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Do perforating lateral osteotomies cause less ecchymosis and edema compared with the popular continuous method? Many studies have demonstrated that perforated osteotomies cause less trauma and periosteal disruption. Numerous investigators have subjectively perceived less postoperative ecchymosis and edema, but no clinical study has compared the perforated methods versus the continuous technique in the same patient. This prospective, randomized, partially blinded study was designed to test the hypothesis that the perforating method causes less postoperative ecchymosis and edema compared with the continuous lateral osteotomy technique. The questions remain: does the type of perforating osteotomy affect the results? Does a percutaneous approach cause more ecchymosis and edema by the access maneuver of piercing the skin? The two perforating lateral nasal osteotomy techniques require the same 2-mm straight osteotome, so any genuine difference in postoperative ecchymosis or edema could only be attributed to the differing surgical approaches. Accordingly, this study also tests whether the external percutaneous perforating osteotomy causes more ecchymosis and edema than the internal transnasal perforating method. Twenty-five consecutive rhinoplasty patients (group A) requiring bilateral osteotomies (50 total lateral osteotomies) were randomized so that each patient received an internal/transnasal perforating lateral osteotomy (2-mm straight chisel) on one side and an internal/transnasal continuous osteotomy (4-mm curved, guarded osteotome) on the other. The next 25 patients studied (group B) received an external/percutaneous perforating lateral osteotomy (same 2-mm straight chisel as used in group A) on one side and the same internal/transnasal continuous osteotomy on the other. The final 25 consecutive rhinoplasty patients (group C) received an external percutaneous perforating lateral osteotomy on one side and an internal transnasal perforating lateral osteotomy on the other. The entry sites for the perforating osteotomies were either external (groups B and C) with a percutaneous skin puncture or intranasal (groups A and C) at the pyriform aperture. All 75 patients (150 total lateral osteotomies) initialed the surgical plan on the Gunter rhinoplasty worksheet, which has been approved by the Institutional Review Board of Abbott-Northwestern Hospital, Minneapolis, Minnesota (study no. 1341-1 M). All patients were evaluated for ecchymosis and edema on the left versus the right side of the face at 2 to 3, 7, and 21 days after the operation. The clinical evaluation was performed by two blinded examiners (clinic registered nurse and the patient with his or her family) and a partially blinded examiner (the surgeon, who did not refresh his memory about the randomization). To compare the two methods in each study (groups A, B, and C) for the six outcomes (edema and ecchymosis at 2 to 3, 7, and 21 days), the authors used an exact binomial test of the null hypothesis that the treatments do not differ. To compare the two methods in each study (groups A, B, and C) using all six outcomes simultaneously, the authors used a permutation test. By both testing methods, the perforating internal method was superior to the continuous technique (group A; p < 0.01 in both tests). Although the perforating external method gave better results than the continuous technique (group B) and the perforating internal method gave better results than the perforating external method (group C), neither of these differences was significant by either testing method. A lateral osteotomy technique should be precise, reproducible, and safe, and it should minimize ecchymosis and edema. Since edema and ecchymosis are comparable regardless of osteotome size, this prospective randomized study confirms the subjective clinical impression that perforating lateral osteotomies with a 2-mm straight osteotome reduce postoperative ecchymosis and edema in rhinoplasty patients compared with the continuous osteotomy (4-mm curved, guarded osteotome). These findings should encourage te the use of perforating osteotomies rather than continuous osteotomies.