between minor surgical trauma and better soft and hard tissue behavior during healing. We felt obliged to point out the above to ensure correct attribution of the paternity of the first application of ultrasound in rhinoplasty. Above all, we wanted to report that the important details and advantages of the use of ultrasound osteotomies in rhinoplasty are superimposable. Therefore, the literature should be evaluated to glean the truth regarding use of ultrasound for osteotomies in rhinoplasty. DOI: 10.1097/PRS.0000000000001188
Massimo Robiony, M.D., F.E.B.O.M.F.S.
University Hospital of Udine Department of Medical and Biological Sciences Ple Kolbe 4-33100 Udine, Italy [email protected]
disclosure The author has no financial interest to declare in relation to the content of this communication. references 1. Cochran CS, Roostaeian J. Use of the ultrasonic bone aspirator for lateral osteotomies in rhinoplasty. Plast Reconstr Surg. 2013;132:1430–1433. 2. Robiony M, Polini F, Costa F, Toro C, Politi M. Ultrasound piezoelectric vibrations to perform osteotomies in rhinoplasty. J Oral Maxillofac Surg. 2007;65:1035–1038. 3. Robiony M, Toro C, Costa F, Sembronio S, Polini F, Politi M. Piezosurgery: A new method for osteotomies in rhinoplasty. J Craniofac Surg. 2007;18:1098–1100. 4. Robiony M, Polini F, Costa F, Vercellotti T, Politi M. Piezoelectric bone cutting in multiple piece maxillary osteotomy. J Oral Maxillofac Surg. 2004;62:759–761.
Reply: Use of the Ultrasonic Bone Aspirator for Lateral Osteotomies in Rhinoplasty Sir:
I would like to properly acknowledge the antecedent work of Dr. Massimo Robiony and colleagues using ultrasound technology in rhinoplasty and give them
922e
correct attribution of the paternity of the first application of ultrasound in rhinoplasty. Dr. Robiony et al. have succinctly described their experience with piezoelectric vibrations and piezosurgery rhinoplasty in the Letter above in addition to their prior publications. I agree with his comment that both their and our “details and advantages of the use of ultrasound osteotomies in rhinoplasty are superimposable.” Please accept my apology for the oversight in citing their contributions to the literature on this subject. DOI: 10.1097/PRS.0000000000001180
C. Spencer Cochran, M.D.
Gunter Center for Aesthetics and Cosmetic Surgery Dallas, Texas
disclosure The author has no financial interest to declare in relation to the content of this communication.
Simplifying the Management of Caudal Septal Deviation in Rhinoplasty Sir:
W
e have read the article entitled “Simplifying the Management of Caudal Septal Deviation in Rhinoplasty” by Constantine et al. with great interest.1 The high percentage of caudal septal deviation in rhinoplasty patients and management of the problem is pointed out in this article. The authors have stated the vertical excess in the C- or S-shaped septum and the importance of excision from the caudal part of the L-strut and anterior nasal spine and maxillary crest. They suture the septum to the contralateral aspect of the nasal spine to establish the relation between these anatomical structures. This suture should be carefully adapted in both sides to prevent any altering effect on the tip projection and rotation. We also have a high percentage of caudal septal deviation in our patients and usually need to perform caudal septal excision to eliminate the detrimental effects of vertical excess of the septum. A gap will usually occur between the L-strut and nasal spine after excision, which makes the adaptation of the aforementioned suture important. To overcome this problem, we use a sheet of polydioxanone foil (PDS plate; Ethicon, Inc., Johnson & Johnson, Inc., New Brunswick, N.J.) to recreate the straight-line relation of the caudal septum with the anterior nasal spine. The versatile and biodegradable polydioxanone plates are commonly used materials in nasal surgery, with the advantages of stabilizing septal fragments and minimizing the cosmetic and functional sequelae associated with nonabsorbable implants.2,3 To briefly describe the technique, a polydioxanone plate is prepared according to the shape of the L-strut and the nasal spine with a minimum width of 10 mm. The prepared polydioxanone plate is perforated with 16-gauge needles and placed in one side of the septum
Use of the Ultrasonic Bone Aspirator for Lateral Osteotomies in Rhinoplasty Sir:
T
he article entitled “Use of the Ultrasonic Bone Aspirator for Lateral Osteotomies in Rhinoplasty” by Cochran and Roostaeian1 claims that the ideal osteotomy technique delivers precise control, consistent results, low complication rates, and minimal postoperative sequelae. The technique offers a new approach to nasal osteotomies in rhinoplasty using ultrasonic vibrations. This was first described by us2,3; however, it is not mentioned by Cochran and Roostaeian, who falsely claim that “no previous studies have examined the role of the ultrasonic bone aspirator in performing lateral osteotomies in rhinoplasty.” In 2007,2,3 we published a new nasal osteotomy technique using piezoelectric ultrasonic vibrations instead of the standard chisel to minimize postoperative sequelae. Cochran and Roostaeian report only five consecutive cases (August to October of 2011) in a retrospective analysis of preoperative and postoperative photographs. Some technical aspects, such as insert tip thickness, are omitted. They suggest creating a subperiosteal tunnel along the planned lateral osteotomy path to the intercanthal line anterior to the lacrimal crest. Their results are as follows: “Intraoperatively, we noted minimal mechanical force required to make the osteotomies and no bleeding following the osteotomy. No patients had visible or palpable stepoff deformities, irregularities, or asymmetries. There were no open-roof or inverted-V deformities, or revision procedures. All patients had minimal pain and minimal-tono bruising at 5 to 7 days postoperatively. No patients reported worsening of their nasal breathing.” They conclude that ultrasonic bone aspiration is feasible for lateral osteotomies in rhinoplasty. Our ultrasound experience for osteotomies in rhinoplasty started with a 2002 cadaver study in which a rapid linear cut, minimal or absent internal mucosal damage, minimal periosteal detachment, and technical feasibility were noted (Fig. 1). The osteotomy was
Fig. 1. (Above) Osteotomy course marked on the skin of the cadaver nose. This was used continuously to control the tip of the piezo scalpel while performing the osteotomy. (Below) Osteotomy course after removal of soft-tissue cover. The osteotomy course is regular, which corresponds exactly to the path marked on the skin. There is only one bony fragment without any comminuted fracture pattern.
Fig. 2. External percutaneous osteotomy.
continuous rather than perforating. Our technique has been performed in 175 patients with a percutaneous approach (Fig. 2) without a subperiosteal tunnel using
921e
Plastic and Reconstructive Surgery • May 2015 an ultrasonic piezosurgical instrument to perform sharp osteotomies (Mectron Medical Technology, Carrasco, Italy). It allows efficient cutting of mineralized tissues with minimal soft-tissue trauma. The insert tip is 0.5 or 0.3 mm thick, allowing an effective cut that preserves osteotomized surface integrity and avoids overheating of mineralized tissue. Previous histologic examination of the cut surfaces of bony segments confirmed the lack of coagulative necrosis and identified live osteocytes.4 In our study, all patients were evaluated for ecchymosis, bleeding, edema, and scarring immediately and at 1 and 2 weeks postoperatively. Reduction of bleeding during surgery, minor edema, periorbital ecchymosis, and no visible scarring were noted immediately postoperatively. Considerable reduction of trauma, postoperative edema, and ecchymosis was noted. These results were confirmed by previous histologic findings that support the relationship between minor surgical trauma and better soft and hard tissue behavior during healing. We felt obliged to point out the above to ensure correct attribution of the paternity of the first application of ultrasound in rhinoplasty. Above all, we wanted to report that the important details and advantages of the use of ultrasound osteotomies in rhinoplasty are superimposable. Therefore, the literature should be evaluated to glean the truth regarding use of ultrasound for osteotomies in rhinoplasty. DOI: 10.1097/PRS.0000000000001188
Massimo Robiony, M.D., F.E.B.O.M.F.S.
University Hospital of Udine Department of Medical and Biological Sciences Ple Kolbe 4-33100 Udine, Italy [email protected]
disclosure The author has no financial interest to declare in relation to the content of this communication. references 1. Cochran CS, Roostaeian J. Use of the ultrasonic bone aspirator for lateral osteotomies in rhinoplasty. Plast Reconstr Surg. 2013;132:1430–1433. 2. Robiony M, Polini F, Costa F, Toro C, Politi M. Ultrasound piezoelectric vibrations to perform osteotomies in rhinoplasty. J Oral Maxillofac Surg. 2007;65:1035–1038. 3. Robiony M, Toro C, Costa F, Sembronio S, Polini F, Politi M. Piezosurgery: A new method for osteotomies in rhinoplasty. J Craniofac Surg. 2007;18:1098–1100. 4. Robiony M, Polini F, Costa F, Vercellotti T, Politi M. Piezoelectric bone cutting in multiple piece maxillary osteotomy. J Oral Maxillofac Surg. 2004;62:759–761.
Reply: Use of the Ultrasonic Bone Aspirator for Lateral Osteotomies in Rhinoplasty Sir:
I would like to properly acknowledge the antecedent work of Dr. Massimo Robiony and colleagues using ultrasound technology in rhinoplasty and give them
922e
correct attribution of the paternity of the first application of ultrasound in rhinoplasty. Dr. Robiony et al. have succinctly described their experience with piezoelectric vibrations and piezosurgery rhinoplasty in the Letter above in addition to their prior publications. I agree with his comment that both their and our “details and advantages of the use of ultrasound osteotomies in rhinoplasty are superimposable.” Please accept my apology for the oversight in citing their contributions to the literature on this subject. DOI: 10.1097/PRS.0000000000001180
C. Spencer Cochran, M.D.
Gunter Center for Aesthetics and Cosmetic Surgery Dallas, Texas
disclosure The author has no financial interest to declare in relation to the content of this communication.
Simplifying the Management of Caudal Septal Deviation in Rhinoplasty Sir:
W
e have read the article entitled “Simplifying the Management of Caudal Septal Deviation in Rhinoplasty” by Constantine et al. with great interest.1 The high percentage of caudal septal deviation in rhinoplasty patients and management of the problem is pointed out in this article. The authors have stated the vertical excess in the C- or S-shaped septum and the importance of excision from the caudal part of the L-strut and anterior nasal spine and maxillary crest. They suture the septum to the contralateral aspect of the nasal spine to establish the relation between these anatomical structures. This suture should be carefully adapted in both sides to prevent any altering effect on the tip projection and rotation. We also have a high percentage of caudal septal deviation in our patients and usually need to perform caudal septal excision to eliminate the detrimental effects of vertical excess of the septum. A gap will usually occur between the L-strut and nasal spine after excision, which makes the adaptation of the aforementioned suture important. To overcome this problem, we use a sheet of polydioxanone foil (PDS plate; Ethicon, Inc., Johnson & Johnson, Inc., New Brunswick, N.J.) to recreate the straight-line relation of the caudal septum with the anterior nasal spine. The versatile and biodegradable polydioxanone plates are commonly used materials in nasal surgery, with the advantages of stabilizing septal fragments and minimizing the cosmetic and functional sequelae associated with nonabsorbable implants.2,3 To briefly describe the technique, a polydioxanone plate is prepared according to the shape of the L-strut and the nasal spine with a minimum width of 10 mm. The prepared polydioxanone plate is perforated with 16-gauge needles and placed in one side of the septum
