Powered instrumentation

What repeats

Four findings that hold across the literature.

Burrs shape, cutting tools divide

The division of labour is consistent across the descriptions. Burrs of different shapes reduce and smooth bone surfaces. Saws, chisels and ultrasonic tips make the cuts that free a segment. One two-centre account of over 350 patients states the rule plainly: burrs for reshaping, ultrasonic tips for cutting bone, with named exceptions.

Rests on: Robotti et al., combining piezo and power tools · Ilhan et al., cylindric burrs · Racy et al., powered rhinoplasty.

Powered work is argued to be more reproducible than a hammer and chisel

The claim made for the motor is repeatability. Manual osteotomy depends on the surgeon judging force and direction by feel, and mechanical osteotomy is described as more reproducible than a manual one. A hammer instrumented to measure impact force predicted the moment of fracture in 83% of impacts, which is a measurement of how much of the manual technique is guesswork.

Rests on: Racy et al. · Giunta et al., instrumented hammer · and nasal osteotomies.

Hand rasping loosens the vault, and that is the case against it

A hand rasp works by broad back and forth strokes, which transmit force to the whole bony vault. A powered burr removes bone where it is placed. The bone taken off can be kept: dust harvested from the hump was used to fill the open roof in 240 patients, with no resorption or displacement seen on follow-up ultrasound at a year.

Rests on: Ilhan et al. · Tas, bone dust for the open roof · and the open roof deformity.

Powered turbinate reduction lasts longer than the alternatives that spare tissue

Turbinate work is where the shaver has the strongest evidence. In a randomised comparison of the two sides of the same nose, powered turbinoplasty beat submucosal cauterisation on crusting, endoscopic size and acoustic rhinometry, and the difference held to five years. Pooling seven randomised trials, the microdebrider gave better symptom scores than radiofrequency at early and late follow-up, and better rhinomanometry in the long term.

Rests on: Joniau et al., powered reduction versus cauterisation · Mirza et al., microdebrider versus radiofrequency · and nasal airway obstruction.

By the part of the operation

One motor unit, several handpieces and several jobs.

Reducing and smoothing the bony hump

The burr replaces the rasp for taking down the bony part of a hump and for smoothing the edges left after a chisel cut. Cylindrical burrs are also used to blend the side wall of the nose into the cheek and to correct bony asymmetry, whether the dorsum is preserved or reduced.

Rests on: Ilhan et al. · Racy et al. · and component dorsal hump reduction.

Making the cuts

A powered oscillating micro saw was used for the transverse cut in 1374 of 1550 operations, under endoscopic control, to avoid the unwanted fracture a blind manual cut can produce near the root of the nose. Drills are also used to reshape the lateral wall as part of a preservation osteotomy plan.

Rests on: Avsar, the oscillating micro saw · Neves et al., osteotomy techniques in preservation rhinoplasty.

Removing bone by suction

An ultrasonic bone aspirator emulsifies bone under irrigation and removes it through the same tip. In 103 consecutive cosmetic rhinoplasties it reduced the nasal spine, deepened the angle at the root, smoothed bony edges and reduced convex nasal bones, with seven minor complications and no skin or soft tissue injury.

Rests on: Greywoode and Pribitkin, sonic rhinoplasty · Pribitkin and Greywoode, applications · and ultrasonic rhinoplasty.

Reducing the turbinates and working on the septum

The microdebrider shaves the soft tissue of the inferior turbinate through a small incision while leaving the lining over it. A systematic review of the turbinate techniques puts submucosal resection and radiofrequency ablation as the methods that combine lasting results with preserved function, and finds no support for out-fracture alone. A conservative alternative, closed microfracture, avoids mucosal trauma altogether.

Rests on: Sinno et al., turbinate systematic review · Lee and Lee, coblation versus microdebrider · Rohrich et al., closed microfracture.

Preservation rhinoplasty done with power tools alone

A retrospective series of 97 primary dorsal preservation cases used high-speed diamond burrs, reciprocating rasps and micro saws and nothing else, through both open and closed approaches. The overall complication rate was 8.5%, and bruising lasted a mean of 5.6 days in patients under 30.

Rests on: Taglialatela Scafati et al., power-assisted preservation rhinoplasty · and preservation rhinoplasty.

What to ask about powered instruments

Questions the evidence supports asking.

Which tool is used at which step

Ask for the list, step by step. The published protocols assign burrs to shaping, saws and ultrasonic tips to cutting, and the shaver to soft tissue. A surgeon who uses all of them should be able to say which does what on your nose.

Rests on: Robotti et al. · Racy et al..

What does the motor cost me

Cost is stated openly in the literature as a drawback of running burrs and ultrasonic tips together. Ask whether the equipment is charged separately.

Rests on: Robotti et al. · Winkler, powered versus cold instruments.

Does a burr generate heat, and what protects the skin

A rotating burr produces heat and can catch the tissue above it. The purpose-built nasal handpieces carry a guard and suction. Ask what shield is used and whether the field is irrigated.

Rests on: Pribitkin and Greywoode · Ilhan et al..

Is my turbinate being shaved, burned or moved

These are different operations with different durability. Shaving and submucosal resection remove tissue and last. Cautery recurs. Out-fracture alone is not supported as a stand-alone treatment.

Rests on: Sinno et al. · Joniau et al. · Mirza et al..

What is in the air while the drill runs

Measured in a cadaver model, opening the skin, endonasal osteotomy and percutaneous osteotomy produced no detectable rise in aerosols, while cautery and endonasal rasping did. This matters for the operating room rather than for the patient, and it is a reason theatre practice differs between units.

Rests on: Ye et al., aerosol and droplet generation.

The terms, defined

The words used about this equipment.

• Burr: a rotating cutting head on a powered handpiece, shaped as a sphere, cylinder, cone or disc, used to reduce and smooth bone. [38698637]
• Microdebrider: a powered handpiece with a rotating inner blade inside an outer sleeve and suction, which shaves tissue and removes it in one pass. [32679584]
• Reciprocating rasp: a powered rasp driven back and forth by a motor rather than by hand. [41211956]
• Oscillating micro saw: a small powered saw used for the transverse cut near the root of the nose. [22738757]
• Ultrasonic bone aspirator: a tip that emulsifies bone under irrigation and suctions it away. [21931085]
• Bone dust: the fine bone removed by a burr or rasp, which can be replaced as a graft. [29879004]
• Turbinoplasty: reduction of the inferior turbinate with the lining over it kept intact. [16652079]
• Submucosal resection: removal of tissue from inside the turbinate through a small incision. [27556616]

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.

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

The device regulator

Surgical drills, shavers and microdebriders 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.

• Product classification ERL, ear, nose and throat surgical drill including handpiece, class II.
• 510(k) K992855, the XPS StraightShot microdebrider system, cleared in 2000.
• The MAUDE database holds the reported malfunctions and injuries for these devices and is searchable by anyone.

The surgeons' own textbook chapter

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries a chapter on this equipment. It is written for surgeons and goes further into technique than a patient page should.

• Powered Instrumentation for Rhinoplasty and Septoplasty

The reference summaries

• Rhinoplasty in StatPearls, full text at no charge.
• Septoplasty in StatPearls, the operation on the wall between the nostrils, where the shaver is also used.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

The trials in progress

Whether turbinate reduction should be added to septoplasty is under test in a registered study.

• Evaluation of the Outcome of Septoplasty With or Without Inferior Turbinate Reduction, not yet recruiting, 40 participants.

What is not settled

• No randomised trial compares a powered burr with a hand rasp for hump reduction. The case for the burr rests on single-surgeon series and on argument. [38698637] [33370051]
• The power-assisted preservation series has no control group and a narrow patient population, which its authors state. [41211956]
• Turbinate trials measure symptom scores and rhinometry at months, and the technique comparisons disagree once follow-up passes a year. [32679584] [16652079]
• Whether combining burrs and ultrasonic tips produces a better result than either alone has not been tested. The two-centre account is an expert description. [39117869]
• Heat injury from rotating instruments is a recognised reason for guards, irrigation and suction, and its actual frequency in rhinoplasty is not reported in any series. [23564245]