The Powered Rasp
Advanced Instrumentation for Rhinoplasty

RELATIVELY RECENT innovations in powered instrumentation have expanded the niche for powered instrumentation by creating the opportunity for improved precision and technical ease while minimizing tis­sue trauma. A new powered rasp for precise takedown or smoothing of the bony hump offers a significant advance in surgical instrumentation. A rasp attachment for a commonly used reciprocating saw that is widely used for other surgical techniques allows this precision instrument to have specific application in rasping of the bony nasal dorsum. These powered rasps reproduce the action of a manual rasp but in a more precisely controlled manner. Rasping may be undertaken under direct visualization. Speeds of up to 15,000 reciprocations per minute with a 5-mm back-and-forth excursion are possible.

The rasp provides a pure horizontal motion without undesirable vertical excursion or chatter, even at the highest speeds. As with all procedures involving powered instrumentation (such as otologic surgery), higher speed allows greater precision and control. Indeed, the high speed allows greater control and provides the opportunity for greater precision in rasping.

Historically, after completion of a conservative hump excision with an osteotome, final bony profile refinements are made with a sharp tung­sten-carbide rasp. Alternatively, the entire bony hump may be addressed with the rasp. The rasp is routinely used to smooth the dorsal edges of the nasal bones comprising the "open roof after hump reduction with an osteotome. Although effective, the manual rasp is a traumatic instru

ment that inflicts temporary damage to the nasal soft tissue, resulting in edema that may interfere with intraoperative assessments and thereby adversely affect the surgical outcome. Palpable or visible irregularities may appear as late as 1 to 5 years postoperatively if small fragments or "bone splinters" are not recognized and removed.

1 " 5 Powered instrumentation appears well suited for precise reduction of the bony dorsal hump or an isolated bony irregularity, or to smooth the edges of the "open roof." 2 " 5 Powered instrumentation has been designed specifically for use on the bony nasal dorsum. 2 " 5 Becker et al 5 reported an extended clinical experience with powered instrumentation in rhinoplasty. A powered drill (47 patients) or powered rasp (10 patients) was used in rhinoplasties requiring bony dor­sal modification from April 1996 to December 1997. Skin thickness varied: 16 patients had thick skin (6 females, 10 males), 33 had mediumthickness skin (22 females, 11 males), and 8 had thin skin (8 females, 0 males). In cases requiring 3 to 4 mm of bony hump reduction (n = 36), the powered instrumentation was used to smooth the bony edges following dorsal reduction with a straight osteotome. In cases requiring 1 to 2 mm of bony dorsum reduction (n=20) it was the sole instrumentation for dorsal modification. In one case requiring 3-mm bony dorsum reduction, powered instrumentation was the sole instru­mentation for dorsal modification. With average follow-up of 13 months (range, 6-26 months), there were no cases of dorsal irregularities.

The authors pointed out that the incidence of postoperative bony dorsal irregularities has not been well quantified in the literature, making comparison to manual instrumen­tation difficult. Nevertheless, there were no cases having this complication with at least 6 months' follow-up in all patients and with greater than 1-year follow-up in over half of the patients. 5

Powered nasal drills by their very nature do not reproduce the rasping motion to which rhinoplasty surgeons have become accustomed, but they do provide a precise approach to modification of the bony nasal dorsum. Nasal dorsum drills (LinvatecHall Surgical Corporation, Largo , Fla , and Xomed/Medtronics, Jacksonville , Fla ) allow resection or smoothing of the bony dorsum under direct vision via an endonasal or external rhinoplasty approach. With the na­sal drills, there is a risk of creating a "divot" in the nasal bone.

Powered, reciprocating rasps (Linvatec-Hall Surgical Corpora­tion) with minimal (0.5 cm) backand-forth excursion are a mini­mally traumatic alternative for modification of the bony dorsum. These powered rasps reproduce the action of a manual rasp but in a more precisely controlled manner. Unlike the manual rasp, powered instrumentation allows direct visualization of the operative site.

Earlier powered rasps were adequate but had an undesired vertical movement or "chatter" that decreased the rasps' effectiveness. The improved powered rasps provide a precise calibrated motion, avoiding any apparent vertical motion or chatter even at speeds of up to 15000 reciprocations per minute with a 5-mm back-and-forth excursion. Higher speeds with a pure horizontal motion allow greater control for bone smoothing and bone takedown. The powered rasp provides the opportunity for greater precision in rasping.

Currently powered instrumentation is not well-suited for modification of the cartilaginous dorsum. Calibrated scalpel excision of the cartilaginous dorsum under direct visualization, when indicated, remains a reliable approach to modi­fying the middle nasal vault.

Recent advances in powered instrumentation for use on the nasal dorsum have dramatically improved their potential effectiveness and highlight the improved efficacy of powered rasps. While rasping is generally undertaken prior to osteotomies, at times the surgeon may find after osteotomies that additional bony takedown is necessary. I have found that the speed and precision of the powered rasp (Linvatec-Hall Surgical Corporation) has allowed me to undertake additional bony takedown under direct vision in these rare circumstances.

Advances in instrument design are guided by the desire to achieve a surgical maneuver more efficaciously and accurately. Facial plastic surgeons are already well familiar with the use of powered instruments in fa­cial trauma. The powered rasp reproduces the time-tested rasping approach to takedown or smoothing of the bony dorsum. Powered instrumentation provides the surgeon with the ability to perform the same rasping maneuver more precisely than would be possible with a manual instrument.

Daniel G. Becker, MD Division of Facial Plastic

and Reconstructive Surgery Department of Otorhinolaryngology University of Pennsylvania Hospital 7 Silverstein/3400 Spruce St Philadelphia, PA 19104 (e-mail: beckermailbox@aol.com)

REFERENCES

1. Tardy ME Jr. Rhinoplasty: The Art and the Science. New York , NY : WB Saunders Co; 1997.
2. Toriumi DM, Becker DG. Rhinoplasty Dissection Manual. Philadelphia , Pa : Lippincott Williams & Wilkins;1999.
3. Becker DG. Technical considerations in powered instrumentation. OtolaryngolClin North Am. 1997; 30:421.
4. Becker DG, Toriumi DM, Gross CW, Tardy ME. Powered instrumentation for dorsal nasal reduction. Facial Plastic Surg. 1997;13:291 -297.
5. Becker DG, Park SS, Toriumi DM. Powered instrumentation for rhinoplasty and septoplasty. Otolaryngol Clin North Am. 1999;32:683693.

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