Reassessing Surgical Management of the Bony Vault in Rhinoplasty

Reassessing Surgical Management of the Bony Vault in Rhinoplasty Abstract Management of the nasal bony vault is an integral part of rhinoplasty surgery, whether reducing the dorsal profile line or narrowing the base bony width. Since 2013, dramatic changes have occurred because of new insights into our understanding of nasal anatomy, how we analyze bony vault deformities, and the introduction of new surgical techniques and technologies including piezosurgery. Therefore, a reassessment and overview of bony vault surgery appears justified. With wide exposure and visualization of the bony vault, we have concluded that all bony vaults are asymmetrical and that the lateral bony wall may be analyzed in 3 axes: longitudinal, sagittal, and transverse. The longitudinal and sagittal axes may be judged as convex, straight, or concave. The transverse axis can be precisely rotated or translated depending on the design of ultrasonic osteotomies. We review this nasal anatomy as well as treatment including sculpting of the nasal bones, as well as different osteotomy patterns. Piezosurgery is certainly a disruptive technology in rhinoplasty that allows bony reshaping with precise osteotomies and sculpting. This versatility allows treatment of any type of bone (thin, brittle, short), mobile bones, and fractured bones. This enables the surgeon to achieve better symmetry with greater accuracy and precision. Level of Evidence: 5 Management of the nasal bony vault is an integral part of rhinoplasty surgery, whether reducing the dorsal profile line or narrowing the base bony width. During the past 5 years, dramatic changes have occurred because of new insights into our understanding of nasal anatomy,1,2 how we analyze bony vault deformities,3 and the introduction of new surgical techniques.4 Therefore, a reassessment and overview of bony vault surgery appears justified. It should be noted that extensive discussion of the historical evolution of bony vault surgery and the use of piezoelectric instrumentation (PEI) have been previously published by the authors in this journal.4 SURGICAL ANATOMY Anatomically, one must reconcile skull-based anthropometric terminology with surface-based surgical descriptions. The bony vault is comprised of the fused radix area (nasal bones with frontal bone), the paired nasal bones, and the bilateral frontal processes of the maxilla. Throughout this article, we will emphasize surgical terminology. From a surgical perspective, we will focus on three components: the radix area, the bony cap, and the lateral bony wall. Radix Area The bony vault can be divided at the nasion (N) into a cephalic (radix area) and caudal portion (bony cap). The cephalic radix area is comprised of three distinct bones: nasal bone, frontal bone, and nasal spine of the frontal bone. These three bones fuse in a solid syndesmosis obliterating the original midline suture lines. This solid triangular bony mass is reduced with difficulty, and osteotomies that extend into this area risk development of “rocker formations.” Surgically, the vast majority of dorsal humps do not extend above the nasion. Alternatively, there are certain cases where deepening of the nasion in an anterior-posterior plane is necessary, and one must distinguish between muscle mass and bony fullness. Bony Cap/Keystone Area The caudal portion of the bony vault is a much thinner bony cap covering the cartilaginous vault and the underlying nasal airway. Palhazi et al2 demonstrated that the nasal bones form a thin bony cap over the underlying cartilaginous vault. The cap measures 0.7 mm (range, 0.5-1.0 mm) in thickness at the keystone junction, and clinically, the bony cap extends 10-14 mm cephalically. This anatomical concept of a bony cap, as opposed to the surgical entity of a bony hump, can be explained embryologically. Growth of the nose occurs from the anterior-posterior expansion of the septum rather than from growth of the nasal bones themselves. During puberty, the cartilaginous nasal septum functions as the dominant growth center of the midface. The nasal hump results from the upward thrust of the underlying cartilaginous vault rather than an equal contribution from the nasal bones and cartilage. Thus, there is no bony hump, only a bony cap that covers a cartilaginous hump. The keystone area can be divided into a dorsal and lateral keystone area. The dorsal keystone area (DKA) measures 9 mm in the midline (range, 4-14 mm).2 The lateral keystone area (LKA) is created by the overlap of the upper lateral cartilages (ULCs) and nasal bones. The degree of overlap is highly variable. However, the amount of longitudinal overlap is greatest along the dorsum. In most dorsal reductions, the osseocartilaginous junction is permanently removed in the midline, and the new osseocartilaginous junction is moved cephalically toward the nasion. Clinically, the mucosa cephalic to the cartilage vault is rarely exposed after the removal of the bony cap. Laterally, the bony-cartilaginous junction moves caudally and posteriorly after hump reduction due to the slope of the pyriform aperture. The management of the LKA is paramount to creating smooth dorsal aesthetic lines (DALs) and must be blended smoothly with the middle vault. Lateral Bony Wall The term lateral bony wall encompasses both the frontal process of the maxilla and the lateral portion of the nasal bones. Surgically, bony cap reduction is confined to the nasal bones, but lateral osteotomies pass within the frontal process of the maxilla. Anatomically, there is a reciprocal size relationship between the frontal process of the maxilla and the nasal bones: the larger the frontal process, the smaller the nasal bones (Figure 1). Likewise, the lateral extent of the ULC closely corresponds to the nasal bone-frontal process of the maxilla suture line. Figure 1. View largeDownload slide (A, B) There exists a reciprocal relationship between the sagittal length of the lateral bony wall and the frontal process of the maxilla. The longer the frontal process, the shorter the length of the nasal bone. Figure 1. View largeDownload slide (A, B) There exists a reciprocal relationship between the sagittal length of the lateral bony wall and the frontal process of the maxilla. The longer the frontal process, the shorter the length of the nasal bone. The configuration of the lateral bony wall is 3-dimensional (3D) and is crucial in planning lateral osteotomies. There can be distinct variations in the contour of the nasal bones and the frontal process of the maxilla—straight, convex, or concave configurations (Figure 2). Equally variable is the shape and width of the pyriform aperture. The length of the lateral bony wall (distance from the medial canthal ligament to the pyriform aperture on the frontal process of the maxilla irrespective of the nasal bones) must also be considered. Figure 2. View largeDownload slide (A) The longitudinal and sagittal axes of the lateral bony wall are shown. (B) The longitudinal and sagittal axes may be convex, straight or concave. Cadaver dissections demonstrate sagittal axes that are (C) convex, (D) straight, or (E) concave. Figure 2. View largeDownload slide (A) The longitudinal and sagittal axes of the lateral bony wall are shown. (B) The longitudinal and sagittal axes may be convex, straight or concave. Cadaver dissections demonstrate sagittal axes that are (C) convex, (D) straight, or (E) concave. AESTHETICS AND ANALYSIS Skin-surface DALs as seen on the anterior view help define the aesthetics of the nasal dorsum. Our understanding of the DAL has been advanced in recent years for two reasons: (1) the polygon concept of Çakir; and (2) direct intraoperative evaluation made possible by wide surgical exposure. Surface Aesthetics Sheen described the dorsal lines as “two divergent concave lines that are unbroken extensions of the superciliary ridges…which connects the radix with the lateral projection of the crura.”5 Recently, Çakir introduced the concept of polygons for analyzing the aesthetics of the nose.6 Nasal polygons are geometric forms derived from a composite of lines, shadows, and highlights with specific proportions and breakpoints with variations in males and females. The osseocartilaginous vault is comprised of four polygons: two bony (dorsal and lateral) and 2 cartilaginous (dorsal and lateral) polygons. Importantly, he notes that DAL are not straight, but rather “fusiform”—narrow in the radix, wider at the keystone, and narrow again at the supratip. In addition, there is a lateral aesthetic line that demonstrates the nasofacial groove, which is the junction between the angulated frontal process of the maxilla and the maxilla itself. The polygon concept of nasal analysis can be expanded to the interface between the nose, radix, and central brow.7 Essentially, there are three polygons: glabellar, medial orbit, and superomedial orbit. Clinically, the DAL and lateral aesthetic lines are connected by the lateral bony wall, with its corresponding shadowing. As noted in the anatomy section, the lateral bony wall can be thought of as having three axes: longitudinal (cephalic to caudal), sagittal (anteroposterior), and transverse (lateral to medial). The longitudinal and sagittal axes can vary from straight to convex to concave. Importantly, the transverse axis can be translated or rotated (Figure 3). Figure 3. View largeDownload slide The transverse axis of the lateral bony wall can be rotated with V-shape osteotomies, and translated with U-shape osteotomies. Figure 3. View largeDownload slide The transverse axis of the lateral bony wall can be rotated with V-shape osteotomies, and translated with U-shape osteotomies. Clinical examination of the nose preoperatively is paramount for analysis. First, the skin thickness must be assessed, because the skin is frequently thinner in the keystone area and also near the medial canthus.8 Nasal bone characteristics are assessed through palpation to estimate the length and width of the bony vault, as well as the shape of the bone segments (straight, convex, concave). In the case of secondary rhinoplasty, palpation can demonstrate irregularities, osteotomy level and type, residual bone width, etc. Radiography Nasal bone thickness and angulation can be assessed through preoperative radiological examination. The cone beam is preferred to the CT scan, because it requires less radiation and is less expensive. This test allows a very precise bone thickness measurement on any computer. This thickness can be especially important in the LKA, because it will help in deciding between sculpting down this area or doing a medial oblique osteotomy. Surgical Observations The complete bony vault was rarely visualized by surgeons until the introduction of the “wide exposure” necessary for piezoelectric osteotomies.4 After elevation of the periosteum, we gain exposure from one maxilla to the other, and the following observations can be made: 1) The bony vault is always asymmetric in shape and frequently there is a more pronounced convexity at the LKA on one side 2) The shape of the medial component in terms of width and the lateral component in terms of straight, convex, or concave can be perfectly analyzed. This analysis will dictate the type of osteotomy and/or sculpturing performed, but also sometimes the need for concavity concealment with diced cartilage, bone dust, or other graft material 3) The exact location of the bony cap removal can be assessed not only on the dorsal segment, but also on the lateral segment. Asymmetric sculpting and removal avoids length discrepancies after medial oblique osteotomies. OPERATIVE SEQUENCE FOR MANAGING THE BONY VAULT Traditional management of the bony vault has evolved to avoid overresection and to conserve cartilage. First, the dorsum is reduced using an en bloc, split, or component technique followed by osteotomies. Although one can achieve good results with traditional instruments, problems still occur, including overresection, asymmetries, and unreliable movement of the nasal bones. These issues are related to the inability to visualize the bony vault and to the inherent disadvantage of traditional instrumentation. With the advent of PEI, greater precision has become possible. Although wide variations are possible to accommodate the anatomical variations encountered, a standard operative sequence is as follows: (1) wide subperiosteal undermining; (2) bony cap removal; (3) osteotomies; and (4) midvault reconstruction. Wide Subperiosteal Exposure Since 2014, an extended bony vault degloving has been used for all primary and secondary rhinoplasties performed by the primary (O.G.) and junior authors (A.K.), except when no bone modification was planned. The dissection is initiated at the level of the anterior septal angle in a supraperichondrial or subperichondrial plane and continued above the cartilaginous dorsum until the bony junction. Then, using a sharp Daniel-Çakir elevator, the subperiosteal plane is entered in each LKA for ease of dissection and then connected in the midline that is much more adherent. The subperiosteal undermining is extensive. Beginning at the keystone junction, it extends dorsally up to and beyond the nasion, then laterally toward the medial canthal ligament, and then caudally along the frontal process of the maxilla. Any perforating vessels are cauterized in the bony foramen with a curved Colorado needle. As one approaches the pyriform aperture, it is often necessary to cut the vertical pyriform attachments and stretch the transverse pyriform ligaments to gain adequate exposure (Figure 4).9 Next, the dissection is extended approximately 1cm lateral to the nasofacial groove out onto the horizontal anterior surface of the maxilla. With this exposure, it is possible to totally analyze the bony vault deformity and to gain access for surgical instrumentation. Figure 4. View largeDownload slide To accurately perform piezo osteotomies, good visualization and exposure are paramount. After subperiosteal dissection of the entire bony vault, release of the (A) vertical pyriform attachments and (B) transverse pyriform ligaments is often necessary. NB, nasal bone; LLC, lower lateral cartilage; ULC, upper lateral cartilage. Figure 4. View largeDownload slide To accurately perform piezo osteotomies, good visualization and exposure are paramount. After subperiosteal dissection of the entire bony vault, release of the (A) vertical pyriform attachments and (B) transverse pyriform ligaments is often necessary. NB, nasal bone; LLC, lower lateral cartilage; ULC, upper lateral cartilage. Management of the Dorsal Hump Once the extensive subperiosteal dissection and a “dorsal time out” to reassess the planned dorsal surgery are completed, then the bony cap is removed in the medial and lateral keystone areas. Traditionally, this is followed by splitting the ULCs from the dorsum and an anterior dorsal resection. However, only the bony cap removal is done initially, and the actual reduction of the cartilaginous vault is performed after the osteotomies, and this is a major change from traditional rhinoplasty surgery. Bony Cap Removal As shown in previous anatomical studies, the osseocartilaginous dorsal hump consists of a thin bony cap overlying an arched cartilaginous vault.2 Rather than use an osteotome, incremental bone removal not only is limited to the central area of the hump but also extends to the LKA if it is too convex. The bone is removed with a coarse PEI rasp first (RHS2H) and then with a finer rasp (RHS2F). The bony DALs can be sculpted by tilting the rasp horizontally on the medial keystone and obliquely on the lateral keystone. When the dorsal hump extends to the nasion or if the radix must be significantly reduced, then a scraper (RHS1) is used followed by a rasp (RHS2F) for refinement. Because PEI does not harm soft cartilaginous tissues, the bony cap can be removed without affecting the underlying ULC or even the mucosa in cases of very significant and cephalic humps. Thus, in contrast to the use of osteotomes or chisels, there is never an open roof with PEI. The roof is only opened if necessary when the ULCs are split off, and then it is closed with the subsequent midvault reconstruction. Moreover, the attachments between the posterior periosteum of the remaining nasal bones and the anterior perichondrium of the ULC are preserved, favoring the middle third for stability and a smooth osseocartilaginous transition. Osteotomy Sequence Historical Perspective To understand the current osteotomy sequence, one must review the historical progression of how modern osteotomy techniques evolved. Since the time of Joseph, lateral osteotomies have been done to narrow the broad nose following hump reduction.10 Initially, osteotomies were performed with saws placed in the nasofacial groove and continued from the pyriform aperture to above the medial canthal ligament. Once the osteotomies were completed, digital pressure was used to move the bones medially. Millard added medial osteotomies to all his rhinoplasties to facilitate bony movement.11 Once both osteotomies were done, the nasal bones were “outfractured” followed by “infracturing” to achieve complete movement of the lateral bony wall. Ultimately, surgeons switched to chisels and osteotomes, because they were less traumatic, so the surgeons did infracturing only. Limited skin undermining was emphasized to promote stability of the mobilized bones. Tardy used 2 mm micro-osteotomes for medial oblique osteotomies followed by low lateral osteotomies.12 Sheen advanced the concept of the low to high osteotomy that begins low on the pyriform aperture and ascends across the frontal process of maxilla ending at the nasal bone.5 Narrowing of the nose and closure of the open roof is accomplished with a transverse greenstick fracture. In contrast, the low to low osteotomy remains within the frontal process of the maxilla and requires another osteotomy to pass from its cephalic termination into the open roof, either through a previous medial oblique osteotomy coming down from the open roof or a transverse osteotomy. The longitudinal extent and location of lateral osteotomies has changed dramatically from Joseph’s original design. First, surgeons realized that there was rarely a need to go above the medical canthal ligament and that doing so risked significant bony irregularities. In the vast majority of cases, the bony vault is “narrow-waisted” at the level of the medial canthal ligament and the bone above is fused and prone to visible rocker formation. Next, surgeons began to place the lateral osteotomy significantly more anterior away from the nasofacial groove and the face of the maxilla. Also, the goal was no longer complete mobilization of the lateral nasal wall, but rather inward tilt and stabilization. In 1977, Webster proposed that a triangle of bone be preserved at the pyriform aperture to maintain an intact airway below the level of the inferior turbinates.13 He advocated use of a curved lateral osteotome placed more anteriorly and superiorly. This dictum led to the concept of a “high-low-high” lateral osteotomy. Surgeons disagree on whether this triangle needs to be kept intact to maintain airway patency. Lateral Osteotomy The first osteotomy cut is done very caudally on the frontal process of the maxilla with a thin saw (RHS5) or with the fan-shape lateral saw (RHS3 L and R). This low initiation point is in direct contrast to the high starting point used by those who favor the preservation of Webster’s triangle. The reasons for not preserving a Webster’s triangle are two possible aesthetic deformities: (1) excessive base bony width near the alar crease; and (2) palpable bone excess. If endonasal assessment after completion of the full osteotomy sequence shows that the inferior turbinate moves significantly inward, then a mucosal reduction with radiofrequency and/or a bone reduction (inferior nasal concha) with a long piezo saw or outfracture could be performed. If this endonasal assessment shows that the pyriform aperture edge moves too much inward, then it can be reduced with a rasp or a scraper. Since 2013, we (O.G. and A.K.) have not found a need for these refinements. Next, the lateral osteotomy is continued in the nasofacial groove using a fan-shape piezo saw (RHS3R for the left side and RHS3L for the right side). This cut follows the nasofacial groove in a cephalic direction until the point where the width of the bony vault is aesthetically correct. If the radix is narrow, there is no need for the lateral osteotomy to go above the medial canthal ligament (MCL). Conversely, if the radix is wide, the lateral osteotomy follows the groove above the MCL. After the lateral osteotomy is completed, the amount of bone movement is checked with an elevator. Most surgeons are surprised that 2 to 5 mm of transverse medial bony movement along the frontal process of the maxilla can and does occur following only a lateral osteotomy. Significant narrowing of the base bony width occurs with just a lateral osteotomy in many cases. If the movement is sufficient without a significant spring effect and the bone orientation is correct, then the osteotomy sequence is stopped. However, if the lateral osteotomy did not achieve sufficient narrowing, then the following options are considered: (1) if the dorsum is wide, a medial oblique osteotomy is done; and (2) if the dorsum is ideal, then a transverse osteotomy is done. Transverse Osteotomy The transverse osteotomy is performed with an angulated, thin piezo saw (RHS4L for the right side and RHS4R for the left side). It begins at the cephalic termination of the lateral osteotomy and continues horizontally until the point where this line would meet a theoretical medial oblique osteotomy (even if this osteotomy is not performed). At this point, bony movement is again checked with an elevator. If the mobilization and orientation of bones are correct, then the osteotomy sequence is ended. If not, then a medial oblique osteotomy is added. Medial Oblique Osteotomy This osteotomy is performed with the same thin saw (RHS5) used for the initial osteotomy. It begins on the LKA at the point where the ideal DAL should be. It is usually oriented toward the medial eyebrow, and there are two possibilities regarding how this osteotomy is used to effect nasal bone movement. First, when the medial oblique osteotomy is combined with only a lateral osteotomy, an intact bony hinge remains. This results in a V-shape osteotomy. This combination is done to narrow the dorsal lines, to increase medial movement of the lateral bony wall, and to allow slight verticalization of the bone. This combination is favored when the bones are thin or fragile and less movement is needed. The second option is to do a complete continuous osteotomy composed of lateral + transverse + medial oblique osteotomies to “translate” the nasal bone medially in its original orientation. This results in a U-shape osteotomy. After this complete fracture, drill holes and sutures can be used to precisely fine-tune the nasal bones if needed. Finishing Touch Smoothing of the osteotomy edges and bony dorsal edges are done with a fine piezo rasp (SL1). Palpation of the nose with wet gloves should find no rough areas; otherwise, they should be smoothed out. This assessment can even be done at the end of the procedure, when the columella is sutured, allowing a final touch through the infracartilaginous access. It should be noted that there is not any bleeding from the nostrils during the procedure, because the mucosa is intact with PEI. Infiltrating the lining before the osteotomies helps to prevent any rare mucosal tears that occur from pushing too hard on the instruments. MOVEMENT OF LATERAL BONY WALL AND OSTEOTOMIES Nasal bone movement depends on the path of the osteotomies. With classic osteotomies, bones are supposed to fracture on the path of least resistance, or to have a greenstick fracture. If these maneuvers are insufficient, more digital pressure is applied and osteotomies can be added. Most frequently, the osteotomy pattern has either a V- or U-shape pattern (Video, available online as Supplementary Material at www.aestheticsurgeryjournal.com). The V-shape osteotomy consists of a lateral low to high and a medial oblique osteotomy with an intact bony hinge. The U-shape osteotomy consists of a lateral low to low osteotomy plus a transverse and medial oblique osteotomy. When V-shape osteotomies are done, there is a hinge at the junction of the two osteotomies that prevents the translation of the bone inwards. In this case, the bone medializes by rotation. This rotation makes the bone more vertical and can alter aesthetics of the sidewall. The result is a tubular appearance of the dorsum, with a vertical shadow laterally and a vertical light area in the middle of the dorsum. When U-shape osteotomies are performed, the lateral bony wall can translate medially without restriction. The two edges of the bone stay end to end on the medial oblique fracture line with minimal angulation on the osteotomy line. Osteotomies are more commonly performed with a U-shape pattern, to narrow the bony vault without altering the aesthetic features of the nasal sidewalls (Figure 5). The bones are moved inward but remain stable, even if complete osteotomies are performed. The primary indication we have for V-shape osteotomies is when the bony vault is wide and flat, and/or bone verticalization must be done. This happens often for “ethnic noses.” Figure 5. View largeDownload slide (A, C, E, G) Preoperative views of a 31-year-old woman who complained of a wide nose who was found to have a convex left nasal bone. (B, D, F, H) Following bony cap removal, bilateral U-shape piezo osteotomies, and additional rasping on the left lateral bony wall, better symmetry and contour of the bony dorsum can be seen at 1 year postoperatively. Spreader flaps were used for midvault reconstruction as well as a septal extension graft and tip suturing. Figure 5. View largeDownload slide (A, C, E, G) Preoperative views of a 31-year-old woman who complained of a wide nose who was found to have a convex left nasal bone. (B, D, F, H) Following bony cap removal, bilateral U-shape piezo osteotomies, and additional rasping on the left lateral bony wall, better symmetry and contour of the bony dorsum can be seen at 1 year postoperatively. Spreader flaps were used for midvault reconstruction as well as a septal extension graft and tip suturing. Video 1 Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjx246 Video 1 Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjx246 Close Overall, the ability to change the shape and orientation of osteotomies under direct visualization is the biggest advantage we have seen with piezosurgery that makes it truly a disruptive technology. Because all bony vaults are asymmetric, it is not uncommon to do a V-shape osteotomy on one side and U-shape osteotomy on the other. Likewise, at times, an osteotomy is done on one side and ultrasonic rhinosculpture is done on the other. ULTRASONIC RHINOSCULPTURE When the bony vault has minimally excessive width and minimal dorsal reduction is indicated, then a thinning of the entire bony vault can be performed with a PEI rasp. This means that no osteotomy is performed, but rather a rasping of the entire bony pyramid, especially the more convex areas, is done. The advantages are that the bones remain perfectly stable and there is very little bruising after the surgery. The new bony dorsal aesthetic lines can be sculpted (Figure 6). Care must be taken not to use rhinosculpture when a significant narrowing of the bones is indicated. At the beginning of his experience with rhinosculpture (2013-2015), the primary and junior authors (O.G. and A.K.) “pushed” the indications of rhinosculpture to cases where osteotomies would have been indicated. In some cases, the bony vault remained too wide. After a minimum of 6 months, a second operation was successfully performed with osteotomies (Supplemental Figure 1). Figure 6. View largeDownload slide (A, D, G) Preoperative views of a 26-year-old woman who presented to the primary author (O.G.) and complained of a wide bony vault and wide nose overall. She was found to have a slightly wide dorsum amenable to ultrasonic rhinosculpture. Spreader flaps and tip suturing were done to reconstruct the middle vault and tip. (B, E, H) Six days and (C, F, I) 11 months postoperatively, the patient has aesthetic and appropriately narrow dorsal aesthetic lines. Figure 6. View largeDownload slide (A, D, G) Preoperative views of a 26-year-old woman who presented to the primary author (O.G.) and complained of a wide bony vault and wide nose overall. She was found to have a slightly wide dorsum amenable to ultrasonic rhinosculpture. Spreader flaps and tip suturing were done to reconstruct the middle vault and tip. (B, E, H) Six days and (C, F, I) 11 months postoperatively, the patient has aesthetic and appropriately narrow dorsal aesthetic lines. BONE MANAGEMENT IN ETHNIC RHINOPLASTY Many people from African or Asian descent have a flat dorsum and wide nasal bones. Likewise, ethnic rhinoplasties usually include dorsal augmentation, tip refinement, and alar base modification. Usually, the nasal bones are left untouched. However, the bony vault may remain too wide in many cases, even though the width is more balanced with a new profile line. Moreover, a step deformity can occur at the junction of the overlay dorsal graft and the underlying bony vault, because there may be a width discrepancy between both if the bony vault is not narrowed. When the bony vault is very wide, we do not hesitate to do lateral osteotomies. These osteotomies are more difficult, because the bones are very dense and further from the midline. In most cases, a low and sometimes transverse osteotomy are enough to narrow the bony vault significantly. In these cases, any verticalization is beneficial. In the treatment of ethnic noses, incorporating narrowing of the bony vault has improved the overall result (Figure 7 and Supplemental Figure 2). The risk of unwanted fractures, bone instability, and bone collapse has also been reduced with PEI. Figure 7. View largeDownload slide (A, C, E) Preoperative and (B, D, F) 13-month postoperative result of a 19-year-old woman from Qatar who presented to the junior author (A.K.) with a wide, flat dorsum and extreme convexity of the lateral bony walls. Piezo saws were used to harvest ethmoid bone in continuity with septal cartilage. The tip was supported on a septal extension graft, and a radix graft was done. V-shape osteotomies were done to verticalize the lateral bony walls and to narrow the dorsum from 18 to 6 millimeters. Figure 7. View largeDownload slide (A, C, E) Preoperative and (B, D, F) 13-month postoperative result of a 19-year-old woman from Qatar who presented to the junior author (A.K.) with a wide, flat dorsum and extreme convexity of the lateral bony walls. Piezo saws were used to harvest ethmoid bone in continuity with septal cartilage. The tip was supported on a septal extension graft, and a radix graft was done. V-shape osteotomies were done to verticalize the lateral bony walls and to narrow the dorsum from 18 to 6 millimeters. BONE MANAGEMENT IN SECONDARY RHINOPLASTY Until the introduction of widespread subperiosteal exposure, the bony deformities found in secondary rhinoplasty cases were difficult to understand and treat. One should consider previous osteotomy location, direction, and completeness as well as the stability and comminution of the lateral bony wall. One can divide secondary bony deformities into the following categories: surface irregularities, contour defects, and lateral bony wall deformities. Surface Irregularities These bony irregularities most commonly occur in the following areas: (1) dorsally where the bony hump was removed; and (2) along the bony edges of greenstick fracture lines or previous osteotomy. The irregularities are much more frequently noticeable in thin-skinned patients. Treatment of surface irregularities is usually done with a piezo rasp. Contour Deformities One of the most common secondary bony vault problems is contour asymmetries. Previously, the solution was a combination of fine rasping and osteotomies done blindly. With wide exposure, the problem can actually be seen and treated directly often with ultrasonic rhinosculpture. With a fine rasp, one can sculpt a wide nasal bone down to match the narrower bone, whereas previously the surgeon was unaware of intrinsic thickness and tried to narrow the wide side with an osteotomy. The most frequent etiology of residual bony convexity is a failure to correct the original preoperative deformity with uneven osteotomies (ostoeotomies performed at different levels). The residual convexity is treated either by rasping if the bone is sufficiently thick or by criss-cross osteotomies if the bone is thin. Lateral Wall Problems Challenges in the lateral bony wall include “step deformities” associated with previous osteotomies and the position of the wall with either inadequate or excessive movement. Step deformities can have moderate palpable separations and major level discrepancies. If a redo osteotomy is not indicated for positional or rotational reasons, then the bony edges can be smoothed with a fine rasp and/or filled with very finely diced cartilage to eliminate palpability. If there is a significant level discrepancy between the two sides of an osteotomy, multiple drill holes are placed through both bones, the lower side is raised, and one to three sutures are inserted with 4/0 PDS on a P3 needle. If there is still a gap after the fracture osteosynthesis, it is filled with a cartilage paste obtained by scratching a piece of cartilage with a number 15 blade or with diced cartilage. If there was a failure to medialize the lateral bony wall and the bony vault remains too wide, then the lateral osteotomies are repeated, but in a more lateral position. When the lateral osteotomy is correctly located but inadequate movement is achieved, then a transverse osteotomy and/or a medial osteotomy are adequate to allow complete mobilization. If excessive bony movement is present, it is usually associated with verticalization of the bony wall. Verticalization is related to bone rotation, with the thick lower posterior base moving medially and the thin anterior portion moving laterally. This rotation results either from the osteotomy design, or from excess narrowing. Excessive movement is usually treated by grafting the lateral aspect of the bone with diced cartilage or other camouflage. Another option is to do a paramedian and transverse osteotomy to outfracture the bone and to place a long spreader graft to stent the bone in the correct position. REFINEMENTS/COMPLICATIONS IN PIEZOSURGERY With any new technology or technique, there are refinements and complications that occur during initial adoption. Pushing the indications for ultrasonic rhinosculpture when osteotomies are indicated has already been discussed above. Since the adoption of piezosurgery by the authors, over 750 rhinoplasties have been performed, with few complications. Because this is the combined work of four authors over a multiyear period, detailed demographic data about the patients treated were not available. The following is a list of issues and refinements that have been made over the last years: The piezo device requires water to assist in ultrasonic vibration and to prevent heating. If water flow is too low, the device can get hot, and a few burns to the skin were observed near the nostrils. At the time of surgery, these were seen and excised without issue to prevent untoward healing. Water flow is paramount to preventing this issue. The waterflow should be at least 50 ml/min to avoid any skin or bone burning. Suction retractor and suction speculum are very useful to ease the procedure and overflooding by the water outflow. It has been demonstrated that bruising and swelling are decreased with piezo osteotomies as compared with conventional instrumentation.14,15 After the osteotomies are completed, dilute steroid is injected next to the bone cuts, and a small drain hole is made in the intra-nasal mucosa to allow for drainage. Subjectively, this has further decreased swelling/bruising after surgery but has not formally been studied. We have found no contraindications to the wide subperiosteal exposure. To avoid favoring fluid collection in the lateral area of the bony vault dissection, large splints must be used. A narrow preshaped splint may compress only the median part of the undermining, favoring a lateral fluid collection. In a few patients over a 4-year period, the primary and junior authors (O.G. and A.K.) have had noticed a buildup of soft tissue callus in lateral osteotomy sites 3-4 weeks after surgery in 3 patients. Dilute steroid has been injected into the callus (under ultrasonic guidance in the senior author’s practice), and this has resolved. In one case, a second injection was necessary. This is not due to the wider area of dissection, but rather secondary to the bone emulsification along the osteotomy lines. The cost of the piezo device and disposable inserts is different in every country. The cost of the device can be up to $10,000, and inserts can each cost over $100. Currently, we are hopeful that reusable inserts are on the horizon. Although this technology is more expensive than osteotomes, all of the advantages described above certainly make it worth it. CONCLUSIONS Since the origins of rhinoplasty, wide exposure of the nose was taboo, even with the “open” approach to prevent bone collapse. With the accuracy of bone reshaping and mobilization with PEI, extending the bone dissection to the whole nose, including the bony vault, is safe and allows full visualization of the nasal bones before and after osteotomy. Piezo surgery is a disruptive technology in rhinoplasty that allows bony reshaping with precise osteotomies and sculpting. This versatility allows the treatment of any type of bone (thin, brittle, short), mobile bones, and fractured bones. This enables the surgeon to achieve better symmetry with more accuracy and precision. Piezo surgery may reduce significantly defects of the bony vault and the keystone area in rhinoplasty, and it adds new options in bone reshaping and in the treatment of bony defects. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures Dr Gerbault is a consultant and receives royalties from COMEG Medical Technologies (La Ciotat, France). Dr Daniel receives royalties from Springer Publishing (New York, NY). Dr Kosins is a shareholder and member of the Medical Advisor Committee for ZO Skin Health, Inc. (Irvine, CA) and also a consultant for Marina Medical (Florida). Dr Palhazi declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. Acknowledgements The authors would like to thank the members of the International Rhinoplasty Research Society, who have followed this work and given their input throughout its conception: Drs. Charles East, Abdülkadir Goksel, Milos Kovacevic, and Yves Saban. REFERENCES 1. Lazovic GD, Daniel RK, Janosevic LBet al.   Rhinoplasty: the nasal bones—anatomy and analysis. Aesthet Surg J . 2015; 35( 3): 255- 263. Google Scholar CrossRef Search ADS PubMed  2. Palhazi P, Daniel RK, Kosins AM. The osseocartilaginous vault of the nose: anatomy and surgical observations. Aesthet Surg J . 2015; 35( 3): 242- 251. Google Scholar CrossRef Search ADS PubMed  3. Çakir B. Aesthetic Septorhinoplasty . Berlin: Springer; 2015. 4. Gerbault O, Daniel RK, Kosins AM. The role of piezoelectric instrumentation in rhinoplasty surgery. Aesthet Surg J . 2016; 36( 1): 21- 34. Google Scholar CrossRef Search ADS PubMed  5. Sheen JH. Aesthetic Rhinoplasty . St Louis, MO: Mosby; 1978. 6. Çakir B, Doğan T, Öreroğlu AR, Daniel RK. Rhinoplasty: surface aesthetics and surgical techniques. Aesthet Surg J . 2013; 33( 3): 363- 375. Google Scholar CrossRef Search ADS PubMed  7. Daniel RK, Kosins A, Sajjadian Aet al.   Rhinoplasty and brow modification: a powerful combination. Aesthet Surg J . 2013; 33( 7): 983- 994. Google Scholar CrossRef Search ADS PubMed  8. Kosins AM, Obagi ZE. Managing the difficult soft tissue envelope in facial and rhinoplasty surgery. Aesthet Surg J . 2017; 37( 2): 143- 157. Google Scholar CrossRef Search ADS PubMed  9. Daniel RK, Palhazi P. Rhinoplasty: An Anatomical and Clinical Atlas . New York: Springer; 2017. 10. Joseph J. Nasenplastik und sonstige gesichtsplastik, nebst einem anhang über mammaplastik , 1931. 11. Millard DR. Rhinoplasty Tetralogy: Corrective, Secondary, Congenital, Reconstructive . Boston: Little, Brown and Company; 1996. 12. Tardy ME, Denneny JC. Micro-osteotomies in rhinoplasty— a technical refinement. Facial Plast Surg . 1984; 2: 137- 145. Google Scholar CrossRef Search ADS   13. Webster RC, Davidson TM, Smith RC. Curved lateral osteotomy for airway protection in rhinoplasty. Arch Otolaryngol . 1977; 103( 8): 454- 458. Google Scholar CrossRef Search ADS PubMed  14. Ilhan AE, Cengiz B, Caypinar Eser B. Double-blind comparison of ultrasonic and conventional osteotomy in terms of early postoperative edema and ecchymosis. Aesthet Surg J . 2016; 36( 4): 390- 401. Google Scholar CrossRef Search ADS PubMed  15. Gerbault O, Kosins AM. Commentary on: Double-blind comparison of ultrasonic and conventional osteotomy in terms of early postoperative edema and ecchymosis. Aesthet Surg J . 2016; 36( 4): 402- 403. Google Scholar CrossRef Search ADS PubMed  © 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

Reassessing Surgical Management of the Bony Vault in Rhinoplasty

Loading next page...
 
/lp/ou_press/reassessing-surgical-management-of-the-bony-vault-in-rhinoplasty-xrEmy79BNq
Publisher
Mosby Inc.
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/sjx246
Publisher site
See Article on Publisher Site

Abstract

Abstract Management of the nasal bony vault is an integral part of rhinoplasty surgery, whether reducing the dorsal profile line or narrowing the base bony width. Since 2013, dramatic changes have occurred because of new insights into our understanding of nasal anatomy, how we analyze bony vault deformities, and the introduction of new surgical techniques and technologies including piezosurgery. Therefore, a reassessment and overview of bony vault surgery appears justified. With wide exposure and visualization of the bony vault, we have concluded that all bony vaults are asymmetrical and that the lateral bony wall may be analyzed in 3 axes: longitudinal, sagittal, and transverse. The longitudinal and sagittal axes may be judged as convex, straight, or concave. The transverse axis can be precisely rotated or translated depending on the design of ultrasonic osteotomies. We review this nasal anatomy as well as treatment including sculpting of the nasal bones, as well as different osteotomy patterns. Piezosurgery is certainly a disruptive technology in rhinoplasty that allows bony reshaping with precise osteotomies and sculpting. This versatility allows treatment of any type of bone (thin, brittle, short), mobile bones, and fractured bones. This enables the surgeon to achieve better symmetry with greater accuracy and precision. Level of Evidence: 5 Management of the nasal bony vault is an integral part of rhinoplasty surgery, whether reducing the dorsal profile line or narrowing the base bony width. During the past 5 years, dramatic changes have occurred because of new insights into our understanding of nasal anatomy,1,2 how we analyze bony vault deformities,3 and the introduction of new surgical techniques.4 Therefore, a reassessment and overview of bony vault surgery appears justified. It should be noted that extensive discussion of the historical evolution of bony vault surgery and the use of piezoelectric instrumentation (PEI) have been previously published by the authors in this journal.4 SURGICAL ANATOMY Anatomically, one must reconcile skull-based anthropometric terminology with surface-based surgical descriptions. The bony vault is comprised of the fused radix area (nasal bones with frontal bone), the paired nasal bones, and the bilateral frontal processes of the maxilla. Throughout this article, we will emphasize surgical terminology. From a surgical perspective, we will focus on three components: the radix area, the bony cap, and the lateral bony wall. Radix Area The bony vault can be divided at the nasion (N) into a cephalic (radix area) and caudal portion (bony cap). The cephalic radix area is comprised of three distinct bones: nasal bone, frontal bone, and nasal spine of the frontal bone. These three bones fuse in a solid syndesmosis obliterating the original midline suture lines. This solid triangular bony mass is reduced with difficulty, and osteotomies that extend into this area risk development of “rocker formations.” Surgically, the vast majority of dorsal humps do not extend above the nasion. Alternatively, there are certain cases where deepening of the nasion in an anterior-posterior plane is necessary, and one must distinguish between muscle mass and bony fullness. Bony Cap/Keystone Area The caudal portion of the bony vault is a much thinner bony cap covering the cartilaginous vault and the underlying nasal airway. Palhazi et al2 demonstrated that the nasal bones form a thin bony cap over the underlying cartilaginous vault. The cap measures 0.7 mm (range, 0.5-1.0 mm) in thickness at the keystone junction, and clinically, the bony cap extends 10-14 mm cephalically. This anatomical concept of a bony cap, as opposed to the surgical entity of a bony hump, can be explained embryologically. Growth of the nose occurs from the anterior-posterior expansion of the septum rather than from growth of the nasal bones themselves. During puberty, the cartilaginous nasal septum functions as the dominant growth center of the midface. The nasal hump results from the upward thrust of the underlying cartilaginous vault rather than an equal contribution from the nasal bones and cartilage. Thus, there is no bony hump, only a bony cap that covers a cartilaginous hump. The keystone area can be divided into a dorsal and lateral keystone area. The dorsal keystone area (DKA) measures 9 mm in the midline (range, 4-14 mm).2 The lateral keystone area (LKA) is created by the overlap of the upper lateral cartilages (ULCs) and nasal bones. The degree of overlap is highly variable. However, the amount of longitudinal overlap is greatest along the dorsum. In most dorsal reductions, the osseocartilaginous junction is permanently removed in the midline, and the new osseocartilaginous junction is moved cephalically toward the nasion. Clinically, the mucosa cephalic to the cartilage vault is rarely exposed after the removal of the bony cap. Laterally, the bony-cartilaginous junction moves caudally and posteriorly after hump reduction due to the slope of the pyriform aperture. The management of the LKA is paramount to creating smooth dorsal aesthetic lines (DALs) and must be blended smoothly with the middle vault. Lateral Bony Wall The term lateral bony wall encompasses both the frontal process of the maxilla and the lateral portion of the nasal bones. Surgically, bony cap reduction is confined to the nasal bones, but lateral osteotomies pass within the frontal process of the maxilla. Anatomically, there is a reciprocal size relationship between the frontal process of the maxilla and the nasal bones: the larger the frontal process, the smaller the nasal bones (Figure 1). Likewise, the lateral extent of the ULC closely corresponds to the nasal bone-frontal process of the maxilla suture line. Figure 1. View largeDownload slide (A, B) There exists a reciprocal relationship between the sagittal length of the lateral bony wall and the frontal process of the maxilla. The longer the frontal process, the shorter the length of the nasal bone. Figure 1. View largeDownload slide (A, B) There exists a reciprocal relationship between the sagittal length of the lateral bony wall and the frontal process of the maxilla. The longer the frontal process, the shorter the length of the nasal bone. The configuration of the lateral bony wall is 3-dimensional (3D) and is crucial in planning lateral osteotomies. There can be distinct variations in the contour of the nasal bones and the frontal process of the maxilla—straight, convex, or concave configurations (Figure 2). Equally variable is the shape and width of the pyriform aperture. The length of the lateral bony wall (distance from the medial canthal ligament to the pyriform aperture on the frontal process of the maxilla irrespective of the nasal bones) must also be considered. Figure 2. View largeDownload slide (A) The longitudinal and sagittal axes of the lateral bony wall are shown. (B) The longitudinal and sagittal axes may be convex, straight or concave. Cadaver dissections demonstrate sagittal axes that are (C) convex, (D) straight, or (E) concave. Figure 2. View largeDownload slide (A) The longitudinal and sagittal axes of the lateral bony wall are shown. (B) The longitudinal and sagittal axes may be convex, straight or concave. Cadaver dissections demonstrate sagittal axes that are (C) convex, (D) straight, or (E) concave. AESTHETICS AND ANALYSIS Skin-surface DALs as seen on the anterior view help define the aesthetics of the nasal dorsum. Our understanding of the DAL has been advanced in recent years for two reasons: (1) the polygon concept of Çakir; and (2) direct intraoperative evaluation made possible by wide surgical exposure. Surface Aesthetics Sheen described the dorsal lines as “two divergent concave lines that are unbroken extensions of the superciliary ridges…which connects the radix with the lateral projection of the crura.”5 Recently, Çakir introduced the concept of polygons for analyzing the aesthetics of the nose.6 Nasal polygons are geometric forms derived from a composite of lines, shadows, and highlights with specific proportions and breakpoints with variations in males and females. The osseocartilaginous vault is comprised of four polygons: two bony (dorsal and lateral) and 2 cartilaginous (dorsal and lateral) polygons. Importantly, he notes that DAL are not straight, but rather “fusiform”—narrow in the radix, wider at the keystone, and narrow again at the supratip. In addition, there is a lateral aesthetic line that demonstrates the nasofacial groove, which is the junction between the angulated frontal process of the maxilla and the maxilla itself. The polygon concept of nasal analysis can be expanded to the interface between the nose, radix, and central brow.7 Essentially, there are three polygons: glabellar, medial orbit, and superomedial orbit. Clinically, the DAL and lateral aesthetic lines are connected by the lateral bony wall, with its corresponding shadowing. As noted in the anatomy section, the lateral bony wall can be thought of as having three axes: longitudinal (cephalic to caudal), sagittal (anteroposterior), and transverse (lateral to medial). The longitudinal and sagittal axes can vary from straight to convex to concave. Importantly, the transverse axis can be translated or rotated (Figure 3). Figure 3. View largeDownload slide The transverse axis of the lateral bony wall can be rotated with V-shape osteotomies, and translated with U-shape osteotomies. Figure 3. View largeDownload slide The transverse axis of the lateral bony wall can be rotated with V-shape osteotomies, and translated with U-shape osteotomies. Clinical examination of the nose preoperatively is paramount for analysis. First, the skin thickness must be assessed, because the skin is frequently thinner in the keystone area and also near the medial canthus.8 Nasal bone characteristics are assessed through palpation to estimate the length and width of the bony vault, as well as the shape of the bone segments (straight, convex, concave). In the case of secondary rhinoplasty, palpation can demonstrate irregularities, osteotomy level and type, residual bone width, etc. Radiography Nasal bone thickness and angulation can be assessed through preoperative radiological examination. The cone beam is preferred to the CT scan, because it requires less radiation and is less expensive. This test allows a very precise bone thickness measurement on any computer. This thickness can be especially important in the LKA, because it will help in deciding between sculpting down this area or doing a medial oblique osteotomy. Surgical Observations The complete bony vault was rarely visualized by surgeons until the introduction of the “wide exposure” necessary for piezoelectric osteotomies.4 After elevation of the periosteum, we gain exposure from one maxilla to the other, and the following observations can be made: 1) The bony vault is always asymmetric in shape and frequently there is a more pronounced convexity at the LKA on one side 2) The shape of the medial component in terms of width and the lateral component in terms of straight, convex, or concave can be perfectly analyzed. This analysis will dictate the type of osteotomy and/or sculpturing performed, but also sometimes the need for concavity concealment with diced cartilage, bone dust, or other graft material 3) The exact location of the bony cap removal can be assessed not only on the dorsal segment, but also on the lateral segment. Asymmetric sculpting and removal avoids length discrepancies after medial oblique osteotomies. OPERATIVE SEQUENCE FOR MANAGING THE BONY VAULT Traditional management of the bony vault has evolved to avoid overresection and to conserve cartilage. First, the dorsum is reduced using an en bloc, split, or component technique followed by osteotomies. Although one can achieve good results with traditional instruments, problems still occur, including overresection, asymmetries, and unreliable movement of the nasal bones. These issues are related to the inability to visualize the bony vault and to the inherent disadvantage of traditional instrumentation. With the advent of PEI, greater precision has become possible. Although wide variations are possible to accommodate the anatomical variations encountered, a standard operative sequence is as follows: (1) wide subperiosteal undermining; (2) bony cap removal; (3) osteotomies; and (4) midvault reconstruction. Wide Subperiosteal Exposure Since 2014, an extended bony vault degloving has been used for all primary and secondary rhinoplasties performed by the primary (O.G.) and junior authors (A.K.), except when no bone modification was planned. The dissection is initiated at the level of the anterior septal angle in a supraperichondrial or subperichondrial plane and continued above the cartilaginous dorsum until the bony junction. Then, using a sharp Daniel-Çakir elevator, the subperiosteal plane is entered in each LKA for ease of dissection and then connected in the midline that is much more adherent. The subperiosteal undermining is extensive. Beginning at the keystone junction, it extends dorsally up to and beyond the nasion, then laterally toward the medial canthal ligament, and then caudally along the frontal process of the maxilla. Any perforating vessels are cauterized in the bony foramen with a curved Colorado needle. As one approaches the pyriform aperture, it is often necessary to cut the vertical pyriform attachments and stretch the transverse pyriform ligaments to gain adequate exposure (Figure 4).9 Next, the dissection is extended approximately 1cm lateral to the nasofacial groove out onto the horizontal anterior surface of the maxilla. With this exposure, it is possible to totally analyze the bony vault deformity and to gain access for surgical instrumentation. Figure 4. View largeDownload slide To accurately perform piezo osteotomies, good visualization and exposure are paramount. After subperiosteal dissection of the entire bony vault, release of the (A) vertical pyriform attachments and (B) transverse pyriform ligaments is often necessary. NB, nasal bone; LLC, lower lateral cartilage; ULC, upper lateral cartilage. Figure 4. View largeDownload slide To accurately perform piezo osteotomies, good visualization and exposure are paramount. After subperiosteal dissection of the entire bony vault, release of the (A) vertical pyriform attachments and (B) transverse pyriform ligaments is often necessary. NB, nasal bone; LLC, lower lateral cartilage; ULC, upper lateral cartilage. Management of the Dorsal Hump Once the extensive subperiosteal dissection and a “dorsal time out” to reassess the planned dorsal surgery are completed, then the bony cap is removed in the medial and lateral keystone areas. Traditionally, this is followed by splitting the ULCs from the dorsum and an anterior dorsal resection. However, only the bony cap removal is done initially, and the actual reduction of the cartilaginous vault is performed after the osteotomies, and this is a major change from traditional rhinoplasty surgery. Bony Cap Removal As shown in previous anatomical studies, the osseocartilaginous dorsal hump consists of a thin bony cap overlying an arched cartilaginous vault.2 Rather than use an osteotome, incremental bone removal not only is limited to the central area of the hump but also extends to the LKA if it is too convex. The bone is removed with a coarse PEI rasp first (RHS2H) and then with a finer rasp (RHS2F). The bony DALs can be sculpted by tilting the rasp horizontally on the medial keystone and obliquely on the lateral keystone. When the dorsal hump extends to the nasion or if the radix must be significantly reduced, then a scraper (RHS1) is used followed by a rasp (RHS2F) for refinement. Because PEI does not harm soft cartilaginous tissues, the bony cap can be removed without affecting the underlying ULC or even the mucosa in cases of very significant and cephalic humps. Thus, in contrast to the use of osteotomes or chisels, there is never an open roof with PEI. The roof is only opened if necessary when the ULCs are split off, and then it is closed with the subsequent midvault reconstruction. Moreover, the attachments between the posterior periosteum of the remaining nasal bones and the anterior perichondrium of the ULC are preserved, favoring the middle third for stability and a smooth osseocartilaginous transition. Osteotomy Sequence Historical Perspective To understand the current osteotomy sequence, one must review the historical progression of how modern osteotomy techniques evolved. Since the time of Joseph, lateral osteotomies have been done to narrow the broad nose following hump reduction.10 Initially, osteotomies were performed with saws placed in the nasofacial groove and continued from the pyriform aperture to above the medial canthal ligament. Once the osteotomies were completed, digital pressure was used to move the bones medially. Millard added medial osteotomies to all his rhinoplasties to facilitate bony movement.11 Once both osteotomies were done, the nasal bones were “outfractured” followed by “infracturing” to achieve complete movement of the lateral bony wall. Ultimately, surgeons switched to chisels and osteotomes, because they were less traumatic, so the surgeons did infracturing only. Limited skin undermining was emphasized to promote stability of the mobilized bones. Tardy used 2 mm micro-osteotomes for medial oblique osteotomies followed by low lateral osteotomies.12 Sheen advanced the concept of the low to high osteotomy that begins low on the pyriform aperture and ascends across the frontal process of maxilla ending at the nasal bone.5 Narrowing of the nose and closure of the open roof is accomplished with a transverse greenstick fracture. In contrast, the low to low osteotomy remains within the frontal process of the maxilla and requires another osteotomy to pass from its cephalic termination into the open roof, either through a previous medial oblique osteotomy coming down from the open roof or a transverse osteotomy. The longitudinal extent and location of lateral osteotomies has changed dramatically from Joseph’s original design. First, surgeons realized that there was rarely a need to go above the medical canthal ligament and that doing so risked significant bony irregularities. In the vast majority of cases, the bony vault is “narrow-waisted” at the level of the medial canthal ligament and the bone above is fused and prone to visible rocker formation. Next, surgeons began to place the lateral osteotomy significantly more anterior away from the nasofacial groove and the face of the maxilla. Also, the goal was no longer complete mobilization of the lateral nasal wall, but rather inward tilt and stabilization. In 1977, Webster proposed that a triangle of bone be preserved at the pyriform aperture to maintain an intact airway below the level of the inferior turbinates.13 He advocated use of a curved lateral osteotome placed more anteriorly and superiorly. This dictum led to the concept of a “high-low-high” lateral osteotomy. Surgeons disagree on whether this triangle needs to be kept intact to maintain airway patency. Lateral Osteotomy The first osteotomy cut is done very caudally on the frontal process of the maxilla with a thin saw (RHS5) or with the fan-shape lateral saw (RHS3 L and R). This low initiation point is in direct contrast to the high starting point used by those who favor the preservation of Webster’s triangle. The reasons for not preserving a Webster’s triangle are two possible aesthetic deformities: (1) excessive base bony width near the alar crease; and (2) palpable bone excess. If endonasal assessment after completion of the full osteotomy sequence shows that the inferior turbinate moves significantly inward, then a mucosal reduction with radiofrequency and/or a bone reduction (inferior nasal concha) with a long piezo saw or outfracture could be performed. If this endonasal assessment shows that the pyriform aperture edge moves too much inward, then it can be reduced with a rasp or a scraper. Since 2013, we (O.G. and A.K.) have not found a need for these refinements. Next, the lateral osteotomy is continued in the nasofacial groove using a fan-shape piezo saw (RHS3R for the left side and RHS3L for the right side). This cut follows the nasofacial groove in a cephalic direction until the point where the width of the bony vault is aesthetically correct. If the radix is narrow, there is no need for the lateral osteotomy to go above the medial canthal ligament (MCL). Conversely, if the radix is wide, the lateral osteotomy follows the groove above the MCL. After the lateral osteotomy is completed, the amount of bone movement is checked with an elevator. Most surgeons are surprised that 2 to 5 mm of transverse medial bony movement along the frontal process of the maxilla can and does occur following only a lateral osteotomy. Significant narrowing of the base bony width occurs with just a lateral osteotomy in many cases. If the movement is sufficient without a significant spring effect and the bone orientation is correct, then the osteotomy sequence is stopped. However, if the lateral osteotomy did not achieve sufficient narrowing, then the following options are considered: (1) if the dorsum is wide, a medial oblique osteotomy is done; and (2) if the dorsum is ideal, then a transverse osteotomy is done. Transverse Osteotomy The transverse osteotomy is performed with an angulated, thin piezo saw (RHS4L for the right side and RHS4R for the left side). It begins at the cephalic termination of the lateral osteotomy and continues horizontally until the point where this line would meet a theoretical medial oblique osteotomy (even if this osteotomy is not performed). At this point, bony movement is again checked with an elevator. If the mobilization and orientation of bones are correct, then the osteotomy sequence is ended. If not, then a medial oblique osteotomy is added. Medial Oblique Osteotomy This osteotomy is performed with the same thin saw (RHS5) used for the initial osteotomy. It begins on the LKA at the point where the ideal DAL should be. It is usually oriented toward the medial eyebrow, and there are two possibilities regarding how this osteotomy is used to effect nasal bone movement. First, when the medial oblique osteotomy is combined with only a lateral osteotomy, an intact bony hinge remains. This results in a V-shape osteotomy. This combination is done to narrow the dorsal lines, to increase medial movement of the lateral bony wall, and to allow slight verticalization of the bone. This combination is favored when the bones are thin or fragile and less movement is needed. The second option is to do a complete continuous osteotomy composed of lateral + transverse + medial oblique osteotomies to “translate” the nasal bone medially in its original orientation. This results in a U-shape osteotomy. After this complete fracture, drill holes and sutures can be used to precisely fine-tune the nasal bones if needed. Finishing Touch Smoothing of the osteotomy edges and bony dorsal edges are done with a fine piezo rasp (SL1). Palpation of the nose with wet gloves should find no rough areas; otherwise, they should be smoothed out. This assessment can even be done at the end of the procedure, when the columella is sutured, allowing a final touch through the infracartilaginous access. It should be noted that there is not any bleeding from the nostrils during the procedure, because the mucosa is intact with PEI. Infiltrating the lining before the osteotomies helps to prevent any rare mucosal tears that occur from pushing too hard on the instruments. MOVEMENT OF LATERAL BONY WALL AND OSTEOTOMIES Nasal bone movement depends on the path of the osteotomies. With classic osteotomies, bones are supposed to fracture on the path of least resistance, or to have a greenstick fracture. If these maneuvers are insufficient, more digital pressure is applied and osteotomies can be added. Most frequently, the osteotomy pattern has either a V- or U-shape pattern (Video, available online as Supplementary Material at www.aestheticsurgeryjournal.com). The V-shape osteotomy consists of a lateral low to high and a medial oblique osteotomy with an intact bony hinge. The U-shape osteotomy consists of a lateral low to low osteotomy plus a transverse and medial oblique osteotomy. When V-shape osteotomies are done, there is a hinge at the junction of the two osteotomies that prevents the translation of the bone inwards. In this case, the bone medializes by rotation. This rotation makes the bone more vertical and can alter aesthetics of the sidewall. The result is a tubular appearance of the dorsum, with a vertical shadow laterally and a vertical light area in the middle of the dorsum. When U-shape osteotomies are performed, the lateral bony wall can translate medially without restriction. The two edges of the bone stay end to end on the medial oblique fracture line with minimal angulation on the osteotomy line. Osteotomies are more commonly performed with a U-shape pattern, to narrow the bony vault without altering the aesthetic features of the nasal sidewalls (Figure 5). The bones are moved inward but remain stable, even if complete osteotomies are performed. The primary indication we have for V-shape osteotomies is when the bony vault is wide and flat, and/or bone verticalization must be done. This happens often for “ethnic noses.” Figure 5. View largeDownload slide (A, C, E, G) Preoperative views of a 31-year-old woman who complained of a wide nose who was found to have a convex left nasal bone. (B, D, F, H) Following bony cap removal, bilateral U-shape piezo osteotomies, and additional rasping on the left lateral bony wall, better symmetry and contour of the bony dorsum can be seen at 1 year postoperatively. Spreader flaps were used for midvault reconstruction as well as a septal extension graft and tip suturing. Figure 5. View largeDownload slide (A, C, E, G) Preoperative views of a 31-year-old woman who complained of a wide nose who was found to have a convex left nasal bone. (B, D, F, H) Following bony cap removal, bilateral U-shape piezo osteotomies, and additional rasping on the left lateral bony wall, better symmetry and contour of the bony dorsum can be seen at 1 year postoperatively. Spreader flaps were used for midvault reconstruction as well as a septal extension graft and tip suturing. Video 1 Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjx246 Video 1 Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjx246 Close Overall, the ability to change the shape and orientation of osteotomies under direct visualization is the biggest advantage we have seen with piezosurgery that makes it truly a disruptive technology. Because all bony vaults are asymmetric, it is not uncommon to do a V-shape osteotomy on one side and U-shape osteotomy on the other. Likewise, at times, an osteotomy is done on one side and ultrasonic rhinosculpture is done on the other. ULTRASONIC RHINOSCULPTURE When the bony vault has minimally excessive width and minimal dorsal reduction is indicated, then a thinning of the entire bony vault can be performed with a PEI rasp. This means that no osteotomy is performed, but rather a rasping of the entire bony pyramid, especially the more convex areas, is done. The advantages are that the bones remain perfectly stable and there is very little bruising after the surgery. The new bony dorsal aesthetic lines can be sculpted (Figure 6). Care must be taken not to use rhinosculpture when a significant narrowing of the bones is indicated. At the beginning of his experience with rhinosculpture (2013-2015), the primary and junior authors (O.G. and A.K.) “pushed” the indications of rhinosculpture to cases where osteotomies would have been indicated. In some cases, the bony vault remained too wide. After a minimum of 6 months, a second operation was successfully performed with osteotomies (Supplemental Figure 1). Figure 6. View largeDownload slide (A, D, G) Preoperative views of a 26-year-old woman who presented to the primary author (O.G.) and complained of a wide bony vault and wide nose overall. She was found to have a slightly wide dorsum amenable to ultrasonic rhinosculpture. Spreader flaps and tip suturing were done to reconstruct the middle vault and tip. (B, E, H) Six days and (C, F, I) 11 months postoperatively, the patient has aesthetic and appropriately narrow dorsal aesthetic lines. Figure 6. View largeDownload slide (A, D, G) Preoperative views of a 26-year-old woman who presented to the primary author (O.G.) and complained of a wide bony vault and wide nose overall. She was found to have a slightly wide dorsum amenable to ultrasonic rhinosculpture. Spreader flaps and tip suturing were done to reconstruct the middle vault and tip. (B, E, H) Six days and (C, F, I) 11 months postoperatively, the patient has aesthetic and appropriately narrow dorsal aesthetic lines. BONE MANAGEMENT IN ETHNIC RHINOPLASTY Many people from African or Asian descent have a flat dorsum and wide nasal bones. Likewise, ethnic rhinoplasties usually include dorsal augmentation, tip refinement, and alar base modification. Usually, the nasal bones are left untouched. However, the bony vault may remain too wide in many cases, even though the width is more balanced with a new profile line. Moreover, a step deformity can occur at the junction of the overlay dorsal graft and the underlying bony vault, because there may be a width discrepancy between both if the bony vault is not narrowed. When the bony vault is very wide, we do not hesitate to do lateral osteotomies. These osteotomies are more difficult, because the bones are very dense and further from the midline. In most cases, a low and sometimes transverse osteotomy are enough to narrow the bony vault significantly. In these cases, any verticalization is beneficial. In the treatment of ethnic noses, incorporating narrowing of the bony vault has improved the overall result (Figure 7 and Supplemental Figure 2). The risk of unwanted fractures, bone instability, and bone collapse has also been reduced with PEI. Figure 7. View largeDownload slide (A, C, E) Preoperative and (B, D, F) 13-month postoperative result of a 19-year-old woman from Qatar who presented to the junior author (A.K.) with a wide, flat dorsum and extreme convexity of the lateral bony walls. Piezo saws were used to harvest ethmoid bone in continuity with septal cartilage. The tip was supported on a septal extension graft, and a radix graft was done. V-shape osteotomies were done to verticalize the lateral bony walls and to narrow the dorsum from 18 to 6 millimeters. Figure 7. View largeDownload slide (A, C, E) Preoperative and (B, D, F) 13-month postoperative result of a 19-year-old woman from Qatar who presented to the junior author (A.K.) with a wide, flat dorsum and extreme convexity of the lateral bony walls. Piezo saws were used to harvest ethmoid bone in continuity with septal cartilage. The tip was supported on a septal extension graft, and a radix graft was done. V-shape osteotomies were done to verticalize the lateral bony walls and to narrow the dorsum from 18 to 6 millimeters. BONE MANAGEMENT IN SECONDARY RHINOPLASTY Until the introduction of widespread subperiosteal exposure, the bony deformities found in secondary rhinoplasty cases were difficult to understand and treat. One should consider previous osteotomy location, direction, and completeness as well as the stability and comminution of the lateral bony wall. One can divide secondary bony deformities into the following categories: surface irregularities, contour defects, and lateral bony wall deformities. Surface Irregularities These bony irregularities most commonly occur in the following areas: (1) dorsally where the bony hump was removed; and (2) along the bony edges of greenstick fracture lines or previous osteotomy. The irregularities are much more frequently noticeable in thin-skinned patients. Treatment of surface irregularities is usually done with a piezo rasp. Contour Deformities One of the most common secondary bony vault problems is contour asymmetries. Previously, the solution was a combination of fine rasping and osteotomies done blindly. With wide exposure, the problem can actually be seen and treated directly often with ultrasonic rhinosculpture. With a fine rasp, one can sculpt a wide nasal bone down to match the narrower bone, whereas previously the surgeon was unaware of intrinsic thickness and tried to narrow the wide side with an osteotomy. The most frequent etiology of residual bony convexity is a failure to correct the original preoperative deformity with uneven osteotomies (ostoeotomies performed at different levels). The residual convexity is treated either by rasping if the bone is sufficiently thick or by criss-cross osteotomies if the bone is thin. Lateral Wall Problems Challenges in the lateral bony wall include “step deformities” associated with previous osteotomies and the position of the wall with either inadequate or excessive movement. Step deformities can have moderate palpable separations and major level discrepancies. If a redo osteotomy is not indicated for positional or rotational reasons, then the bony edges can be smoothed with a fine rasp and/or filled with very finely diced cartilage to eliminate palpability. If there is a significant level discrepancy between the two sides of an osteotomy, multiple drill holes are placed through both bones, the lower side is raised, and one to three sutures are inserted with 4/0 PDS on a P3 needle. If there is still a gap after the fracture osteosynthesis, it is filled with a cartilage paste obtained by scratching a piece of cartilage with a number 15 blade or with diced cartilage. If there was a failure to medialize the lateral bony wall and the bony vault remains too wide, then the lateral osteotomies are repeated, but in a more lateral position. When the lateral osteotomy is correctly located but inadequate movement is achieved, then a transverse osteotomy and/or a medial osteotomy are adequate to allow complete mobilization. If excessive bony movement is present, it is usually associated with verticalization of the bony wall. Verticalization is related to bone rotation, with the thick lower posterior base moving medially and the thin anterior portion moving laterally. This rotation results either from the osteotomy design, or from excess narrowing. Excessive movement is usually treated by grafting the lateral aspect of the bone with diced cartilage or other camouflage. Another option is to do a paramedian and transverse osteotomy to outfracture the bone and to place a long spreader graft to stent the bone in the correct position. REFINEMENTS/COMPLICATIONS IN PIEZOSURGERY With any new technology or technique, there are refinements and complications that occur during initial adoption. Pushing the indications for ultrasonic rhinosculpture when osteotomies are indicated has already been discussed above. Since the adoption of piezosurgery by the authors, over 750 rhinoplasties have been performed, with few complications. Because this is the combined work of four authors over a multiyear period, detailed demographic data about the patients treated were not available. The following is a list of issues and refinements that have been made over the last years: The piezo device requires water to assist in ultrasonic vibration and to prevent heating. If water flow is too low, the device can get hot, and a few burns to the skin were observed near the nostrils. At the time of surgery, these were seen and excised without issue to prevent untoward healing. Water flow is paramount to preventing this issue. The waterflow should be at least 50 ml/min to avoid any skin or bone burning. Suction retractor and suction speculum are very useful to ease the procedure and overflooding by the water outflow. It has been demonstrated that bruising and swelling are decreased with piezo osteotomies as compared with conventional instrumentation.14,15 After the osteotomies are completed, dilute steroid is injected next to the bone cuts, and a small drain hole is made in the intra-nasal mucosa to allow for drainage. Subjectively, this has further decreased swelling/bruising after surgery but has not formally been studied. We have found no contraindications to the wide subperiosteal exposure. To avoid favoring fluid collection in the lateral area of the bony vault dissection, large splints must be used. A narrow preshaped splint may compress only the median part of the undermining, favoring a lateral fluid collection. In a few patients over a 4-year period, the primary and junior authors (O.G. and A.K.) have had noticed a buildup of soft tissue callus in lateral osteotomy sites 3-4 weeks after surgery in 3 patients. Dilute steroid has been injected into the callus (under ultrasonic guidance in the senior author’s practice), and this has resolved. In one case, a second injection was necessary. This is not due to the wider area of dissection, but rather secondary to the bone emulsification along the osteotomy lines. The cost of the piezo device and disposable inserts is different in every country. The cost of the device can be up to $10,000, and inserts can each cost over $100. Currently, we are hopeful that reusable inserts are on the horizon. Although this technology is more expensive than osteotomes, all of the advantages described above certainly make it worth it. CONCLUSIONS Since the origins of rhinoplasty, wide exposure of the nose was taboo, even with the “open” approach to prevent bone collapse. With the accuracy of bone reshaping and mobilization with PEI, extending the bone dissection to the whole nose, including the bony vault, is safe and allows full visualization of the nasal bones before and after osteotomy. Piezo surgery is a disruptive technology in rhinoplasty that allows bony reshaping with precise osteotomies and sculpting. This versatility allows the treatment of any type of bone (thin, brittle, short), mobile bones, and fractured bones. This enables the surgeon to achieve better symmetry with more accuracy and precision. Piezo surgery may reduce significantly defects of the bony vault and the keystone area in rhinoplasty, and it adds new options in bone reshaping and in the treatment of bony defects. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures Dr Gerbault is a consultant and receives royalties from COMEG Medical Technologies (La Ciotat, France). Dr Daniel receives royalties from Springer Publishing (New York, NY). Dr Kosins is a shareholder and member of the Medical Advisor Committee for ZO Skin Health, Inc. (Irvine, CA) and also a consultant for Marina Medical (Florida). Dr Palhazi declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. Acknowledgements The authors would like to thank the members of the International Rhinoplasty Research Society, who have followed this work and given their input throughout its conception: Drs. Charles East, Abdülkadir Goksel, Milos Kovacevic, and Yves Saban. REFERENCES 1. Lazovic GD, Daniel RK, Janosevic LBet al.   Rhinoplasty: the nasal bones—anatomy and analysis. Aesthet Surg J . 2015; 35( 3): 255- 263. Google Scholar CrossRef Search ADS PubMed  2. Palhazi P, Daniel RK, Kosins AM. The osseocartilaginous vault of the nose: anatomy and surgical observations. Aesthet Surg J . 2015; 35( 3): 242- 251. Google Scholar CrossRef Search ADS PubMed  3. Çakir B. Aesthetic Septorhinoplasty . Berlin: Springer; 2015. 4. Gerbault O, Daniel RK, Kosins AM. The role of piezoelectric instrumentation in rhinoplasty surgery. Aesthet Surg J . 2016; 36( 1): 21- 34. Google Scholar CrossRef Search ADS PubMed  5. Sheen JH. Aesthetic Rhinoplasty . St Louis, MO: Mosby; 1978. 6. Çakir B, Doğan T, Öreroğlu AR, Daniel RK. Rhinoplasty: surface aesthetics and surgical techniques. Aesthet Surg J . 2013; 33( 3): 363- 375. Google Scholar CrossRef Search ADS PubMed  7. Daniel RK, Kosins A, Sajjadian Aet al.   Rhinoplasty and brow modification: a powerful combination. Aesthet Surg J . 2013; 33( 7): 983- 994. Google Scholar CrossRef Search ADS PubMed  8. Kosins AM, Obagi ZE. Managing the difficult soft tissue envelope in facial and rhinoplasty surgery. Aesthet Surg J . 2017; 37( 2): 143- 157. Google Scholar CrossRef Search ADS PubMed  9. Daniel RK, Palhazi P. Rhinoplasty: An Anatomical and Clinical Atlas . New York: Springer; 2017. 10. Joseph J. Nasenplastik und sonstige gesichtsplastik, nebst einem anhang über mammaplastik , 1931. 11. Millard DR. Rhinoplasty Tetralogy: Corrective, Secondary, Congenital, Reconstructive . Boston: Little, Brown and Company; 1996. 12. Tardy ME, Denneny JC. Micro-osteotomies in rhinoplasty— a technical refinement. Facial Plast Surg . 1984; 2: 137- 145. Google Scholar CrossRef Search ADS   13. Webster RC, Davidson TM, Smith RC. Curved lateral osteotomy for airway protection in rhinoplasty. Arch Otolaryngol . 1977; 103( 8): 454- 458. Google Scholar CrossRef Search ADS PubMed  14. Ilhan AE, Cengiz B, Caypinar Eser B. Double-blind comparison of ultrasonic and conventional osteotomy in terms of early postoperative edema and ecchymosis. Aesthet Surg J . 2016; 36( 4): 390- 401. Google Scholar CrossRef Search ADS PubMed  15. Gerbault O, Kosins AM. Commentary on: Double-blind comparison of ultrasonic and conventional osteotomy in terms of early postoperative edema and ecchymosis. Aesthet Surg J . 2016; 36( 4): 402- 403. Google Scholar CrossRef Search ADS PubMed  © 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: Feb 8, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off