الفهرس 
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Abstract
Even though rhinoplasty is a common procedure, only few surgeons are thought to be experts in the complex range of its technical details. It was claimed that while rhinoplasty is not very difficult to do, it is very tough to achieve consistently excellent outcomes. This procedure often involves changing the skeletal structure of the nose. The desire to achieve pleasing dorsal aesthetic lines, a refined nasal bony pyramid, a smoothly looking nasal dorsum on profile view, or to straighten a crooked nose, is what drives the patient to alter the original shape of the bony skeleton of the nose. The evolution of osteotomy instruments over time possessed different shapes and methods of application. from manually guided to electrically powered tools via blinded approaches or controlled under vision.
The instruments used in lateral nasal bony cuts can be divided into powered and non-powered. The latter come in different shapes and are used via multiple approaches. Osteotomy saws were developed to perform nasal osteotomies. Conventional osteotomes are used nowadays to perform lateral osteotomies either continuous internally with a guarded osteotome or using the perforating method via an external or an internal approach. Regardless of the pattern, approach and instrument used for lateral osteotomy, a surgeon should achieve a balance between nasal bone fracture for mobilization and preserving its stability with minimal injury to the surrounding soft tissues. Among the powered instruments, the (PEI) works through the concept of the “reverse piezoelectric effect” which is the production of micrometric vibrations of a piezoelectric material when exposed to an electric current. PEI has been used for a long time in the dental field and oral maxillofacial specialty. In 2007, PEI was first used in rhinoplasty, and since then, many surgeons have adopted it to become a useful tool for precise nasal bony osteotomies and contouring, with reduction in bleeding and adjacent soft tissue injuries.
Due to its close anatomical proximity to the nose, the eye is susceptible to sequelae after rhinoplasty. Ocular problems include minor complaints like periorbital edema, ecchymosis, and subconjunctival hemorrhage. Inflammation and hemorrhage that take place during lateral osteotomies are what contribute to periorbital postoperative sequelae. Since the invention of rhinoplasty, these signs, which are frequently unpleasant to the patient, have been generally understood. It is intended to use the optimal approach while performing lateral osteotomies in order to establish correct nasal bone architecture and decrease postoperative symptoms. The best instrument to employ, however, is still up for debate.
Rhinoplasty operations are often evaluated using the patient’s subjective interpretation and the surgeon’s intraoperative assessment. Therefore, it is crucial for patient reported outcome measures (PROMs) to assess patient satisfaction levels and evaluate the outcomes of routine clinical practice. Cosmetic operations are intended to increase patient satisfaction, which in turn will enhance their quality of life. Numerous PROMs have been used for that aim and the recently validated 10-item questionnaire called the Standardized Cosmesis and Health Nasal Outcomes (SCHNOS) assesses both nasal function and appearance. Visual analogue scale (VAS) is a psychometric measuring tool used to evaluate the severity of a patient’s symptoms. Additionally, it is employed to track symptom response and evaluate the efficacy of particular therapy regimens.
The study was carried out to compare between conventional method using osteotomes and the use of (PEI) on nasal bone osteotomies. Postoperative evaluation was compared according to:
1. The degree of postoperative sequelae (eyelid edema, ecchymosis and subconjunctival hemorrhage) on the 7th postoperative day.
2. Patient reported outcome measures (PROMs); by using the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) and visual analogue scales (VAS).
3. Operative time and osteotomy time.
The study was carried out on 30 open rhinoplasty patients at Maxillofacial and Plastic Surgery Department, Faculty of Dentistry, Alexandria University and the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford School of Medicine, CA, USA during the period from August 2021 till December 2022. 15 patients were performed using conventional osteotomes and 15 patients were performed with PEI.
Inclusion criteria included patients requesting aesthetic rhinoplasty, post traumatic rhinoplasty and post cleft nose rhinoplasty. Exclusion criteria included medically unfit patients with severe systemic diseases, patients with autoimmune and skin diseases, psychological disorders and Female patients younger than 16 years of age and male patients younger than 18 years of age.
Patients were examined on their preoperative visit and were handed the SCHNOS and VAS to complete. Under general anesthesia, the rhinoplasty procedure for this study was done using an open technique. Nasal bone osteotomies were performed using the conventional osteotomes of using PEI. Operative duration and osteotomy time were recorded. Taping and nasal splinting were applied at the completion of the procedure and removed on the 7th day follow up. The Kara and Gokalan grading scheme were used to grade the periorbital sequelae during the same visit. On the subsequent postoperative appointment, examination was done, and presence of any complications were identified and managed accordingly. Postoperative PROM sheets were distributed and collected.
The study revealed the following main results:
Twenty percent were males, twenty percent of patients had a history of nasal trauma, 43.3% were cleft lip nose patients, 7 patients were performed by dorsal preservation (DPR) procedure.
The mean operative time was 182.07 ± 63.79 minutes.
The mean osteotomy time was 3.8 ± 1.16 minutes.
Postoperative PROMs were improved compared to their preoperative results in both conventional and PEI groups.
SCHNOS-C questions showed statistically significant improvement on postoperative surveys compared to preoperative ones regardless of which method used for osteotomy.
SHCNOS questions 1 and 2 showed statistically significant improvement only when conventional osteotomes were used.
SCHNOS-O did not conclude statistical significance in the conventional osteotomy group. While SCHNOS-C, VAS-F and VAS-C showed statistical significance.
Only cosmetic outcomes in the PEI group showed statistically significant improvement between preoperative and postoperative surveys.
No statistically significant difference was shown between both groups regarding postoperative sequelae on the 7th postoperative day.
On comparing post operative PROMs between the conventional osteotomes and PEI, SCHNOS-C showed superior outcomes with statistically significant difference.
Concerning the change in scores, VAS-C was the only domain that had a P value less than 0.05.
Surgeries performed by PEI had a shorter operative time, yet, not statistically significant.
Despite postoperative periorbital manifestation, other complications that were accompanied with the patient population included:
1. Residual dorsal hump.
2. Nasal infection.
3. Postoperative trauma with no consequence.
4. Loss of tip support.
5. Tip stiffness and palpation of cap graft.
6. Palpable dorsal irregularities.
7. Tip asymmetry.
8. Nostril asymmetry.
9. Rhinorrhea.
10. Persistent nasal obstruction.
11. Inadequate nasal bony vault narrowing.