Piezo rhinoplasty

What repeats

Four findings that hold across the literature.

It selects bone and spares the lining

Selectivity is the mechanism the whole technique rests on. Across ten studies and 554 patients, the odds of a mucosal tear were lower with the ultrasonic device than with the osteotome. In a review of nineteen randomised studies and 905 patients, mucosal integrity was lost in none of the piezo cases.

Rests on: Khajuria et al., piezoelectric versus conventional osteotomy · Armanfar et al., GRADE review · and nasal osteotomies.

Bruising, swelling and pain are lower in the first week

Three separate pooled analyses agree on direction. Swelling favoured piezo at day 2 and day 7, bruising at days 1, 2 and 7, and pain at day 2. A systematic review of eight randomised trials and 440 patients found the reduction in swelling statistically significant in 75% of the trials and the reduction in bruising in 87.5%. In a prospective series of 113 patients, bruising of the lower eyelid was lower with piezo on every day measured.

Rests on: Armanfar et al. · Kisel et al., oedema and ecchymosis · Vural and Koycu, eyelid comparison · and recovery.

The operation takes at least as long

The time saving does not appear. Pooled data show no difference in the duration of the osteotomy or of the whole operation, with wide variation between studies. In a matched radiological comparison of 60 patients, the operating time was significantly longer in the piezo group.

Rests on: Khajuria et al. · Armanfar et al. · Kandemir et al., radiological comparison.

It changed what surgeons do to the bone, not just how they cut it

Because the tip does not tear the lining, the bone can be exposed widely and sculpted rather than only fractured. Ultrasonic rhinosculpture was used to shape the bony vault without any osteotomy in 95 of 185 cases in the series that introduced the method. A later series applied the same approach to 165 cases, giving priority to leaving the nasal bones stable.

Rests on: Gerbault et al., the role of piezoelectric instrumentation · Zholtikov et al., a sequential approach to the bony vault · and narrowing the bridge.

By what the surgeon is trying to do

The same handpiece is used at several different steps.

Make the osteotomies under direct vision

The core use. The cuts are placed where the surgeon can see them rather than by feel, and the periosteum underneath is left attached, so the freed bone keeps its blood supply and stays where it is put.

Rests on: Gerbault et al. · Gerbault, ultrasonic rhinoplasty and septoplasty.

Preserve the dorsum instead of removing it

Dorsal preservation lowers the whole bridge rather than cutting the hump off, which demands precise bone work at the base. Piezo inserts are used for the lateral, transverse and paramedian cuts and for removing the perpendicular plate of the ethmoid. One closed-approach series of 734 patients reports a 6% revision rate, mostly for dorsal contour. A closed piezo preservation series of 134 patients reports satisfaction rated excellent in 96%, with two residual humps.

Rests on: Goksel et al., piezoelectric osteotomies in dorsal preservation · Guilarte and Malzone, closed-approach preservation · Almazov et al., closed piezo preservation · and preservation rhinoplasty.

Smooth the bone after the hump comes off

An ultrasonic bone aspirator emulsifies and suctions bone under irrigation. In 103 consecutive cosmetic rhinoplasties it was used to reduce the nasal spine, deepen the angle at the root, smooth bony edges after a medial cut and reduce convex nasal bones. Seven patients had a minor complication, and none had a skin or soft tissue injury.

Rests on: Greywoode and Pribitkin, sonic rhinoplasty · Pribitkin and Greywoode, applications · and component dorsal hump reduction.

Choose the tool step by step

Piezo is one option among the chisel, the saw, the rasp and the burr, and the case for it is argued rather than settled. A published algorithm assigns each step to a tool, and a decision diagram sorts noses by anatomy before the technique is chosen. One such series covers 107 consecutive cases.

Rests on: Winkler, powered versus cold instruments · Taglialatela Scafati and Regalado-Briz, when and why · and powered instrumentation.

What to ask about piezo rhinoplasty

Questions the evidence supports asking.

How many of these has the surgeon done

The learning curve is the honest answer to most of the marketing. Working ultrasonically requires a wide subperiosteal exposure that conventional technique does not, and the published series are single-surgeon counts that run from 107 cases to 734. Ask for the surgeon's own number and how long they have used the device.

Rests on: Taglialatela Scafati and Regalado-Briz · Guilarte and Malzone · Gerbault et al..

Will I bruise less, and by how much

Ask for photographs at days 1, 3 and 7. The pooled effect is real in the first week and shrinks afterward, and the trials measure observer-graded scores rather than time off work.

Rests on: Armanfar et al. · Kisel et al..

Does it take longer, and does that cost me anything

It usually does take longer, and general anaesthetic time is not free. Ask for the surgeon's typical operating time with and without the device.

Rests on: Kandemir et al. · Khajuria et al..

What does the device do that the chisel does not

The chisel transmits impact. In a randomised comparison of 40 patients, optic nerve sheath diameter, a proxy for intracranial pressure, rose after conventional osteotomy but not after the piezo cut. In the same radiological series that found longer operating times, the cut ran closer to the nasolacrimal duct in the piezo group.

Rests on: Gunes et al., intracranial pressure · Kandemir et al..

What is still done to reduce the swelling

Piezo does not remove the problem. In 110 patients who all had piezo-assisted osteotomies, adding a subperiosteal drain lowered bruising scores at days 3 and 7 but left swelling unchanged.

Rests on: Uzunoglu et al., subperiosteal drains · and recovery.

The terms, defined

The words used about this equipment.

• Piezoelectric instrument: a handpiece whose tip vibrates at ultrasonic frequency, cutting mineralised tissue while sparing soft tissue at the same setting. [26545389]
• Piezo osteotomy: a cut in the nasal bone made with that handpiece rather than a chisel. [36448013]
• Rhinosculpture: shaping the surface of the nasal bones with an ultrasonic tip instead of fracturing and repositioning them. [26545389]
• Ultrasonic bone aspirator: a related device that emulsifies bone and removes it by suction under irrigation. [21931085]
• Insert: the interchangeable working tip, shaped for cutting, scraping or sculpting. [39812015]
• Subperiosteal dissection: lifting the tissue off the bone widely so the osteotomy can be seen while it is made. [26545389]
• Dorsal preservation: lowering the bridge as a unit rather than removing the hump, the setting where piezo cuts are most used. [33220846]
• Optic nerve sheath diameter: an ultrasound measurement used as a proxy for pressure inside the skull. [41491324]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should assess and document, whatever instrument is used on the bone.

Rests on: the clinical practice guideline · the plain language summary.

The device regulator

Piezoelectric bone surgery units are regulated medical devices in the United States. Each model reaches the market through a 510(k) premarket notification, and the public record names the applicant, the product code and the decision date.

• 510(k) K043408, the Piezosurgery Device, cleared in 2005.
• Product classification JDX, sonic surgical instrument and accessory, class II.
• The MAUDE database holds the reported malfunctions and injuries for these devices, and is searchable by anyone. Pasick and colleagues read it for ultrasonic bone saws from January 2014 to June 2024 and analysed 432 of the 673 reports filed. Inability to irrigate led the device faults at 186 reports, ahead of overheating or melting at 148 and fracture of the insert tip at 58. Patient injury was reported in 31 cases and left 15 morbidities, thermal burn the commonest at 13.

Rests on: Pasick et al., adverse events reported on ultrasonic bone saws.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries two chapters on ultrasonic bone work. They are written for surgeons and go further into technique than a patient page should.

• Rhinoplasty: Bony Vault Surgery with Piezoelectric Instruments
• Ultrasonic Rhinoplasty. Osteotomies and Dorsum Refinement

The reference summary

Rhinoplasty in StatPearls, on the National Library of Medicine's Bookshelf, gives the anatomy, the indications and the complication list in full text at no charge. See also The Rhinoplasty Society and associations.

The trials in progress

Healing after piezo and endonasal osteotomy is under test in a registered study.

• The Evaluation of Piezo and Endonasal Osteotomy Methods on Postoperative Healing Process in Septorhinoplasty, status unknown, 60 participants.

What is not settled

• The pooled trials measure swelling, bruising and pain in the first week. No trial reports the shape of the nose at a year, the revision rate, or patient satisfaction as its primary endpoint. [36448013] [42013314]
• Trial quality is the limiting factor. The larger review rates the evidence as weak and calls for level I data reporting patient-reported outcomes. [36448013]
• Operating time is reported as unchanged in pooled data and as longer in a matched comparison. The question is open. [42013314] [40908317]
• The proximity of the cut to the nasolacrimal duct in the piezo group is a single-series finding and has not been reproduced. [40908317]
• The intracranial pressure signal rests on optic nerve sheath diameter in 40 patients, which is a proxy measurement, not a pressure reading. [41491324]
• Whether the wide subperiosteal exposure the technique needs carries a cost of its own has not been measured against the narrower conventional dissection. [26545389] [31157882]
• Device malfunction is recorded in the national adverse event database rather than in the trials. Failure to irrigate, overheating and tip fracture lead those reports, and thermal burn is the commonest injury. [40293065]