Ultrasonic (piezoelectric) rhinoplasty in Madrid: cosmetic and functional

In ultrasonic (or piezoelectric) rhinoplasty, the bones of the nose are cut and reduced with an instrument that vibrates ultrasonically, instead of with osteotomes and a mallet [1][2]. It can be done for cosmetic or functional reasons, or both: to change the shape of the nose and, at the same time, to make sure it breathes well inside.

Dr. Méndez-Benegassi is an ENT (ear, nose and throat) surgeon who also works on snoring and sleep apnea. He performs ultrasonic rhinoplasty, both cosmetic and functional, as well as septum and turbinate surgery. This page explains what the studies say, including what ultrasound does not change.

What is ultrasonic rhinoplasty and how does it differ from the classic technique?

What changes is the tool used to cut the bone: in the classic technique, osteotomes and rasps; in the ultrasonic one, a piezoelectric instrument that vibrates. In clinical trials this meant less swelling, less bruising and less pain in the first week [1][2].

The instrument is designed for bone: in the trials it did not damage the lining inside the nose in any case [1]. The cartilage — the tip, the nostrils and the lower part of the bridge — is not worked with ultrasound. The plate shows where the bone ends and the cartilage begins.

What the studies compared: ultrasound versus the classic technique

The authors of one of the meta-analyses describe this evidence as weak, because of the low quality of the studies [2]. Both techniques are valid; what is decided in each case is what that particular nose needs.

What can be changed in a cosmetic rhinoplasty?

The usual reasons are a hump, a drooping or wide tip and a crooked nose. The bony part of the hump and the width of the nasal bones are worked with ultrasound; the tip is cartilage and is shaped with other techniques. Before surgery, you agree what to change.

Hump on the bridge of the nose

The hump has a bony part at the top and a cartilage part below (see the plate above). There are two ways of dealing with it: reducing it (structural technique) or lowering the whole bridge while keeping its surface (preservation rhinoplasty). In a meta-analysis of 10 studies, preservation left fewer irregularities on the bridge, but the hump remained or came back more often; breathing was the same with both [5]. In another meta-analysis of 22 studies, the hump came back in about 4 out of 100 people after preservation [6]. The choice depends on each nose.

Drooping, wide or bulbous tip

The tip is formed by the alar cartilages (plate below), not by bone, so ultrasound does not act on it. In a series of 369 cosmetic rhinoplasties, not addressing the tip in the first operation was associated with more dissatisfaction [7]. That is why the tip is planned together with the rest, even when what bothers you is the hump.

Crooked nose

A nose can be crooked on the outside (bones and cartilage), on the inside (the septum) or both. When the septum is straightened and the outer parts are also moved to make the nose more symmetrical, the operation is called a septorhinoplasty [24]; we explain it in functional septorhinoplasty (functional rhinoplasty). If only the septum is deviated, the operation is a septoplasty.

ENT surgeon or plastic surgeon: who performs a rhinoplasty?

Both specialties are trained to operate on the nose, and both include surgeons with experience in rhinoplasty. What an ENT surgeon brings is knowledge of the inside of the nose and of the airway: the septum, the turbinates, the nasal valve and, in this case, snoring and sleep apnea.

Whoever you choose, it helps to ask the same questions: what can and cannot change in your nose, how your breathing will be checked before and after, and what recovery to expect.

What is recovery like, week by week?

Bruising around the eyes usually lasts a few days [24], and it is in that first week that ultrasound makes a difference [1]. The swelling you cannot see takes longer: about two-thirds goes in the first month and the rest, little by little, over the rest of the first year [18].

First days

The nose is a little sore; the discomfort is managed with simple painkillers [24]. A small splint is usually placed on the outside of the nose to hold the bones while they heal [24]. Bruising around the eyes is common; with ultrasound it was less on days 1, 2 and 7 [1].

Two weeks

In a study of 110 people operated on with ultrasound, by day 14 the swelling around the eyes had gone and bruising was minimal [17]. When to go back to work depends on your job and on what was done; your surgeon will tell you.

First month

About two-thirds of the swelling has gone [18].

Six months

Around 95% of the swelling has gone [18]: most of the change can already be seen.

One year

Around 97.5% [18]: this is when the final result is assessed. In 17 studies, satisfaction with the nose (ROE questionnaire, 0 to 100) averaged 33.5 before surgery, 69.6 in the first six months and 80.25 at one year [19].

This is what the studies and guidelines describe; your surgeon will give you the instructions for your case. For surgery in general, see recovering from sleep apnea surgery.

Is nasal packing used after a rhinoplasty?

In most cases, no. Dr. Méndez-Benegassi avoids the classic packing and uses biodegradable materials or stitches. In septum surgery, trials show that full nasal packing causes more discomfort and does not prevent bleeding [20]. There are fewer studies in septorhinoplasty: in one trial, devices that let air through were more comfortable than packing [21].

In a meta-analysis of 47 trials in septum surgery, packing caused more difficulty breathing, pain and poor sleep, without reducing bleeding; stitches through the septum were an alternative with fewer problems [20]. If packing or splints are needed in your case, your surgeon will tell you for how long.

What are the risks, and how often is a revision needed?

Serious complications are uncommon: in 4,978 cosmetic rhinoplasties, 0.7% needed emergency care, admission or another operation in the first month, mainly for a blood collection (haematoma) or infection [22]. Having another operation is more common: depending on the series, between 2 and 10 out of 100 people [7][23].

• Who has more risk: in that same series, complications were more frequent from the age of 40 and when the rhinoplasty was combined with other cosmetic operations [22].
• Hump: it can remain or come back, more often with preservation rhinoplasty [5][6].
• Breathing: in many second operations, one of the complaints is not being able to breathe well [9]; that is why breathing is assessed before the first one.
• Satisfaction: in a series of 369 cosmetic rhinoplasties, 15.4% were not satisfied [7]. Talking through expectations beforehand is part of the operation.