- Email: [email protected]
Aesthetic Surgery to Augment Orthognathic Surgery
Oral Maxillofacial Surg Clin N Am 19 (2007) 435–447
Aesthetic Surgery to Augment Orthognathic Surgery Tirbod Fattahi, DDS, MD, FACS Division of Oral & Maxillofacial Surgery, University of Florida Health Science Center, 653-1 W. 8th Street, Jacksonville, FL 32209, USA
One of the greatest assets of an oral and maxillofacial surgeon is the ability to perform orthognathic surgery. Corrective jaw surgery, along with all of its modifications and improvements over the past three decades, has made a significant impact on the field of oral and maxillofacial surgery and quality of life for thousands of patients. The ability to predictably move and alter the dentofacial skeleton to improve occlusion, function, and aesthetics is remarkable. Historically, orthognathic surgery requires an extensive preoperative evaluation. Preoperative models, panoramic and cephalometric radiographs, facial and intraoral pictures, model surgery, and cephalometric tracings play an integral role in the preoperative phase. Cephalometric analyses are typically performed to compare a patient’s measurements versus the ‘‘normal’’ standards. Specific bony movements and surgical procedures are determined based on the available data. It is important to recall that most cephalometric preoperative evaluation of patients for orthognathic surgery involves evaluation of hard tissues. We often look at the position of upper incisors, the size of the palatal shelf, the anteroposterior dimension of the maxilla and the mandible, and the position of the bony chin. Although we can predict the final location of these bony markers after orthognathic surgery, we might fail to consider some of the three-dimensional soft tissue changes that may be altered by surgery. We also sometimes fail to consider other aesthetic procedures available that can dramatically improve our final result. The old adage of ‘‘the mind only knows what the eye sees’’ is important to keep in mind when considering the final aesthetic outcome
E-mail address: [email protected]fl.edu
of orthognathic surgery, both hard and soft tissues. The purpose of this article is to discuss some of the more commonly performed aesthetic surgical procedures to augment the final outcome of orthognathic surgery. These procedures are divided into two categories: those that can safely and predictably be performed simultaneously with orthognathic surgery and those that ideally should be performed independently of orthognathic surgery. This latter category also includes camouflage surgery, which includes aesthetic surgical procedures that are performed to camouflage or mask underlying dentofacial deformities in patients who, for various reasons, are not candidates for traditional orthognathic surgery or prefer a ‘‘smaller’’ operation. With modern minimally invasive surgery, patients often wish to augment their appearance with the least amount of surgery. Camouflage surgery may be an attractive alternative for this group of patients because it is usually a much smaller operation and has a shorter recovery period. Procedures Genioplasty A genioplasty or ‘‘chin surgery’’ is the most commonly performed aesthetic surgery at the time of orthognathic surgery. The surgical procedure may involve chin reduction, central and lateral augmentation along the pre-jowl sulcus, reduction of height, and correction of a chin cant or asymmetry. There are numerous methods of determining the ‘‘ideal’’ chin position in relation to the mandible and maxilla. This discussion is beyond the scope of this article, however. The most commonly performed genioplastic procedure is augmentation of the chin. The
1042-3699/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.coms.2007.04.002
oralmaxsurgery.theclinics.com
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FATTAHI
versatility of this procedure is multi-fold. An aesthetically pleasing chin is one of the central focuses of beauty when the face is viewed in profile. The surgeon has two choices in augmentation genioplasty: osteoplastic genioplasty and alloplastic genioplasty. Regardless of the method of augmentation, this procedure can be performed simultaneously with orthognathic surgery, or it can be performed in camouflage surgery in patients who do not want to undergo orthognathic surgery but desire a stronger chin. In addition to the improvement of the overall aesthetic appearance of the lower face, the following specific improvements can be obtained with augmentation genioplasty: effacement of a deep labiomental groove, decrease in cervicomental angle (ideal 90 –110 ), and effacement of the pre-jowl sulcus. Osteoplastic genioplasty, also known as sliding genioplasty, is a predictable, stable, and relatively safe operation. When performed properly, the entire chin and the inferior border of the body of the mandible are advanced anteriorly. Because the mentalis muscle remains attached to the chin point, the amount of soft tissue augmentation mirrors that of the bony augmentation. For example, a chin advancement of 8 mm also advances the soft tissue pogonion approximately 8 mm. The main potential complication of this procedure is the possibility of mental nerve injury during the osteotomy. In contrast to osteoplastic genioplasty, alloplastic genioplasty has a lower chance of injury to the mental nerve because no osteotomy is performed. This is the preferred method of augmentation of the chin by the author for several reasons: (1) decreased chance of mental nerve injury (no osteotomy), (2) shorter recovery period postoperatively, (3) ability to improve the pre-jowl sulcus to obtain a more harmonious appearance of the lower face, and (4) shorter procedure to perform compared with osteoplastic genioplasty. The most commonly used alloplasts for chin augmentation are solid silicone implants. These implants have been used in craniofacial augmentation for more than three decades and have an excellent track record. Although the implant can be placed from an extraoral approach, the author prefers the intraoral approach because it offers a better visualization of the entire implant as it is being secured by sutures/screws. It is important to dissect a subperiosteal pocket larger than the size of the implant to ensure a passively placed implant. The overall rate of infection associated with silicone implants is less than 2%.
Augmentation genioplasty, whether osteoplastic or alloplastic, can be an excellent surgical alternative to orthognathic surgery in a patient who does not wish to undergo a traditional mandibular osteotomy (bilateral sagittal split osteotomy [BSSO]). If an acceptable dental occlusion can be obtained with orthodontic manipulation, a ‘‘weak’’ chin can be corrected predictably, quickly, and safely in an office setting with minimal anesthesia and much improved aesthetics for the patient. Cervicoplasty The ability to surgically alter the anterior portion of the neck by cervicoplasty along with platysmaplasty and submental liposuction can be gratifying to the surgeon and the patient. This procedure can be done safely and predictably at the same time of mandibular osteotomy (BSSO) or can be done independently. It is important to understand that although a mandibular advancement improves chin position and occlusion and augments the cervicomental relationship, a ptotic platysma, platysmal banding, and submental lipomatosis can only be addressed via a formal cervicoplasty. The following improvements are possible through the use of cervicoplasty: (1) improvement of the cervicomental angle, (2) elimination of the platysmal redundancy (ptosis) and bands (platysma pleats), (3) elimination of submental lipomatosis, and (4) better definition of the jaw line. Any patient scheduled to undergo a BSSO for mandibular advancement should have a formal assessment of the anterior neck. The central portion of the platysma muscle should be evaluated and the presence of significant submental lipomatosis should be assessed. It is important to recall that a cervicoplasty with platysmaplasty and submental liposuction only addresses the anterior neck. If there are significant jowls, the patient may need a formal face lift. If the patient is scheduled to undergo orthognathic surgery and a cervicoplasty, the orthognathic component of the surgery should be completed first. The surgical sites are scrubbed and draped for the cervicoplasty. Although the complete surgical procedure is described elsewhere, an open submental liposuction is performed initially followed by a formal corset platysmaplasty. This operation yields excellent results for patients who are undergoing a BSSO at the same time of the cervicoplasty because almost every component of the lower face aesthetics (eg, occlusion, mandibular and chin position, jaw line, submental fat,
AESTHETIC SURGERY TO AUGMENT ORTHOGNATHIC SURGERY
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platysma, and cervicomental angle) is altered and improved simultaneously in one operation.
a patient’s profile and can produce a more harmonious mid- and lower face relationship without the need for orthognathic surgery.
Rhinoplasty
Malarplasty
Considered the most difficult cosmetic operation to perform, rhinoplasty can have a significant impact on the aesthetics of the midface. Not only can the appearance of the nose be enhanced but also significant improvements in function (air flow) can be obtained by a septorhinoplasty. Should a rhinoplasty be performed at the time of orthognathic surgery? Several articles have been published on the benefits of simultaneous rhinoplasty and orthognathic surgery. Advocates of such reports claim high patient satisfaction with a single operation addressing maxillomandibular discrepancies and nasoseptal deformities. There are some draw backs to a single operation addressing both areas, however. One of the major challenges of a simultaneous orthognathic surgery and rhinoplasty is the need for an endotracheal tube change from a nasotracheal to an orotracheal tube at the completion of the orthognathic surgery. Although this can be challenging, most experienced anesthesiologists and oral and maxillofacial surgeons can perform this maneuver safely. Perhaps the biggest drawback of performing a rhinoplasty at the time of orthognathic surgery is the inability to control the amount of intraoperative swelling and edema around the nose, which can distort nasal architecture and have a negative effect on the overall final result of nasal surgery. A primary rhinoplasty has a 21% revision rate, which is a rather high rate for a nose that has never been operated on before. If one were to introduce additional factors, such as swelling and edema, from simultaneous orthognathic surgery, the revision rate might increase and potentially increase the number of complications. Rhinoplasty, when performed independently, can drastically improve the appearance of the face. Similar to augmentation genioplasty, a rhinoplasty can camouflage some maxillomandibular discrepancies. For example, a ptotic nasal tip in a patient with a hypoplastic maxilla who does not wish to have a Le Fort I osteotomy can be corrected by tip plasty and cephalic trim. An overprojected nose (tension-nose), which is often seen in patients with a long lower face, also can be underprojected by a septorhinoplasty. Perhaps one of the most aesthetically pleasing camouflage procedures involves rhinoplasty and augmentation genioplasty performed at the same time. This combination procedure dramatically improves
Patients who have maxillary hypoplasia often have hypoplasia of the infraorbital rims or the tear troughs. These patients have a negative vector (infraorbital rims posterior to the cornea) associated with their midface, which is also known as a ‘‘polar bear’’ appearance. Advancing the maxilla without addressing the infraorbital rim hypoplasia can have a less-than-pleasing aesthetic result, which has led to the creation of the ‘‘high’’ Le Fort I osteotomy to advance the infraorbital rims along with the maxilla. Alternatively, infraorbital rims or tear troughs can be augmented by placing malar/submalar implants at the time of a standard Le Fort I osteotomy. These solid silicone implants can be secured via titanium screws after applying rigid fixation to the advanced maxilla. These implants create a much more harmonious effect to the midface when placed at the time of a Le Fort I osteotomy. If performing the augmentation malarplasty at the time of a Le Fort I advancement, the author has found more aesthetically pleasing outcomes by choosing a slightly smaller implant than usual (to compensate for the bony advancement of the maxilla). For example, if a medium silicone implant sizer looks appropriate at the time of the preoperative evaluation, placing a small implant at the time of surgery gives a much more pleasing result. Augmentation malarplasty also can be performed independently of a Le Fort I osteotomy or as a camouflage procedure in patients not wanting to undergo a traditional osteotomy. Bilateral malar augmentation with silicone implants can be performed in the office with minimal anesthesia in a brief amount of time. Because of the versatility of implant sizers, specific regions that are hypoplastic can be identified preoperatively and selectively augmented with the proper implant. Just as with silicone augmentation genioplasty, it is imperative to create a subperiosteal pocket that is larger than the implant, which ensures lack of visible ‘‘borders’’ or ‘‘edges’’ upon animation. Summary It is important to keep in mind that the final result of orthognathic surgery should augment hard and soft tissues of the face. Although it is critical to obtain a ‘‘normal’’ occlusion by corrective jaw surgery, one also must have an aesthetic
438
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eye for adjunctive or complementary procedures that can further enhance the final result. Some of these procedures can safely and predictably be performed at the time of orthognathic surgery, whereas others should be done independently. It is just as imperative to offer patients alternatives to orthognathic surgery in the form of camouflage surgery if a patient is not interested in traditional osteotomy. Camouflage surgery can have a drastic effect on the facial skeleton and appearance. It is usually a much smaller operation, requires less recovery period, and often can be performed with minimal anesthesia compared with orthognathic surgery. The final outcome of camouflage surgery can be gratifying to the surgeon and the patient.
surgery and camouflage surgery used to augment orthognathic surgery. In some cases, the procedures are performed in a simultaneous fashion with orthognathic surgery. In other cases they are staged.
Case presentations
Case 2
The following cases illustrate some of the aforementioned concepts regarding aesthetic
A 50-year-old woman presented with concerns of a weak chin and a full neck. Clinical evaluation
Case 1 A 47-year-old woman who had undergone previous orthognathic surgery to advance her mandible presented for aesthetic evaluation of her midface. She did not like the sagging appearance of her cheeks (Fig. 1A–C). To address her concerns, she underwent bilateral silicone augmentation malarplasty (Fig. 2A,B). Note the improved definition to the midface and infraorbital region.
Fig. 1. (A) Preoperative frontal view. (B) Preoperative three-fourths view. (C) Panoramic radiograph shows previous mandibular advancement.
AESTHETIC SURGERY TO AUGMENT ORTHOGNATHIC SURGERY
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Fig. 2. (A) Postoperative frontal view after bilateral silicone augmentation malarplasty. (B) Postoperative three-fourths view.
revealed that she had significant mandibular hypoplasia, platysmal redundancy, and submental lipomatosis, which resulted in an unattractive neck (Fig. 3). A skeletal analysis confirmed that she was mandibular deficient (Fig. 4). A decision was made to address her skeletal and aesthetic concerns simultaneously. Her surgical procedures involved a mandibular advancement with a BSSO and simultaneous cervicoplasty, including
Fig. 3. Profile of second patient. Note mandibular hypoplasia, platysmal redundancy, and submental lipomatosis.
platysmaplasty and open submental liposuction (Fig 5). In Fig. 5, the combined effects of the skeletal and soft tissue procedures can be seen in her improved cervicomental angle and chin projection. Case 3 A 40-year-old woman presented with skeletal and soft tissue concerns. Her preoperative examination showed that she had maxillary hypoplasia and submental fullness (Fig. 6). Preoperative models and lateral cephalometric radiograph confirmed the skeletal diagnosis (Fig. 7A,B). Her surgical procedures included a Le Fort I maxillary
Fig. 4. Preoperative model shows class II malocclusion.
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Fig. 5. Postoperative profile view after mandibular advancement and simultaneous cervicoplasty, including platysmaplasty and open submental liposuction.
advancement and simultaneous cervicoplasty, including platysmaplasty and open submental liposuction. After surgery, improvement in the mid- and lower face and the neck were visible (Fig. 8). Case 4
Fig. 7. (A) Preoperative lateral cephalogram. (B) Preoperative models.
A 22-year-old woman presented for an orthognathic consultation for maxillary hypoplasia. Clinical examination showed that she had hypoplasia of the maxilla and the infraorbital regions, with an asymmetric nose and fullness to the left side of her face (Fig. 9A,B). Lateral cephalometric radiograph confirmed the maxillary hypoplasia (Fig. 10). After an extensive consultation she elected to have a Le Fort I advancement and simultaneous bilateral malar augmentation with silicone implants (Fig. 11A,B). Although the asymmetry of the left side of her face was discussed and various options were given to her, she elected not to have it addressed. In Fig. 11A and B, the improvement in the midface is evident. A rhinoplasty to address the asymmetry of her nose will be performed at a later date.
Case 5 Fig. 6. Profile of the third patient shows maxillary hypoplasia and submental fullness.
A 55-year-old woman presented with significant class II malocclusion, deep labiomental crease, and
AESTHETIC SURGERY TO AUGMENT ORTHOGNATHIC SURGERY
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Fig. 10. Lateral cephalogram.
Fig. 8. Postoperative lateral photograph.
platysmal redundancy (Fig. 12A,B). To correct her skeletal and soft tissue concerns, she underwent a BSSO advancement, a chin reduction, and a simultaneous cervicoplasty, including platysmaplasty and open submental liposuction. Intraoperative photographs are of the cervicoplasty, including the resected redundant platysma (Fig. 13A,B). Postoperative photographs are of the patients at 6 weeks (Fig. 14A,B). Note improvement in the labiomental region and the neck.
Case 6 A 23-year-old woman sought consultation for evaluation of the midface. The patient was found to have infraorbital rim hypoplasia and transverse maxillary deficiency (Fig. 15A–D). After discussion with the patient, it was determined that she would be managed with camouflage surgery via bilateral malar augmentation with silicone implants. Preoperative and intraoperative photos show implant location and placement transorally
Fig. 9. (A) Preoperative frontal view with asymmetric nose, fullness to the left side of face, and maxillary hypoplasia. (B) Preoperative lateral view.
Fig. 11. (A) Frontal view after surgery. (B) Lateral view after surgery.
Fig. 12. (A) Frontal view. (B) Lateral view.
Fig. 13. (A) Intraoperative photograph of the cervicoplasty. (B) Resected redundant platysma.
Fig. 14. (A) Postoperative frontal view. (B) Lateral view.
Fig. 15. (A) Preoperative frontal view. (B) Lateral view. (C) Intraoral view shows the transverse discrepancy. (D) Lateral cephalogram.
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Fig. 16. (A) Intraoperative outline intended position. (B) Intraoral dissection and implant placement.
(Fig. 16A,B). Intraoperative photographs show implant placement on the right side only (Fig. 17A) and at the completion of both sides (Fig. 17B). Fig. 18A,B shows postoperative photographs of the patient at 3 weeks. Note improvement in the midface without orthognathic surgery. Case 7 A 28-year-old patient who had previous orthodontic treatment sought consultation because he did not like the appearance of his lower face
(Fig. 19A,B). He had a class I dental occlusion with deficient chin, bilateral pre-jowl sulcus, and an exaggerated cervicomental angle. To address his concerns he was scheduled to undergo an alloplastic augmentation genioplasty and a cervicoplasty, including platysmaplasty and open submental liposuction. His genial region was exposed through the cervicoplasty incision with placement of an implant through this incision (Fig. 20A,B). Postoperative photographs show the patient at 2 months (Fig. 21A,B).
Fig. 17. (A) Augmentation of the right side. (B) Augmentation of both sides.
Fig. 18. (A) Postoperative frontal view. (B) Lateral view.
Fig. 19. (A) Preoperative frontal view. (B) Lateral view.
Fig. 20. (A) Alloplastic implant. (B) Cervicoplasty incision after open liposuction and placement of implant.
Fig. 21. (A) Postoperative frontal view. (B) Lateral view.
Fig. 22. (A) Preoperative frontal view. (B) Lateral view.
Case 8 A 27-year-old man presented with the complaints of having a ‘‘small chin’’ and a nasal ‘‘hump’’ (Fig. 22A,B). He was not interested in orthognathic surgery and opted for camouflage surgery. His procedures included an alloplastic augmentation genioplasty and a simultaneous rhinoplasty. Intraoperative photographs are of the chin implant placed transorally (Fig. 23). Additional photographs are of the patient 2.5 years after surgery (Fig. 24A,B).
Fig. 23. Intraoral placement of alloplastic implant.
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Fig. 24. (A) Postoperative frontal view. (B) Lateral view.
Further Readings Fattahi T. Management of isolated neck deformity. Atlas Oral Maxillofac Surg Clin North Am 2004;12: 261–70. Greer SE, Matarasso A, Wallach SG, et al. Importance of the nasal-to-cervical relationship to the profile in rhinoplasty surgery. Plast Reconstr Surg 2001;108:522–31. Levine RA, Garza JR, Wang PT, et al. Adult facial growth: applications to aesthetic surgery. Aesthetic Plast Surg 2003;27:265–8.
Louis PJ, Cuzalina LA. Alloplastic augmentation of the face. Atlas Oral Maxillofac Surg Clin North Am 2000;8:127–91. Profitt WR, White RP, Sarver DM. Adjunctive esthetic surgery. In: Contemporary treatment of dentofacial deformity. St. Louis (MO): Mosby; 2003. Waite PD, Matukas VJ. Indications for simultaneous orthognathic and septorhinoplastic surgery. J Oral Maxillofac Surg 1991;49:133–40. Yaremchuk MJ. Mandibular augmentation. Plast Reconstr Surg 2000;106:697.
Aesthetic Surgery to Augment Orthognathic Surgery Tirbod Fattahi, DDS, MD, FACS Division of Oral & Maxillofacial Surgery, University of Florida Health Science Center, 653-1 W. 8th Street, Jacksonville, FL 32209, USA
One of the greatest assets of an oral and maxillofacial surgeon is the ability to perform orthognathic surgery. Corrective jaw surgery, along with all of its modifications and improvements over the past three decades, has made a significant impact on the field of oral and maxillofacial surgery and quality of life for thousands of patients. The ability to predictably move and alter the dentofacial skeleton to improve occlusion, function, and aesthetics is remarkable. Historically, orthognathic surgery requires an extensive preoperative evaluation. Preoperative models, panoramic and cephalometric radiographs, facial and intraoral pictures, model surgery, and cephalometric tracings play an integral role in the preoperative phase. Cephalometric analyses are typically performed to compare a patient’s measurements versus the ‘‘normal’’ standards. Specific bony movements and surgical procedures are determined based on the available data. It is important to recall that most cephalometric preoperative evaluation of patients for orthognathic surgery involves evaluation of hard tissues. We often look at the position of upper incisors, the size of the palatal shelf, the anteroposterior dimension of the maxilla and the mandible, and the position of the bony chin. Although we can predict the final location of these bony markers after orthognathic surgery, we might fail to consider some of the three-dimensional soft tissue changes that may be altered by surgery. We also sometimes fail to consider other aesthetic procedures available that can dramatically improve our final result. The old adage of ‘‘the mind only knows what the eye sees’’ is important to keep in mind when considering the final aesthetic outcome
E-mail address: [email protected]fl.edu
of orthognathic surgery, both hard and soft tissues. The purpose of this article is to discuss some of the more commonly performed aesthetic surgical procedures to augment the final outcome of orthognathic surgery. These procedures are divided into two categories: those that can safely and predictably be performed simultaneously with orthognathic surgery and those that ideally should be performed independently of orthognathic surgery. This latter category also includes camouflage surgery, which includes aesthetic surgical procedures that are performed to camouflage or mask underlying dentofacial deformities in patients who, for various reasons, are not candidates for traditional orthognathic surgery or prefer a ‘‘smaller’’ operation. With modern minimally invasive surgery, patients often wish to augment their appearance with the least amount of surgery. Camouflage surgery may be an attractive alternative for this group of patients because it is usually a much smaller operation and has a shorter recovery period. Procedures Genioplasty A genioplasty or ‘‘chin surgery’’ is the most commonly performed aesthetic surgery at the time of orthognathic surgery. The surgical procedure may involve chin reduction, central and lateral augmentation along the pre-jowl sulcus, reduction of height, and correction of a chin cant or asymmetry. There are numerous methods of determining the ‘‘ideal’’ chin position in relation to the mandible and maxilla. This discussion is beyond the scope of this article, however. The most commonly performed genioplastic procedure is augmentation of the chin. The
1042-3699/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.coms.2007.04.002
oralmaxsurgery.theclinics.com
436
FATTAHI
versatility of this procedure is multi-fold. An aesthetically pleasing chin is one of the central focuses of beauty when the face is viewed in profile. The surgeon has two choices in augmentation genioplasty: osteoplastic genioplasty and alloplastic genioplasty. Regardless of the method of augmentation, this procedure can be performed simultaneously with orthognathic surgery, or it can be performed in camouflage surgery in patients who do not want to undergo orthognathic surgery but desire a stronger chin. In addition to the improvement of the overall aesthetic appearance of the lower face, the following specific improvements can be obtained with augmentation genioplasty: effacement of a deep labiomental groove, decrease in cervicomental angle (ideal 90 –110 ), and effacement of the pre-jowl sulcus. Osteoplastic genioplasty, also known as sliding genioplasty, is a predictable, stable, and relatively safe operation. When performed properly, the entire chin and the inferior border of the body of the mandible are advanced anteriorly. Because the mentalis muscle remains attached to the chin point, the amount of soft tissue augmentation mirrors that of the bony augmentation. For example, a chin advancement of 8 mm also advances the soft tissue pogonion approximately 8 mm. The main potential complication of this procedure is the possibility of mental nerve injury during the osteotomy. In contrast to osteoplastic genioplasty, alloplastic genioplasty has a lower chance of injury to the mental nerve because no osteotomy is performed. This is the preferred method of augmentation of the chin by the author for several reasons: (1) decreased chance of mental nerve injury (no osteotomy), (2) shorter recovery period postoperatively, (3) ability to improve the pre-jowl sulcus to obtain a more harmonious appearance of the lower face, and (4) shorter procedure to perform compared with osteoplastic genioplasty. The most commonly used alloplasts for chin augmentation are solid silicone implants. These implants have been used in craniofacial augmentation for more than three decades and have an excellent track record. Although the implant can be placed from an extraoral approach, the author prefers the intraoral approach because it offers a better visualization of the entire implant as it is being secured by sutures/screws. It is important to dissect a subperiosteal pocket larger than the size of the implant to ensure a passively placed implant. The overall rate of infection associated with silicone implants is less than 2%.
Augmentation genioplasty, whether osteoplastic or alloplastic, can be an excellent surgical alternative to orthognathic surgery in a patient who does not wish to undergo a traditional mandibular osteotomy (bilateral sagittal split osteotomy [BSSO]). If an acceptable dental occlusion can be obtained with orthodontic manipulation, a ‘‘weak’’ chin can be corrected predictably, quickly, and safely in an office setting with minimal anesthesia and much improved aesthetics for the patient. Cervicoplasty The ability to surgically alter the anterior portion of the neck by cervicoplasty along with platysmaplasty and submental liposuction can be gratifying to the surgeon and the patient. This procedure can be done safely and predictably at the same time of mandibular osteotomy (BSSO) or can be done independently. It is important to understand that although a mandibular advancement improves chin position and occlusion and augments the cervicomental relationship, a ptotic platysma, platysmal banding, and submental lipomatosis can only be addressed via a formal cervicoplasty. The following improvements are possible through the use of cervicoplasty: (1) improvement of the cervicomental angle, (2) elimination of the platysmal redundancy (ptosis) and bands (platysma pleats), (3) elimination of submental lipomatosis, and (4) better definition of the jaw line. Any patient scheduled to undergo a BSSO for mandibular advancement should have a formal assessment of the anterior neck. The central portion of the platysma muscle should be evaluated and the presence of significant submental lipomatosis should be assessed. It is important to recall that a cervicoplasty with platysmaplasty and submental liposuction only addresses the anterior neck. If there are significant jowls, the patient may need a formal face lift. If the patient is scheduled to undergo orthognathic surgery and a cervicoplasty, the orthognathic component of the surgery should be completed first. The surgical sites are scrubbed and draped for the cervicoplasty. Although the complete surgical procedure is described elsewhere, an open submental liposuction is performed initially followed by a formal corset platysmaplasty. This operation yields excellent results for patients who are undergoing a BSSO at the same time of the cervicoplasty because almost every component of the lower face aesthetics (eg, occlusion, mandibular and chin position, jaw line, submental fat,
AESTHETIC SURGERY TO AUGMENT ORTHOGNATHIC SURGERY
437
platysma, and cervicomental angle) is altered and improved simultaneously in one operation.
a patient’s profile and can produce a more harmonious mid- and lower face relationship without the need for orthognathic surgery.
Rhinoplasty
Malarplasty
Considered the most difficult cosmetic operation to perform, rhinoplasty can have a significant impact on the aesthetics of the midface. Not only can the appearance of the nose be enhanced but also significant improvements in function (air flow) can be obtained by a septorhinoplasty. Should a rhinoplasty be performed at the time of orthognathic surgery? Several articles have been published on the benefits of simultaneous rhinoplasty and orthognathic surgery. Advocates of such reports claim high patient satisfaction with a single operation addressing maxillomandibular discrepancies and nasoseptal deformities. There are some draw backs to a single operation addressing both areas, however. One of the major challenges of a simultaneous orthognathic surgery and rhinoplasty is the need for an endotracheal tube change from a nasotracheal to an orotracheal tube at the completion of the orthognathic surgery. Although this can be challenging, most experienced anesthesiologists and oral and maxillofacial surgeons can perform this maneuver safely. Perhaps the biggest drawback of performing a rhinoplasty at the time of orthognathic surgery is the inability to control the amount of intraoperative swelling and edema around the nose, which can distort nasal architecture and have a negative effect on the overall final result of nasal surgery. A primary rhinoplasty has a 21% revision rate, which is a rather high rate for a nose that has never been operated on before. If one were to introduce additional factors, such as swelling and edema, from simultaneous orthognathic surgery, the revision rate might increase and potentially increase the number of complications. Rhinoplasty, when performed independently, can drastically improve the appearance of the face. Similar to augmentation genioplasty, a rhinoplasty can camouflage some maxillomandibular discrepancies. For example, a ptotic nasal tip in a patient with a hypoplastic maxilla who does not wish to have a Le Fort I osteotomy can be corrected by tip plasty and cephalic trim. An overprojected nose (tension-nose), which is often seen in patients with a long lower face, also can be underprojected by a septorhinoplasty. Perhaps one of the most aesthetically pleasing camouflage procedures involves rhinoplasty and augmentation genioplasty performed at the same time. This combination procedure dramatically improves
Patients who have maxillary hypoplasia often have hypoplasia of the infraorbital rims or the tear troughs. These patients have a negative vector (infraorbital rims posterior to the cornea) associated with their midface, which is also known as a ‘‘polar bear’’ appearance. Advancing the maxilla without addressing the infraorbital rim hypoplasia can have a less-than-pleasing aesthetic result, which has led to the creation of the ‘‘high’’ Le Fort I osteotomy to advance the infraorbital rims along with the maxilla. Alternatively, infraorbital rims or tear troughs can be augmented by placing malar/submalar implants at the time of a standard Le Fort I osteotomy. These solid silicone implants can be secured via titanium screws after applying rigid fixation to the advanced maxilla. These implants create a much more harmonious effect to the midface when placed at the time of a Le Fort I osteotomy. If performing the augmentation malarplasty at the time of a Le Fort I advancement, the author has found more aesthetically pleasing outcomes by choosing a slightly smaller implant than usual (to compensate for the bony advancement of the maxilla). For example, if a medium silicone implant sizer looks appropriate at the time of the preoperative evaluation, placing a small implant at the time of surgery gives a much more pleasing result. Augmentation malarplasty also can be performed independently of a Le Fort I osteotomy or as a camouflage procedure in patients not wanting to undergo a traditional osteotomy. Bilateral malar augmentation with silicone implants can be performed in the office with minimal anesthesia in a brief amount of time. Because of the versatility of implant sizers, specific regions that are hypoplastic can be identified preoperatively and selectively augmented with the proper implant. Just as with silicone augmentation genioplasty, it is imperative to create a subperiosteal pocket that is larger than the implant, which ensures lack of visible ‘‘borders’’ or ‘‘edges’’ upon animation. Summary It is important to keep in mind that the final result of orthognathic surgery should augment hard and soft tissues of the face. Although it is critical to obtain a ‘‘normal’’ occlusion by corrective jaw surgery, one also must have an aesthetic
438
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eye for adjunctive or complementary procedures that can further enhance the final result. Some of these procedures can safely and predictably be performed at the time of orthognathic surgery, whereas others should be done independently. It is just as imperative to offer patients alternatives to orthognathic surgery in the form of camouflage surgery if a patient is not interested in traditional osteotomy. Camouflage surgery can have a drastic effect on the facial skeleton and appearance. It is usually a much smaller operation, requires less recovery period, and often can be performed with minimal anesthesia compared with orthognathic surgery. The final outcome of camouflage surgery can be gratifying to the surgeon and the patient.
surgery and camouflage surgery used to augment orthognathic surgery. In some cases, the procedures are performed in a simultaneous fashion with orthognathic surgery. In other cases they are staged.
Case presentations
Case 2
The following cases illustrate some of the aforementioned concepts regarding aesthetic
A 50-year-old woman presented with concerns of a weak chin and a full neck. Clinical evaluation
Case 1 A 47-year-old woman who had undergone previous orthognathic surgery to advance her mandible presented for aesthetic evaluation of her midface. She did not like the sagging appearance of her cheeks (Fig. 1A–C). To address her concerns, she underwent bilateral silicone augmentation malarplasty (Fig. 2A,B). Note the improved definition to the midface and infraorbital region.
Fig. 1. (A) Preoperative frontal view. (B) Preoperative three-fourths view. (C) Panoramic radiograph shows previous mandibular advancement.
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Fig. 2. (A) Postoperative frontal view after bilateral silicone augmentation malarplasty. (B) Postoperative three-fourths view.
revealed that she had significant mandibular hypoplasia, platysmal redundancy, and submental lipomatosis, which resulted in an unattractive neck (Fig. 3). A skeletal analysis confirmed that she was mandibular deficient (Fig. 4). A decision was made to address her skeletal and aesthetic concerns simultaneously. Her surgical procedures involved a mandibular advancement with a BSSO and simultaneous cervicoplasty, including
Fig. 3. Profile of second patient. Note mandibular hypoplasia, platysmal redundancy, and submental lipomatosis.
platysmaplasty and open submental liposuction (Fig 5). In Fig. 5, the combined effects of the skeletal and soft tissue procedures can be seen in her improved cervicomental angle and chin projection. Case 3 A 40-year-old woman presented with skeletal and soft tissue concerns. Her preoperative examination showed that she had maxillary hypoplasia and submental fullness (Fig. 6). Preoperative models and lateral cephalometric radiograph confirmed the skeletal diagnosis (Fig. 7A,B). Her surgical procedures included a Le Fort I maxillary
Fig. 4. Preoperative model shows class II malocclusion.
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Fig. 5. Postoperative profile view after mandibular advancement and simultaneous cervicoplasty, including platysmaplasty and open submental liposuction.
advancement and simultaneous cervicoplasty, including platysmaplasty and open submental liposuction. After surgery, improvement in the mid- and lower face and the neck were visible (Fig. 8). Case 4
Fig. 7. (A) Preoperative lateral cephalogram. (B) Preoperative models.
A 22-year-old woman presented for an orthognathic consultation for maxillary hypoplasia. Clinical examination showed that she had hypoplasia of the maxilla and the infraorbital regions, with an asymmetric nose and fullness to the left side of her face (Fig. 9A,B). Lateral cephalometric radiograph confirmed the maxillary hypoplasia (Fig. 10). After an extensive consultation she elected to have a Le Fort I advancement and simultaneous bilateral malar augmentation with silicone implants (Fig. 11A,B). Although the asymmetry of the left side of her face was discussed and various options were given to her, she elected not to have it addressed. In Fig. 11A and B, the improvement in the midface is evident. A rhinoplasty to address the asymmetry of her nose will be performed at a later date.
Case 5 Fig. 6. Profile of the third patient shows maxillary hypoplasia and submental fullness.
A 55-year-old woman presented with significant class II malocclusion, deep labiomental crease, and
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Fig. 10. Lateral cephalogram.
Fig. 8. Postoperative lateral photograph.
platysmal redundancy (Fig. 12A,B). To correct her skeletal and soft tissue concerns, she underwent a BSSO advancement, a chin reduction, and a simultaneous cervicoplasty, including platysmaplasty and open submental liposuction. Intraoperative photographs are of the cervicoplasty, including the resected redundant platysma (Fig. 13A,B). Postoperative photographs are of the patients at 6 weeks (Fig. 14A,B). Note improvement in the labiomental region and the neck.
Case 6 A 23-year-old woman sought consultation for evaluation of the midface. The patient was found to have infraorbital rim hypoplasia and transverse maxillary deficiency (Fig. 15A–D). After discussion with the patient, it was determined that she would be managed with camouflage surgery via bilateral malar augmentation with silicone implants. Preoperative and intraoperative photos show implant location and placement transorally
Fig. 9. (A) Preoperative frontal view with asymmetric nose, fullness to the left side of face, and maxillary hypoplasia. (B) Preoperative lateral view.
Fig. 11. (A) Frontal view after surgery. (B) Lateral view after surgery.
Fig. 12. (A) Frontal view. (B) Lateral view.
Fig. 13. (A) Intraoperative photograph of the cervicoplasty. (B) Resected redundant platysma.
Fig. 14. (A) Postoperative frontal view. (B) Lateral view.
Fig. 15. (A) Preoperative frontal view. (B) Lateral view. (C) Intraoral view shows the transverse discrepancy. (D) Lateral cephalogram.
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Fig. 16. (A) Intraoperative outline intended position. (B) Intraoral dissection and implant placement.
(Fig. 16A,B). Intraoperative photographs show implant placement on the right side only (Fig. 17A) and at the completion of both sides (Fig. 17B). Fig. 18A,B shows postoperative photographs of the patient at 3 weeks. Note improvement in the midface without orthognathic surgery. Case 7 A 28-year-old patient who had previous orthodontic treatment sought consultation because he did not like the appearance of his lower face
(Fig. 19A,B). He had a class I dental occlusion with deficient chin, bilateral pre-jowl sulcus, and an exaggerated cervicomental angle. To address his concerns he was scheduled to undergo an alloplastic augmentation genioplasty and a cervicoplasty, including platysmaplasty and open submental liposuction. His genial region was exposed through the cervicoplasty incision with placement of an implant through this incision (Fig. 20A,B). Postoperative photographs show the patient at 2 months (Fig. 21A,B).
Fig. 17. (A) Augmentation of the right side. (B) Augmentation of both sides.
Fig. 18. (A) Postoperative frontal view. (B) Lateral view.
Fig. 19. (A) Preoperative frontal view. (B) Lateral view.
Fig. 20. (A) Alloplastic implant. (B) Cervicoplasty incision after open liposuction and placement of implant.
Fig. 21. (A) Postoperative frontal view. (B) Lateral view.
Fig. 22. (A) Preoperative frontal view. (B) Lateral view.
Case 8 A 27-year-old man presented with the complaints of having a ‘‘small chin’’ and a nasal ‘‘hump’’ (Fig. 22A,B). He was not interested in orthognathic surgery and opted for camouflage surgery. His procedures included an alloplastic augmentation genioplasty and a simultaneous rhinoplasty. Intraoperative photographs are of the chin implant placed transorally (Fig. 23). Additional photographs are of the patient 2.5 years after surgery (Fig. 24A,B).
Fig. 23. Intraoral placement of alloplastic implant.
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Fig. 24. (A) Postoperative frontal view. (B) Lateral view.
Further Readings Fattahi T. Management of isolated neck deformity. Atlas Oral Maxillofac Surg Clin North Am 2004;12: 261–70. Greer SE, Matarasso A, Wallach SG, et al. Importance of the nasal-to-cervical relationship to the profile in rhinoplasty surgery. Plast Reconstr Surg 2001;108:522–31. Levine RA, Garza JR, Wang PT, et al. Adult facial growth: applications to aesthetic surgery. Aesthetic Plast Surg 2003;27:265–8.
Louis PJ, Cuzalina LA. Alloplastic augmentation of the face. Atlas Oral Maxillofac Surg Clin North Am 2000;8:127–91. Profitt WR, White RP, Sarver DM. Adjunctive esthetic surgery. In: Contemporary treatment of dentofacial deformity. St. Louis (MO): Mosby; 2003. Waite PD, Matukas VJ. Indications for simultaneous orthognathic and septorhinoplastic surgery. J Oral Maxillofac Surg 1991;49:133–40. Yaremchuk MJ. Mandibular augmentation. Plast Reconstr Surg 2000;106:697.