Ideas and Innovations Use of the Ultrasonic Bone Aspirator for Lateral Osteotomies in Rhinoplasty C. Spencer Cochran, M.D. Jason Roostaeian, M.D. Dallas, Texas
Summary: There remains considerable debate over the optimal method and approach to performing lateral osteotomies. Current methods rely on mechanical energy for performance of osteotomies, which can lead to soft-tissue injury and/or disruption of the bony or cartilaginous framework. The authors report the novel use of an ultrasonic bone aspirator device for performance of lateral osteotomies in rhinoplasty. The authors have found this technology to be safe and effective in a series of five consecutive patients. The main benefits of the device include avoidance of soft-tissue/mucosal injury, minimal bleeding/bruising, and the ability to avoid mechanical force to create bony cuts, which can destabilize the bony and/or cartilaginous construct of the nose. Being able to minimize tissue trauma with its associated morbidity while maintaining efficacy makes the ultrasonic bone aspirator an attractive option for lateral osteotomies in rhinoplasty that warrants further investigation. (Plast. Reconstr. Surg. 132: 1430, 2013.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
L
ateral osteotomies are an integral component of many reconstructive and cosmetic rhinoplasty procedures and can be performed using a variety of techniques. Despite having clear indications, there remains considerable debate over the optimal method and approach to performing osteotomies.1,2 Currently, the two most commonly used methods are the external perforated technique and the internal continuous technique. These techniques typically use 2- and 4-mm osteotomes, respectively, and are associated with the following drawbacks: (1) they can cause mucosal injury; (2) they require significant mechanical force and good bony stability to be performed; (3) they can be traumatic to overlying soft tissue and lead to increased bleeding, bruising, and edema; and (4) they incorporate blind manipulation and dependence on surgical experience and intuition.1,3–7 The ideal technique for performing osteotomies would deliver precise control, consistent results, and a low complication rate and would also minimize postoperative sequelae, such as bleeding, ecchymosis, and edema.8–10 From the Departments of Plastic Surgery and OtolaryngologyHead and Neck Surgery, University of Texas Southwestern Medical Center. Received for publication March 2, 2013; accepted June 13, 2013. Copyright © 2013 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000434404.83692.5b
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The ultrasonic bone aspirator is a device that was initially developed for neurosurgical procedures that require precise cuts through bone while avoiding any soft-tissue injury. U.S. Food and Drug Administration–approved for use in the head and neck, the device has recently found application in nasal surgery. Pribitkin et al. have applied this modality toward the reduction of the nasal dorsum, nasal spine, and turbinates.11 However, no previous studies have examined the role of the ultrasonic bone aspirator in performing lateral osteotomies in rhinoplasty. In this study, we present our experience using the Stryker Sonopet ultrasonic bone aspirator (Stryker, Kalamazoo, Mich.) to perform lateral osteotomies in primary open rhinoplasty.
Disclosure: The authors have no financial interest or commercial association with any of the subject matter or products mentioned in this article.
Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (www. PRSJournal.com).
www.PRSJournal.com
Volume 132, Number 6 • Lateral Osteotomies in Rhinoplasty
Video. Supplemental Digital Content 1 demonstrates the operative technique for lateral osteotomies using the Sonopet device during a cosmetic rhinoplasty, http://links.lww.com/PRS/A896.
PATIENTS AND METHODS We evaluated the outcomes of five consecutive patients who underwent intranasal lateral osteotomy using the Stryker Sonopet ultrasonic bone aspirator between August of 2011 and October of 2011. The Declaration of Helsinki protocols were followed, and all patients gave written informed consent to participate in this study using the Sonopet device, which is U.S. Food and Drug Administration–approved for plastic and reconstructive surgery. A retrospective chart review was performed. Preoperative and postoperative photographs were analyzed. All patients had undergone a primary open rhinoplasty. Any complications or revisions were documented. Surgical Technique Lateral internal continuous osteotomies are performed using the Stryker Sonopet ultrasonic bone aspirator. (See Video, Supplemental Digital Content 1, which demonstrates the operative technique for lateral osteotomies using the Sonopet device during a cosmetic rhinoplasty, http://links.lww.com/PRS/A896.) A stab incision is made in the nasal vestibular mucosa along the piriform rim superolateral to the attachment of the inferior turbinate. A Joseph elevator is used to elevate a subperiosteal tunnel along the planned path of the lateral osteotomy and extends to the intercanthal line anterior to the lacrimal crest. The Sonopet handpiece (Fig. 1) is introduced into the incision and its tip advanced to the superiormost point of the subperiosteal tunnel, which is the initiation point of the osteotomy. The Sonopet device is activated with a
foot pedal, and a continuous full-thickness cut through bone is made in a low-to-low fashion as the tip of the handpiece is withdrawn from the tunnel in a single pass. After the complete osteotomy has been created, gentle digital pressure allows infracturing of the nasal bone.
RESULTS The average age of our patients was 30 years (range, 23 to 45 years). One patient was male, and three patients were Caucasian and two were of Hispanic origin. The indications for rhinoplasty were purely aesthetic in two patients and aesthetic/ functional in three patients. Intraoperatively, we noted minimal mechanical force required to make the osteotomies and no bleeding following the osteotomy.
Fig. 1. Stryker Sonopet ultrasonic bone aspirator handpiece.
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Plastic and Reconstructive Surgery • December 2013
Fig. 2. Preoperative (left) and 1-year postoperative (right) views of a 26-yearold Caucasian female patient who underwent primary rhinoplasty including lateral osteotomies performed with the ultrasonic bone aspirator.
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Volume 132, Number 6 • Lateral Osteotomies in Rhinoplasty Postoperative follow-up evaluation ranged from 6 months to 1.2 years, with a mean follow-up of 44.6 weeks. No complications were observed. No patients had visible or palpable stepoff deformities, irregularities, or asymmetries. There were no open roof or inverted-V deformities. No patients required a revision procedure (Fig. 2). All patients were noted to have minimal pain and minimal to no bruising at the 5- to 7-day postoperative visit. No patients reported worsening of their nasal breathing.
DISCUSSION The ultrasonic bone aspirator has many potential benefits when compared with conventional osteotomes in performing lateral osteotomies in rhinoplasty. The device uses a longitudinal torsional motion and ultrasonic energy to emulsify bone, with minimal thermal conduction to the surrounding tissues. Concurrent irrigation and suction also allow for precise incremental removal of bone and a clean surgical field, with preservation of surrounding soft tissue.11,12 In addition to the conservation of adjacent soft tissue, the ultrasonic bone aspirator was found to preserve cartilage tissue as well both grossly and on histologic analysis.12 This can be ideal in the setting of lateral osteotomies where there is often significant overlap between the nasal bones and the upper lateral cartilages. In contrast, the osteotome necessitates transmission of a great deal of force to underlying bone and soft tissue to sufficiently mobilize the nasal bones. This need for increased mobility, however, must be balanced with preservation of sufficient stability to maintain a stable aesthetic contour. A distinct advantage of the Sonopet device is that it is able to accomplish a continuous osteotomy, which provides good mobility and maintains the integrity of underlying soft-tissue attachments that provides stability. Damage to underlying soft tissue and mucosa is always a concern with the use of the osteotome and has been documented in previous studies.3 Given the sequelae associated with a traditional osteotome, and the potential benefits of the ultrasonic bone aspirator, we decided to evaluate its utility in lateral osteotomies. We have found the device to be both safe and effective, with no complications or need for revisions. We have also noted less bleeding intraoperatively and less bruising and pain in the perioperative period. The main drawbacks of the device include increased surgical time and cost. The increase in operative
time is relatively minimal, never taking more than approximately 1 minute per side for a lateral continuous osteotomy. The ultrasonic bone aspirator is a safe and effective modality for performing lateral osteotomies. Being able to avoid soft-tissue trauma with its associated morbidity for the patient while maintaining efficacy makes the ultrasonic bone aspirator an attractive option for lateral osteotomies in rhinoplasty that warrants further investigation. Jason Roostaeian, M.D. Department of Plastic Surgery University of Texas Southwestern Medical Center 1801 Inwood Road Dallas, Texas 75390-9132 [email protected]
PATIENT CONSENT
The patient provided written consent for the use of her images. REFERENCES 1. Rohrich RJ, Krueger JK, Adams WP Jr, Hollier LH Jr. Achieving consistency in the lateral nasal osteotomy during rhinoplasty: An external perforated technique. Plast Reconstr Surg. 2001;108:2122–2130; discussion 2131. 2. Cochran CS, Ducic Y, Defatta RJ. Rethinking nasal osteotomies: An anatomic approach. Laryngoscope 2007;117: 662–667. 3. Rohrich RJ, Minoli JJ, Adams WP, Hollier LH. The lateral nasal osteotomy in rhinoplasty: An anatomic endoscopic comparison of the external versus the internal approach. Plast Reconstr Surg. 1997;99:1309–1312; discussion 1313. 4. Goldfarb M, Gallups JM, Gerwin JM. Perforating osteotomies in rhinoplasty. Arch Otolaryngol Head Neck Surg. 1993;119:624–627. 5. Lawson W, Kessler S, Biller HF. Unusual and fatal complications of rhinoplasty. Arch Otolaryngol. 1983;109:164–169. 6. Parkes ML, Kamer F, Morgan WR. Double lateral osteotomy in rhinoplasty. Arch Otolaryngol. 1977;103:344–348. 7. Kim JT, Kim SK. Endoscopically assisted, intraorally approached corrective rhinoplasty. Plast Reconstr Surg. 2001;108:199–205; discussion 206. 8. Harshbarger RJ, Sullivan PK. Lateral nasal osteotomies: Implications of bony thickness on fracture patterns. Ann Plast Surg. 1999;42:365–370; discussion 370. 9. Parkes ML, Borowiecki B, Binder W. Functional sequelae of rhinoplasty. Ann Plast Surg. 1980;4:116–120. 10. Lavine DM, Lehman JA, Jackson T. Is the lacrimal apparatus injured following cosmetic rhinoplasty? Arch Otolaryngol. 1979;105:719–720. 11. Pribitkin EA, Lavasani LS, Shindle C, Greywoode JD. Sonic rhinoplasty: Sculpting the nasal dorsum with the ultrasonic bone aspirator. Laryngoscope 2010;120:1504–1507. 12. Greywoode JD, Pribitkin EA. Sonic rhinoplasty: Histologic correlates and technical refinements using the ultrasonic bone aspirator. Arch Facial Plast Surg. 2011;13:316–321.
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Summary: There remains considerable debate over the optimal method and approach to performing lateral osteotomies. Current methods rely on mechanical energy for performance of osteotomies, which can lead to soft-tissue injury and/or disruption of the bony or cartilaginous framework. The authors report the novel use of an ultrasonic bone aspirator device for performance of lateral osteotomies in rhinoplasty. The authors have found this technology to be safe and effective in a series of five consecutive patients. The main benefits of the device include avoidance of soft-tissue/mucosal injury, minimal bleeding/bruising, and the ability to avoid mechanical force to create bony cuts, which can destabilize the bony and/or cartilaginous construct of the nose. Being able to minimize tissue trauma with its associated morbidity while maintaining efficacy makes the ultrasonic bone aspirator an attractive option for lateral osteotomies in rhinoplasty that warrants further investigation. (Plast. Reconstr. Surg. 132: 1430, 2013.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
L
ateral osteotomies are an integral component of many reconstructive and cosmetic rhinoplasty procedures and can be performed using a variety of techniques. Despite having clear indications, there remains considerable debate over the optimal method and approach to performing osteotomies.1,2 Currently, the two most commonly used methods are the external perforated technique and the internal continuous technique. These techniques typically use 2- and 4-mm osteotomes, respectively, and are associated with the following drawbacks: (1) they can cause mucosal injury; (2) they require significant mechanical force and good bony stability to be performed; (3) they can be traumatic to overlying soft tissue and lead to increased bleeding, bruising, and edema; and (4) they incorporate blind manipulation and dependence on surgical experience and intuition.1,3–7 The ideal technique for performing osteotomies would deliver precise control, consistent results, and a low complication rate and would also minimize postoperative sequelae, such as bleeding, ecchymosis, and edema.8–10 From the Departments of Plastic Surgery and OtolaryngologyHead and Neck Surgery, University of Texas Southwestern Medical Center. Received for publication March 2, 2013; accepted June 13, 2013. Copyright © 2013 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000434404.83692.5b
1430
The ultrasonic bone aspirator is a device that was initially developed for neurosurgical procedures that require precise cuts through bone while avoiding any soft-tissue injury. U.S. Food and Drug Administration–approved for use in the head and neck, the device has recently found application in nasal surgery. Pribitkin et al. have applied this modality toward the reduction of the nasal dorsum, nasal spine, and turbinates.11 However, no previous studies have examined the role of the ultrasonic bone aspirator in performing lateral osteotomies in rhinoplasty. In this study, we present our experience using the Stryker Sonopet ultrasonic bone aspirator (Stryker, Kalamazoo, Mich.) to perform lateral osteotomies in primary open rhinoplasty.
Disclosure: The authors have no financial interest or commercial association with any of the subject matter or products mentioned in this article.
Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (www. PRSJournal.com).
www.PRSJournal.com
Volume 132, Number 6 • Lateral Osteotomies in Rhinoplasty
Video. Supplemental Digital Content 1 demonstrates the operative technique for lateral osteotomies using the Sonopet device during a cosmetic rhinoplasty, http://links.lww.com/PRS/A896.
PATIENTS AND METHODS We evaluated the outcomes of five consecutive patients who underwent intranasal lateral osteotomy using the Stryker Sonopet ultrasonic bone aspirator between August of 2011 and October of 2011. The Declaration of Helsinki protocols were followed, and all patients gave written informed consent to participate in this study using the Sonopet device, which is U.S. Food and Drug Administration–approved for plastic and reconstructive surgery. A retrospective chart review was performed. Preoperative and postoperative photographs were analyzed. All patients had undergone a primary open rhinoplasty. Any complications or revisions were documented. Surgical Technique Lateral internal continuous osteotomies are performed using the Stryker Sonopet ultrasonic bone aspirator. (See Video, Supplemental Digital Content 1, which demonstrates the operative technique for lateral osteotomies using the Sonopet device during a cosmetic rhinoplasty, http://links.lww.com/PRS/A896.) A stab incision is made in the nasal vestibular mucosa along the piriform rim superolateral to the attachment of the inferior turbinate. A Joseph elevator is used to elevate a subperiosteal tunnel along the planned path of the lateral osteotomy and extends to the intercanthal line anterior to the lacrimal crest. The Sonopet handpiece (Fig. 1) is introduced into the incision and its tip advanced to the superiormost point of the subperiosteal tunnel, which is the initiation point of the osteotomy. The Sonopet device is activated with a
foot pedal, and a continuous full-thickness cut through bone is made in a low-to-low fashion as the tip of the handpiece is withdrawn from the tunnel in a single pass. After the complete osteotomy has been created, gentle digital pressure allows infracturing of the nasal bone.
RESULTS The average age of our patients was 30 years (range, 23 to 45 years). One patient was male, and three patients were Caucasian and two were of Hispanic origin. The indications for rhinoplasty were purely aesthetic in two patients and aesthetic/ functional in three patients. Intraoperatively, we noted minimal mechanical force required to make the osteotomies and no bleeding following the osteotomy.
Fig. 1. Stryker Sonopet ultrasonic bone aspirator handpiece.
1431
Plastic and Reconstructive Surgery • December 2013
Fig. 2. Preoperative (left) and 1-year postoperative (right) views of a 26-yearold Caucasian female patient who underwent primary rhinoplasty including lateral osteotomies performed with the ultrasonic bone aspirator.
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Volume 132, Number 6 • Lateral Osteotomies in Rhinoplasty Postoperative follow-up evaluation ranged from 6 months to 1.2 years, with a mean follow-up of 44.6 weeks. No complications were observed. No patients had visible or palpable stepoff deformities, irregularities, or asymmetries. There were no open roof or inverted-V deformities. No patients required a revision procedure (Fig. 2). All patients were noted to have minimal pain and minimal to no bruising at the 5- to 7-day postoperative visit. No patients reported worsening of their nasal breathing.
DISCUSSION The ultrasonic bone aspirator has many potential benefits when compared with conventional osteotomes in performing lateral osteotomies in rhinoplasty. The device uses a longitudinal torsional motion and ultrasonic energy to emulsify bone, with minimal thermal conduction to the surrounding tissues. Concurrent irrigation and suction also allow for precise incremental removal of bone and a clean surgical field, with preservation of surrounding soft tissue.11,12 In addition to the conservation of adjacent soft tissue, the ultrasonic bone aspirator was found to preserve cartilage tissue as well both grossly and on histologic analysis.12 This can be ideal in the setting of lateral osteotomies where there is often significant overlap between the nasal bones and the upper lateral cartilages. In contrast, the osteotome necessitates transmission of a great deal of force to underlying bone and soft tissue to sufficiently mobilize the nasal bones. This need for increased mobility, however, must be balanced with preservation of sufficient stability to maintain a stable aesthetic contour. A distinct advantage of the Sonopet device is that it is able to accomplish a continuous osteotomy, which provides good mobility and maintains the integrity of underlying soft-tissue attachments that provides stability. Damage to underlying soft tissue and mucosa is always a concern with the use of the osteotome and has been documented in previous studies.3 Given the sequelae associated with a traditional osteotome, and the potential benefits of the ultrasonic bone aspirator, we decided to evaluate its utility in lateral osteotomies. We have found the device to be both safe and effective, with no complications or need for revisions. We have also noted less bleeding intraoperatively and less bruising and pain in the perioperative period. The main drawbacks of the device include increased surgical time and cost. The increase in operative
time is relatively minimal, never taking more than approximately 1 minute per side for a lateral continuous osteotomy. The ultrasonic bone aspirator is a safe and effective modality for performing lateral osteotomies. Being able to avoid soft-tissue trauma with its associated morbidity for the patient while maintaining efficacy makes the ultrasonic bone aspirator an attractive option for lateral osteotomies in rhinoplasty that warrants further investigation. Jason Roostaeian, M.D. Department of Plastic Surgery University of Texas Southwestern Medical Center 1801 Inwood Road Dallas, Texas 75390-9132 [email protected]
PATIENT CONSENT
The patient provided written consent for the use of her images. REFERENCES 1. Rohrich RJ, Krueger JK, Adams WP Jr, Hollier LH Jr. Achieving consistency in the lateral nasal osteotomy during rhinoplasty: An external perforated technique. Plast Reconstr Surg. 2001;108:2122–2130; discussion 2131. 2. Cochran CS, Ducic Y, Defatta RJ. Rethinking nasal osteotomies: An anatomic approach. Laryngoscope 2007;117: 662–667. 3. Rohrich RJ, Minoli JJ, Adams WP, Hollier LH. The lateral nasal osteotomy in rhinoplasty: An anatomic endoscopic comparison of the external versus the internal approach. Plast Reconstr Surg. 1997;99:1309–1312; discussion 1313. 4. Goldfarb M, Gallups JM, Gerwin JM. Perforating osteotomies in rhinoplasty. Arch Otolaryngol Head Neck Surg. 1993;119:624–627. 5. Lawson W, Kessler S, Biller HF. Unusual and fatal complications of rhinoplasty. Arch Otolaryngol. 1983;109:164–169. 6. Parkes ML, Kamer F, Morgan WR. Double lateral osteotomy in rhinoplasty. Arch Otolaryngol. 1977;103:344–348. 7. Kim JT, Kim SK. Endoscopically assisted, intraorally approached corrective rhinoplasty. Plast Reconstr Surg. 2001;108:199–205; discussion 206. 8. Harshbarger RJ, Sullivan PK. Lateral nasal osteotomies: Implications of bony thickness on fracture patterns. Ann Plast Surg. 1999;42:365–370; discussion 370. 9. Parkes ML, Borowiecki B, Binder W. Functional sequelae of rhinoplasty. Ann Plast Surg. 1980;4:116–120. 10. Lavine DM, Lehman JA, Jackson T. Is the lacrimal apparatus injured following cosmetic rhinoplasty? Arch Otolaryngol. 1979;105:719–720. 11. Pribitkin EA, Lavasani LS, Shindle C, Greywoode JD. Sonic rhinoplasty: Sculpting the nasal dorsum with the ultrasonic bone aspirator. Laryngoscope 2010;120:1504–1507. 12. Greywoode JD, Pribitkin EA. Sonic rhinoplasty: Histologic correlates and technical refinements using the ultrasonic bone aspirator. Arch Facial Plast Surg. 2011;13:316–321.
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