Commentary on: Reassessing Surgical Management of the Bony Vault in Rhinoplasty

Commentary on: Reassessing Surgical Management of the Bony Vault in Rhinoplasty In this paper, the authors have redefined the pertinent surgical anatomy of the bony nasal vault.1 Their observations are not only impactful from a technical point of view but also help to justify the introduction of a new method of managing the bony nasal vault. Their description of the “bony cap” over the osseous nasal vault improves the surgeons understanding of the relationship between the cartilaginous vault and bony vault. The authors note that the nasal hump results from the anterior movement of the cartilaginous vault, pushing the bony cap forward. The authors state, “Thus, there is no bony hump, only a bony cap that covers a cartilaginous hump.” Their anatomic observations more accurately represent the bony nasal vault that we see clinically. The authors provide an elegant description of the 3-dimensional contours of the bony vault. They describe the asymmetries of the nasal bones structures which they note as universal. With the wider exposure of the bony vault, these asymmetries are seen, and the authors are then compelled to treat these asymmetries. With conventional osteotomies using limited dissection and limited visualization of the actual nasal bone contour, most experienced rhinoplasty surgeons are still able to achieve good alignment of the nasal bones with adequate narrowing. With conventional techniques, the surgeon is almost exclusively manipulating external contour and not reacting to defects seen when the bones are completely exposed. By keeping the skin and periosteum attached to the underlying bone, changes in bony vault contour are relatively predictable. Of course this leads us to the question, how do treating these asymmetries impact the final outcome of management of the bony vault? Are the outcomes improved? Will this wide field dissection create a paradigm shift similar to the move from endonasal rhinoplasty to open rhinoplasty? With the wide field dissection necessary when using Piezo instrumentation, the soft tissue (skin and periosteum) must redrape over the modified bony vault after bony manipulation is completed. This may introduce a new variable that can complicate the operation and impact outcomes. With conventional osteotomies, the attachments of the periosteum over the nasal bones acts to prevent collapse of the nasal bones. What is the potential for destabilization of the nasal bones after complete osteotomies in combination with a wide field dissection? When the nose is opened (external rhinoplasty approach), tissues redrape differently, potential “dead space” is created, and compensatory maneuvers are needed to account for these new variables. With open rhinoplasty, increased support is needed in the base of the nose, the potential for polybeak deformity increases in the thick-skinned nose and long-term scar contracture becomes more apparent in the thin-skinned nose. The authors mentioned the potential for fluid accumulation or callous formation after the wide-field dissection of the bony dorsum. This can be a significant problem when bone work is performed. It is difficult to predict which patients will present with callous formation, however, one might expect the incidence of callous formation to be higher with the wider field dissection and more extensive bony work in patients that are prone to this phenomenon. In my estimation, one of the greatest advantages of the Piezo technology lies in the potential “sculpting” capability in patients with variant bony vault anatomy, asymmetries or atypical prominences. In these cases, the Piezo rasp could be used to contour the irregularities with less trauma and more precision. The authors point out that care must be taken when this technique is used to prevent overthinning the bone. With the author’s cautious approach to ultrasonic rhinosculpture, and more recent shift to using the Piezo to execute osteotomies, the advantage of the Piezo over conventional methods of bony work becomes less apparent. The potential for Piezo to simplify drilling holes in nasal bones, thinning and sculpting ethmoid/vomer bone grafts, contouring the nasal spine, lowering the high radix, and cutting/shaping ossified rib cartilage are all very attractive. However, these uses may not warrant the cost of a single-use Piezo insert that is then discarded. I do not believe many experienced rhinoplasty surgeons that are comfortable with their osteotomes will make the move to Piezo instruments. They may use it in select situations, but will likely continue to use conventional methods of managing the bony vault in uncomplicated cases. However, the younger surgeon that is less experienced with the conventional osteotomies may find this technology very helpful. In the future, we may see a shift toward Piezo if younger surgeons take up this technology early in their practices. These surgeons may never need to “tap..tap” a conventional osteotome. The other factors of time and cost are important when considering the use of the Piezo technology. The cost for the device can be up to $10,000.00 and the inserts can cost over $100.00. If you use multiple inserts (fine Piezo rasp, thin Piezo saw, etc.) that cost multiplies. The hope is that the inserts will become reusable, which could significantly decrease the cost of using Piezo instrumentation. Conventional osteotomies are associated with minimal cost and it only takes a couple of minutes to complete the bony work. The Piezo technology requires the wide field dissection with increased operative time and the associated cost related to the instrumentation. These are issues that each surgeon will have to assess in their own practices. The bottom line is patient satisfaction. At least in my practice, postoperative problems are rarely related to an issue with the bony vault. In most cases, if problems arise, they are noted in the lower two thirds of the nose. For this reason, I will likely continue to use my conventional osteotomy techniques in uncomplicated cases. However, I believe Piezo is here to stay and the primary benefit will be with management of atypical deformities of the bony vault and in the correction of bony deformities noted after previous rhinoplasty or trauma. In the future, the authors should consider assessing patient satisfaction and try to demonstrate superior outcomes using the Piezo technology over conventional methods. Simply demonstrating less postoperative edema or ecchymosis may not be enough to make it worth the effort to change techniques and invest in the new technology. One of the most significant contributions of this article is the author’s description of the different means of moving the lateral bony wall. This concept is very important and provides the reader with a better understanding of the effect of different combinations of osteotomies on the movement of the lateral bony wall. They describe the V-shape osteotomy to narrow the dorsal lines and create subtle verticalization of the nasal bone. This creates a “hinge” superiorly and the bones medialize by rotation around a hinge. The authors note that excessive verticalization can create a “tubular” look to the nasal dorsum. This deformity is very common and very difficult to correct. The U-shaped osteotomy acts to free the lateral wall and allow it to “translate” medially. The lateral wall is moved medially with less rotation, avoiding excess narrowing along the lateral osteotomy site, avoiding verticalization. The goal in most patients is to preserve a wider nasal base and narrower dorsal line, preserving the pyramidal shape of the normal bony dorsum. Creating a vertical lateral wall is rarely a favorable change and takes away the elegant lateral wall shadowing that is seen in a natural appearing nasal dorsum. If the reader takes this simple yet very important concept away from reading this article, patients will benefit from more natural appearing nasal dorsums. I am impressed with the amount of important information in this article and the authors should be proud of what they have presented. Time will tell whether Piezo becomes a mainstay in the rhinoplasty surgeon’s armamentarium. Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCE 1. Gerbault O , Daniel RK , Palhazi P . Kosins AM. Reassessing surgical management of the bony vault in rhinoplasty . Aesthet Surg J . 2018 ; 38 ( 6 ): 590 - 602 . © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Commentary on: Reassessing Surgical Management of the Bony Vault in Rhinoplasty

Aesthetic Surgery Journal , Volume Advance Article (6) – Mar 28, 2018

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Publisher
Oxford University Press
Copyright
© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
ISSN
1090-820X
eISSN
1527-330X
D.O.I.
10.1093/asj/sjy039
Publisher site
See Article on Publisher Site

Abstract

In this paper, the authors have redefined the pertinent surgical anatomy of the bony nasal vault.1 Their observations are not only impactful from a technical point of view but also help to justify the introduction of a new method of managing the bony nasal vault. Their description of the “bony cap” over the osseous nasal vault improves the surgeons understanding of the relationship between the cartilaginous vault and bony vault. The authors note that the nasal hump results from the anterior movement of the cartilaginous vault, pushing the bony cap forward. The authors state, “Thus, there is no bony hump, only a bony cap that covers a cartilaginous hump.” Their anatomic observations more accurately represent the bony nasal vault that we see clinically. The authors provide an elegant description of the 3-dimensional contours of the bony vault. They describe the asymmetries of the nasal bones structures which they note as universal. With the wider exposure of the bony vault, these asymmetries are seen, and the authors are then compelled to treat these asymmetries. With conventional osteotomies using limited dissection and limited visualization of the actual nasal bone contour, most experienced rhinoplasty surgeons are still able to achieve good alignment of the nasal bones with adequate narrowing. With conventional techniques, the surgeon is almost exclusively manipulating external contour and not reacting to defects seen when the bones are completely exposed. By keeping the skin and periosteum attached to the underlying bone, changes in bony vault contour are relatively predictable. Of course this leads us to the question, how do treating these asymmetries impact the final outcome of management of the bony vault? Are the outcomes improved? Will this wide field dissection create a paradigm shift similar to the move from endonasal rhinoplasty to open rhinoplasty? With the wide field dissection necessary when using Piezo instrumentation, the soft tissue (skin and periosteum) must redrape over the modified bony vault after bony manipulation is completed. This may introduce a new variable that can complicate the operation and impact outcomes. With conventional osteotomies, the attachments of the periosteum over the nasal bones acts to prevent collapse of the nasal bones. What is the potential for destabilization of the nasal bones after complete osteotomies in combination with a wide field dissection? When the nose is opened (external rhinoplasty approach), tissues redrape differently, potential “dead space” is created, and compensatory maneuvers are needed to account for these new variables. With open rhinoplasty, increased support is needed in the base of the nose, the potential for polybeak deformity increases in the thick-skinned nose and long-term scar contracture becomes more apparent in the thin-skinned nose. The authors mentioned the potential for fluid accumulation or callous formation after the wide-field dissection of the bony dorsum. This can be a significant problem when bone work is performed. It is difficult to predict which patients will present with callous formation, however, one might expect the incidence of callous formation to be higher with the wider field dissection and more extensive bony work in patients that are prone to this phenomenon. In my estimation, one of the greatest advantages of the Piezo technology lies in the potential “sculpting” capability in patients with variant bony vault anatomy, asymmetries or atypical prominences. In these cases, the Piezo rasp could be used to contour the irregularities with less trauma and more precision. The authors point out that care must be taken when this technique is used to prevent overthinning the bone. With the author’s cautious approach to ultrasonic rhinosculpture, and more recent shift to using the Piezo to execute osteotomies, the advantage of the Piezo over conventional methods of bony work becomes less apparent. The potential for Piezo to simplify drilling holes in nasal bones, thinning and sculpting ethmoid/vomer bone grafts, contouring the nasal spine, lowering the high radix, and cutting/shaping ossified rib cartilage are all very attractive. However, these uses may not warrant the cost of a single-use Piezo insert that is then discarded. I do not believe many experienced rhinoplasty surgeons that are comfortable with their osteotomes will make the move to Piezo instruments. They may use it in select situations, but will likely continue to use conventional methods of managing the bony vault in uncomplicated cases. However, the younger surgeon that is less experienced with the conventional osteotomies may find this technology very helpful. In the future, we may see a shift toward Piezo if younger surgeons take up this technology early in their practices. These surgeons may never need to “tap..tap” a conventional osteotome. The other factors of time and cost are important when considering the use of the Piezo technology. The cost for the device can be up to $10,000.00 and the inserts can cost over $100.00. If you use multiple inserts (fine Piezo rasp, thin Piezo saw, etc.) that cost multiplies. The hope is that the inserts will become reusable, which could significantly decrease the cost of using Piezo instrumentation. Conventional osteotomies are associated with minimal cost and it only takes a couple of minutes to complete the bony work. The Piezo technology requires the wide field dissection with increased operative time and the associated cost related to the instrumentation. These are issues that each surgeon will have to assess in their own practices. The bottom line is patient satisfaction. At least in my practice, postoperative problems are rarely related to an issue with the bony vault. In most cases, if problems arise, they are noted in the lower two thirds of the nose. For this reason, I will likely continue to use my conventional osteotomy techniques in uncomplicated cases. However, I believe Piezo is here to stay and the primary benefit will be with management of atypical deformities of the bony vault and in the correction of bony deformities noted after previous rhinoplasty or trauma. In the future, the authors should consider assessing patient satisfaction and try to demonstrate superior outcomes using the Piezo technology over conventional methods. Simply demonstrating less postoperative edema or ecchymosis may not be enough to make it worth the effort to change techniques and invest in the new technology. One of the most significant contributions of this article is the author’s description of the different means of moving the lateral bony wall. This concept is very important and provides the reader with a better understanding of the effect of different combinations of osteotomies on the movement of the lateral bony wall. They describe the V-shape osteotomy to narrow the dorsal lines and create subtle verticalization of the nasal bone. This creates a “hinge” superiorly and the bones medialize by rotation around a hinge. The authors note that excessive verticalization can create a “tubular” look to the nasal dorsum. This deformity is very common and very difficult to correct. The U-shaped osteotomy acts to free the lateral wall and allow it to “translate” medially. The lateral wall is moved medially with less rotation, avoiding excess narrowing along the lateral osteotomy site, avoiding verticalization. The goal in most patients is to preserve a wider nasal base and narrower dorsal line, preserving the pyramidal shape of the normal bony dorsum. Creating a vertical lateral wall is rarely a favorable change and takes away the elegant lateral wall shadowing that is seen in a natural appearing nasal dorsum. If the reader takes this simple yet very important concept away from reading this article, patients will benefit from more natural appearing nasal dorsums. I am impressed with the amount of important information in this article and the authors should be proud of what they have presented. Time will tell whether Piezo becomes a mainstay in the rhinoplasty surgeon’s armamentarium. Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCE 1. Gerbault O , Daniel RK , Palhazi P . Kosins AM. Reassessing surgical management of the bony vault in rhinoplasty . Aesthet Surg J . 2018 ; 38 ( 6 ): 590 - 602 . © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Aesthetic Surgery JournalOxford University Press

Published: Mar 28, 2018

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