Keywords
sonic rhinoplasty - ultrasonic bone aspirator - functional rhinoplasty - cosmetic
rhinoplasty
The use of the ultrasonic bone aspirator (UBA) for rhinoplasty has been previously
described.[1]
[2]
[3]
[4] However, since the publication of these articles, the UBA has been improved and
its uses for rhinoplasty have been modified and expanded.
The specific UBA device used at our institution is the Sonopet (Stryker Neuro Spine
ENT). The Sonopet, as described by its manufacturer, emulsifies bone with ultrasonic
vibration technology. The operative handpiece tip couples longitudinal vibration with
torsional oscillation. This technology allows for smooth bone cuts while effectively
minimizing trauma to surrounding and underlying soft tissue. The degree of bone removal
is dependent on the geometry of the surgical tip, the power setting of the console,
the density of the bone, and the amount of time the surgical tip spends in contact
with the bone. In general, the greater the power setting and the less dense the bone,
the faster and easier the handpiece tip cuts through the bone. The Sonopet is able
to move soft tissue away from the vibrating and oscillating tip, while bone is unable
to.[5] We have found the bone tips to be effective not only for bone cuts but in the contouring
of cartilage as well.
Original descriptions of Sonopet use for rhinoplasty have discussed its application
for multiple aspects of cosmetic and functional rhinoplasty.[1]
[2]
[3]
[4] We describe our experience and techniques gained over the past 5 years of using
the Sonopet for open approach rhinoplasty.
Uses
Dorsal Hump Reduction with Concurrent Glabellar Reduction
Once a soft-tissue envelope is elevated and osteotomies have been performed, our attention
turns to the bony and cartilaginous dorsal hump. Our preference is to use an Aufricht
retractor to elevate the soft-tissue envelope to allow full visualization.[1]
[3] We proceed to lower the cartilaginous septum with a scalpel and removed the excised
septal cartilage from the field. We previously used the Sonopet's “Spetzler Claw”
handpiece tip to smooth and reduce any remaining cartilaginous or bony irregularities.
However, since the development of Sonopet's newer “Payner 360” handpiece tip, we now
address the dorsal hump with this modification ([Video 1]). We have found that this 360-degree tip provides an easier ability to precisely
contour the bony and cartilaginous aspects of the dorsal hump due to its ability to
move the handpiece side to side. The “Spetzler Claw” only allows for a front-to-back
motion.
Video 1 Demonstrations of Sonopet use with the “Payner 360” and “Spetzler Claw” handpiece
tips. Videos were obtained from the senior authors (E.P., R.N.H., H.K.) during several
different rhinoplasties; use is tailored to the needs of the patient and goals of
the operation. (Presented with permission of Jefferson Facial Plastic Surgery).
Similar to the side-to-side technique used with a diamond burr drill, the Payner tip
allows us to contour and reduce the glabella in a controlled and precise fashion.
As compared with a drill, the Sonopet does not skip off of bone which would put the
surrounding soft tissue at risk of injury.[1]
[3] Our observed results between handpiece tips are similar for glabellar and hump reduction,
but we believe contouring in a side-to-side motion with the “Payner 360” reduces operative
time and allows for easier use.
Sculpting of Mobile Fragments and Recontouring Nasal Bones
Similar to our approach for the dorsal hump, we have adopted the “Payner 360” tip
over the “Spetzler Claw” for contouring of the mobile nasal bones following osteotomies.
Visualization of deformities is provided with an Aufricht retractor to elevate the
soft-tissue envelope off of the fractured nasal bones. Using the Sonopet to smooth
these irregularities is not only important for thin skinned patients but also can
reduce trauma in all patients when the alternative rasp or drill is used.[1] Although we do not use the device for osteotomies, Cochran and Roostaeian have found
success when using the UBA for this procedure.[6]
Septoplasty
The Sonopet can be used to precisely address potentially problematic deviations of
the nasal septum in a controlled, targeted fashion. Although complete mucoperichondrial
flap elevation is often necessary for large deviations or required for cartilage harvest,
in instances of isolated septal spurs a small incision can be made at the anterior
leading edge of a deviation.[1] The overlying cartilage and bony spur are then reduced with the “Payner 360” tip.
This technique leaves the contralateral mucoperichondrial flap undisturbed, thus reducing
the risk of perforation or hematoma along with minimizing the need for nasal packing
or splinting.
The Sonopet can also be used for the controlled reduction of a widened or deviated
maxillary crest ([Video 1]). Using this technique is a controlled alternative to the use of osteotomes which
may result in bony abnormalities, sharp projections, and perforations of the mucoperichondrial
flap.
Additionally, the Sonopet may be used to safely address and reduce deviations of the
superior bony septum. The controlled reduction of this region helps in preserving
the keystone area and thus the stability of the dorsal septum. Its use also helps
reduce risk of torque on the ethmoid plate and skull-base, which could potentially
cause a cerebrospinal fluid leak.[7]
Sculpting of Upper and Lower Lateral Cartilage, Septal and Rib Cartilage Grafts
An undescribed use of the Sonopet is its ability to shape free autologous or allogeneic
cartilage. Once septal or rib cartilage is harvested or allogeneic rib cartilage is
brought to the field for nasal grafts, the Sonopet with the “Payner 360” tip is found
to be useful for shaping the cartilage graft ([Video 1]). Traditionally, we have used a scalpel to shape and shave these cartilage grafts
to a desired form. Although the scalpel has been effective at acquiring the desired
size and shape of our grafts, we found the Sonopet to be effective for small and quick
modifications. Using the “Payner 360” tip, cartilage graft edges are easy to contour
as needed.
The lower and upper lateral cartilages may be modified with utilization of either
the “Spetzler Claw” or “Payner 360” handpiece tip. Cartilage irregularities that may
appear in a thin-skinned patient can be smoothed in a controlled manner with the use
of the Sonopet ([Video 1]). In addition to contouring, the Sonopet also allows for the surgeon to excise unwanted
or excess cartilage.
Piriform Aperture Enlargement
First described in 2015 by Roy et al, the Sonopet can be used for piriform aperture
enlargement in a functional rhinoplasty.[8] The nasal valve is bounded laterally by the nasal process of the maxilla and head
of the inferior turbinate concha. By incising through the mucosa at the height of
the head of the inferior turbinate concha and elevating the mucosa and periosteum
with a cottle, the head of the concha and lateral process of the maxilla is exposed.
The Sonopet, affixed with the “Spetzler Claw,” is then used in a back-and-forth motion
to emulsify the desired amount of bone to widen the piriform aperture and expand the
nasal airway. The non-serrated back side of the “Spetzler Claw” in this procedure
protects the surrounding soft tissue that will inevitably lay against the Sonopet
during its use. This prevents unnecessary trauma while effectively removing bone within
a small surgical area.[8]
Inferior Turbinate Reduction
Although numerous techniques for inferior turbinate reduction have been described
and are widely used, we have found the ultrasound bone aspirator in a submucosal plane
to be a safe, efficient, and effectual approach.[1] Preparation for our reduction first begins with topically vasoconstricting the turbinate
mucosa with oxymetazoline pledgets followed by injection with lidocaine with epinephrine.
The turbinate is then fractured medially. We then sharply incise the mucosal head
of the inferior turbinate down to bone. A cottle is then used to submucosally and
freely dissect a plane overlying the bone of the inferior turbinate. The Sonopet using
a “Spetzler Claw” tip is then introduced into this plane with the aspirating surface
of the tip facing the conchal bone ([Video 1]). The bone is then reduced systematically and uniformly along the entire length.
Care and attention are given to ensure that the proximal end of the Sonopet does not
make contact with the nasal ala, columella, or sill during this maneuver. Advantageously,
the lack of trauma to the mucosa prevents future formation of synechia.[1] The use of this technique has been previously demonstrated to be a safe and efficient
technique in addressing inferior turbinate hypertrophy resulting in mean reduction
of Nasal Obstruction Symptom Evaluation scale scores from 51 to 25.[4]
Reducing the Nasal Spine
Traditionally, the reduction of the anterior nasal spine necessitates the use of rongeurs
or osteotomes which can result in bony abnormalities and sharp projections. These
bony irregularities are then typically addressed with rasping which can result in
overresection of the spine due to the challenging and imprecise nature of the technique.[1] Overresection of the anterior nasal spine can lead to cosmetic and functional consequences
in the form of reduced nasal tip support.[9] We found the use of the “Payner 360” tip to be efficient in precisely reducing and
smoothly contouring the anterior nasal spine, limiting chances of over resection ([Video 1]).
Discussion
All the authors of this article are facial plastic and reconstructive surgeons, among
which three are senior authors (E.P., H.K., R.N.H.). They found subjective success
with the use of the Sonopet, each using the device to different degrees due to personal
preference. The instrument has proven to be an effective tool for all of their cosmetic
and functional rhinoplasty techniques.
Sonopet currently has two console models, three different handpieces, and multiple
soft tissue and bone-specific handpiece tips.[5] We have consistently used the original “Sonopet Console” and “Universal 25-kHz Angled
Handpiece.” Previous publications of Sonopet use have only described use of the 2.8-mm-width
“Spetzler Claw” handpiece tip; however, we have adopted the use of the 3.12-mm-width
“Payner 360” handpiece tip and have noted improved functionality in some of our operative
techniques.[1]
[2]
[3]
[4] We have neither used the latest model of console “Sonopet iQ” nor the latest model
of handpiece “34-kHz Angled Handpiece.” Both allows for faster cutting and more precision.[5] The Sonopet is primarily marketed and has been studied to be effective for orthopaedic
and neurosurgical use, but facial plastic and reconstructive surgery is also listed
as an application.[10]
[11] The “Piezoelectric System” is another ultrasonic surgical device often used by facial
plastic surgeons.[12]
[13]
[14] However, we do not have this device at our institution. Studies comparing the “Piezoelectric
System” with the Sonopet would be beneficial to the surgical community.
According to Greywood et al, the Sonopet is an expensive equipment that may best serve
surgeons who can split the cost within a surgical group or within a hospital setting.[4] Other previously described uses of the device have been noted to include dacryocystorhinostomy,
endoscopic transorbital decompression, and functional endoscopic sinus surgery.[15]
[16]
[17] Due to the size of the handpiece, an image guidance apparatus can be affixed to
it, allowing for safe endonasal use. The multifunctionality may make the device a
more cost-effective purchase, but it is dependent on each surgeon's extent of use
and comfortability with the instrument. No major complications have been experienced
by the senior authors (E.P., H.K., R.N.H.). However, there is the risk of burns to
the nasal vestibule if the Sonopet is not sheathed.
Conclusion
The UBA allows for precision and provides ease of use in multiple steps of cosmetic
and functional rhinoplasties. The Sonopet's “Payner 360” tip has enabled even more
efficiency and maneuverability as compared with the “Spetzler Claw.” Patient results
have subjectively been found to be more acceptable, if not better, than with the use
of other rhinoplasty instruments. Further studies are needed to determine if the device
does improve operative time and, as a result, is cost-effective.
