Double-Blind Comparison of Ultrasonic and Conventional Osteotomy in Terms of Early Postoperative Edema and Ecchymosis

The Effect of Topical Tranexamic Acid on Postrhinoplasty Periorbital Ecchymosis and Eyelid Edema

BACKGROUND

This study aimed to examine the effectiveness of topical tranexamic acid application in overcoming periorbital ecchymosis and eyelid edema in patients who have undergone open-technique rhinoplasty.

METHODS

Fifty patients were included in the study and divided into two groups: those who had topical tranexamic acid applied and those who did not (controls). In the tranexamic acid group, tranexamic acid-soaked pledgets were placed under the skin flap in a way that both sides could reach the osteotomy area and left for 5 minutes. In the control group, isotonic saline-soaked pledgets were placed under the skin flap in the same manner and left for 5 minutes. Digital photographs were obtained on postoperative days 1, 3, and 7. Eyelid edema and periorbital ecchymosis were scored by two different examiners and averaged for comparison.

RESULTS

Edema that developed in the patients who had tranexamic acid applied was significantly less than in the control group on postoperative day 1. There was no difference between the two groups on postoperative day 3 or 7. Ecchymosis that developed in patients who had tranexamic acid applied was significantly less than in the control group on all days.

CONCLUSIONS

Topical tranexamic acid applied to the surgical field immediately after osteotomy in rhinoplasty surgery reduces the development of postoperative periorbital ecchymosis. In addition, the topical tranexamic acid application also reduces the development of eyelid edema in the early postoperative period.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Effects of Two Different Cold Application Methods After Rhinoplasty: A Randomized Clinical Trial

The aim of this prospective, randomized controlled clinical trial was to evaluate the effects of two methods of cold application on eye ecchymosis, periorbital edema, pain around the eyes and face, and patient comfort in postoperative rhinoplasty patients. Patients were randomly divided and evaluated in two groups: an ice in disposable latex gloves (IDLG) group and a cooling gel eye mask (CGEM) group. We used the CONSORT checklist to report the study. There were no significant differences between the groups in terms of age, gender, preoperative blood pressure, respiration, fever status, oxygen saturation, or postoperative vital signs. Patients in the IDLG group had significantly higher scores for pain around the eyes, facial pain, and periorbital edema on the first postoperative day, and significantly higher facial edema scores during the first postoperative hour (p ≤ .05). Patients in the CGEM group reported that they slept more comfortably (p ≤ .05). The results of our study showed that CGEMs reduce pain, periorbital edema, and facial edema after rhinoplasty.

Evaluation of Periorbital Edema and Ecchymosis After Osteotomy in Septorhinoplasty Cases by Measuring Bone Density and Thickness

PURPOSE

Periorbital edema and ecchymosis that may occur after surgery in septorhinoplasty patients who have undergone lateral osteotomy are common morbidities and are seen as the main limiting factors for the recovery process of the patients. There are many different studies in the literature about the causes of periorbital edema and ecchymosis. In this study, the authors aimed to investigate the possible relationships between the bone density and bone thickness measured in the frontal process of the maxillary bone, and postoperative periorbital edema and ecchymosis, which are suitable for the osteotomy lines that they will detect in computerized tomography.

METHODS

Between January 1, 2019 and November 11, 2020, 59 patients whose nasal pathologies were determined by paranasal sinus computed tomography examination due to nasal deformity and nasal deformity and who underwent septorhinoplasty operation were included in this study. Bone density and thickness measurements were performed on the frontal process of the maxillary bone in accordance with the lateral osteotomy lines on the lateral nasal wall in each patient, right and left side. According to the bone density values measured at the point determined on the lateral osteotomy line, 2 groups were formed as "very dense" and "less dense." According to the bone thickness values of the patients, 2 groups were determined as "thick" and "thin." Thus, the authors investigated the relationship between periorbital edema and ecchymosis on the postoperative first, third, and seventh days obtained from the examination files of the patients.

FINDINGS

When bone density subgroups are examined, it has been shown that the degree of periorbital edema of the patients in the "very dense" and "less dense" group categories decreased from the first day to the seventh postoperative day. The degrees of periorbital edema on the third postoperative day were statistically higher in the "less dense" group than in the "very dense" group. In the authors' study, no correlation was found between the degrees of postoperative periorbital edema and ecchymosis and bone density subgroups on other days. While an increase was observed in the periorbital ecchymosis grades of the patients in the "less dense" subgroup category from the first day to the third postoperative day, the periorbital ecchymosis grades of the patients in the "very dense" subgroup category decreased from the first day to the third day. In both subgroups, the lowest periorbital ecchymosis levels were observed on the postoperative seventh day.When bone thickness subgroups are examined, it has been shown that the degree of periorbital edema of the patients in the "thick" and "thin" group categories decreases from the first day to the seventh day postoperatively. When the bone thickness subgroups were examined, the periorbital ecchymosis degrees of the patients in the "thick" and "thin" group categories increased on the third postoperative day, while it reached the lowest level on the postoperative seventh day. There was no significant difference between the first, third, and seventh-day periorbital edema and ecchymosis conditions in the "thick" and "thin" groups.

CONCLUSION

The authors observed that periorbital edema and ecchymosis that may occur after septorhinoplasty can be affected by the variable features of the lateral nasal wall bone structure. The authors conclude that the changes in the healing process can be affected by different bone density values in particular.

Advantages of a High-Powered Ultrasonic Vibration Cutting Device for Orthognathic Surgeries

This study aimed to evaluate the advantages of using a high-powered ultrasonic vibration cutting device (HP-UVCD) in orthognathic surgeries. We analyzed 22 consecutive patients who underwent Le FortⅠosteotomy and bilateral sagittal split osteotomies for cleft lip and palate. We used conventional power instruments, such as reciprocating saws and rotating burrs in the first 10 patients, and an HP-UVCD in the remaining 12 patients. Surgical time, intraoperative blood loss, and postoperative inferior alveolar nerve affection were retrospectively investigated. The surgical time in the ultrasonic group (223±12.217 min) was significantly shorter than that in the conventional group (278±11.153 min, P =0.008). The amount of intraoperative blood loss in the ultrasonic group was an average of 230±45.154 g, and that in the conventional group was an average of 343±49.463 g. Although the blood loss in the ultrasonic group was reduced compared with that in the conventional group, this difference was not statistically significant ( P =0.118). All patients in both groups recovered normal sensation by 6 months postoperatively. Our findings suggest that the HP-UVCD can be used in place of a reciprocating saw or rotating burrs in orthognathic surgeries, resulting in reduced surgical time and minimal blood loss. The use of an ultrasonic bone-cutting device may allow for a safer and less invasive orthognathic surgery.

Comparisons of Auditory and Vestibular Functions After Septorhinoplasty Performed with the Micro-compass Saw Technique and the Classical Technique

AIM

To evaluate hearing and labyrinth functions following different osteotomy types (micro-compass saw, osteotome, and no osteotomy) performed in septorhinoplasty operations.

MATERIAL AND METHOD

The study included 74 patients operated between January 2020 and March 2022, separated into 3 groups: Group 1: 24 patients (16 females and 8 males): osteotome was used for the osteotomy; Group 2: 24 patients (12 females and 12 males): micro-saw was used for osteotomy; and Group 3: 26 patients (17 females and 9 males): open technique septoplasty with no osteotomy. At 1 day before and 1 week after the operation, all the patients underwent audiological examination, tympanometry, vestibular evoked myogenic potentials (c-VEMP), video head impulse test (v-HIT), videonystagmography (VNG), and distortion product otoacoustic emission (DPOAE) tests.

RESULTS

In the c-VEMP tests, significant differences were determined between the groups in respect of N1, P1, and N1-P1 latencies and N1-P1 amplitudes before and after the operation. In the v-HIT test, the change in right-side posterior gain postoperatively was statistically significant in the micro-saw group (p<0.05). The postoperative right lateral canal values were determined to be statistically significantly increased in the micro-saw group compared to the osteotome group (p<0.05).

CONCLUSION

This is the only study in the literature to have determined vestibular effects with the evaluation of such a wide range of techniques. Previous studies in the literature have found no effect of osteotomy technique on the balance and hearing systems. The results of this study demonstrated that the preoperative and postoperative difference between the osteotomy techniques had an effect on the balance system. The change in the balance tests following an operation with classic osteotomy shows a greater predisposition to benign positional vertigo. In this sense, the micro-saw can be considered safer. Level of Evidence II This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reducing Postoperative Swelling, Edema, and Ecchymosis after Open Rhinoplasty Using Intranasal Drainage

Reducing postoperative strain on the patient after rhinoplasty is an important goal for the surgeon. Many strategies are described to reach that goal. One strategy is to remove blood from under the dissected soft tissue envelope by drains, before it can infiltrate the different layers causing ecchymosis, edema, and swelling. In our setting with wide degloving and using drains, we could show a significant reduction in ecchymosis on day 2 and 14 after surgery (p = 0.006 and p = 0.017). We also observed a significant effect for edema and general swelling on day 2 (p = 0.027 and p = 0.004), but this effect did not reach significance for these two parameters on day 14. And although the long-term effect needs to be assessed in the future, we found that using drains in open rhinoplasty with wide degloving is an easily applicable, cheap, and reproducible approach to reduce postoperative ecchymosis, edema, and swelling.

Postoperative Periorbital Edema and Ecchymosis After External Lateral Osteotomy "Comparing Conventional Osteotome and Piezo Scalpel in Rhinoplasty"

The piezo surgery was reported to cause minimal trauma to the soft tissue. The aim of this study was to compare the periorbital edema and ecchymosis after transcutaneous lateral osteotomy in rhinoplasty using 2-mm osteotome versus Piezo scalpel respectively. In a randomized clinical trial and split-mouth-design, we performed primary rhinoplasty in 15 patients (7 men, 8 women; age 18-35 years, mean age 26.6 ± 5.7 years). Transcutaneous lateral osteotomy was performed using a 2-mm osteotome on the one side and a piezo scalpel on the opposite side. We took digital photographs of the face on 1, 3, 7 and 14 postoperative days. Three examiners used a standard 5-point Kara-Gokalan scale to assess the early postoperative periorbital edema and ecchymosis on each side. We found more difficult to use the piezo scalpel via only one incision and found easier to use two stab incisions for inserting the piezo scalpel. The time spend for each osteotomy was similar (P > 0.05). The inter-observer agreement was high (> 0.676). The postoperative edema showed to be significantly different on day 1, 3 and 7 (P-value < 0.05), ecchymosis was much less on piezo side but not significantly. It was more difficult to use piezo scalpel via only one incision. The piezo scalpel showed to reduce the postoperative edema significantly and improved the ecchymosis. Swelling and bleeding could have crossed the midline and blurred the comparison of two sides. However, this is the best design to achieve the highest similarity in study condition. Level of Evidence Level I, therapeutic study.

Comparing the piezoelectric and conventional osteotome in rhinoplasty

IMPORTANCE

Edema affects outcomes in Rhinoplasty. Edema and bruising influences patient satisfaction in the perioperative period.

OBJECTIVE

A qualitative analysis of edema comparing piezoelectric and conventional osteotome, and a qualitative comparison of bruising between these methods.

DESIGN

A prospective cohort study of 31 aesthetic Rhinoplasty cases. Participants act as their own control measure. An osteotome is used on one side of the nasal bone and a piezoelectric is used contralaterally.

MAIN OUTCOMES AND MEASURES

Edema is calculated by comparing a pre and post-operative 3-D image with volumetric analysis. Ecchymosis is scored and compared.

RESULTS

The mean volume of the piezoelectric was 1.37 cc (SD 0.87) and the mean volume of the osteotome was 1.17 cc (SD 0.70) (0.19 absolute difference [95 % CI 0.3 to 0.35], p = 0.02). Bruising scores were 0.35 points lower for the piezoelectric arm (-0.35 absolute difference [95%CI -0.7 to 0.06], p < 0.01). This corresponded to 26 % of lateral piezo osteotomies having significant bruising compared to 38 % of the lateral osteotomies using the conventional technique.

CONCLUSION

There is a difference in postoperative edema and bruising with the piezoelectric and conventional osteotome for lateral osteoetomy in Rhinoplasty. There is more edema with the piezoelectric and more ecchymosis with the conventional osteotome.

ASSESSMENT OF THE EFFICIENCY OF PIEZOELECTRIC AND CLASSIC OSTEOTOMY WHEN PERFORMING SEPTORHINOPLASTY

OBJECTIVE

The aim: Comparison and analysis of the main intraoperative and postoperative results of piezoelectric and traditional osteotomy in septorhinoplasty.

PATIENTS AND METHODS

Materials and methods: Examination and treatment were carried out in 40 patients who were divided into two groups. The first included patients who underwent septorhinoplasty using a traditional osteotomy - 20 people (control group). In the second group of patients, piezoelectric surgery was used for septorhinoplasty. This research group consisted of 20 people. All patients of both groups underwent only primary septorhinoplasty by closed and open methods. Piezoelectric surgery was performed using a Japanese VarioSurg3 NSK piezotome.

RESULTS

Results: The research was conducted on the first day after surgery, 3 days and a week after treatment. The following indicators were evaluated: intraoperative complications (mucosa damage), postoperative complications: (swelling of the eyelids,periorbital ecchymoses, nasal secretion activity, inflammatory reaction of the nasal cavity, postoperative pain). Significantly fewer cases of mucosal damage were detected in the second study group compared to the first. And the severity of postoperative complications in the second group of patients who underwent septorhinoplasty with the help of a piezotome was statistically significantly (p<0.05) lower than in patients of the control group.

CONCLUSION

Conclusions: Piezoelectric surgery has a number of advantages over traditional osteotomy techniques, such as selectivity of impact on soft tissues, accuracy of bone destruction. Piezoelectric osteotomy during septorhinoplasty can reduce intra- and postoperative complications with statistical reliability.

A Comparison Between Piezosurgery and Conventional Osteotomies in Rhinoplasty on Post-Operative Oedema and Ecchymosis: A Systematic Review

Piezosurgery use has become increasingly prevalent in osteotomies. Piezoelectric ultrasound waves can cut bone effectively, and some studies have shown reduced post-operative morbidities compared to conventional osteotomies. Oedema and ecchymosis are common complications of rhinoplasty and can impact patient satisfaction, wound healing, and recovery. We aim to provide an up-to-date comparison of post-operative oedema and ecchymosis in piezosurgery and conventional osteotomies. A literature search was conducted using the following online libraries; Pubmed, Cochrane, Science Direct, and ISRCTN (International Standard Randomised Controlled Trial Number). English publications between 2015 and 2020 were included. A systematic review was completed, and a comparison of oedema and ecchymosis in piezosurgery and conventional osteotomies was examined alongside other outcomes such as pain, mucosal injury, and surgery time. Eight randomised controlled trials (RCTs) met our criteria with a combined total of 440 patients: 191 male and 249 female. Piezosurgery had statistically significant (p < 0.05) reduction in short-term oedema compared to conventional osteotomies in 75% of the papers included, and in 50% this persisted across the whole follow-up period. Similarly, ecchymosis scoring was initially statistically lower (p < 0.05) in piezosurgery in 87.5% of the RCTs, and in 75% this persisted across the whole follow-up period. A reduction in pain (p < 0.05) and mucosal injury (p < 0.05) was also seen in piezoelectric osteotomies. The length of surgery time varied. Piezoelectric osteotomies reduce oedema and ecchymosis compared to conventional osteotomies, in addition to improving pain and mucosal injury. However, disadvantages such as length of surgery time and cost have been reported. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Drainage tube use for the reduction of postoperative ecchymosis in rhinoplasty

BACKGROUND

Postoperative healing after rhinoplasty can have a negative impact on patient quality of life.

OBJECTIVES

In our study, we aimed to reduce postoperative edema and ecchymosis by applying a minidrain system. We evaluated this intervention's benefit on postoperative morbidity by observing the patient with left and right sides, intervention side and control side respectively.

METHODS

All surgeries were performed using a piezo device with an open technique septorhinoplasty. We only used a left-sided minidrain system through the osteotomy lines just in front of the piriform aperture for all patients with no other intervention on the right side of the same patient.

RESULTS

Use of a drain on the left side was associated with a statistically significant decrease in ecchymosis at postoperative day 7 (P<0.05).

CONCLUSIONS

We found that using a minidrain system through internal osteotomy lines was effective in reducing the amount of ecchymosis by day seven after surgery.

Piezosurgery versus Conventional Cutting Techniques in Craniofacial Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Despite its increasing use in craniofacial surgery, the evidence for piezosurgery over conventional bone-cutting techniques has not been critically appraised. The purpose of this systematic review and meta-analysis was to identify and assess the evidence that exists for the use of piezosurgery in craniofacial surgery.

METHODS

A systematic review was undertaken using a computerized search. Publication descriptors, methodologic details, and outcomes were extracted. Articles were assessed using the methodologic index for nonrandomized studies and Cochrane instruments. Random effects meta-analysis was completed.

RESULTS

Thirty-nine studies were included. Most studies were published within the past 5 years (51.3 percent) and were randomized controlled trials (56.4 percent). The mean age of patients was 27 years (range, 0.2 to 57 years), and the mean sample size was 44 (range, 12 to 180). Meta-analysis revealed that compared to conventional instruments, piezosurgery had a lower postoperative incidence of sensory disturbance, principally in mandibular procedures (OR, 0.29; 95 percent CI, 0.11 to 0.77; p = 0.01) and pain at postoperative day 3 (mean difference, -0.86; 95 percent CI, -1.20 to -0.53; p < 0.01). There was no statistically significant difference in operating room time (mean difference, 8.60; 95 percent CI, -1.27 to 18.47; p = 0.80) or osteotomy time (mean difference, 0.35; 95 percent CI, -2.99 to 3.68; p = 0.84). Most studies were clinically homogenous (92 percent) and of high quality based on the methodologic index for nonrandomized studies instrument (84 percent). Few studies had domains at high risk of bias based on the Cochrane instrument (28.6 percent).

CONCLUSIONS

Piezosurgery has considerable benefits when compared to conventional instruments. Future studies should investigate its cost-effectiveness and benefits in terms of blood loss, edema/ecchymosis, and patient satisfaction.

Endoscopic Lateral Osteotomy in Rhinoplasty

OBJECTIVES

The purpose of this study was to investigate the advantages of endoscopic lateral osteotomy, to evaluate the effects of the periosteal elevation on ecchymosis and to search the reasons for the ecchymosis and the intranasal mucosal tears.

METHODS

On a randomly chosen side a subperiosteal tunnel was elevated, on the other side a subperiosteal tunnel was not elevated. Bilateral lateral osteotomies were performed. Internal nasal packing was not used. The post-operative care was similar for all patients. The patients were evaluated on the third post-operative day. The intranasal mucosal tears, the lateral osteotomy cut on the periosteal elevation side were examined using endoscopes. The degree of ecchymosis was determined by 2 other surgeons, who were unaware of the elevated side, using the grading system adapted from Hoffman et al.

RESULTS

The intranasal mucosal injury was seen in 16 of non-elevated side whereas it was 14 on the periosteal elevated side. Endoscopy showed the perforating arteries and elevation of the periosteum caused rupture and oozing from these arteries which might be a cause for ecchymosis. Ecchymosis was more severe on the side with subperiosteal tunnel in 6 patients; whereas only in 2 patients it was more severe on the side with no subperiosteal tunnel elevation while in 12 patients the degree of ecchymosis was the same on both sides.

CONCLUSION

Endoscopy gives a great opportunity to visualize the lateral osteotomy site. Besides the lateral osteotomy cut, the arteries and the intranasal mucosal injury can be visualized. Periost elevation increases the severity of ecchymosis due to the rupture of the perforating arteries, not due to the trauma of the angular artery. Intramucosal tears do not increase the severity of the ecchymosis.

Endoscopic Sphenopalatine Ganglion Block Efficacy in the Management of Periorbital Edema and Ecchymosis After Septorhinoplasty

AIM

This study aims to evaluate the efficacy of sphenopalatine ganglion block (SPGB) on postoperative edema and ecchymosis for the patients undergoing septorhinoplasty (SRP).

METHODS

In the study, a total number of 55 participant patients (40% male and 60% female, aged between 18 and 42 years) undergoing hump resection and osteotomies were allocated into 2 groups. The SPGB (+) group consisted of 27 patients who underwent SPGB, while the SPGB (-) group consisted of 28 patients who underwent SRP without SPGB. On the first, third, and seventh postoperative days (POD1, POD3, POD7), the score marks of periorbital edema and ecchymosis of the patients were evaluated. Additionally, postoperative upper eyelid edema and upper eyelid ecchymosis as well as lower eyelid edema, and lower eyelid ecchymosis on POD1, POD3, POD7 were evaluated. A comparison with regard to intraoperative bleeding, surgical field, and operation time between the 2 groups was also conducted.

RESULTS

Upper eyelid edema, upper eyelid ecchymosis, lower eyelid edema, lower eyelid ecchymosis on POD 1, 3, 7 were found to be significantly lower in SPGB (+) group in comparison to SPGB (-) group (P < 0.001). Intraoperative blood loss and surgical field were found to be significantly lower in SPGB group (+) than in SPGB (-) group (P < 0.00). The operation time was not found statistically significant between the 2 groups (P = 0.212).

CONCLUSION

Sphenopalatine ganglion block is a safe and effective way of reducing postoperative edema and ecchymosis after SRP. Besides, it provides a better surgical field and reduced bleeding intraoperatively.

Modalities of Post-Rhinoplasty Edema and Ecchymosis Measurement: A Systematic Review

Background:

Post-rhinoplasty edema and ecchymosis can influence patient satisfaction with surgery as well as result in poor quality of life. Methods to quantify such edema and ecchymosis have been described in the literature. Despite this, there is currently no collective understanding of which methods are the most effective. Hence, this systematic review aims to describe and analyze the literature on post-rhinoplasty edema and ecchymosis measurement techniques.

Methods:

Standard bibliographic databases (OVID Medline, EMBASE, and PubMed) were searched from their inception to December 2019 for the terms: “rhinoplasty”, “postoperative”, “edema”, and “ecchymosis”. Descriptive analysis was completed.

Results:

The search revealed 1116 articles of which 33 met inclusion criteria and were included for qualitative synthesis. A total of 1801 patients from all studies were included. Of the 33 included studies, there were 57 unique ecchymosis/edema measurements. The majority of studies measured edema/ecchymosis on post-operative day 1, 2, 3 and 7. Ninety-three percent of measurements described were taken subjectively from a human rater. Other techniques described included magnetic resonance imaging, ultrasound, 3-dimensional imaging, and digital analysis. Less than half of the subjective ecchymosis/edema gradings were completed by a blinded rater.

Conclusion:

There are a wide variety of post-rhinoplasty edema and ecchymosis techniques being used by rhinoplasty surgeons. The majority of post-rhinoplasty edema and ecchymosis measurements are completed by unblinded subjective raters. It is important that facial plastic surgeons select an accurate measurement tool so they may be able to initiate precise patient-specific management of edema and ecchymosis.

Surgical Burr-Assisted Lateral Osteotomy Technique in Septorhinoplasty

ABSTRACT

Achieving aesthetic and functional results in rhinoplasty requires meticulous techniques, and postoperative edema, ecchymosis, and pain can deteriorate the desired outcomes. Different osteotomy techniques are defined to have optimal outcomes while reducing edema, ecchymosis, and pain. In this study, the authors compared conventional and power-assisted surgical burr osteotomy techniques in terms of early postoperative complications. Patients who underwent primary open septorhinoplasty were included in the study and were divided into 2 groups. The first group had lateral endonasal osteotomy with conventional guided osteotomes, and the second group had lateral osteotomy with surgical round burr. Edema and ecchymosis scoring systems were used on the postoperative first, third, and seventh day to evaluate postoperative edema and ecchymosis, and the visual analog scale was used to evaluate pain severity on the postoperative period. Out of 70 patients who had undergone septorhinoplasty, 36 received conventional osteotomy and 34 received surgical round burr osteotomy. Periorbital ecchymosis scores were significantly lower in the second group on the postoperative first, third, and seventh days. The periorbital edema scores were significantly lower in the second group on the first postoperative day but no difference was found between postoperative days 3 and 7. Also, the pain scores were significantly lower in the second group. Osteotomy with surgical round burr yields less ecchymosis, edema, and pain in the early postoperative period than conventional osteotomy in primary septorhinoplasty patients.

Comparison of Early and Long-Term Effects of Piezosurgery With Conventional Techniques for Osteotomies in Rhinoplasty

OBJECTIVE

Osteotomy is a critical step of rhinoplasty. Various osteotomy techniques have been developed to reduce postoperative edema and ecchymosis and achieve optimal aesthetic results. In this study, we aimed to compare the early and long-term effects of piezoelectric surgery with conventional osteotomy.

METHODS

In this prospective study, 72 rhinoplasty patients were randomly divided into 2 groups according to osteotomy technique used, either conventional osteotomy or piezosurgery. These 2 groups were compared for postoperative edema, ecchymosis, and pain on the first and seventh postoperative days. The sinonasal outcome test-22 (SNOT-22), peak nasal flowmetry, and Connecticut Chemosensory Clinical Research Center test were applied to all patients before and 8 weeks after surgery.

RESULTS

The study consisted of 72 patients, 42 of whom were female and 30 were male. The mean age was 28.1 ± 6.5 (range 18-49 years). On the first postoperative day, edema and ecchymosis were significantly less in the piezosurgery group (P < 0.001). VAS results showed that only the piezosurgery group experienced less pain on the first postoperative day (P < 0.001). Nasal airflow of the patients was evaluated preoperatively and postoperatively, nasal airflow decreased postoperatively in both groups, but this decrease was not statistically significant, and no significant difference was found between the groups. The preoperative and postoperative comparison of odor functions was similar in both groups after the operation, and there was no significant difference between the groups.

CONCLUSION

Piezosurgery in the early period after rhinoplasty has been shown to decrease eyelid edema, periorbital ecchymosis, and pain compared to conventional osteotomy techniques. However, the superiority of piezosurgery in terms of nasal airflow, olfactory functions and quality of life were not found in the long term.

Effects of Periosteal Elevation Before Lateral Osteotomy in Rhinoplasty: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

Although osteotomy is an important part of rhinoplasty, it is known to be closely related to postoperative eyelid edema and ecchymosis. We aimed to evaluate the effects of periosteal elevation prior to osteotomy on eyelid edema and ecchymosis.

METHODS

Two authors reviewed studies in the Medline, Scopus, and Cochrane databases published through May 2019. Randomized controlled trials comparing periosteal elevation (subperiosteal tunneling) with periosteal preservation that reported eyelid edema or ecchymosis or subconjunctival hemorrhage as outcomes of interest were included. From each study, the baseline characteristics of the study subjects, the quality of the study, the number of patients in the treatment and control groups, and outcomes were extracted.

RESULTS

Data for meta-analysis were identified in six studies with a total of 208 patients. Eyelid ecchymosis and edema within 3 days postoperatively were significantly more common in the periosteal elevation group than in the preservation group, although such an association was not found for edema on postoperative day 7 (standardized mean difference [SMD], 0.21; 95% confidence interval [CI], -0.09 to 0.50; I2 =0%). There was no significant difference in subconjunctival hemorrhage on day 1 (SMD, 0.31; 95% CI, -0.09 to 0.72; I2 =0%).

CONCLUSION

Periosteal preservation during lateral osteotomy may reduce eyelid edema and ecchymosis compared to periosteal elevation. Further studies with rigorous research methods should be carried out to determine the effectiveness of different techniques in lateral osteotomy.

Method of Lateral Osteotomy to Reduce Eyelid Edema and Ecchymosis After Rhinoplasty: A Meta-analysis

OBJECTIVES

Although lateral osteotomy is an important part of rhinoplasty, it is known to be closely associated with postoperative eyelid edema and ecchymosis after rhinoplasty. There is no consensus on which osteotomy methods are effective in reducing morbidity from rhinoplasty. This study compared the effects of different osteotomy methods on edema and ecchymosis after lateral osteotomy using a meta-analysis.

STUDY DESIGN

A literature search using MEDLINE, SCOPUS, and Cochrane databases.

METHODS

Two authors independently reviewed the databases published until May 2019. Randomized controlled trials that compared lateral osteotomy methods (external approach) with different methods (internal approach), for which the outcomes of interest were mucosal injury, edema, and ecchymosis on postoperative days, were included. Sufficient data for meta-analysis was found in six studies with a total of 224 patients.

RESULTS

In a comparison of the external approach with the internal approach, mucosal injury was significantly lower in the external approach (odds ratio = 0.41; 95% confidence interval = [0.11; 0.99], I² = 29%). There were significant differences between the external and internal approach in eyelid ecchymosis and edema, except for eyelid ecchymosis at 7 days postoperatively. However, all significant results showed a small effect size with a standardized mean difference near 0.2.

CONCLUSIONS

The external approach during lateral osteotomy had no significant advantage in edema and ecchymosis compared to the internal approach. Further studies with good research methodology should be carried out to determine the effect on the postoperative complications of different lateral osteotomy methods. Laryngoscope, 131:54-58, 2021.

Reporting Outcomes and Outcome Measures in Open Rhinoplasty: A Systematic Review

BACKGROUND

Comparative studies have shown little statistical difference in outcomes following rhinoplasty, demonstrating near equivalent results across all surgical techniques. Cross-study comparisons of these trials are difficult because variation in outcome reporting prevents statistical pooling and analysis.

OBJECTIVES

The authors sought to identify all outcomes and outcome measures used to evaluate postoperative results in rhinoplasty.

METHODS

An extensive computerized database search of MEDLINE and EMBASE was performed; all trials involving n ≥ 20 patients, aged 18 years and older undergoing a primary, open rhinoplasty procedure, were included for review.

RESULTS

Of the 3235 citations initially screened, 72 studies met the stated inclusion criteria. A total of 53 unique outcomes and 55 postoperative outcome measures were identified. Outcomes were divided into 6 unique domains: objective signs, subjective symptom severity, physical function related to activities of daily living, patient satisfaction, surgeon satisfaction, and quality of life. The identified outcome measures consisted of 5 nasal-specific, author-reported instruments; 5 nasal specific, patient-reported instruments; 5 patient-reported, generic instruments; and 40 author-generated instruments. Of the outcome measures identified, the Rhinoplasty Outcomes Evaluation, Sino-Nasal Outcome Test-22, and FACE-Q were the only instruments to demonstrate adequate validity, reliability, and responsiveness to change in patients who underwent a rhinoplasty procedure.

CONCLUSIONS

There is heterogeneity in the outcomes and outcome measures employed to assess postsurgical outcomes following rhinoplasty. A standardized core outcome set is urgently needed to make it possible for future investigators to compare results of various techniques in rhinoplasty surgery.

LEVEL OF EVIDENCE: 2

Is Piezoelectric Surgery Really Harmless to Soft Tissue?

AIM

The aim of this study was to investigate the effect of piezoelectric surgery (piezosurgery) on soft tissue in open septorhinoplasty.

METHODS

A total of 30 patients (21 females, 9 males; mean age 29.16 ± 8.17 years; range, 18-43 years) who underwent open septorhinoplasty between January 2019 and February 2019 were randomly divided into 2 groups. After the nasal dorsum was opened in all groups, 1 mm tissue under the skin in radix region was taken as punch biopsy. In the first group (classical group, n =  15), the cartilage hump was resected with number 15 scalpel and the bone hump with the help of a chisel. Lateral and median osteotomies were conducted using 4 mm sharp osteotomes. Rasping was performed to dorsum to correct bone deformities. Then, 1 mm punch biopsy was taken from under the skin tissue of the nose back near the radix. In the second group (piezo group, n = 15) hump excision, osteotomies and rasping were performed by piezoelectric surgery. Then, 1 mm punch biopsy was taken from the subcutaneous tissue of the nose back near the radix. Biopsies were examined histopathologically in the light microscope for edema, necrosis, and inflammation.

RESULTS

Of the 30 patients presented in this series, 21 were female and 9 were male. In the classical group, edema in the soft tissue was seen in 86.7% of the cases after osteotomy, while this rate was 26.7% in the piezosurgery group. The difference was statistically significant (P < 0.05). Although necrosis was not seen prior to the osteotomy in both groups, the rate of necrosis in the classical group was 13.3% and in the piezo group it was 66.7%. Necrosis was significantly different in the piezosurgery group compared with the classical osteotomy group (P < 0.05).

CONCLUSION

Piezosurgery is not completely harmless to soft tissue. A statistically significant increase in subcutaneous necrosis compared with the classical group can be explained by long-term soft tissue trauma caused by piezoelectric vibrations. We think that developing necrosis may cause problems in late period, especially in patients with thin skin.

[Advantages of piezoelectric technology in rhinoplasty]

BACKGROUND

Facial plastic and reconstructive surgery requires delicate, atraumatic handling of cartilage, bone and the surrounding soft tissue. Piezoelectric instrumentation (PEI) has previously been shown to be a precise and safe surgical instrument in rhinoplasty. It offers good preservation of surrounding soft tissue and high cutting precision and thus a good surgical applicability in rhinoplasty.

OBJECTIVE

This article presents experiences using PEI for cartilage preparation and modelling for various indications in facial plastic surgery. The use of PEI in rhinoplasty, its safety and preciseness were evaluated and postoperative results are discussed with respect to facial swelling and bruising.

MATERIAL AND METHODS

This retrospective study included 35 patients undergoing rhinoplasty and follow-up. Surgery was conducted by two expert surgeons in rhinoplasty in the department of otorhinolaryngology at the University Clinic of LMU Munich. Surgical performance of PEI in comparison with conventional instruments was evaluated by a customized questionnaire. The postoperative assessment of pain, facial swelling and bruising was documented.

RESULTS

This article presents the different options for the use of PEI in rhinoplasty. In bone modelling procedures, such as hump removal, osteotomy and bony fixations, PEI was evaluated as being superior to conventional instruments. Intraoperative bleeding was reduced, which led to reduced facial swelling and/or bruising. Postoperative pain assessment showed no or only mild pain in two thirds of the patients.

CONCLUSION

The results show that PEI enables a safe and very precise operation. Further development of surgical inserts will enable new surgical steps and facilitate the handling.

Piezoelectric Drilling Hole Technique in Septal Fixation

OBJECTIVES

The act of securing the septum to the midline is very important for the success of the operation during septoplasty and septorhinoplasty operations. The authors' aim in this study is to open a hole in the anterior nasal spine with the Piezoelectric drilling hole technique so as to fix the septum to the midline with a suture passing through that hole.

METHODS

Patients with anterior segmental deviation on whom we performed septoplasty or closed technique septorhinoplasty were included in the study. The patients were divided into 2 groups, as the Classic and Piezo Groups. A total of 63 patients were included in the study; in the Classic Group, we performed septum fixation with suture of the nasal spine to the mucoperiosteum in 27 patients; whereas in the Piezo Group, fixation was performed on 36 patients using the piezo-surgical suture through a nasal spinal opening. Patients were assessed preoperatively and postoperatively by VAS and NOSE scores, and also by postoperative examinations.

RESULTS

Preoperative and postoperative VAS-NOSE scores were found to be statistically significantly different in both groups (P < 0.0001, P < 0.0001). Redeviation with no need for revision surgery was reported to develop in 1 patient of the classical group (3.7%).

CONCLUSION

Piezoelectric drilling hole technique provides stronger fixation in the midline and prevents postoperative redeviation. Its most important superiority over the other methods used in fixing the septum to the nasal spine is its ability to provide adequate stabilization without damaging soft tissue.

Evaluation of Surgical Outcome in Rhinoplasty: A Comparison Between Rasp and Osteotome in Dorsal Hump Removal

Dorsal hump reduction is a crucial point of rhinoplasty, as it has a great impact on the final shape of nasal pyramid. Depending on morphological features of the hump, its removal is usually obtained by the use of an osteotome or a rasp. In our study, we describe a closed rhinoplasty technique performed in 2 groups of patients: the only difference between the groups is the surgical tools used during the dorsal hump removal phase (rasp vs the 5-mm osteotome).We used 2 questionnaires of quality of life (QoL), Nasal Obstruction Symptom Evaluation (NOSE), and Rhinoplasty Outcome Evaluation (ROE) questionnaire, to evaluate postoperative outcome (6 months after surgery).Closed rhinoplasty was performed in 107 patients. Dorsal hump removal was carried out with rasp on 35 patients; while in 72 cases, it was performed using a 5-mm osteotome. All the patients were given 2 copies of NOSE and ROE questionnaires (1 month before surgery and 6 months after surgery) to evaluate postoperative QoL. In our study emerged that the use of osteotome in dorsal hump reduction is associated with a better aesthetic outcome (evaluated by analyzing patients QoL with ROE questionnaire) without any difference between the 2 groups in terms of functional outcome (expressed by NOSE questionnaire), major and minor complications and surgical procedure duration.

Is Nasal Skin Thickness a Prognostic Indicator to Postoperative Edema and Ecchymosis?

BACKGROUND

The size, shape, and symmetry of the nose contribute significantly to the facial aesthetic, so it is understandable why rhinoplasty is one of the most popular cosmetic procedures undertaken nowadays. Several factors are associated with the rates of both success and postoperative complications of rhinoplasty.

AIM

To determine the relationship between nasal skin thickness and postoperative periorbital ecchymosis and edema among patients who underwent rhinoplasty at King Abdulaziz University Hospital.

METHODOLOGY

A prospective study was conducted among all patients operated on for rhinoplasty at King Abdulaziz University Hospital in the Department of Otolaryngology, Riyadh, Saudi Arabia, between May and December 2018. To determine the relationship between nasal skin thickness and postoperative periorbital edema and ecchymosis, demographic data (gender, age), mean nasal skin thickness, surgical factors (time of surgery, extent of intraoperative bleeding), and scoring for periorbital ecchymosis and edema were obtained. The statistical analysis was done by comparing means and frequency using analysis of variance.

RESULTS

A total of 54 patients participated in this study with ages ranging from 19 to 33 years and a mean age of 24.43. According to this study, postoperative edema presentation on the first, third, and seventh days upon examination was higher among patients with thicker nasal skin (6 mm), and results are statistically significant (P = .001). Ecchymosis was also higher among patients with thicker nasal skin (6 mm) on day 1 examinations, but there was no correlation with nasal thickness during the other examinations. Therefore, there is some degree of correlation between ecchymosis and nasal skin thickness overall, but the results are not significant (P = .26).

CONCLUSION

This study concludes that the severity of edema and ecchymosis correlates with nasal skin thickness. The degree of edema and ecchymosis was higher during the initial postoperative examinations, but following that, it was reduced and completely diminished by the 21st day post-surgery.

[Comparison of piezoelectric and conventional osteotomy in rhinoplasty : A systematic review]

BACKGROUND

Postoperative periorbital edema and ecchymosis after rhinoplasty are mainly caused by the osteotomy with hammer and chisel. The introduction of piezoelectric surgery could lead to a better early postoperative outcome due to improved preservation of soft tissues. The aim of this systematic review was to evaluate the methods and results of studies comparing conventional osteotomy to piezoelectric osteotomy.

METHODS

A systematic literature search was conducted in the PubMed/MEDLINE and Google Scholar databases. In the primary selection, all studies on the comparison of conventional and piezoelectric osteotomies with regard to postoperative periorbital edema and/or ecchymosis were identified. Secondary selection included only study designs with a control group.

RESULTS

Primary selection resulted in 15 thematically relevant publications with a notable increase in annual publications between 2007 and 2017. Six studies with control groups were selected secondarily. Qualitatively and methodologically, the studies were very heterogeneous. The results of five of the six studies indicated a significant advantage of piezo technology compared to conventional osteotomy. Only in one study was no significant difference found in the investigated postoperative outcome.

CONCLUSION

Piezoelectric osteotomy resulted in a reduced propensity for postoperative edema and ecchymosis compared to the conventional osteotomy technique with a chisel. At this time, the results should be regarded as a trend. A definite recommendation favoring piezoelectric osteotomy cannot be made until more studies with higher patient numbers become available.

Supercooled Liquid Serum Physiologic Solution Instantly Crystallized on the Nurse Table Used for Cooling of Periorbital Region During Rhinoplasty

INTRODUCTION

Formation of less periorbital ecchymosis in post-operative period of rhinoplasty is a popular trend. We present the use of instantly crystallizing supercooled serum physiologic solution for periorbital cooling.

PHYSICS OF SUPERCOOLING

There are circumstances in which water temperature drops below its freezing point, but no phase transition happens while water remains in the liquid phase. This is called supercooling. Pure water can be supercooled below the freezing temperature without transforming into ice. Tap water will not supercool because it contains impurities that serve as nucleation sites for crystallization. For freezer temperatures in the range of - 4 °C, - 6 °C, and - 8 °C, nucleation was not observed and pure water remained in the supercooled condition for a long time.

DESCRIPTION OF THE TECHNIQUE

Sterile serum physiologic solution at + 5 °C can be supercooled in the freezer at - 14 °C only between the 257 and 277 min time interval. But when it is supercooled in the freezer at - 8 °C it is possible to save it in liquid form for at least 7 days as we have observed in our trials.

CLINICAL USE AND DISCUSSION

It is easily possible to transform this supercooled liquid sterile serum physiologic within a few seconds into moldable snow-like ice that can be used safely and more nicely rather than solid ice for periorbital cooling in rhinoplasty operations. Its sterile inner bag is held tight and struck over the sterile nurse table and it crystallizes within a few seconds. For frozen solutions, tearing of the inner plastic bag and extracting the ice and then crushing of big masses of ice to small pieces is exhaustive and a time-consuming process. The temperature of the supercooled fluid will be zero at the moment of nucleation with no risk of frostbite. The crystallized serum physiologic solution preserves its ice-gel form for nearly 25 min.

CONCLUSION

The instant crystallization of supercooled liquid serum physiologic solution can be applied as a tissue cooling method in rhinoplasty and in several other surgical procedures.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effect of Piezoelectric Technique on Auditory Function on Postoperative Day One in Septorhinoplasty Surgery

AIM

To examine the effect of the piezoelectric application used increasingly for osteotomy and correction of nasal dorsum in septorhinoplasty surgeries on early auditory functions.

METHODS

Our study was conducted after the decision of 10840098-604.01.01-E.9057 taken from Istanbul Medipol University Clinical Research Local Ethics Committee. This study was designed to be prospective, randomized and controlled. Twenty patients between 18 and 50 years of age that piezoelectric technique was used in the study group and 10 patients in the same age range who underwent nasal surgery (endoscopic sinus surgery, septoplasty, lower concha radiofrequency and nasal valve surgery) for any reason in the control group were included in the study. Audiologic functions of the patients in both the groups were assessed by pure audio audiometry, tympanometry and distortion product otoacoustic emission test before the surgery and 24 hours after the surgery. The data obtained were statistically compared using the SPSS 22.0 program and P < 0.05 was considered significant.

RESULTS

Twenty patients (5 males, 15 females) that piezoelectric (ultrasonics) technique was used during septorhinoplasty in the study group and 10 patients (5 males, 5 females) in the control group were included in the study. In the study and the control groups, preoperative and postoperative air/bone path thresholds at the right and left ears did not differ significantly (P > 0.05) at 250, 500, 1000, 2000, 4000, 6000, and 8000 Hz. The results of distortion product otoacoustic emission results (signal/noise ratio) obtained postoperatively were not statistically significant (P > 0.05) with the results obtained preoperatively.

CONCLUSION

The results of the study show that the piezoelectric technique used in septorhinoplasty does not cause a negative effect on auditory functions. This study is the first comparative study to investigate the effect of piezoelectric technique used in septorhinoplasty surgery on auditory functions. After further clinical studies performed with well-selected and large patient population, the piezoelectric techniques can be a preferred technique during septorhinoplasty operations.

Comparison of edema and ecchymosis in rhinoplasty candidates after lateral nasal osteotomy using piezosurgery and external osteotomy

Rhinoplasty is done with external and endonasal methods. One of the main stages of rhinoplasty in both external and endonasal methods is the lateral nasal osteotomy. Lateral nasal osteotomy is the main cause of edema and ecchymosis after rhinoplasty, which is annoying and unpleasant for patients. Piezosurgery is a new method that uses electronic-ultrasonic waves to perform nasal osteotomies. The aim of this study was to compare of edema and ecchymosis after lateral nasal osteotomy using piezosurgery with external osteotomy in rhinoplasty candidates. In this clinical trial, 66 experimental patients for rhinoplasty surgery were selected from Imam Reza hospital in Tabriz, Iran. After examination, the patients were randomly divided into two groups. One group of patients had lateral nasal osteotomy by using the piezosurgery technique, and the other group had a lateral osteotomy with the conventional method of external subcutaneous. On the third and 7 days after the operation, the level of edema and ecchymosis in the patients were examined as per the Gökalan questionnaire (adopted by Yucel) by two persons who were not aware of the goals of the study, and then, they evaluated and scored the questionnaire. The obtained data were analyzed by the SPSS 19 software. The highest level of edema and ecchymosis was observed 3 days after surgery in both groups. Meanwhile, the findings revealed a significant difference between the two groups in the amount of edema and ecchymosis on day 3 after surgery. Furthermore on day 7, the amount of edema and ecchymosis compared to that of the 3rd day was statistically significant for both groups. In general, in all studied groups, edema, and ecchymosis decreased in 7 days compared to 3 days and also piezosurgery is more promising and effective than osteotomy.

Reassessing Surgical Management of the Bony Vault in Rhinoplasty

LEVEL OF EVIDENCE 5

A comparison of piezosurgery with conventional techniques for internal osteotomy

To compare conventional osteotomy with the piezosurgery medical device, in terms of postoperative edema, ecchymosis, pain, operation time, and mucosal integrity, in rhinoplasty patients. In this prospective study, 49 rhinoplasty patients were randomly divided into two groups according to osteotomy technique used, either conventional osteotomy or piezosurgery. For all patients, the total duration of the operation was recorded, and photographs were taken and scored for ecchymosis and edema on postoperative days 2, 4, and 7. In addition, pain level was evaluated on postoperative day 2, and mucosal integrity was assessed on day 4. All scoring and evaluation was conducted by a physician who was blinded to the osteotomy procedure. In the piezosurgery group, edema scores on postoperative day 2 and ecchymosis scores on postoperative days 2, 4, and 7 were significantly lower than in the conventional osteotomy group (p < 0.05). On postoperative day 2, the pain level was lower in the piezosurgery group than in the conventional osteotomy group (p < 0.05). In an endoscopic examination on postoperative day 4, while 24% of the patients in the conventional osteotomy group had mucosal damage, no such damage was observed in the piezosurgery group. When total operation duration was compared, there was no significant difference between the groups (p > 0.05). Piezosurgery is a safe osteotomy method, with less edema (in the early postoperative period) and ecchymosis compared with conventional osteotomy, as well as less pain, a similar operation duration, and no mucosal damage.

The comparison of edema and ecchymosis after piezoelectric and conventional osteotomy in rhinoplasty

The basic aim of our study is to compare the results of the conventional and piezoelectric osteotomy in rhinoplasty by complete subperiosteal degloving of nasal bone to minimize soft-tissue injury. The study was designed as a prospective, double-blind, randomized, and controlled study. Setting is a tertiary referral hospital in Turkey. Ninety patients who underwent primary open rhinoplasty with osteotomy, performed by either the conventional instruments or the piezoelectric device. The complete subperiosteal degloving of the entire nasal bone was done up to the nasal maxillary sulcus, medial canthus, and nasion in all patients, independent of the type of osteotomy device used. Patients subsequently underwent median-oblique and lateral osteotomy, either with an ultrasonic device or a conventional 2-mm guarded, straight osteotome. The postoperative edema and ecchymosis were evaluated by another surgeon who was blinded to the osteotomy procedure on postoperative days 2 and 7. The edema scores were significantly increased on the second day compared with the seventh day in both groups 1 and 2. However, there was no significant difference between groups. The ecchymosis scores were slightly higher in postoperative day 2, compared with day 7, in both groups 1 and 2, but statistically not significant. This study showed that the main reason edema and ecchymosis are seen post-rhinoplasty is related to soft-tissue injury during osteotomy.