surggery tool, Dr. Alireza Ghassemi

1. CRANIOMAXILLOFACIAL DEFORMITIES/COSMETIC SURGERY
Osteotomy of the Nasal Wall Using a Newly
Designed Piezo Scalpel—A Cadaver Study
Alireza Ghassemi, MD, DDS, PhD,* Andreas Prescher, MD, PhD,y
Mohammad Talebzadeh, DDS,z Frank H€olzle, MD, DDS, PhD,x and
Ali Modabber, MD, DDS, PhDk
Purpose: Achieving the desired outcome in rhinoplasty depends on many factors. Osteotomy and
adjustment of the lateral nasal wall are important steps that necessitate careful planning and execution.
A cadaver study was performed to evaluate the osteotomy result obtained with a newly designed
piezoelectric-based scalpel.
Materials and Methods: Twenty lateral osteotomies of the nasal wall were performed in 10 human
cadaver noses. The osteotomies were conducted in 6 female and 4 male cadavers (age range, 65 to 83
yr; mean age, 74.8 yr). A specially designed Piezosurgery-based scalpel was used endonasally to perform
the lateral osteotomy. Cutting of the bony nasal wall was performed subperiostally along the planned
osteotomy route under tactile control. Digital infracturing was accomplished by applying gentle pressure.
After completing the osteotomy, the osteotomy line and nasal mucosa were examined endoscopically. The
skin cover was removed to examine the lateral bony nasal wall for the shape and amount of bone
fragments, the osteotomy path, and mucosa involvement.
Results: Using the Piezosurgery-based scalpel required a learning curve, but the handling was easy.
It allowed an exact performance of the osteotomy and caused no mucosal tearing. If excessive force
was used, the piezo tip stopped working. There was no comminuted fracture pattern and the lateral nasal
wall remained in 1 piece. The duration of the osteotomy was 5 to 10 minutes on each side.
Conclusion: The piezoelectric-based scalpel is a useful tool, which can be used to perform osteotomy of
the nasal wall. In addition, this specifically designed tool tip allows an endonasal approach, is easy to han-
dle, and allows effective irrigation of the osteotomy region.
Ó 2013 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg -:e1-e6, 2013
A significant yet difficult contributor to operative suc-
cess in rhinoplasty is shaping the underlying nasal
bony structures.1,2
Depending on the deformities
presented, different osteotomy techniques—lateral,
medial, and transverse—can be indicated to achieve
the desired esthetic and functional outcome.3
Two dif-
ferent approaches—endonasal and percutaneous—
with corresponding instruments have been developed
tomakethissteppredictable,less traumatic,easy toper-
form, and controllable.2,4-7
Nevertheless, every tech-
nique has its advantages and disadvantages, and
osteotomy can cause soft tissue injury, irregularity of
the bony lateral wall, a comminuted fracture pattern,
and, as sequels, prolonged postoperative edema and
ecchymosis and functional nasal obstruction with an
undesired esthetic and functional outcome.2,5-7
Soft
*Assistant Professor, Department of Oral, Maxillofacial, and
Plastic Facial Surgery, University Hospital RWTH-Aachen, Aachen,
Germany.
yAssistant Professor, Institute of Anatomy, Medical Faculty of
RWTH-Aachen, Aachen, Germany.
zResident, Department of Oral, Maxillofacial, and Plastic Facial
Surgery, University Hospital RWTH-Aachen, Aachen, Germany.
xHead and Chairman, Department of Oral, Maxillofacial, and
Plastic Facial Surgery, University Hospital RWTH-Aachen, Aachen,
Germany.
kSenior Resident, Department of Oral, Maxillofacial, and Plastic
Facial Surgery, University Hospital RWTH-Aachen, Aachen, Germany.
Address correspondence and reprint requests to Dr Ghassemi:
Pauwelsstr 30, 52074 Aachen, Germany; e-mail: aghassemi@
ukaachen.de
Received June 18 2013
Accepted July 26 2013
Ó 2013 American Association of Oral and Maxillofacial Surgeons
0278-2391/13/00939-7$36.00/0
http://dx.doi.org/10.1016/j.joms.2013.07.028
e1

2. tissue trauma may contribute to destabilization,
hemorrhage, and prolonged postoperative ecchymosis
and edema. The nasal skin is very thin and any nasal
wall irregularity from a comminuted fracture and
irregular-shaped bony fragments will be apparent.8,9
Horton et al10,11
introduced piezo surgery in alveolar
bone surgery in 1975, using the piezoelectric ultrasonic
vibration for gentle cutting of the bone. They reported
better bone healing of the bony fragments when using
piezo surgery. Subsequently, additional uses were
introduced, such as cutting a bony window in the
maxillary sinus wall to perform sinus augmentation or
to perform orthognathic surgery.10-16
In 2007,
Robiony et al17
suggested this technique for nasal os-
teotomy. This device cuts the bone micrometrically us-
ing ultrasonic piezoelectric vibration, and it can be
adjusted by changing the frequency and cutting power.
It has proved a useful tool for cutting thin bone with
precision, causing minimal damage to soft tissue and
avoiding osteonecrosis.18
Since then, the technique
has improved rapidly and has extended its indication.12
This anatomic study was undertaken to perform
osteotomy of the nasal wall with a newly designed
piezo scalpel. The degree of difficulty of performing
osteotomy was evaluated using this scalpel through
an endonasal approach. In addition, the effectiveness
of the cooling capacity, the condition of the osteotomy
path, the amount and shape of bony fragments, and
mucosal injuries were examined.
Materials and Methods
Ten human cadaver heads were used for performing
lateral osteotomy (age range, 65 to 83 yr; mean age,
74.8 yr; gender distribution, 4 male and 6 female).
One experienced rhinoplasty surgeon, who was famil-
iar in applying the Piezosurgery device (Mectron Med-
ical Technology, Carasco, Italy), performed the
osteotomies through an endonasal approach. A spe-
cially designed piezo scalpel was used to dissect a tun-
nel and to perform the osteotomy (Figs 1, 2). In
addition, irrigation with internal cooling and a flow
of 40 mL/min was used to avoid heating the bone.
The coolant was transferred to the osteotomy area
through a hole at the end of the tool tip (Fig 2).
The mucosa was incised along the lower edge of the
pyriform aperture for about 3 mm to access the bony
lateral wall. A special tool tip was used as a periosteal
elevator to create a subperiosteal tunnel around the
pyriform aperture along the planned osteotomy
path, as marked on the skin (Fig 3). The piezo scalpel
was inserted into this tunnel and the osteotomy was
performed along the osteotomy path under digital con-
trol. After accomplishing the endonasal cutting of the
bony lateral nasal wall, 3 independent examiners (ex-
cluding the surgeons) who were blinded to the tech-
nique inspected the intranasal cavities of all cadavers
on each side with a 4-mm 30
rigid endoscope (Karl
Storz GmbH Co KG, Tuttlingen; Germany). They
looked for lacerations of the nasal mucosa. Then, the
nasal pyramid was infractured digitally on each ca-
daver. The soft tissue envelope was removed after in-
fracturing to evaluate the condition of the osteotomy
line and the size, shape, and amount of the bony frag-
ments. Special inspection was performed for contour
irregularities, bony spur or spicules generated, and
greenstick infracture characteristics. This step was fol-
lowed by an intranasal examination to explore the
nasal mucosa.
Results
Altogether, 20 lateral osteotomies were performed
in human cadaver specimens. The osteotomy path
was marked on the skin (Fig 3). It was easy to cut
through the bony wall all the way along the osteotomy
line by digitally controlling the piezo inset (Figs 1, 2).
Because of the learning curve, 10 minutes was re-
quired for the first nose and 7 minutes was required
for the second nose. For the next 8 noses, approxi-
mately 5 minutes was required. For continuous cut-
ting, the scalpel should be moved along the bone
FIGURE 1. Working insert for soft periosteal elevation. The cooling hole (arrow) is in the shaft near the handle.
Ghassemi et al. Piezo Surgery for Osteotomy of Nasal Wall. J Oral Maxillofac Surg 2013.
e2 PIEZO SURGERY FOR OSTEOTOMY OF NASAL WALL

3. surface by applying gentle pressure. This is sufficient
to cut partly or completely through the bone, as indi-
cated. As soon as any extensive force was exerted,
the piezo stopped working. Near the nasal root, cut-
ting the bone required more time. At the end of piezo
surgery, digital infracturing could be performed by ap-
plying gentle pressure and no forceful manipulation
was necessary.
All examiners independently recorded identical
findings from their separate endoscopic examinations
FIGURE 2. The cutting working tip with the hole close to the tip. The cooling hole (arrow) and the pathway along the shaft, where the irrigation
has to flow to reach the tip (2-headed arrow), are depicted.
Ghassemi et al. Piezo Surgery for Osteotomy of Nasal Wall. J Oral Maxillofac Surg 2013.
FIGURE 3. Osteotomy course marked on the skin of the cadaver
nose. This was used continuously to control the tip of the piezo scal-
pel while performing the osteotomy.
Ghassemi et al. Piezo Surgery for Osteotomy of Nasal Wall. J Oral
Maxillofac Surg 2013.
FIGURE 4. Endoscopic inspection of nasal mucosa after osteot-
omy. No injury to the mucosa is observed.
Ghassemi et al. Piezo Surgery for Osteotomy of Nasal Wall. J Oral
Maxillofac Surg 2013.
GHASSEMI ET AL e3

4. and from the condition of the lateral nasal wall. None
of the cadavers exhibited perforation of the nasal mu-
cosa (Fig 4). The examiners recorded 1 complete nasal
wall on each side, with small irregularities resembling
the tooth of the piezo scalpel. There was minimal loss
of bone material along the osteotomy line (Fig 5).
Discussion
Successful rhinoplasty is the result of controlled
changes in the nasal framework and its soft tissue cover.
Alterations and shaping of the nasal bony structure pres-
ent an ongoing challenge in esthetic and reconstructive
surgery.1
Numerous lateral osteotomy techniques
evolved in the previous century, incorporating the use
of different instruments from the saw to the chisel to
the diamond.2-7,19-21
Various modifications of available
techniques have been introduced to rhinoplasty
surgery to increase ease of performance, precision,
controllability, and reliability, on the one hand, and
reproducibility with low morbidity, on the other.
Despite the many previously described methods, it
remains difficult to perform osteotomies in such
a way as to provide esthetically pleasing and reliable re-
sults.Lateralosteotomyis associated with an increase in
hemorrhage, edema, and ecchymosis. This has been
substantiated byother studiesandcancontribute signif-
icantly to postoperative morbidity after rhinoplasty.2,5-9
Perforated lateral osteotomy preserves the support of
the periosteum and is supposed to decrease lateral
nasal wall collapse and minimize hemorrhages and
edema.5-7
However, this method is suspected of
causing comminuted fractures with irregular bony
fragments, which can cause postoperative esthetic
deformity.4
The perforating technique is reliable only
inthehandsofanexperiencedsurgeon,becauseitisdif-
ficult to direct and may need repeated passes.2,9
Murakami and Larrabee4
found more irregular osteoto-
mies and more soft tissue trauma when using the per-
cutaneous approach, and they preferred building
a subperiosteal tunnel and using an adequate technique
to ensure proper stability. In a cadaver study, Kuran
et al19
evaluated fracture line and mucosal injuries.
They found that a wide osteotome causes significantly
more mucosal injuries.
The piezo scalpel allows the cutting of a bony win-
dow into the maxilla without any laceration of the del-
icate mucosa of the maxillary sinus.13
Robiony et al17
introduced the piezo technique in rhinoplasty and em-
phasized the advantages of this method. They used an
external approach to insert the piezo scalpel. Although
soft tissue probably will not be lacerated by slight
touches, continuous irrigation would be difficult using
this approach. Robiony et al reported decreased bleed-
ing during surgery, minor edema, and periorbital ec-
chymosis immediately after surgery. The Piezosurgery
device offers effortless handling and requires very little
manual pressure.22
Moreover, it is an optimal tech-
nique for selectively cutting mineralized tissue.10
It al-
lows the exact placement and control of the tool tip
to cut along the desired path using micrometric move-
ment, and the piezo scalpel is armed with a peristaltic
pump for irrigation.14,16,22
Although this instrument
was originally developed for augmentation surgery in
the dentoalveolar field, there are different working
tips for currently available indications.11-17,22
The main purpose of this cadaver study was to
evaluate the quality of osteotomy when using the Pie-
zosurgery device. The newly designed piezo scalpel
allowed the osteotomy from an endonasal approach
and irrigation of the bone through a hole close to
the tip of the scalpel (Fig 2). Lateral osteotomy was
performed in 10 human cadaver noses (20 lateral
walls) according to the technique described earlier.
A 3-mm incision in the mobile mucosa of the pyri-
form aperture and narrow exposure of the osteotomy
site were sufficient to easily access the lateral nasal
wall. A short learning curve was necessary to become
familiar with the procedure. The exposure of bone
FIGURE 5. Osteotomy course after removal of soft tissue cover. A
very tiny tooth mark along the osteotomy path, caused by the tip
of the piezo scalpel, is depicted. The osteotomy course is regular,
which corresponds exactly to the path marked on the skin. There
is only 1 bony fragment without any comminuted fracture pattern.
Ghassemi et al. Piezo Surgery for Osteotomy of Nasal Wall. J Oral
Maxillofac Surg 2013.
e4 PIEZO SURGERY FOR OSTEOTOMY OF NASAL WALL

5. surface at the osteotomy site was less extensive than
with other methods. The line of osteotomy, which
had been marked on the skin along the nasofacial
crease, could be palpated and followed exactly
through the skin (Fig 3). The hand piece stopped
moving if any excessive force was used.22
It should
just be guided over the bone gently, as in piezo sur-
gery generally. It does not involve the risk of acciden-
tal dislocation of the osteotome and the course of
osteotomy can always be followed exactly as
planned.22
The sound of the cutting also can help
as acoustic feedback to guide the applied force.
The infracturing of the bony lateral wall can be ac-
complished with gentle pressure. The endoscopic ex-
amination along the osteotomy line showed a bone
ridge with spikes, similar to the tip of the scalpel,
but no major irregularity or comminuted fracture
(Fig 5). No tear of nasal mucosa was apparent
(Fig 4). The average time for incision and preparation
was 5 minutes after a learning curve in the first 2 os-
teotomies. No residual deformity, such as a bony
spur, was observed. The lateral nasal wall was ob-
served as a whole bone fragment, with some irregu-
larities of the bone edge caused by the tooth of the
piezo tool tip. The osteotomy part of the bone
showed signs of adequate irrigation and no sign of
heat development. The irrigation flowed through
the shaft of the scalpel to the tip. This had an addi-
tional cooling effect on the surrounding soft tissue
coverage (Fig 2). In some noses, the osteotomy
path was osteotomized incompletely. Nevertheless,
the infracturing could be performed easily. The re-
sulting osteotomy gap was approximately 0.5 mm.22
Because the use of piezo surgery does not cause any
soft tissue injury, minimal hemorrhage and ecchymosis
are expected postoperatively, as was shown clinically
by Robiony et al.17
The dissection of a narrow subper-
iosteal tunnel, combined with healthy and unlacerated
nasal mucosa, will hinder the collapse of the osteotom-
ized lateral nasal wall and thus decrease postoperative
edema and swelling.9
A precise and reproducible lateral
osteotomy can be performed, which is the requirement
for successful rhinoplasty. It can be controlled transcu-
taneouslytoperform theosteotomy inanexact planned
course. It makes this step easier to perform and more
controllable, with a predictable and consistent result.
This promotes faster healing and shortens postopera-
tive hospital stay.9
Because the bone thickness does
not exceed 3 mm at any point on the osteotomy lines,
piezo surgery is optimal for this procedure.19,23
In
addition, there is no need to cut through the entire
thickness of the nasal bone to infracture the nasal wall.
All kinds of osteotomies, such as transverse, median,
paramedian, and hump removal, also can be performed
as required. Although there is limited scarring from the
percutaneous approach, the concept of an external
incision conjures debate when an internal option
exists.2
Thisspeciallydesignedpiezoscalpelallowsanen-
donasal approach and thus avoids any risk of possible
scar formation.
The optimal technique for osteotomy should be safe,
precise, and reproducible, with minimal postoperative
ecchymosis and edema, and deliver a predictable re-
sult. The piezo scalpel is easy to handle and does not
cause any mucosa laceration; the osteotomy can be
performed exactly in the planned osteotomy track
and does not result in any comminuted fractures. It is
a nontraumatic and controllable alternative to known
osteotomy techniques. A learning curve may be neces-
sary, but it is a straightforward method to learn.
References
1. Thomas JR, Griner NR, Remmler DJ: Steps for a safer method of
osteotomy in rhinoplasty. Laryngoscope 97:746, 1987
2. Becker DG, McLaughlin RB, Loevner LA, et al: The lateral osteot-
omy in rhinoplasty: Clinical and radiographic rationale for osteo-
tome selection. Plast Reconstr Surg 105:1806, 2000
3. Harshbarger RJ, Sullivan P: The optimal medial osteotomy: A
study of nasal bone thickness and fracture patterns. Plast Re-
constr Surg 108:2114, 2001
4. Murakami CS, Larrabee WF: Comparison of osteotomy tech-
niques in the treatment of nasal fractures. Facial Plast Surg 8:
209, 1992
5. Goldfarb M, Gallups J, Gerwin J: Perforating osteotomies in rhi-
noplasty. Arch Otolaryngol Head Neck Surg 119:624, 1993
6. Rohrich RJ, Janis JE, Adams WP, et al: An update on the lateral
nasal osteotomy in rhinoplasty: An anatomic endoscopic com-
parison of the external versus the internal approach. Plast Re-
constr Surg 111:2461, 2003
7. Gryskiewicz JM, Gryskiewicz KM: Nasal osteotomies: A clinical
comparison of the perforating methods versus the continuous
technique. Plast Reconstr Surg 113:1445, 2004
8. Ford CN, Battaglia DG, Gentry LR: Preservation of periosteal at-
tachment in lateral osteotomy. Ann Plast Surg 13:107, 1984
9. Erisir F, Tahamiller R: Lateral osteotomies in rhinoplasty: A safer
and less traumatic method. Aesthet Surg J 28:518, 2008
10. Horton JE, Tarpley TM, Wood LD: The healing of surgical defects
in alveolar bone produced with ultrasonic instrumentation,
chisel, and rotary burr in the surgical removal of bone. Oral
Surg Oral Med Oral Pathol 39:536, 1975
11. Horton JE, Tarpley TM, Jacoway JR: Clinical applications of ultra-
sonic instrumentation in the surgical removal of bone. Oral Surg
Oral Med Oral Pathol 51:236, 1981
12. Sherman JA, Davies HT: UltracisionÒ: The harmonic scalpel and
its possible uses in maxillofacial surgery. Br J Oral Maxillofac
Surg 38:530, 2000
13. Vercelotti T, de Paoli S, Nevins M: The piezoelectric bony
window osteotomy and sinus membrane elevation: Introduc-
tion of a new technique for simplification of the sinus aug-
mentation procedure. Int J Periodontics Restorative Dent
21:561, 2001
14. Eggers G, Klein J, Blank J, et al: Piezosurgery: An ultrasound de-
vice for cutting bone and its use and limitations in maxillofacial
surgery. Br J Oral Maxillofac Surg 42:451, 2004
15. Gruber RM, Kramer FJ, Merten HA, et al: Ultrasonic surgery—An
alternative way in orthognathic surgery of the mandible. A pilot
study. Int J Oral Maxillofac Surg 34:590, 2005
16. Robiony M, Polini F, Costa F, et al: Piezoelectric bone cutting in
multipiece maxillary osteotomies. J Oral Maxillifac Surg 62:759,
2004
17. Robiony M, Toro C, Costa F, et al: Piezosurgery: A new
method for osteotomies in rhinoplasty. J Craniofac Surg 18:
1098, 2007
GHASSEMI ET AL e5

6. 18. Preti G, Martinasso G, Peirone B, et al: Cytokines and growth fac-
tors involved in the osseointegration of oral titanium implants
positioned using piezoelectric bone surgery versus a drill tech-
nique: A pilot study in minipigs. J Periodontol 78:716, 2007
19. Kuran I, Ozcan H, Usta A, et al: Comparison of four different
types of osteotomies for lateral osteotomy: A cadaver study. Aes-
thetic Plast Surg 20:323, 1996
20. Mottura AA: Internal lateral nasal osteotomy: Double-guarded os-
teotome and mucosa tearing. Aesthetic Plast Surg 35:171, 2011
21. Ghassemi A, Riediger D, H€olzle F, et al: The intraoral approach to
lateral osteotomy: The role of a diamond burr. Aesthetic Plast
Surg 37:135, 2013
22. Kramer FJ, Ludwig HC, Materna T, et al: Piezoelectric osteoto-
mies in craniofacial procedures. A series of 15 pediatric patients.
J Neurosurg 104:68, 2006
23. Harshbarger RJ, Sullivan PK: Lateral nasal osteotomies: Implica-
tions of bony thickness on fracture patterns. Ann Plast Surg 42:
370, 1999
e6 PIEZO SURGERY FOR OSTEOTOMY OF NASAL WALL