In their Letter to the Editor, Robiony et al reviewed their experience with piezoelectric instruments (PEI) and provided updated studies.1 The authors then raise two questions. First, Dr. Robiony, who is a maxillofacial surgeon, finds the subperiosteal dissection of the osseous nasal vault to be too aggressive and wonders about bony healing and devascualrization. Yet, most maxillofacial operations involve very extensive subperiosteal dissection, especially in orthognatic procedures, without concern for bony necrosis and limited vascularization. Equally, extensive skull and facial exposure is done subperiosteally in craniofacial surgery without long term bone …