A e s t h e t i c Ad j u n c t s wi t h Orthognathic Surgery Waheed V. Mohamed, MD, DDSa, Jon D. Perenack, MD, DDSb,* KEYWORDS
Orthognathic surgery
Soft tissue fillers
Hard tissue augmentation
Submental liposuction
Liplift
Rhinoplasty

KEY POINTS

INTRODUCTION Orthognathic surgery, although serving to correct functional skeletal and dental discrepancies, should be based on the maximal aesthetic outcome achievable for the patient. Patients are generally referred by the orthodontist or primarylevel care provider to evaluate and correct a skeletal and/or dental malocclusion. However, approaching these patients with aesthetic concerns in mind maximizes the overall benefit of orthognathic surgery. First introduced by Worms and colleagues,1 and further modified by McCollum and Evans,2 treatment planning was suggested primarily to establish the most favorable contours of the soft tissue facial profile. Once assessed, these data could then be used to determine the amount and direction of tooth and skeletal movement to achieve the specific soft tissue contours. This approach directs importance to the soft tissues, because they introduce greater variability to the final result, followed by manipulation of the hard

tissues, which are more fixed in their ultimate position. Orthognathic surgical treatment planning may be limited to isolated maxillary or mandibular osteotomies (single jaw), or combined maxillary and mandibular surgery (double or 2-jaw) when appropriate. Regardless, a vigilant surgeon should consider additional aesthetic adjuncts that may dramatically improve patient appearance (Box 1). These changes are ideally based on achieving symmetry, balance, proportion, and overall facial harmony. It is important to prioritize this outcome from the initial consultation, thus providing the philosophic framework for surgical optimization and a final aesthetic result. Using this approach, multiple adjunctive procedures exist that can improve on the outcomes achieved with skeletal movements alone. The skeletal and soft tissue discrepancies that are present, the specific surgical treatment planned, and the personal desires of the patient dictate these options.

Disclosures: None. a Carolinas Center for Cosmetic Surgery, 411 Billingsley Rd. 105, Charlotte, NC 28211, USA; b LSU Oral and Maxillofacial Surgery, Louisiana State University Health Sciences Center, 1100 Florida Avenue, New Orleans, LA 70019, USA * Corresponding author. 3724 Rue Chardonnay, Metaire, LA 70002. E-mail address: [email protected] Oral Maxillofacial Surg Clin N Am - (2014) -–http://dx.doi.org/10.1016/j.coms.2014.08.010 1042-3699/14/$ – see front matter Published by Elsevier Inc.

oralmaxsurgery.theclinics.com


Traditional orthognathic surgery aligns the patient’s bony jaws into a desired, more appropriate position but may leave other cosmetic issues unaddressed.
Soft tissue deformities may be treated concomitantly with orthognathic surgery, including soft tissue augmentation (fillers), reduction (liposuction), hard tissue augmentation, cosmetic lip procedures, and rhinoplasty.
Some cosmetic adjunctive procedures may be performed at a later date after soft tissue edema from orthognathic surgery has resolved to achieve a more predictable outcome.
Undesired cosmetic changes may occur months to years after orthognathic surgery and may be addressed by adjunctive cosmetic procedures.

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Box 1 Orthognathic procedures

Box 2 Adjunctive procedures

Midface surgery

Skin procedures

Le Fort I, II, III osteotomies

Laser hair removal

Orbital osteotomies

Skin resurfacing

Zygoma osteotomies

Treatment of red/brown lesions

Mandibular surgery

Upper face procedures

Sagittal split osteotomies

Hairline augmentation

Vertical ramus osteotomies

Temple augmentation

Anterior segmental osteotomy

Forehead/brow augmentation

Angle/inferior border resection

Midface procedures Orbital augmentation

Jones and Smith3 described the sequencing of cosmetic surgery to be based on orthognathic surgery. A similar method to categorize procedures is described as: 1. Procedures that enhance the result of orthognathic surgery, performed concomitantly. 2. Procedures performed perioperatively that supplement the orthognathic surgery result. Typically performed 3 to 6 months after orthognathic surgery. 3. Procedures performed at a distant time from orthognathic surgery, often to correct unfavorable orthognathic surgery sequelae. 4. Camouflage cosmetic surgery performed on patients not desiring optimal orthognathic surgery but still desiring some aspect of favorable soft tissue improvement. This route should be discussed with the patient’s orthodontist to determine whether a functional and stable occlusion can be obtained with orthodontic therapy alone (Box 2).

Procedures Performed at the Time of Orthognathic Surgery Simultaneous augmentation/alteration of the skin, submentum, and nasal tissues offers the advantage of cost-effective, convenient, and comprehensive treatment of the patient and minimizes the risk of anesthesia to a single surgery. Disadvantages include soft tissue edema secondary to orthognathic surgical manipulation, variation in the soft tissue drape, and increased operating time.4

Procedures Performed Perioperatively to Orthognathic Surgery Delayed adjunctive aesthetic procedures are recommended in cases that create a higher risk of

Malar osteotomies/implants Piriform augmentation Soft tissue augmentation Lip augmentation/shortening Rhinoplasty Lower face procedures Chin augmentation/reduction Mandibular angle modification Submental/jowl liposculpting Lower face/neck rhytidectomy

unpredictable changes at the time of surgery, which include:
Complex or drastic changes to the nasal structures
Compromises to the vascularity of the epithelium

Procedures Performed Temporally Distant to Orthognathic Surgery Correcting soft and hard tissue deformities created iatrogenically during orthognathic surgery is in the category of delayed treatment. These deformities include mandibular inferior border notching caused by a sagittal split osteotomy or sliding anterior segmental osteotomy, and socalled winging of the mandible caused by a vertical ramus osteotomy. Hard and soft tissue facial asymmetry may need to be camouflaged if control of yaw movements during 2-jaw surgery or genioplasty was lost. Common iatrogenic soft tissue deformities include an unaesthetic labiomental crease, malar or submalar asymmetry or deficiency, and unaesthetic changes to the nasal appearance.

Aesthetic Adjuncts to Orthognathic Surgery Camouflage Cosmetic Surgery Camouflage cosmetic surgeries typically involve creating changes to the skin–soft tissue envelope without osteotomies and repositioning of the underlying skeletal structures. These surgeries classically include the use of facial implants, soft tissue augmentation or reduction/liposuction, and rhinoplasty.

Box 3 Goals of cosmetic maxillofacial surgery Correction of functional deformities that affect appearance Enhancement of the patient’s self-esteem and quality of life Achievement of the patient’s improved maxillofacial contour

desire

for

INITIAL EVALUATION

Achievement of the desired change in bone and/or soft tissue maxillofacial contour

Patients should be directed to provide both written and verbal rationales for their desire to seek orthognathic and/or cosmetic surgery. A thorough history of previous trauma and cosmetic or orthognathic surgery should be documented. Medical history and the appropriate consults need to be established before any procedures are performed.

Stable clinical results

Physical Examination and Diagnosis Skeletal discrepancy Soft tissue discrepancy Combined deficiencies A finalized treatment plan involving both the orthognathic and cosmetic adjuncts should be established and presented to the patient. For patients interested in adjunctive cosmetic surgery related to orthognathic surgery, a classic orthognathic surgery examination and analysis should be performed. Orthognathic evaluation should reveal and categorize hard tissue deformities. In addition, an appropriate examination of the skin–soft tissue envelope includes evaluation of solar damage, skin elasticity, skin thickness, skin glandularity, and the presence of any existing scars. These aspects of skin health and resiliency may dramatically affect how the skin–soft tissue envelope redrapes after a procedure. Systematic evaluation of sites amenable to recontouring should also be performed. Contour deficiencies are typically categorized as being caused by hard tissue, soft tissue, or combined deficiencies (Box 3).

Hard Tissue Deformity Only: Soft Tissue Deformities Primarily Caused by Skeletal Deformities Certain orthognathic skeletal discrepancies are highly associated with predictable aesthetic soft tissue deformities, with no true soft tissue deficit or excess present. Maxillary anterior-posterior hypoplasia often coexists with malar hypoplasia involving deficiency of the infraorbital rims in single or multiple dimensions. This condition in turn presents as a soft tissue tear trough deformity and

Satisfaction of the patient’s desire for change in maxillofacial contour Appropriate understanding by patient (and family) of treatment options and acceptance of the treatment plan Appropriate understanding and acceptance by patient (and family) of favorable outcomes and known risks and complications Adapted from Fattahi T. 2012 AAOMS parameters of care. AAOMS ParCare 2012. J Oral Maxillofac Surg 2012;70(Suppl 3):e1–11.

possibly prolapsed orbital contents.5 Traditional Le Fort I advancements do not address these deficiencies. A high Le Fort I (or level II–III) may be treatment planned, or the use of facial cheek or rim implants may obviate the more aggressive osteotomy. The skeletal correction often completely corrects the soft tissue deformity, eliminating a need for soft tissue surgery. These same patients may also present with nasal deformities secondary to a deficient nasal pedestal. The deformities associated with maxillary deficiency and the predictable changes as a result of Le Fort I correction are well described in the literature.4,6,7 A ptotic nasal tip or relative nasal dorsal hump may be apparent on presentation; however, once the maxillary position is optimized, a rhinoplasty may or may not be indicated.8,9 Mandibular hypoplasia similarly may coexist with chin hypoplasia and an obtuse cervicomental angle.10 This combination may require genioplasty and cervicoplasty with submental lipectomy, in addition to mandibular advancement. Knowledge of the combined or associated discrepancies aids in an accurate diagnosis and enables the surgeon to present the appropriate treatment options to the patient. For patients in whom a soft tissue deformity is suspected, but is not certain, it is appropriate to plan a delayed perioperative approach to soft tissue corrective surgery.

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Mohamed & Perenack Soft Tissue Deformities Areas of soft tissue deficiency/excess should be further categorized in relation to the deep fat pad layer or superficial fat pad layer. Areas of muscle hypertrophy or atrophy should be noted. Any motion-related abnormalities of facial expression should be explored for cause. In the aged patient, atrophy of the deep fat pads often dictates areas for soft tissue augmentation. For these patients soft tissue volume loss may present in the temple (temporal fat pad and temporal extension of buccal fat pad), the anterior cheek (suborbital oculi fat [SOOF] layer), the submalar region (buccal fat pad), and occasionally in the subplatysmal region (subplatysmal fat pad). Contour deformities of the orbit, nasolabial fold, marionette line, and prejowl may be developmental or age related because the bony lateral orbit, pyriform rim, mandibular angle, and prejowl all undergo remodeling and resorption with age.11 In the previously operated mandibular orthognathic patient particular attention should be paid to the integrity of the line of the inferior border. Overlying superficial fat pad atrophy or hypertrophy may add to a contour deformity and need to be addressed. Deformities associated with hypertrophy of the superficial fat pad are most noticeable in the areas of the nasolabial fold, the jowls, and submentum. Atrophy of the superficial fat pad is often seen in the aged patient and contributes to a deflated look to the face with loss of overlying skin resiliency. Superficial fat pad hypertrophy is often best addressed with some type of liposuction. Atrophy in this layer may dictate that soft tissue augmentation be performed. Chin position, height, and symmetry should be evaluated along with the associated labiomental crease. Cervicomental angle and hyoid bone position should be documented.

Combined Hard and Soft Tissue Deformities In the presence of a severe skeletal deformity, the degree of soft tissue deformity may be particularly difficult to quantify or plan treatment for. In these situations, a delayed or sequenced cosmetic procedure should be considered. The patient should be informed of the possible need for adjunctive perioperative cosmetic surgery to achieve an optimal, predictable aesthetic result.

Photography Photographs are an essential part of the consultation process and the medical legal record. Standard, 6-view photographs are generally taken (front-repose, front-smile, three-quarters left and

right, profile left and right) In addition, when undertaking rhinoplasty, obtaining worm’s-eye and bird’s-eye view photographs is recommended. When treating deformities of the ear, a true submental view revealing the conchal-mastoid and conchal-scaphoid angles should be obtained.12 Imaging of the planned contour changes allows a dialogue between the surgeon and patient of the intended surgical goals. Imaging should be conservative to prevent overpromising and should always be accompanied by the caveat that there is no implied guarantee of results. As a standard, the primary goal when approaching orthognathic patients is to determine both the hard and soft tissue discrepancies that exist, to ask the patients their specific goals and desires (nonsurgical vs surgical adjuncts), and to establish realistic expectations. The limitations of what orthognathic surgery can achieve need to be explained and the adjunctive procedures should be clearly defined. This approach not only fully informs the patient but also allows a better decision to be made by all parties involved (see Box 3). It is ideal to obtain both preoperative and postoperative photographs, at least 3 months after surgery and after any debanding. Careful evaluation of achieved versus predicted results is critical for cosmetic facial/orthognathic surgeons to improve their diagnosis, treatment planning, and technique.

ANATOMY Facial Adipose The facial/neck adipose tissue is present in superficial and deep planes. The face represents approximately 80% of adipose tissue with the neck assuming the remaining 20%. Superficial fat is a continuous layer intertwined in a dense weblike network of fascia extending from superficial fascia to dermis, making up more than half of the facial fat. The deep fat (44%) is contained in loosely supported fascia and is divided into discreet fat pads.13

Retaining Ligaments of the Face The true and false ligaments represent the soft tissue support structures of the face. These anchorage points aid in resisting facial aging. Understanding the anatomy and manipulating these anchorage points is important in achieving aesthetic outcomes.5 The true ligaments of the face extend from the periosteum to dermis and are made up of the orbital, zygomatic, mandibular, and buccomaxillary ligaments. The false ligaments extend between the fascial structures and consist

Aesthetic Adjuncts to Orthognathic Surgery of the platysma-auricular, masseteric-cutaneous, and buccal-maxillary (Table 1).

Table 2 Skeletal and soft tissue remodeling with age

Changes Associated with the Aging Face

Women

Predictable skeletal remodeling takes place among men and women with aging. Women lose more soft tissue volume and experience a decrease in facial height with age, whereas men retain a more stable soft tissue envelope and have greater changes in skeletal width (Table 2). Therefore, soft tissue augmentation being performed with orthognathic surgery must consider these likely changes.14,15

TREATMENT PLANNING Treatment planning adjunctive cosmetic procedures to occur simultaneously or perioperatively with orthognathic surgery should take into account predictable soft tissue changes that occur with skeletal realignment.

Soft Tissue Changes Associated with Orthognathic Surgery The soft tissue changes associated with orthognathic surgery have been well described.6,7,9,16

Mandibular Surgery Mandibular surgery produces close to a 0.9:1 soft/ hard tissue change regarding pogonion to point B, when minimal changes of soft tissue thinning occur. Less predictability of this ratio occurs in patients with a significantly thick soft tissue chin prominence. Lower lip changes of up to a 0.75:1 ratio, with considerable variation, is present in advancements versus setbacks. Bell and Dann17 reported results of patients undergoing genioplasty (both ASO and silicone implants) finding a mean ratio of soft tissue response to advancement at pogonion of 0.6:1.6,10,16

Maxillary Surgery Maxillary advancements in which V-Y closure is involved show consistent lip and soft tissue to hard tissue ratios of 0.9:1.6 The presence of

Table 1 True and false ligaments of the face True Retaining Ligaments

False Retaining Ligaments

Orbital Zygomatic Buccal-maxillary Mandibular

Platysma-auricular Masseteric-cutaneous Buccal-maxillary —

Upper Face Less Decrease in skeletal width More decrease in soft tissue envelope than men More loss of height (convexity) Midface Stable More decrease in soft tissue envelope Lower Face Width decreases Downward and backward mandibular rotation

Men More decrease in skeletal width More stable soft tissue envelope than women —

Stable width —

Increase in width More forward rotation of the mandible and increased prominence

an airspace between the maxillary central incisors and the upper lip may introduce some variability. Stella and colleagues18 determined that completely accurate predictions cannot be made as a result of variation in lip thickness among individuals. Changes in the display of the upper central incisors with maxillary superior or inferior repositioning approaches a 1:1 ratio. Advancement of the maxilla may increase incisal display at a ratio approaching 0.5:1. With maxillary retrusion, the soft tissue follows the maxillary incisor approximately 0.76:1 in a horizontal plane and 0.38:1 in a vertical plane, as described by Schendel and colleagues.19 The nasolabial angle changes approximately 1.2 for every 1 mm of change in hard tissue, with increases in advancements and inferior repositioning, and decreases in impaction and maxillary retrusion. Vasudavan and colleagues8 reported that maxillary advancement elevates the nasal tip, increases nasal tip protrusion, and reduces the nasofrontal angle. The effect of maxillary surgery on alar base widening has been largely corrected with alar cinch procedures.

TREATMENT PLANNING RHINOPLASTY Addressing a nasal deformity, whether functional or cosmetic, deserves particular attention. The central position of the nose relative to the face creates a situation in which even minor asymmetries or deformities of 1 mm or less are readily apparent.

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Mohamed & Perenack Mandibular osteotomies show minimal change to the nasal structures; however, advancing or retruding the mandible increases or decreases the prominence of the chin, respectively. The perception of a more or less prominent chin creates the illusion of a smaller or larger nose respectively. Therefore, the mandibular movement should be taken into consideration when shaping the nose. Nonetheless, Waite and colleagues20 reported no absolute contraindications for concomitant nasal surgery with mandibular osteotomies, citing the high predictability of the soft tissue response. Placement of the endotracheal tube dictates sequencing the mandibular osteotomies before rhinoplasty. It is recommended to change from a

nasal to an oral intubation after the mandibular osteotomy is completed (Fig. 1). Maxillary movements are reported to affect nasal tip rotation by 20% to 30%. Maxillary advancements create several predictable changes to the nose, which include increases in nasolabial angle, alar base widening, and an increase in tip projection. Maxillary superior repositioning decreases the appearance of a dorsal hump through increases in nasal projection and superior rotation of the nasal tip. A decrease in nasolabial angle and alar base widening also occurs. The amount of nasal tip change in 3 dimensions is difficult to predict accurately, because nasal tip projection depends on many factors independent of the

Fig. 1. Preoperative and 6-month postoperative photographs of patient receiving simultaneous mandibular advancement, sliding genioplasty, submental liposuction, and rhinoplasty.

Aesthetic Adjuncts to Orthognathic Surgery maxillary position.9 Long-term scar contracture and healing of the tip adds to the unpredictability of tip procedures. Controversy surrounds whether simultaneous rhinoplasty with maxillary orthognathic surgery should be performed. Waite and colleagues20 described simultaneous rhinoplasty with maxillary and mandibular osteotomies as having a positive patient response. The indications for simultaneous rhinoplasty are moderate dorsal deformities and minor abnormalities of tip morphology and alar base. The contraindications are patient-directed minor changes in the nasal tip position and shape. These parameters depend on the degree of maxillary movements. Rigid fixation of the maxilla is emphasized along with alar cinching sutures and V-Y closure of the lip.20,21 For the discerning (picky) rhinoplasty patient, it is ideal to separate the maxillary and nasal surgeries. If the decision is made to perform the rhinoplasty at some point after a maxillary surgery, it is important to allow most soft tissue edema and scar contracture to occur before proceeding. A minimum of at least 3 to 6 months is recommended depending on the degree of maxillary surgery. When maxillary surgery is performed before nasal surgery, it is important to maintain as much septal cartilage as possible to provide building materials for the rhinoplasty.

TREATMENT PLANNING ADJUNCTIVE LIP SURGERY Long Lip/Inadequate Incisal Display Maxillary movements are largely dictated by the desired amount of tooth display at repose. Excess or inadequate incisal display may be secondary to vertical skeletal deformities in the maxilla or the soft tissue length of the upper lip. If a patient presents with a long upper lip, obtaining the optimal incisal display may cause the maxilla to be placed more inferiorly than is ideal, which can create more patient morbidity because a bone graft may be required to support an inherently less stable movement. A subnasal liplift performed either

at the time of maxillary surgery or, more optimally, at a perioperative date allows the reduction of upper lip length and increased incisal display (Fig. 2). This procedure is especially useful in older patients, in whom longer lips are generally present. Predictable changes that occur with aging include loss of lip volume and architecture, lip lengthening and inversion, and rhytid formation secondary to accumulated actinic damage and muscle mimetics. Liplift surgery is indicated for any patient with a longer upper lip, inadequate vermillion display/eversion, and inadequate maxillary incisal display. It may be performed simultaneously with mandibular surgery or as a camouflage procedure.22

Excess Gingival Display Patients with vertical maxillary excess may show some residual degree of excess gingiva when smiling after maxillary superior repositioning. Adding volume to the body of the upper lip typically displaces the margin inferiorly, gaining 1 to 2 mm of gingival coverage (Fig. 3). Lip volumizing is most easily achieved with 0.5 to 1.0 mL of hyaluronic acid (HA) injection into the body of the vermillion. Injectable HA is also effective in creating more defined lip architecture, roll, and pout. At present there are no permanent US Food and Drug Administration (FDA)–approved injectables for lip augmentation. For body volumizing of the lips, free fat transfer has been used with some success, as has translip placement of rolls of autologous fascia, dermis, acellular cadaveric dermis, and polytetrafluoroethylene (PTFE) implants. For patients with a very thin display of upper lip vermillion, a subnasal liplift is recommended to achieve greater lip eversion before augmentation of the body of the lip.22

Facial Augmentation or Recontouring In augmenting the angle of the mandible, chin, or cheek, several options exist. The areas can be

Fig. 2. Preoperative and immediate postoperative photographs after subnasal liplift to increase maxillary incisal display.

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Fig. 3. Lip augmentation with a hyaluronic acid filler to lower lip line and reduce gingival display.

addressed with an osteotomy, a solid implantable device, or an injectable material. As previously discussed, modifications in osteotomy design allow favorable changes to areas of concern. The advantages of using modified osteotomies are versatility, permanence, and no foreign material being introduced, excepting fixation. The disadvantages include the permanency of change; the unpredictability of the soft tissue response, particularly in the midface region; prolonged recovery; asymmetry; sensory disturbance; and inferior border notching. Solid implantable devices are able to address most hard tissue augmentation goals. The advantages of implantable devices include a predetermined size, minimal chance of sensory disturbance, ability to modify the implant or customizable implants, and ability to remove the implant at a later time. The disadvantages are related to the small possibility of a foreign body reaction, early or late implant infection, movement of the implant or shift over time, difficulty in correcting large vertical deficiencies, scar, and asymmetry between implant positions. Peri-implant bone resorption has also been documented. Several materials are currently FDA-approved for implantable devices. Many FDA-approved nonpermanent injectable fillers (and 1 permanent filler) are currently available for recontouring in the face. Advantages of injectable fillers include ease of application with little to no patient downtime; exceptional precision with small augmentations; and versatility. Disadvantages include lack of permanence with additional cost incurred over the lifetime of the patient; difficulty in creating large hard and soft tissue augmentations; and limited ability to cantilever small hard tissue augmentations. Injectable fillers present an optimal option for correcting small bony defects or notching after osteotomy.

Solid Implant Materials Solid silicone rubber Silastic (silicone rubber) facial implants are available in multiple sizes and can be used in multiple areas of the face, including temples, orbital rims, malar, submalar, piriform aperture, nasal dorsum, chin, and mandibular angles. Silastic implants are easily modified during surgery to the desired shape and conformation. The implants do not contain any pores, eliminating fibrous ingrowth and reducing the inflammatory response. Custom Silastic implants may be created using virtual surgical planning. A soft tissue pocket is created slightly larger than the implant, which is then secured either with a screw or suture. Bony resorption, implant infection, and implant displacement have been noted. Silastic implants are soft and inherently unstable when cantilevered and unsupported by bone, and thus are prone to shifting and/or bony resorption. Porous polyethylene Preformed implants are available in the form of a high-density polyethylene that contains pores sized at 100 mm. The pore volume constitutes more than 50% of the product. Implants are available in preformed or custom-shaped sizes similar to Silastic implants. The preformed product is easily carved to the desired shape during surgery. Placement is in a subperiosteal plane and the implants can be secured with titanium screws to inhibit migration. Tissue ingrowth occurs through the large pore size. The complication rate associated with the use of porous polyethylene (PPE) is low, with fracture and infection being reported. Applications that have been reported for PPE include orbital reconstruction, rhinoplasty, midfacial skeleton augmentation, cranioplasty, and auricular reconstruction. The solid nature of the PPE implant better allows it to cantilever from bone, unlike

Aesthetic Adjuncts to Orthognathic Surgery Silastic. However, because of this same characteristic, PPE implants do not as easily conform to irregular surfaces and are more prone to postoperative asymmetries. Polytetrafluoroethylene Expanded PTFE (Gore-Tex) is a less commonly used implantable device that has a long history of medical application. Gore-Tex has pores of approximately 22 mm. The pores allow fibrous ingrowth and incorporation into the implant. PTFE is extremely biocompatible, with low complication rates documented. Implant hardening and fracture are the most common complications. Injectable materials Injectable fillers allow the surgeon to precisely augment the face in a nonsurgical technique with minimal downtime. The use of soft tissue fillers can be categorized by their degree of permanence and the viscoelasticity (G0 ). HA is the most commonly used filler material in the United States and offers good versatility, with several viscosities available. A high degree of cross-linking in HAs creates a viscous injectable material. Because a gel resists movement it is better able to displace overlying tissue. More viscous fillers are currently available than the hyaluronics, principally calcium hydroxyapatite. At present only 1 FDA-approved synthetic permanent injectable is available. Methylmethacrylate spheres contained within a degradable bovine collagen carrier create a firm collagen response that mimics hard tissue. Autologous free

fat transfer offers another option for semipermanent or permanent soft tissue augmentation, but is considered a surgical procedure. The variety of handling characteristics found in injectable materials currently offers the surgeon a remarkable versatility in correcting soft tissue deformities. The ideal filler possesses safety, efficacy, and is practical. The different G0 of fillers allows layering of material such that less viscoelastic materials are placed more superficially, mimicking fat, and firmer fillers are placed deeply, mimicking hard tissue.23 Hyaluronic acid HA is present in all organisms. It is found in the proteoglycan portion of mesenchymal tissues. The introduction of HA fillers has allowed quick and reversible modification of many soft tissue deformities. The advantages of HA fillers are minimal to no downtime, immediate results, and reversibility. Disadvantages include technique sensitivity, lack of permanence, and the possibility of asymmetry. Cost per unit volume also represents a significant disadvantage. Several forms of HA are available in the United States (Table 3). The primary areas for HA include nasojugal folds (tear trough), malar region, nasolabial folds, perioral rhytids, marionette lines, jowls and angles of the mandible, and the lips. If HA filler is placed injudiciously, or evidence of clumping exists, hyaluronidase can be injected directly into the site, which effectively degrades the filler.23,24

Table 3 Forms of HA that are available in the United States

Source

Trade Name

Use

Duration

Delivery Technique

Approved

Bacterial cultured and stabilized Bacterial cultured and stabilized Bacterial cultured and stabilized

Restylane

Moderate depth

12 mo

Mid-dermal

FDA and HPB

Perlane

12 mo

Deep dermal

FDA and HPB

12–18 mo

Mid-dermal to deep dermal

FDA

Bacterial cultured and stabilized Bacterial cultured and stabilized

Belotero

Deep defects, shaping facial contours Ultra: moderate depth Ultra Plus: deep, shaping facial contours Superficial, moderate, and deep Deep

12 mo

Mid-dermal to deep dermal

FDA

12–24 mo

Deep dermal to supraperiosteal

FDA

Juvederm Ultra and Ultra Plus

Voluma

Abbreviation: HPB, Health Protection Branch.

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Mohamed & Perenack Calcium hydroxyapatite Calcium hydroxyapatite is a bioceramic semipermanent material that is nonirritating to tissues. Radiesse (Radiesse, Bioform, San Mateo, CA) is supplied as a single-use sterile, ready to use paste in 0.8-mL and 1.5-mL syringes. The calcium hydroxyapatite is suspended in an aqueous gel and contains glycerin and sodium carboxycellulose. When injected, there is a 1:1 immediate product to soft tissue response. At present it is used for soft and hard tissue facial augmentation, the material is degraded by macrophages over time, and lasts 1 to 2 years. Because of the material’s high G0 and robust collagen-stimulating response, it represents a particularly useful filler for hard tissue augmentation of angles, cheeks, and bony defects that are seen after osteotomies. It is not recommended for lip augmentation.25,26 Polymethyl methacrylate The polymethyl methacrylate (PMMA) that is used in the United States is marketed as Artefil. It consists of homogeneous PMMA microspheres (20%), evenly suspended in a solution of partly denatured 3.5% bovine collagen (80%), thus requiring skin testing for hypersensitivity. The product is premixed with lidocaine. The collagen contained in the product is absorbed over 3 months and is replaced with native collagen. The PMMA microspheres serve as a collagen stimulus, resulting in encapsulation of the individual spheres by collagen. After completion of the remodeling process, the augmented area consists of 80% native collagen and 20% PMMA microspheres to form a pliable implant. As an injectable filler, it is ideal for permanent correction of minor (1–2 mL) hard tissue defects.24

PLACEMENT OF INJECTABLES Tear Trough Placement of the filler is in the nasojugal folds and in areas of fat atrophy just below the inferior orbital

rim. Augmentation is in the submuscular plane above the periosteum, often in the SOOF pad, to prevent visible clumping or nodule formation.27 Once injected, the area is gently massaged. Results are immediate (Fig. 4). Malar region: dermal and subdermal planes. Higher G0 injectables provide results that rival solid implantable devices. Nasolabial folds: dermal and subdermal planes. Marionette lines: dermal and subdermal planes. Prejowl: layering of filler through dermal, subdermal, and supraperiosteal planes. Angle/inferior border: placed beneath masseter muscle and immediately supraperiosteal. Lips: placement of the filler can be to recreate lip architecture or to restore fullness. In recreating lip architecture, the area injected follows the vermillion border and defines the shape of the lip. Restoring fullness requires placement into the body of the lip deep to the submucosa. Injecting into the body of the lip has shown decreases in incisal show ranging from 1 to 3 mm, which benefits individuals with excess gingival show but may create a negative result for patients with optimal or suboptimal incisor display.11,28

Cervicoplasty, Platysmaplasty, and Rhytidectomy Lipomatosis in the submental region may coexist with mandibular skeletal deformities. Undesirable overcontoured nasolabial and jowl fat may also be present. In cases of a mandibular setback, previously minor problems may become exacerbated. Jaw advancement or chin augmentation may improve the contours of these fat pads. The submentum can be addressed with liposculpting, skin tightening, and platysma tightening. Although mandibular advancements positively alter the cervicomental relationship, to appropriately address submental lipomatosis, platysmal

Fig. 4. Tear trough deficiency reduction with an injectable HA filler and simultaneous lower blepharoplasty.

Aesthetic Adjuncts to Orthognathic Surgery banding, and platysma ptosis with the associated skin, additional cervical alterations must be accomplished. The predictability of soft to hard tissue changes favors simultaneous modification of the chin. Epker and Stella29 describe simultaneous lipectomy with orthognathic surgery with favorable results to patients. Fattahi5 describes addressing the submental liposuction and/or platysmaplasty simultaneously with mandibular osteotomies with safety (Fig. 5).5,30–35 Submental liposuction can be performed with ease before or after advancement or setback of the mandible. If platysmal banding or ptosis is being addressed, an approximately 1.5-cm incision is placed in the submental crease and the platysma is incised and reapproximated in a running fashion. In situations involving excess skin, the appropriate avenue may involve a necklift procedure or lower traditional facelifting. Appropriate recovery time from the osteotomy before soft tissue augmentation may yield superior results in these cases.

Sequence for Closed Submental Liposuction The patient is placed in the upright position for skin marking. Tumescent infiltration with a dilute lidocaine solution containing epinephrine is injected in the subcutaneous plane. Stab incisions are created at the earlobes and submentum and, if nasolabial folds are added, incisions are made at each ala. Lipodissection (1.5-mm to 2-mm cannulas) followed by closed liposuction using increasing diameter (2–3 mm) cannulas with feathering is ultimately performed. For liposuction performed above the mandibular border, use of smaller cannulas (1.0–2.0 mm) is preferred. If a large midline submental fat deposit is noted, it is recommended that the area is opened in the subcutaneous plane using facelift scissors, and liposuction under direct vision is performed. A simultaneous platysmal plication can then easily be performed if desired.

Iatrogenic Deformities Created as a Result of Orthognathic Surgery Orthognathic surgery occasionally creates an undesired cosmetic result that requires attention either perioperatively or at a distant time. Facial asymmetries Facial asymmetries may be noticed perioperatively or at a later date. Asymmetries may be the result of an inadequate or flawed orthognathic treatment plan and surgical work-up, or intraoperative error in technique. Patients who have profound facial asymmetries at consultation often cannot be completely corrected even by the most skilled of surgeons. If a surgical error is apparent, reoperation and correction of the osteotomies is optimal. However, when this is not feasible or agreeable to the patient, camouflage procedures may be attempted. The deficient side of the face may be augmented with any or all of an implantable device, injectable filler, or fat transfer, depending on the nature of the deficiency. The overcontoured side of the face may be reduced by surgically reducing bone or selective liposuction. Bony notching Bony notching can be seen at the site of osteotomies of the mandible most notably after bilateral sagittal split osteotomy (BSSO) and genioplasty. These notches may be addressed either by injection of permanent filler immediately supraperiosteally, with a solid implantable device, or through bone grafting. PMMA injectable filler offers a simple resolution to this problem (Fig. 6). Motion abnormalities Motion abnormalities related to hyperfunction are rarely seen in patients after orthognathic surgery. These conditions may be addressed by intramuscular injection of botulinum toxin A. Patients are typically injected in the hyperfunctioning muscle every 4 to 6 months. Often, after repeated

Fig. 5. Preoperative and 5-month postoperative photographs of patient receiving simultaneous mandibular setback and closed submental liposuction.

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Fig. 6. (A) Intraoperative mandibular notching 15 years after BSSO with correction by placement of PPE angle implant. (B) Preoperative and 4-month postoperative correction of mandibular notching and facial/neck laxity. Procedures: simultaneous facelift and 1.6 mL of methylmethacrylate injectable filler to each mandibular defect.

treatments, the motion abnormality is extinguished and no further treatment is needed.

hard tissue anatomy, as well as the changes that result from orthognathic surgery, is imperative in achieving optimal results for patients.

DISCUSSION Orthognathic surgery involves understanding of both hard and soft tissue anatomy and the soft tissue changes associated with skeletal movements. The skeletal and soft tissue changes associated with aging are also factors in finalizing the treatment plan. Despite soft tissue changes that can be manipulated with orthognathic surgery, deformities in the soft and hard tissues may persist that require adjunctive procedures. The malar, submalar, and chin regions can be addressed with implants and injectable volumizers, and these procedures may be performed at the time of orthognathic surgery or later. Rhinoplasty in combination with mandibular surgery is routinely performed with reliable and predictable soft tissue response. In maxillary surgery, the rhinoplasty should be limited to cases that do not involve large changes in tip position and large dorsal hump modifications, because the soft tissue healing shows increased variability. The submentum and platysmal areas can also be addressed simultaneously, and have been documented favorably. Facelifting may be performed at the time of orthognathic surgery or may be deferred until later. With regard to volume deficiencies and deformities of the lips, tear trough, nasolabial, labiomental, and perioral regions, soft tissue volumizers provide a beneficial adjunct to orthognathic surgery and contribute favorably to the aesthetic outcome. Procedures performed simultaneously, shortly after, or that are delayed until the patient heals from orthognathic surgery should be based on the soft tissue predictability. If unpredictability exists, the safest route should separate the adjunctive procedures from orthognathic surgery. A thorough understanding of both the soft and

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