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Aesthetic Facial Osteotomies in Latin Americans
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CLINICS IN PLASTIC SURGERY Clin Plastic Surg 34 (2007) e31–e36
Aesthetic Facial Osteotomies in Latin Americans Fernando Molina, -
-
MD*
The malar-zygoma osteotomy for augmentation Dentoalveolar deformities
There are considerable differences in the facial appearance of different races resulting from the shape and proportions of the skeletal support, the muscle insertions, and the color and quality of the skin. Until recently, the facial features of many of these groups were considered the aesthetic ideal in that particular society and cultural background. Accepted standards of beauty universally promoted through journals, the cinema, and television reflect the ideal characteristics of the European face, also referred to as ‘‘Caucasian’’ or, according to ethnologic terminology, as ‘‘Indo-European’’ [1]. Individuals of all races, in all corners of the world, with every variety of facial features, desire to meet an aesthetic ideal. The surgeon’s challenge is to understand the ethnic concepts of beauty and the unique anatomic characteristics of the individual face. Latin American people represent a mixture of European immigrants and the native population of the American continent. Because of the origin of the Amerindians in northeast Asia, there is a strong Mongoloid component in their facial features, making the aesthetic surgery of the craniofacial skeleton techniques that are successful in this group also applicable to the Asian populations. Because of similarities in anatomic characteristics such as skin thickness, wide bigonial angle, and Mongoloid eyes, the basic technical concepts for the mestizo
-
Summary References
face also can be used for facial correction of some individuals of Mediterranean and African origin. Although African slaves were imported to most countries on the American continent during colonial times, their contribution to the genetic core was limited, because of small numbers or unfavorable conditions, except in Brazil, the Caribbean, and the United States [2]. In full-face view, the forehead region from hairline to glabella should make up approximately one third of the total facial height. From the glabella the forehead curves gently backward as one proceeds toward the hairline. This curve is slightly more accentuated in females. The visible bitemporal distance is slightly less than the bigonial distance in the normally proportioned face. In males, frontal sinus development creates marked fullness over the medial forehead [3]. The superior orbital rim is immediately subjacent to the eyebrow, as a visible promontory in the youthful well-proportioned face. The intercanthal distance approximates the inner-to-outer canthal distance only one third of the time and is slightly greater in two thirds of individuals. The palpebral fissure is slightly longer than in Indo-Europeans. In women, the position of the lateral canthus is 4 to 6 mm higher than the inner canthus; thus the inclination of the eye fissure goes upward from medial to lateral, creating the Mongoloid
Department of Plastic Surgery, Hospital General ‘‘Dr. Manuel Gea Gonzalez’’ and the Post-Graduate Division of the Medical School, Universidad Nacional Auto´noma de Me´xico, Mexico City, Mexico. * Calzada de Tlalpan 4800, Col. Toriello Guerra, Me´xico, Mexico D.F., 01400, Mexico. E-mail address: [email protected] 0094-1298/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
doi:10.1016/j.cps.2007.05.010
e32
Molina
palpebral fissure, one of the most striking components of the mestizo face. The facial skin of the mestizo population of many areas of Latin American is moderately thick. The thickness of the skin cover is produced by the presence of a layer of sebaceous glands that are more numerous than in the Indo-European face, especially in the nasal skin. Another common feature of the mestizo face is the protrusion of the anterior dental arches, which project the upper lip anteriorly, resulting in an acute nasolabial angle. The nasal spine, which usually is located in a prominent position, appears receded because of the prominence of the upper dental arch. The paranasal area may be slightly depressed, but the effect is exaggerated further by the prominence of the dental arch. The chin typically is located in a good position, but it may appear to be receding because of the prominence of the dental arches; an apparently receding chin further accentuates the facial convexity. In the middle third of the face, the malar region presents extreme variability in projection and form. The malar eminences are visible highlights and are positioned anterior and medial within the widest portion of the face and are responsible for the aesthetically pleasing oval shape of the face [4]. This oval shape is the more desired face in Latin American people (Fig. 1). Surgical alterations of the upper third of the face by osteotomies that involve the orbit and malar complex can alter facial aesthetics significantly. These relatively simple procedures can have a dramatic effect on facial appearance and in the author’s practice frequently are performed in combination with nasal and facial rejuvenation surgery. The common surgical procedures of the facial skeleton include Lefort I osteotomy to advance,
shorten, or elongate the maxilla, mandibular osteotomies to advance or retroposition the lower jaw, and segmental maxillary and mandibular osteotomies for the correction of dentoalveolar disharmonies. Although equally relevant for this patient population, the first two groups of osteotomies are discussed elsewhere in this issue. The scope of this article is limited to the surgical procedures on the skeleton of the zygoma-malar region and the correction of the anterior projection of the dental arches that are relevant to this patient population.
The malar-zygoma osteotomy for augmentation Through a combined coronal and vestibular approach, the craniofacial skeleton is exposed in the subperiosteal plane. The osteotomy as initially described by Tessier [5] encompasses the body of the zygoma (Fig. 2). A reciprocating saw is used to initiate the osteotomy lateral to the infraorbital nerve; the osteotomy is continued through the body of the zygoma to the middle third of the zygomatic arch. With an osteotome the zygoma is outfractured and ‘‘hinged’’ superiorly. The orbital rim with approximately 5 mm of the orbital floor and lateral orbital wall is included. A cranial bone graft from the parietal region then is placed beneath the osteotomy [5,6]. Positioning of the graft beneath the malar eminence will increase the anteroposterior projection as well as in the bizygomatic transverse dimension (Figs. 3 and 4). The volume increases gradually from the inferior half of the lateral orbital rim, reaching the maximal projection at the level of the zygomatic arch. Facial rejuvenation, when indicated, can be accomplished through the coronal approach as an adjunctive procedure with
Fig. 1. The pleasing oval face as a result of combined osteotomies at the mallar prominence and at the superior dentoalveolar. (A) Dotted lines show the osteotomies in the two skeletal regions. (B) The skeletal changes after the osteotomies and (C) the aesthetic final result.
Aesthetic Facial Osteotomies in Latin Americans
Fig. 2. The operative procedure for malar augmentation as proposed by Tessier and described by Wolfe. (A) Dotted lines show the osteotomy limits. (B) With a reciprocating saw, the osteotomy is performed from lateral to medial. (C) The osteotomy is completed with a curve chisel and after grafts are inserted.
a subperiosteal suspension of the soft tissue envelope of the midface. With this approach the surgeon can modify the patient’s biologic boundary by using autogenous tissue and can avoid the use of alloplastic materials that may lead to secondary, late problems and may have an unnatural appearance with facial animation.
Dentoalveolar deformities Maxillary alveolar protrusion is characterized by overprojection of the upper lip relative to the lower lip (Fig. 5). In the bimaxillary protrusion, both lips are projected anteriorly with excessive gingival display and exaggerated lip strain (Fig. 6). The relationship with the chin is altered, and the sublabial sulcus is absent. Surgical treatment of
the alveolar protrusion requires careful planning with preoperative orthodontics. Model surgery is performed to ensure coordination of the dental arches after segmental surgery. Occlusal plates are fabricated based on the model surgery. A single plate is used intraoperatively after the segmental maxillary osteotomy, and two plates are necessary when maxillary and mandible protrusion are to be corrected in a single stage. Surgical refinements and better understanding of the vascularity of the maxilla have made these osteotomies safe, with predictable results and minimal morbidity [7,8]. Segmental aesthetic osteotomies have several requirements: (1) to provide adequate exposure for the osteotomies without injuring adjacent teeth, (2) to preserve the blood supply of the mucosa of the osseous segments, and
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Fig. 3. (A) Before and (B) after malar augmentation.
(3) to mobilize the segments without the need for postoperative intermaxillary fixation. The operation is performed under general anesthesia with nasotracheal intubation. One premolar on each side is extracted from the upper arch, and a vertical incision is made on each side from the central part of the alveolus of the first premolar directed superiorly to the vestibular cul-de-sac. Next,
with a combination of a fine burr and an oscillation saw, a segment of bone is resected from the alveolar arch and from the palatine process to displace the premaxilla to the desired position. The segments are immobilized with an orthodontic bar fixed to the dental bands. Stainless steel wire fixation across the osteotomy sometimes is necessary to stabilize the segment further.
Fig. 4. (A) Before and (B) after malar augmentation.
Aesthetic Facial Osteotomies in Latin Americans
Fig. 5. Maxillary excess. (A) Before and (B) after anterior maxillary segmental setback.
A similar technique is used to correct the mandibular dental arch. The mucosa is incised vertically from the midsection of the first premolars in a caudal direction to the vestibular sulcus bilaterally. Subperiosteal dissections on the anterior and lingual surfaces of the mandible then are made. Two parallel osteotomies at the extracted premolar site are extended caudally beyond the dental roots, and the intervening bone is resected. Next a horizontal
osteotomy is made joining the vertical osteotomies. The bone segment is mobilized to the preplanned position using the occlusal plate, and an orthodontic bar is placed to achieve immobilization. As an adjunctive measure to improve the depressed perialar areas in some patients, the author and colleagues use costal cartilage grafts. The grafts are carved in a semilunar shape to conform to the piriform aperture and are introduced into a limited
Fig. 6. (A) Bimaxillary protrusion seen in many Latin American populations. (B) After anterior maxillary and anterior mandibular segmental setback procedure.
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Fig. 7. (A) Before and (B) after perialar augmentation, rhinoplasty, and osseous genioplasty.
subperiosteal pocket through a 1-cm buccal vestibular incision. When necessary, a third graft shaped as a bar about 25 to 30 mm in length and 5 mm in diameter may be inserted at the nasal base in front of the nasal spine to complement the correction of the depressed paranasal area (Fig. 7).
Summary The standard orthognathic procedures for correcting various dentofacial skeletal deformities are equally applicable to the Latin American population. The anterior segmental procedures are the procedures most commonly used because of the prominence of the dental arches in this population. Additionally, skeletal surgery in those who seek aesthetic enhancement focuses on achieving the appropriate balance between the malar eminence and the ‘‘ideal‘‘ face as perceived by the patient. Frequently, skeletal surgery is combined with adjunctive procedures (forehead lift, face lift, rhinoplasty) that further enhance the facial appearance.
References [1] Ricketts RM. Divine proportion in facial aesthetics. Clin Plast Surg 1982;9:401–18. [2] Ortiz Monasterio F. The non-Indoeuropean nose, in rhynoplasty. Philadelphia: W.B. Saunders; 1994. p. 171–90. [3] Bartlett SP, Wormon I III, Whitaker L. Evaluation on facial skeletal aesthetics and surgical planning. Clin Plast Surg 1991;18:1–9. [4] Wolfe SA, Vitenas P Jr. Malar augmentation using autogenous materials. Clin Plast Surg 1991;18:39–54. [5] Tessier P. Transactions of the Fourth International Congress of Plastic Surgery in Rome, 1967. Amsterdam: Excerpta Medica; 1968. [6] Whitaker LA. Aesthetic augmentation of the malar midface structures. Plast Reconstr Surg 1987;80: 337–47. [7] Ortiz Monasterio F. Aesthetic facial osteotomies. In: Terino E, editor. Three dimensional facial sculpting. New York: Informa Healthcare; 2007. p. 219–42. [8] Wunderer S. Profile correction of the midfacial area with the help of a pediculated maxillary fragment method. Transactions of the Fifth International Congress of Plastic and Reconstructive Surgery, Rome, 1967.
CLINICS IN PLASTIC SURGERY Clin Plastic Surg 34 (2007) e31–e36
Aesthetic Facial Osteotomies in Latin Americans Fernando Molina, -
-
MD*
The malar-zygoma osteotomy for augmentation Dentoalveolar deformities
There are considerable differences in the facial appearance of different races resulting from the shape and proportions of the skeletal support, the muscle insertions, and the color and quality of the skin. Until recently, the facial features of many of these groups were considered the aesthetic ideal in that particular society and cultural background. Accepted standards of beauty universally promoted through journals, the cinema, and television reflect the ideal characteristics of the European face, also referred to as ‘‘Caucasian’’ or, according to ethnologic terminology, as ‘‘Indo-European’’ [1]. Individuals of all races, in all corners of the world, with every variety of facial features, desire to meet an aesthetic ideal. The surgeon’s challenge is to understand the ethnic concepts of beauty and the unique anatomic characteristics of the individual face. Latin American people represent a mixture of European immigrants and the native population of the American continent. Because of the origin of the Amerindians in northeast Asia, there is a strong Mongoloid component in their facial features, making the aesthetic surgery of the craniofacial skeleton techniques that are successful in this group also applicable to the Asian populations. Because of similarities in anatomic characteristics such as skin thickness, wide bigonial angle, and Mongoloid eyes, the basic technical concepts for the mestizo
-
Summary References
face also can be used for facial correction of some individuals of Mediterranean and African origin. Although African slaves were imported to most countries on the American continent during colonial times, their contribution to the genetic core was limited, because of small numbers or unfavorable conditions, except in Brazil, the Caribbean, and the United States [2]. In full-face view, the forehead region from hairline to glabella should make up approximately one third of the total facial height. From the glabella the forehead curves gently backward as one proceeds toward the hairline. This curve is slightly more accentuated in females. The visible bitemporal distance is slightly less than the bigonial distance in the normally proportioned face. In males, frontal sinus development creates marked fullness over the medial forehead [3]. The superior orbital rim is immediately subjacent to the eyebrow, as a visible promontory in the youthful well-proportioned face. The intercanthal distance approximates the inner-to-outer canthal distance only one third of the time and is slightly greater in two thirds of individuals. The palpebral fissure is slightly longer than in Indo-Europeans. In women, the position of the lateral canthus is 4 to 6 mm higher than the inner canthus; thus the inclination of the eye fissure goes upward from medial to lateral, creating the Mongoloid
Department of Plastic Surgery, Hospital General ‘‘Dr. Manuel Gea Gonzalez’’ and the Post-Graduate Division of the Medical School, Universidad Nacional Auto´noma de Me´xico, Mexico City, Mexico. * Calzada de Tlalpan 4800, Col. Toriello Guerra, Me´xico, Mexico D.F., 01400, Mexico. E-mail address: [email protected] 0094-1298/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
doi:10.1016/j.cps.2007.05.010
e32
Molina
palpebral fissure, one of the most striking components of the mestizo face. The facial skin of the mestizo population of many areas of Latin American is moderately thick. The thickness of the skin cover is produced by the presence of a layer of sebaceous glands that are more numerous than in the Indo-European face, especially in the nasal skin. Another common feature of the mestizo face is the protrusion of the anterior dental arches, which project the upper lip anteriorly, resulting in an acute nasolabial angle. The nasal spine, which usually is located in a prominent position, appears receded because of the prominence of the upper dental arch. The paranasal area may be slightly depressed, but the effect is exaggerated further by the prominence of the dental arch. The chin typically is located in a good position, but it may appear to be receding because of the prominence of the dental arches; an apparently receding chin further accentuates the facial convexity. In the middle third of the face, the malar region presents extreme variability in projection and form. The malar eminences are visible highlights and are positioned anterior and medial within the widest portion of the face and are responsible for the aesthetically pleasing oval shape of the face [4]. This oval shape is the more desired face in Latin American people (Fig. 1). Surgical alterations of the upper third of the face by osteotomies that involve the orbit and malar complex can alter facial aesthetics significantly. These relatively simple procedures can have a dramatic effect on facial appearance and in the author’s practice frequently are performed in combination with nasal and facial rejuvenation surgery. The common surgical procedures of the facial skeleton include Lefort I osteotomy to advance,
shorten, or elongate the maxilla, mandibular osteotomies to advance or retroposition the lower jaw, and segmental maxillary and mandibular osteotomies for the correction of dentoalveolar disharmonies. Although equally relevant for this patient population, the first two groups of osteotomies are discussed elsewhere in this issue. The scope of this article is limited to the surgical procedures on the skeleton of the zygoma-malar region and the correction of the anterior projection of the dental arches that are relevant to this patient population.
The malar-zygoma osteotomy for augmentation Through a combined coronal and vestibular approach, the craniofacial skeleton is exposed in the subperiosteal plane. The osteotomy as initially described by Tessier [5] encompasses the body of the zygoma (Fig. 2). A reciprocating saw is used to initiate the osteotomy lateral to the infraorbital nerve; the osteotomy is continued through the body of the zygoma to the middle third of the zygomatic arch. With an osteotome the zygoma is outfractured and ‘‘hinged’’ superiorly. The orbital rim with approximately 5 mm of the orbital floor and lateral orbital wall is included. A cranial bone graft from the parietal region then is placed beneath the osteotomy [5,6]. Positioning of the graft beneath the malar eminence will increase the anteroposterior projection as well as in the bizygomatic transverse dimension (Figs. 3 and 4). The volume increases gradually from the inferior half of the lateral orbital rim, reaching the maximal projection at the level of the zygomatic arch. Facial rejuvenation, when indicated, can be accomplished through the coronal approach as an adjunctive procedure with
Fig. 1. The pleasing oval face as a result of combined osteotomies at the mallar prominence and at the superior dentoalveolar. (A) Dotted lines show the osteotomies in the two skeletal regions. (B) The skeletal changes after the osteotomies and (C) the aesthetic final result.
Aesthetic Facial Osteotomies in Latin Americans
Fig. 2. The operative procedure for malar augmentation as proposed by Tessier and described by Wolfe. (A) Dotted lines show the osteotomy limits. (B) With a reciprocating saw, the osteotomy is performed from lateral to medial. (C) The osteotomy is completed with a curve chisel and after grafts are inserted.
a subperiosteal suspension of the soft tissue envelope of the midface. With this approach the surgeon can modify the patient’s biologic boundary by using autogenous tissue and can avoid the use of alloplastic materials that may lead to secondary, late problems and may have an unnatural appearance with facial animation.
Dentoalveolar deformities Maxillary alveolar protrusion is characterized by overprojection of the upper lip relative to the lower lip (Fig. 5). In the bimaxillary protrusion, both lips are projected anteriorly with excessive gingival display and exaggerated lip strain (Fig. 6). The relationship with the chin is altered, and the sublabial sulcus is absent. Surgical treatment of
the alveolar protrusion requires careful planning with preoperative orthodontics. Model surgery is performed to ensure coordination of the dental arches after segmental surgery. Occlusal plates are fabricated based on the model surgery. A single plate is used intraoperatively after the segmental maxillary osteotomy, and two plates are necessary when maxillary and mandible protrusion are to be corrected in a single stage. Surgical refinements and better understanding of the vascularity of the maxilla have made these osteotomies safe, with predictable results and minimal morbidity [7,8]. Segmental aesthetic osteotomies have several requirements: (1) to provide adequate exposure for the osteotomies without injuring adjacent teeth, (2) to preserve the blood supply of the mucosa of the osseous segments, and
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Fig. 3. (A) Before and (B) after malar augmentation.
(3) to mobilize the segments without the need for postoperative intermaxillary fixation. The operation is performed under general anesthesia with nasotracheal intubation. One premolar on each side is extracted from the upper arch, and a vertical incision is made on each side from the central part of the alveolus of the first premolar directed superiorly to the vestibular cul-de-sac. Next,
with a combination of a fine burr and an oscillation saw, a segment of bone is resected from the alveolar arch and from the palatine process to displace the premaxilla to the desired position. The segments are immobilized with an orthodontic bar fixed to the dental bands. Stainless steel wire fixation across the osteotomy sometimes is necessary to stabilize the segment further.
Fig. 4. (A) Before and (B) after malar augmentation.
Aesthetic Facial Osteotomies in Latin Americans
Fig. 5. Maxillary excess. (A) Before and (B) after anterior maxillary segmental setback.
A similar technique is used to correct the mandibular dental arch. The mucosa is incised vertically from the midsection of the first premolars in a caudal direction to the vestibular sulcus bilaterally. Subperiosteal dissections on the anterior and lingual surfaces of the mandible then are made. Two parallel osteotomies at the extracted premolar site are extended caudally beyond the dental roots, and the intervening bone is resected. Next a horizontal
osteotomy is made joining the vertical osteotomies. The bone segment is mobilized to the preplanned position using the occlusal plate, and an orthodontic bar is placed to achieve immobilization. As an adjunctive measure to improve the depressed perialar areas in some patients, the author and colleagues use costal cartilage grafts. The grafts are carved in a semilunar shape to conform to the piriform aperture and are introduced into a limited
Fig. 6. (A) Bimaxillary protrusion seen in many Latin American populations. (B) After anterior maxillary and anterior mandibular segmental setback procedure.
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Fig. 7. (A) Before and (B) after perialar augmentation, rhinoplasty, and osseous genioplasty.
subperiosteal pocket through a 1-cm buccal vestibular incision. When necessary, a third graft shaped as a bar about 25 to 30 mm in length and 5 mm in diameter may be inserted at the nasal base in front of the nasal spine to complement the correction of the depressed paranasal area (Fig. 7).
Summary The standard orthognathic procedures for correcting various dentofacial skeletal deformities are equally applicable to the Latin American population. The anterior segmental procedures are the procedures most commonly used because of the prominence of the dental arches in this population. Additionally, skeletal surgery in those who seek aesthetic enhancement focuses on achieving the appropriate balance between the malar eminence and the ‘‘ideal‘‘ face as perceived by the patient. Frequently, skeletal surgery is combined with adjunctive procedures (forehead lift, face lift, rhinoplasty) that further enhance the facial appearance.
References [1] Ricketts RM. Divine proportion in facial aesthetics. Clin Plast Surg 1982;9:401–18. [2] Ortiz Monasterio F. The non-Indoeuropean nose, in rhynoplasty. Philadelphia: W.B. Saunders; 1994. p. 171–90. [3] Bartlett SP, Wormon I III, Whitaker L. Evaluation on facial skeletal aesthetics and surgical planning. Clin Plast Surg 1991;18:1–9. [4] Wolfe SA, Vitenas P Jr. Malar augmentation using autogenous materials. Clin Plast Surg 1991;18:39–54. [5] Tessier P. Transactions of the Fourth International Congress of Plastic Surgery in Rome, 1967. Amsterdam: Excerpta Medica; 1968. [6] Whitaker LA. Aesthetic augmentation of the malar midface structures. Plast Reconstr Surg 1987;80: 337–47. [7] Ortiz Monasterio F. Aesthetic facial osteotomies. In: Terino E, editor. Three dimensional facial sculpting. New York: Informa Healthcare; 2007. p. 219–42. [8] Wunderer S. Profile correction of the midfacial area with the help of a pediculated maxillary fragment method. Transactions of the Fifth International Congress of Plastic and Reconstructive Surgery, Rome, 1967.