Rhinoplasty: A Sequential Approach to Managing the Bony Vault

Overview

Managing the nasal bones is part of most rhinoplasties and traditionally means hump removal and osteotomies (controlled fractures). The authors, including Gerbault (who introduced piezo instruments to rhinoplasty) and Daniel, describe an algorithm in which piezoelectric instruments sculpt bone, with osteotomies added only as needed according to the degree of asymmetry, always through a fully open approach for visibility.

Sections of note

• 165 cases, December 2016 to July 2018.
• Patients grouped into 5 categories by the bony-pyramid algorithm chosen.
• Priority: preserve nasal bone stability by using rhinosculpture broadly, alone or with osteotomies, while preserving the bridge.
• The fully open approach was used in all cases to exploit the piezo instruments' capabilities.
• Stated benefit: limited bone movement and stable side walls short and long term.

What it means for a patient

• Instead of fracturing the nasal bones to narrow them, ultrasonic tools can shave and shape them, which the authors say leaves the bones more stable.
• This requires an open approach and specialised equipment.
• The paper describes method and experience; outcome measures are not reported in the abstract.

Why this paper matters

It is a foundational algorithm paper for piezo bone work from the technique's originators. Limits: no outcome data, no comparison group.

Terms

• Bony vault (pyramid): the paired nasal bones forming the upper third of the nose.
• Piezoelectric instrument: an ultrasonic tip that cuts and shaves bone without cutting soft tissue.
• Rhinosculpture: shaping bone by shaving rather than fracturing.
• Osteotomy: a controlled cut through bone to move it.
• Open approach: an external columellar incision allowing the skin to be lifted.