Histopathological comparison of bone healing effects of endonasal and percutaneous lateral osteotomy methods in rabbit rhinoplasty model

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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Histopathological

comparison

of

bone

healing

effects

of

endonasal

and

percutaneous

lateral

osteotomy

methods

in

rabbit

rhinoplasty

model

夽

S

¸ahin

Ö˘

greden

a

_,

_Sedat

_Rüzgar

a

_,

_Hasan

_Deniz

_Tansuker

a_,_∗

_,

_Ümit

_Tas

_¸kın

a

_,

Yalc

¸ın

Alimo˘

glu

b

_,

_Salih

_Aydın

a

_,

_Mehmet

_Faruk

_Oktay

a

_,

_U˘

_{gur ˙Izol}

c

a_University_of_Health_Sciences,_Bagcilar_Training_and_Research_Hospital,_Department_of_{Otolaryngology,}_Istanbul,_Turkey b_Haseki_Training_and_Research_Hospital,_Department_of_{Otolaryngology,}_Istanbul,_Turkey

c_University_of_Health_Sciences,_Bagcilar_Training_and_Research_Hospital,_Department_of_Pathology,_Istanbul,_Turkey

Received29May2017;accepted22June2017 Availableonline17July2017

KEYWORDS Endonasalosteotomy; Percutaneous osteotomy; Rhinoplasty; Animalmodel Abstract

Introduction:Lateralosteotomyismainlyperformedeitherendonasallyorpercutaneouslyin rhinoplastywhichisafrequentlyperformedoperationforthecorrectionofnasaldeformities. Bothtechniqueshavebothadvantagesanddisadvantagesrelativetoeachother.

Objective:The aimofthisstudy wastocomparethehistopathological effectsofendonasal andpercutaneousosteotomytechniquesperformedinrhinoplastyonbonehealingandnasal stabilityinanexperimentalanimalmodel.

Methods:Eightoneyear-oldNewZealandwhiterabbitswereincluded.Xylazinehydrocloride andintramuscularketamineanesthesiawereadministeredtotherabbits.Endonasalosteotomy (8bones)wasperformedinGroup1(n=4),andpercutaneousosteotomy(8bones)inGroup 2(n=4).Onemonthlatertherabbitsweresacriﬁced.Bonehealingoftherabbitswasstaged accordingtothebonehealingscoreofHuddlestonetal.Inbothgroups,nasalboneintegrity wasassessedsubjectively.

Results:Inthepercutaneousosteotomygroup,Grade1bonehealingwasobservedintwo sam-ples(25%),Grade2bonehealingintwosamples(25%),Grade3bonehealinginfoursamples (50%).Intheendonasalosteotomygroup,Grade1bonehealingwasobservedin6samples(75%) andGrade2bonehealingwasobservedin2samples(25%).Inthepercutaneousgroup,ﬁbrous tissuewasobservedin2,predominantlyﬁbroustissueandalesseramountofcartilage was

夽 _Please_cite_this_article_as:_Ö˘_greden_S_¸,_Rüzgar_S,_Tansuker_HD,_Tas¸kın_Ü,_Alimoglu_Y, _Aydın_S,_et_al._{Histopathological}_comparison_of bonehealingeffects ofendonasaland percutaneous lateralosteotomymethodsinrabbit rhinoplasty model. Braz JOtorhinolaryngol. 2018;84:540---44.

∗_{Corresponding}_author.

E-mail:[email protected](H.D.Tansuker).

PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2017.06.008

1808-8694/©2017AssociaçãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

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observedin2andanequalamountoffibroustissueandcartilagewasobservedin4samples.In theendonasalgroup,fibroustissuewasobservedin6samples,andpredominantlyfibroustissue withalesseramountofcartilagewasobservedin2samples.Inbothgroups,whenmanualforce wasappliedtothenasalbones,subjectivelythesameresistancewasobserved.

Conclusion: Percutaneouslateralosteotomy techniquewasfound toresultinless boneand periosttraumaandbetterbonehealingcomparedtotheendonasalosteotomytechnique. © 2017 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). PALAVRAS-CHAVE Osteotomia endonasal; Osteotomia percutânea; Rinoplastia; Modeloanimal

Comparac¸ãohistopatológicadosefeitosdacicatrizac¸ãoósseaentreastécnicasde osteotomialateralendonasalepercutâneaemmodeloderinoplastiaemcoelhos

Resumo

Introduc¸ão: Nasrinoplastias,aosteotomialateralérealizadaprincipalmenteporviaendonasal oupercutâneaparacorrec¸ãodedeformidadesnasais.Ambasastécnicasapresentamvantagens edesvantagens.

Objetivo: Compararosefeitoshistopatológicossobreacicatrizac¸ãoósseaeestabilidadenasal entreastécnicasdeosteotomiaendonasalepercutâneaemrinoplastiaemummodeloanimal experimental.

Método: Foramincluídosoito coelhosbrancosdaNovaZelândiadeumanodeidade. Hidro-cloretodexilazinaecetaminaintramuscular foramadministradosaoscoelhoscomoagentes anestésicos. Osteotomia endonasal (8 ossos) foi realizada no Grupo 1 (n=4) e osteotomia percutânea (8 ossos) no Grupo 2(n=4). Um mês depois, os coelhos foram sacrificados. A cicatrizaçãoósseadoscoelhosfoiavaliadadeacordocomoescoredecicatrizaçãoósseade Huddlestonetal.Emambososgrupos,aintegridadedoossonasalfoiavaliadasubjetivamente.

Resultados: Nogrupodaosteotomiapercutânea,observou-secicatrizaçãoósseadegrau1em duas amostras (25%), cicatrizaçãoóssea de grau 2em duas amostras (25%), ecicatrização óssea de grau 3 em quatro amostras (50%). No grupo da osteotomia endonasal, observou-se cicatrização óssea de grau 1em 6amostras (75%) e acicatrização óssea de grau 2foi observadaem 2amostras (25%).No grupopercutâneo, otecidofibroso foi observadoem 2 amostras,enquantotecidopredominantementefibrosoeumamenorquantidadedecartilagem foiobservadaem2eumaquantidadeigual detecidofibrosoecartilagemfoiobservadaem 4amostras.Nogrupoendonasal,observou-setecidofibrosoem6amostrasetecido predom-inantementefibrosocomumamenorquantidadedecartilagemem2amostras.Emambosos grupos,quandoforçamanualfoiaplicadaaosossosnasais,amesmaresistênciafoiobservada subjetivamente.

Conclusão:Atécnicadeosteotomialateralpercutânearesultouemmenortraumatismoósseoe periostealemelhorcicatrizaçãoósseaemcomparaçãocomatécnicadeosteotomiaendonasal. © 2017 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publicado por Elsevier Editora Ltda. Este é um artigo Open Access sob uma licença CC BY (http:// creativecommons.org/licenses/by/4.0/).

Introduction

Rhinoplasty is a frequently performed operation for the

correction of nasal deformities. Lateral osteotomies are

usually performed at the ﬁnal stage of esthetic surgery.1

Because osteotomies are not performed under direct

visual observation butby feelingtactile stimulation,they

carry the risk of damaging the mucosa, the supporting

tissues and the periosteum.2 _Ideal _osteotomy _should _be

reproducible,predictableand beabletoproducedeﬁnite

results with good functional outcomes, and soft tissue

damageshouldbeminimal.3_Lateral_osteotomy_may_cause

excessivedamagetotheintranasalmucosaandperiosteum,

increasedbleeding, excessively mobilizednose, excessive

edema, increased ecchymoses, and excessive narrowing

of the nose.4 _The _lateral _osteotomy _performed _after _the

hump resection corrects the open roof deformities, the

curvedlateral nasal wall and the broad nasal base.5 _The

lateralosteotomy is mainlyperformed either endonasally

or percutaneously. Bothtechniques have both advantages

anddisadvantagesrelativetoeachother.

The rabbit nasal bone is thinner and elongated than

the human nasal bone. In rabbit facial anatomy, both

nasal bones fusesto form roofof nasal cavity and forms

the dorsal border of the piriform aperture. Nasal bones

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pup rabbits the frontonasal suture is the active growth

zone.6

Bones have regeneration and repair capacity after

fracture. The fracture healing process involves platelets,

inﬂammatory cells, ﬁbroblasts, endothelial cells,

osteo-clastsandosteoblasts.Themostcriticalroleinthisprocess

isattributedtoosteoblastsbecausetheyareresponsiblefor

thesynthesisandmineralizationofthebonematrix.7,8

In thisstudy,we aimed tocompare histopathologically

theeffectofendonasalandpercutaneouslateralosteotomy

techniquesonbone healingandtoevaluatenasalstability

clinicallyusingarabbitmodel.

Methods

Eightoneyear-oldNewZealandwhiterabbitswereincluded

inthisstudy.The rabbitsweredivided into2groups each

containing4. Group 1 included endonasal osteotomy

per-formed rabbits, and Group 2 included the percutaneous

osteotomyperformedrabbits.Mucosa,periosteumandthe

softtissueswerenotelevatedduringtheinternalosteotomy.

In both groups the rabbits were given anesthesia with

5mg/kg xylazine hydrochloride and 35mg/kg

intramuscu-lar ketamine. Then, bilateral incisions superior to their

naresweremade,and bonewasreachedin therabbitsin

Group1.Completeosteotomywasperformedusingguided

osteotomy.InGroup2,thenasalbonewasexposedby

mak-ing a skin incision on the back of the nose. Perforating

osteotomies were made in the nasal bone using a 2mm

unguided sharp osteotomy and a greenstick fracture was

created.Thesizeoftheosteotomefortheendonasal

tech-niquewas2mmtoo.Attheendoftheoperation,theincised

skinwassuturedand closed.Onemonthlater,therabbits

weresacriﬁcedbyintracardiacadministrationofahighdose

120mgpentobarbital.Thenasalbonesoftherabbitswere

resected from the bilateral frontal process of the

max-illary bone and separated from the nasal spindle of the

frontalbone.Thespecimenswereﬁxedwith10%buffered

formaldehyde. Hematoxylin---eosin was used for staining.

Bonehealingwasstagedaccordingtothegradingdescribed

byHuddlestonetal.9_The_progression_of_{fracture-healing}_in

eachspecimenwasquantiﬁedwithuseofascalethatassigns

agradebasedontherelativepercentagesofﬁbroustissue,

cartilage,wovenbone,andmatureboneinthecallus.9₄_␮m

sectionsweretaken.Usingamicroscope(B×51Japan),

his-tological grading was performed. The grading was asthe

following:Grade1---Fibroustissue,Grade2---Dominantly

ﬁbrous tissue less cartilage, Grade 3 --- Equal amount of

cartilage andﬁbrous tissue,Grade 4 --- Only cartilage

tis-sue,Grade5---Predominantlycartilageandsmallamountof

wovenbone,Grade6---Equalamountoflateralcartilageand

immature bone, Grade 7--- Predominantly immature bone

andlesscartilage,Grade8---Totallyimmaturebone,Grade

9---Immatureboneandlesseramountofmaturebone,and

Grade10 ---Mature (lamella) bone.In both ofthe groups,

bonestrengthwasassessedsubjectivelybyapplyingmanual

forcetothenasalbones.

This study wasapproved by the experimental animals

local ethics committee of Ba˘gcılar Training and Research

Hospital(2015,n◦ 2015---07).

Table1 Histologicalscoringoftheeffectofendonasaland percutaneousosteotomytechniquesonbonehealing. Histologicalscore Researchgroups

Percutaneous (n=8) Endonasal (n=8) 1 2(25%) 6(75%) 2 2(25%) 2(25%) 3 4(50%) 0 4 0 0 5 0 0 6 0 0 7 0 0 8 0 0 9 0 0 10 0 0

Figure1 Fibroustissueandcartilageproliferationinfracture line(H&E_×40).

Results

Bonehealingwasevaluatedhistopathologicallyin16 sam-ples takenfromeightrabbits.Inthepercutaneous lateral osteotomygroup,Grade1 bonehealingwasobserved in2 samples(25%),Grade2bonehealingin2samples(25%),and Grade3bonehealingin4samples(50%).Intheendonasal lateralosteotomygroup,Grade1bonehealingwasobserved in6samples(75%)andGrade2bonehealingwasobservedin 2samples(25%)(Table1).Inthepercutaneousgroup,ﬁbrous

tissuewasobservedin2,predominantlyﬁbroustissueanda

lesseramountofcartilagewasobservedin2andan equal

amount of ﬁbrous tissue and cartilage was observed in 4

samples(Fig.1).Intheendonasalgroup,ﬁbroustissuewas

observed in6 samples(Fig.2),andpredominantly ﬁbrous

tissuewithalesseramount ofcartilagewasobserved in2

samples(Table2).Inbothgroups,whenmanualforcewas

appliedtothenasalbones,theyhadsubjectivelythesame

resistance.

Discussion

Lateralosteotomyisoneofthebasicproceduresincosmetic

nasalsurgery.Itisusuallydonetocorrectopenroof

defor-mities after hump resection,to narrow the wide nose or

to thin the nasal pyramid. Surgeons generally prefer one

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Figure2 Oldbleedingﬁndingsinfracturelineandﬁbroblastic proliferation(H&E×40).

Table2 Histopathologicalscoringofbonehealing. Histological appearance Researchgroups Percutaneous Endonasal Fibroustissue 2(25%) 6(75%) Weightedﬁbrous tissueandless cartilage 2(25%) 2(25%) Equalamountsof ﬁbrousand cartilaginoustissue 4(50%) 0(0%)

endonasal continuous osteotomy or external perforating osteotomy.Theexternalperforatingosteotomyhas advan-tagessuchaslessmucosalandperiostealdamage,lessnose mobilizationduetoperiostealstabilityandmorecontrolled fracture. However, endonasal continuous osteotomy pro-videsmoremobilizationandmoreprecisenarrowinginthe nasalpyramid.4,10

Rohrichetal.reportedthatthelateralosteotomy

tech-nique caused less bleeding, edema and ecchymoses, and

alsoitprovideddecreasedtheriskofnasalinstabilitydue

to periosteal preservation.4,10 _In _our _animal _model _study,

we observed that the technique of percutaneous lateral

osteotomyhadapositiveeffectonnasalstability.Rhoetal.

described internal perforatinglateral osteotomy with the

wide periosteal elevation and they noted less

postoper-ative ecchymosis, edema, and hemorrhage, and that the

patientreturnedtohisorhersociallifesooner.11_Similarly,

Hontanillaet al.reportedthat the patientswithexternal

perforating lateral osteotomy where the periosteum was

preservedwerelesslikelytohaveecchymosis,edema and

hemorrhage.12_Esteves_et_al._conducted_a_study_in_rats,_and

examinedhistologicalandimmunohistochemicalproperties

of bone healing after osteotomy with piezosurgery and

classical drilling methods and compared both methods.

Althoughbonehealingwithpiezoosteotomywassuperiorto

conventionalosteotomyintheearlyperiod,itwasreported

that it was the same as the conventional method in the

lateperiod.13_In_our_study,_we_have_seen_that_in_the_rabbit

rhinoplasty model, bone healing is superior histologically

in the perforated osteotomy technique as compared to

endonasalcontinuousosteotomy.

Inanetal.comparedtheeffectofmedianands-shaped

sternotomy methods on bone healing and sternal

stabil-ity in 31 sheep’s. They have reported that the stability

of the sternum and bone healing were better

histo-logically with s-shaped sternotomy.14 _In _our _study _with

rabbits, we observed histologically superior bone

heal-ing with perforating osteotomy technique compared to

continuous endonasal technique. However, when manual

pressuretothenasalbone wasapplied,both groupswere

equallyresistantsubjectively.Inanandcolleaguesreported

that thorax stability was stronger in the sheep with

S-shapedsternotomy.Likewise,Kucukdurmazetal.reported

that a small, non-zigzag-shaped osteotomy was superior

to plain osteotomy.15 _Sinha _et _al. _compared _the

postop-erativeeffects of endonasal and percutaneous osteotomy

techniques during rhinoplasty in 45 patients. Endonasal

osteotomyhasbeenreportedtocauseecchymosis,edema

andhemorrhage more frequently when compared to

per-cutaneouslateralosteotomy.16 _Gryskiewicz_et_al._reported

that in 50 patients with lateral osteotomy, patients with

percutaneous lateral osteotomy had less ecchymosis and

edema compared to the endonasal group.17 _In _our _study,

bone healing was slower and ﬁbrous tissue was

predomi-nantlyobservedintheendonasalosteotomygroupcompared

tothepercutaneousosteotomygroup.Malhotraetal.

stud-iedbonehealinghistologicallyandradiologicallyin4sheeps

onwhichtheycreated bonedefectsofvariouswidthsand

thesame depths in thedistal femur andfound that bone

healingwasassociatedwiththedefectwidth.18

We concludedthat the external perforatingosteotomy

hasadvantagesinamorecontrolledfractureandlessnose

mobilization, which leads to less mucosal and periosteal

damageduetoperiostealstability.Sincethisisa

histopatho-logicalstudy insteadof clinicalones, swellingandbruises

were not evaluatedpostoperatively. The major

disadvan-tageof thisstudy wasthe lownumber ofthe rabbitsdue

tofactthattherehadbeendifﬁculty ofethicscommittee

approvalforhighernumberofrabbits.

Conclusion

Althoughthepercutaneouslateralosteotomytechniquehas

been shown to be more effective in terms of

histologi-calbonehealingthantheendonasalosteotomytechnique,

theremaybeaneedforwiderserieswithlongerperiodsof

timeandcorrelationwiththeclinicalobservationtofurther

clarifythisissue.

Conﬂicts

of

interest

Theauthorsdeclarenoconﬂictsofinterest.

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