TECHNICAL STRATEGY
Ultrasonic Aesthetic Cranioplasty Massimo Robiony, MD, FEBOMFS, Matteo Casadei, MD, Massimo Sbuelz, MD, Lorenzo Della Pietra, and Massimo Politi, MD, DDS Abstract: The management of frontal bone injury is an important issue, and inappropriate management of such injuries may give rise to serious complications. Piezosurgery is a technique used to perform safe and effective osteotomies using piezoelectric ultrasonic vibrations. This instrument allows a safe method for osteotomy of the cranial vault in close proximity to extremely injury-sensitive tissue such as the brain. After a wide review of the literature, the authors present this technical report, introduce the use of piezosurgery to perform a safe “slimosteotomies” for treatment of posttraumatic frontal bone deformities, and suggest the use of this instrument for aesthetic recontouring of the craniofacial skeleton. Key Words: Bone, cranioplasty, fracture, frontal, piezosurgery, ultrasonic (J Craniofac Surg 2014;25: 1448–1450)
U
ltrasonic bone cutting is a technique used to perform safe and effective osteotomies using piezoelectric ultrasonic vibrations. It was initially conceived by Vercellotti and first reported for use in preprosthetic surgery.1–3 This report introduces the use of piezosurgery for performing osteotomies during treatment of posttraumatic frontal bone deformities. The management of frontal bone with or without frontal sinus injury is an important issue because inappropriate management of these injuries not only leads to cosmetic deformities and functional problems but may also give rise to serious complications.4,5 Cosmetic deformities such as depressed skull fractures and unsightly scars are often a psychologic problem with non–negligible impact on the quality of life, especially in young patients (Figs. 1, 2). The authors introduce a new technique, based on the micrometric slim-osteotomies, to cutting bone for aesthetic remodeling of cranial deformities named ultrasonic aesthetic cranioplasty.
MT1-10 to perform osteotomies of the contour of the deformed bone (Fig. 3B) and then Insert MT1S-10 to exploit the fracture lines of the trauma to obtain thin plates of bone that can be used to restore the bone defect (Fig. 3C). If the sizes of the plates are not sufficient to cover the entire defect, it is possible to harvest a calvarial bone graft from the parietal bone using piezosurgery to reconstruct the cranial vault of the frontal bone. Bone segments are fixed with microplates and screws (Fig. 3D). Before concluding the procedure, remodel soft tissue, release fibrosis, and put a collagen membrane in place to cover the titanium plates and screws.
DISCUSSION The management of frontal bone with or without frontal sinus injury is an important issue because inappropriate management of these injuries not only leads to cosmetic deformities and functional problems but may also give rise to serious complications, including the development of mucoceles, osteomyelitis, and potentially fatal central nervous system complications such as meningitis and brain abscesses. To prevent such complications, we propose the use of piezoelectric surgery in this critical multipiece surgery, as we previously
SURGICAL PROCEDURE Bicoronal incision provides good exposure of frontal bone deformities; if necessary, the supraorbital dissection can be extended inferiorly to the nasofrontal area and over the orbital rims into the upper circumference of the orbital cavity to release the supraorbital neurovascular bundle (Fig. 3A). Cranioplasty requires many osteotomies of the fragments, which can be performed with ultrasound bone cutting tip. Use Insert From the Department of Maxillofacial Surgery, University Teaching Hospital of Santa Maria della Misericordia, Udine, Italy. Received December 16, 2013. Accepted for publication January 17, 2014. Address correspondence and reprint requests to Massimo Robiony, MD, FEBOMFS, University-Hospital of Santa Maria della Misericordia, Piazzale Santa Maria della Misericordia, 33100, Udine, Italy; E-mail: [email protected] The authors report no conflicts of interest. KEY MESSAGES: Ultrasonic cutting can be considered a precious innovation for aesthetic sculpturing of the craniofacial skeleton. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000793
1448
FIGURE 1. Images of a 30-year-old woman who was involved 7 years previously in an automobile collision: frontal view (A), three-fourth view (B), and top view (C).
The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014
Ultrasonic Aesthetic Cranioplasty
FIGURE 2. Preoperative computed tomographic scans.
reported for segmental maxillary osteotomies,6,7 rhinoplasty,8,9 and thyroglossal duct cyst surgery.10 We believe that, in case of consolidated fractures of frontal bone, the ultrasonic cosmetic cranioplasty can guarantee the best results in the short, medium, and long term. Our preliminary experience with this technique consisted of 15 patients; the clinical evaluation of the effectiveness of the technique was found on intraoperative and postoperative parameters. Piezosurgery represents a meticulous and soft-tissue–sparing system for bone cutting based on ultrasonic piezoelectric microvibrations. The first advantage of ultrasonic bone cutting is the complete preservation of soft tissues, including tissues closely related to the central nervous system.11,12 Osteotomies can be performed with minimal risk for temperature increase and marginal osteonecrosis. Previous histologic examinations carried out on the cut surfaces of bony segments revealed the presence of live osteocytes, confirming the lack of coagulative necrosis.3 For craniofacial surgery, the advantage of ultrasound osteotomy seems real because it is possible to perform “blind” cutting of bone with fewer precautions necessary for the dura mater and globe. Micrometric vibration in piezoelectric bone surgery ensures precise cutting action and, at the same time, maintains a blood-free operative area because of the cavitation effect from the irrigation solution. Furthermore, piezosurgery uses an easily managed device that permits great intraoperative visible control with consequent increase in safety, especially in anatomically difficult areas.11 Moreover, the new insert (MT1S-10) with a thickness of only 0.35 mm allows micrometric slim osteotomies to be performed, keeping tissue
FIGURE 3. Intraoperative views: bone deformity (A), ultrasonic bone cutting (B), frontal bone defect (C), and fixation of bone segments with plates and screws (D).
FIGURE 4. Insert MT1S-10, only 0.35 mm of thickness.
loss to a minimum (Fig. 4). According to cutting time alone, ultrasound osteotomy was clearly less effective than mechanical saws. Looking at the cumulative time for surgery, ultrasonic and mechanical cutting did not differ because the lack of soft tissue injury and the very precise nature of the osteotomy led to shorter operative times.11 Piezosurgery has only a short learning curve, but it is important to gain adequate surgical dexterity because the technique is different from that used in bone surgery with burs, oscillating saws, and the like. To overcome any problems during surgery, instead of
FIGURE 5. Aesthetic result: frontal view (A), three-fourth view (B), and top view (C).
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1449
The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014
Robiony et al
FIGURE 6. Postoperative CT scans.
increasing pressure on the handpiece, as in traditional techniques, it is necessary to find the correct pressure to achieve the desired result. With piezoelectric surgery, increasing the working pressure above a certain limit impedes vibration of the insert, the energy is transformed into heat, and tissue damage can occur.13 The sound of the cutting can be used as acoustic feedback to ensure that the correct force is used.12 With piezosurgery, if necessary, we can obtain thin bone plate grafts from the same surgical field, minimizing the risk for serious complications such as dura mater injury and central nervous system tissue damage. Because of the cutting precision, the graft fit the defect without the necessity for bends or cuts that could reduce the supportive strength of the graft.14 Furthermore, there is no need for extensive and costly preoperative planning, and the biocompatibility is ideal.15 In conclusion, ultrasonic aesthetic cranioplasty by means of piezosurgery is a safe method for osteotomy of the cranial vault in close proximity to soft tissue, including extremely injury-sensitive tissue such as the brain. Narrow and rectilinear slim-osteotomies can be easily performed with varying vibrating scalpels. Ultrasonic cutting can be considered a precious innovation for aesthetic sculpturing of the craniofacial skeleton (Figs. 5, 6).
REFERENCES 1. Vercellotti T. Piezoelectric surgery in implantology: a case report—a new piezoelectric expansion technique. Int J Periodontics Restorative Dent 2000;20:359
1450
2. Politi M, Vercellotti T, Polini F, et al. Piezoelectric surgery: a new method of bone cutting. Preliminary experience in alveolar osteogenesis distraction. In: Proceedings of the 2nd International Meeting on Distraction Osteogenesis of the Facial Skeleton. Bologna, Italy, September 26–28, 2002 3. Vercellotti T, Crovace A, Palermo A, et al. The piezoelectric osteotomy in orthopedics: clinical and histological evaluations (pilot study in animals). Mediterr J Surg Med 2001;9:89 4. Larrabee WF Jr, Travis LW, Tabb HG. Frontal sinus fractures—their suppurative complications and surgical management. Laryngoscope 1980;90:1810 5. Wilson BC, Davidson B, Corey JP, et al. Comparison of complications following frontal sinus fractures managed with exploration with or without obliteration over 10 years. Laryngoscope 1988;98:516 6. Robiony M, Polini F, Costa F, et al. Piezoelectric bone cutting in multipiece maxillary osteotomies. J Oral Maxillofac Surg 2004;62:759–761 7. Robiony M, Polini F, Costa F, et al. Ultrasonic bone cutting for surgically assisted rapid maxillary expansion (SARME) under local anaesthesia. Int J Oral Maxillofac Surg 2007;36:267–269 8. Robiony M, Toro C, Costa F, et al. Piezosurgery: a new method for osteotomies in rhinoplasty. J Craniofac Surg 2007;18:1098–1100 9. Robiony M, Polini F, Costa F, et al. Ultrasound piezoelectric vibrations to perform osteotomies in rhinoplasty. J Oral Maxillofac Surg 2007;65:1035–1038 10. Salgarelli AC, Robiony M, Consolo U, et al. Piezosurgery to perform hyoid bone osteotomies in thyroglossal duct cyst surgery. J Craniofac Surg 2011;22:2272–2274 11. Beziat JL, Bera JC, Lavandier B, et al. Ultrasonic osteotomy as a new technique in craniomaxillofacial surgery. Int J Oral Maxillofac Surg 2007;36:493–500 12. Pavlíková G, Foltán R, Burian M, et al. Piezosurgery prevents brain tissue damage: an experimental study on a new rat model. Int J Oral Maxillofac Surg 2011;40:840–844 13. Robiony M, Polini F. Piezosurgery: a safe method to perform osteotomies in young children affected by hemifacial microsomia. J Craniofac Surg 2010;21:1813–1815 14. Kiyokawa K, Hayakawa K, Tanabe HY, et al. Cranioplasty with split lateral skull plate segments for reconstruction of skull defects. J Craniomaxillofac Surg 1998;26:379–385 15. Oppenheimer AJ, Mesa J, Buchman SR. Current and emerging basic science concepts in bone biology: implications in craniofacial surgery. J Craniofac Surg 2012;23:30–36
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Ultrasonic Aesthetic Cranioplasty Massimo Robiony, MD, FEBOMFS, Matteo Casadei, MD, Massimo Sbuelz, MD, Lorenzo Della Pietra, and Massimo Politi, MD, DDS Abstract: The management of frontal bone injury is an important issue, and inappropriate management of such injuries may give rise to serious complications. Piezosurgery is a technique used to perform safe and effective osteotomies using piezoelectric ultrasonic vibrations. This instrument allows a safe method for osteotomy of the cranial vault in close proximity to extremely injury-sensitive tissue such as the brain. After a wide review of the literature, the authors present this technical report, introduce the use of piezosurgery to perform a safe “slimosteotomies” for treatment of posttraumatic frontal bone deformities, and suggest the use of this instrument for aesthetic recontouring of the craniofacial skeleton. Key Words: Bone, cranioplasty, fracture, frontal, piezosurgery, ultrasonic (J Craniofac Surg 2014;25: 1448–1450)
U
ltrasonic bone cutting is a technique used to perform safe and effective osteotomies using piezoelectric ultrasonic vibrations. It was initially conceived by Vercellotti and first reported for use in preprosthetic surgery.1–3 This report introduces the use of piezosurgery for performing osteotomies during treatment of posttraumatic frontal bone deformities. The management of frontal bone with or without frontal sinus injury is an important issue because inappropriate management of these injuries not only leads to cosmetic deformities and functional problems but may also give rise to serious complications.4,5 Cosmetic deformities such as depressed skull fractures and unsightly scars are often a psychologic problem with non–negligible impact on the quality of life, especially in young patients (Figs. 1, 2). The authors introduce a new technique, based on the micrometric slim-osteotomies, to cutting bone for aesthetic remodeling of cranial deformities named ultrasonic aesthetic cranioplasty.
MT1-10 to perform osteotomies of the contour of the deformed bone (Fig. 3B) and then Insert MT1S-10 to exploit the fracture lines of the trauma to obtain thin plates of bone that can be used to restore the bone defect (Fig. 3C). If the sizes of the plates are not sufficient to cover the entire defect, it is possible to harvest a calvarial bone graft from the parietal bone using piezosurgery to reconstruct the cranial vault of the frontal bone. Bone segments are fixed with microplates and screws (Fig. 3D). Before concluding the procedure, remodel soft tissue, release fibrosis, and put a collagen membrane in place to cover the titanium plates and screws.
DISCUSSION The management of frontal bone with or without frontal sinus injury is an important issue because inappropriate management of these injuries not only leads to cosmetic deformities and functional problems but may also give rise to serious complications, including the development of mucoceles, osteomyelitis, and potentially fatal central nervous system complications such as meningitis and brain abscesses. To prevent such complications, we propose the use of piezoelectric surgery in this critical multipiece surgery, as we previously
SURGICAL PROCEDURE Bicoronal incision provides good exposure of frontal bone deformities; if necessary, the supraorbital dissection can be extended inferiorly to the nasofrontal area and over the orbital rims into the upper circumference of the orbital cavity to release the supraorbital neurovascular bundle (Fig. 3A). Cranioplasty requires many osteotomies of the fragments, which can be performed with ultrasound bone cutting tip. Use Insert From the Department of Maxillofacial Surgery, University Teaching Hospital of Santa Maria della Misericordia, Udine, Italy. Received December 16, 2013. Accepted for publication January 17, 2014. Address correspondence and reprint requests to Massimo Robiony, MD, FEBOMFS, University-Hospital of Santa Maria della Misericordia, Piazzale Santa Maria della Misericordia, 33100, Udine, Italy; E-mail: [email protected] The authors report no conflicts of interest. KEY MESSAGES: Ultrasonic cutting can be considered a precious innovation for aesthetic sculpturing of the craniofacial skeleton. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000793
1448
FIGURE 1. Images of a 30-year-old woman who was involved 7 years previously in an automobile collision: frontal view (A), three-fourth view (B), and top view (C).
The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014
Ultrasonic Aesthetic Cranioplasty
FIGURE 2. Preoperative computed tomographic scans.
reported for segmental maxillary osteotomies,6,7 rhinoplasty,8,9 and thyroglossal duct cyst surgery.10 We believe that, in case of consolidated fractures of frontal bone, the ultrasonic cosmetic cranioplasty can guarantee the best results in the short, medium, and long term. Our preliminary experience with this technique consisted of 15 patients; the clinical evaluation of the effectiveness of the technique was found on intraoperative and postoperative parameters. Piezosurgery represents a meticulous and soft-tissue–sparing system for bone cutting based on ultrasonic piezoelectric microvibrations. The first advantage of ultrasonic bone cutting is the complete preservation of soft tissues, including tissues closely related to the central nervous system.11,12 Osteotomies can be performed with minimal risk for temperature increase and marginal osteonecrosis. Previous histologic examinations carried out on the cut surfaces of bony segments revealed the presence of live osteocytes, confirming the lack of coagulative necrosis.3 For craniofacial surgery, the advantage of ultrasound osteotomy seems real because it is possible to perform “blind” cutting of bone with fewer precautions necessary for the dura mater and globe. Micrometric vibration in piezoelectric bone surgery ensures precise cutting action and, at the same time, maintains a blood-free operative area because of the cavitation effect from the irrigation solution. Furthermore, piezosurgery uses an easily managed device that permits great intraoperative visible control with consequent increase in safety, especially in anatomically difficult areas.11 Moreover, the new insert (MT1S-10) with a thickness of only 0.35 mm allows micrometric slim osteotomies to be performed, keeping tissue
FIGURE 3. Intraoperative views: bone deformity (A), ultrasonic bone cutting (B), frontal bone defect (C), and fixation of bone segments with plates and screws (D).
FIGURE 4. Insert MT1S-10, only 0.35 mm of thickness.
loss to a minimum (Fig. 4). According to cutting time alone, ultrasound osteotomy was clearly less effective than mechanical saws. Looking at the cumulative time for surgery, ultrasonic and mechanical cutting did not differ because the lack of soft tissue injury and the very precise nature of the osteotomy led to shorter operative times.11 Piezosurgery has only a short learning curve, but it is important to gain adequate surgical dexterity because the technique is different from that used in bone surgery with burs, oscillating saws, and the like. To overcome any problems during surgery, instead of
FIGURE 5. Aesthetic result: frontal view (A), three-fourth view (B), and top view (C).
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1449
The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014
Robiony et al
FIGURE 6. Postoperative CT scans.
increasing pressure on the handpiece, as in traditional techniques, it is necessary to find the correct pressure to achieve the desired result. With piezoelectric surgery, increasing the working pressure above a certain limit impedes vibration of the insert, the energy is transformed into heat, and tissue damage can occur.13 The sound of the cutting can be used as acoustic feedback to ensure that the correct force is used.12 With piezosurgery, if necessary, we can obtain thin bone plate grafts from the same surgical field, minimizing the risk for serious complications such as dura mater injury and central nervous system tissue damage. Because of the cutting precision, the graft fit the defect without the necessity for bends or cuts that could reduce the supportive strength of the graft.14 Furthermore, there is no need for extensive and costly preoperative planning, and the biocompatibility is ideal.15 In conclusion, ultrasonic aesthetic cranioplasty by means of piezosurgery is a safe method for osteotomy of the cranial vault in close proximity to soft tissue, including extremely injury-sensitive tissue such as the brain. Narrow and rectilinear slim-osteotomies can be easily performed with varying vibrating scalpels. Ultrasonic cutting can be considered a precious innovation for aesthetic sculpturing of the craniofacial skeleton (Figs. 5, 6).
REFERENCES 1. Vercellotti T. Piezoelectric surgery in implantology: a case report—a new piezoelectric expansion technique. Int J Periodontics Restorative Dent 2000;20:359
1450
2. Politi M, Vercellotti T, Polini F, et al. Piezoelectric surgery: a new method of bone cutting. Preliminary experience in alveolar osteogenesis distraction. In: Proceedings of the 2nd International Meeting on Distraction Osteogenesis of the Facial Skeleton. Bologna, Italy, September 26–28, 2002 3. Vercellotti T, Crovace A, Palermo A, et al. The piezoelectric osteotomy in orthopedics: clinical and histological evaluations (pilot study in animals). Mediterr J Surg Med 2001;9:89 4. Larrabee WF Jr, Travis LW, Tabb HG. Frontal sinus fractures—their suppurative complications and surgical management. Laryngoscope 1980;90:1810 5. Wilson BC, Davidson B, Corey JP, et al. Comparison of complications following frontal sinus fractures managed with exploration with or without obliteration over 10 years. Laryngoscope 1988;98:516 6. Robiony M, Polini F, Costa F, et al. Piezoelectric bone cutting in multipiece maxillary osteotomies. J Oral Maxillofac Surg 2004;62:759–761 7. Robiony M, Polini F, Costa F, et al. Ultrasonic bone cutting for surgically assisted rapid maxillary expansion (SARME) under local anaesthesia. Int J Oral Maxillofac Surg 2007;36:267–269 8. Robiony M, Toro C, Costa F, et al. Piezosurgery: a new method for osteotomies in rhinoplasty. J Craniofac Surg 2007;18:1098–1100 9. Robiony M, Polini F, Costa F, et al. Ultrasound piezoelectric vibrations to perform osteotomies in rhinoplasty. J Oral Maxillofac Surg 2007;65:1035–1038 10. Salgarelli AC, Robiony M, Consolo U, et al. Piezosurgery to perform hyoid bone osteotomies in thyroglossal duct cyst surgery. J Craniofac Surg 2011;22:2272–2274 11. Beziat JL, Bera JC, Lavandier B, et al. Ultrasonic osteotomy as a new technique in craniomaxillofacial surgery. Int J Oral Maxillofac Surg 2007;36:493–500 12. Pavlíková G, Foltán R, Burian M, et al. Piezosurgery prevents brain tissue damage: an experimental study on a new rat model. Int J Oral Maxillofac Surg 2011;40:840–844 13. Robiony M, Polini F. Piezosurgery: a safe method to perform osteotomies in young children affected by hemifacial microsomia. J Craniofac Surg 2010;21:1813–1815 14. Kiyokawa K, Hayakawa K, Tanabe HY, et al. Cranioplasty with split lateral skull plate segments for reconstruction of skull defects. J Craniomaxillofac Surg 1998;26:379–385 15. Oppenheimer AJ, Mesa J, Buchman SR. Current and emerging basic science concepts in bone biology: implications in craniofacial surgery. J Craniofac Surg 2012;23:30–36
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
