Asian Facial Cosmetic Surgery

PREMAXILLARY AUGMENTATION WITH BONE GRAFT
310
sawing is estimated based on the knowledge obtained
from the perimeter drilling. Every effort is made to obtain
a sudden relief of resistance from the bone as the saw
penetrates into the diploic space. Even with these two
parameters, extreme caution is needed to prevent pene-
tration beyond the diploic space. If there is any doubt, the
surgeon should stop the vertical penetration process. Next,
a 10-mm, heavy, slightly curved sharp chisel is introduced
into one of the grooves. Gentle tapping under the cortical
bone is continued until each segment of bone piece is
fractured along the divided saw lines. Sharp skull bone
edges are softened by drilling with a large cutting burr.
Bleeders are controlled with electrocautery and bone wax.
Excess bone wax is carefully and thoroughly wiped away.
Unless oozing continues despite hemostasis, draining is
unnecessary. The scalp is closed in layers using 3-0
VicrylTM sutures (Ethicon, Inc., Somerville, NJ) for the
galeal closure and staples or 4-0 nylon sutures for the scalp
closure. A head dressing is applied in the usual fashion.
Perinasal Bone Graft Fixation
The face is prepped and draped in a sterile fashion using
Phisohex soap (Sanofi-Synthelabo, Inc., New York, NY).
Preoperative oral hygiene and mouthwash with an alcohol-
based solution are advised. The teeth are covered with
sterile 4 × 4 gauze. The incision is made in the gingivo-
buccal gutter from one premolar to the other, with 1 cm of
mucosal cuff remaining attached to the gingiva. The inci-
sion is carried downward to the periosteum. The perio-
steum is then elevated from the upper maxilla, exposing
the lower half of the piriform aperture and the adjacent
alveolar fossae (Figure 31-3). Every effort is made to avoid
breaking into the nasal cavity. The skull bone grafts match
the perinasal bone surface quite well because of their
relatively small and flat surface. The grafts are fixated with
wires or bone screws (Figure 31-4).5 Because of the thin
nature of the membraneous bone in this area and the
presence of the roots of the teeth, extreme caution in
drilling is advised. Hemostasis is obtained. The wound is
irrigated with antibiotic solution. The gingival incision is
closed with 3-0 chromic catgut sutures in a watertight
fashion.
Postoperative Care
The head dressing usually comes off on its own after 1 or 2
days. It is not necessary to reinforce the head dressing. Iced
Figure 31-1
Calvatrial graft harvest.
Figure 31-2
Planning of peripyriform sinus placement of grafts.
Figure 31-3
Exposure of premaxillary bone.

CASE STUDY
311
cold compresses are applied to the cheek area for 2 days. A
liquid diet followed by a spoon-fed soft diet is continued
for 1 week. Gentle toothbrushing with careful vertical
stroking motions may be allowed after 3 days. Broad-
spectrum oral antibiotics are prescribed for 1 week.
Vigorous physical activities are allowed after 3 weeks,
barring direct impact to the skull or perinasal area.
Recovery
Although swelling subsides in 2 weeks, the patient may
resume work that does not involve heavy physical labor
after 1 week. Vigorous activities are postponed for 6 weeks.
Complications
Donor site complications include hematomas, seromas,
and dural tears. Graft site complications include graft
displacement, extrusion, and infection. None of these
complications will compromise the clinical result.1
Case Study
See Figure 31-5.
Figure 31-4
Square blocks of calvarial bone are fixated with wire.
A
B
Figure 31-5
A, Preoperative view. B, Postoperative view.

PREMAXILLARY AUGMENTATION WITH BONE GRAFT
312
References
1. Powell NB, Riley RW: Cranial bone grafting in facial aesthetic
and reconstructive contouting, Arch Otolaryngol Head Neck
Surg 113:713-719, 1987.
2. Zins JE, Whitaker LA: Membranous versus endochondral
bone: implications for craniofacial reconstruction, Plast
Reconstr Surg 6:778-784, 1983.
3. Jackson IT, Pellett C, Smith JM: The skull as a bone graft
donor site, Ann Plast Surg 11(6):527-532, 1983.
4. Hunter D, Baker S, Sobol SM: Split calvarial grafts in
maxillofacial reconstruction, Otolaryngol Head Neck Surg
102(4):345-350, 1990.
5. Phillips JH, Rahn BA: Fixation effects on membranous and
endochondral onlay bone-graft resorption, Plast Reconstr
Surg 82(5):872-877, 1988.

313
A deficiency of the paranasal area is difficult to describe
quantitatively but often affects facial aesthetics, especially
the gracefulness of the profile. If the deficiency is severe, it
affects the appearance of the eyes, because the lower eyelid
tends to droop downward when it is not adequately
supported. This area can be augmented by a high Le Fort I
osteotomy, but if a Le Fort I osteotomy is not indicated,
then augmentation of the midface offers a reasonable
alternative.1 In Asia and especially in Korea, many patients
have bimaxillary protrusion. When these patients are older
and the nasolabial fold caves in, the patient looks older
and less attractive. Usually the surgeon would advise
these patients to undergo bone surgery, but if the patient
dislikes the idea because of its expense of the use of general
anesthesia, then the patient may select an alternative
operation such as paranasal augmentation, which is
performed under local anesthesia.2 Remodelling of an
onlay bone graft on the flat anterior surface of the maxilla
is unpredictable. Cartilage or alloplastic materials (e.g.,
porous polyethylene Medpor® (Porex Surgical, Inc.,
Fairburn, GA), polytetrafluoroethylene Gore-Tex® (W.L.
Gore & Associates, Newark, NJ), silicone, or Alloderm®
(Life Cell, Woodland, TX) may be used. Many surgeons
still believe that cartilage is the ideal material for grafting
because it is a natural material that tolerates absorbtion,
can be harvested in large amounts, and has sufficient elasti-
city to provide softness to the touch.3 Regarding alloplastic
grafts, it has been suggested that the most important key
for a good outcome is determined by the design, size, and
shape of the implant, and not by the material used. 4 The
use of porous hydroxyapatite granules has been described
in the augmentation literature, although these granules
may be difficult to shape and are subject to compression
forces that may limit their ability to provide adequate
structural support.4,5 Paranasal augmentation can be used
to correct a shallow upper lip.6 Paranasal augmentation is
Paranasal Augmentation
with Implant
Jin-Young Choi and Ronald P. Chao
also required when a degree of maxillary hypoplasia exists,
as in many skeletal Class III patients, and it is particularly
important in the treatment of severe bilateral cleft lip
and cleft palate patients. A premaxillary implant is also
indicated to correct the concave midfacial profile of the
Asian patient.7 The hallmark of maxillary retroposition is
the acute nasolabial angle. If the surgeon attempts to use
columellar grafts instead of maxillary onlay grafts to
correct an acute angle caused by maxillary retroposition,
the result may be excessive columellar show and an over-
rotated appearance. Although many patients may seek
rhinoplasty to correct this problem, the proper evaluation
for the cause of the acute nasolabial angle will dictate the
appropriate treatment. The main limitations for the use of
onlay grafts include limited vertical space and thin tissue
covering over the paranasal maxilla so that the anterior
surface of the implant appears relatively flat with the
inferior edge tapered and somewhat nonlinear.8
The surgery may have the following results:
1. Correction of a protruding mouth
2. Improvement in the nasolabial fold contour
3. More attractive lips secondary to improvements in the
nasolabial angle
4. The appearance of a smaller, better-proportioned face
5. Correction of a coexisting gummy smile with the use of
a peripyriform implant, if the gummy smile is caused by
excessive lip excursion rather than a long maxilla. In this
case, the implant acts as a blocking device to prevent
overelevation of the lip.9
Preoperative Care
Before the operation, a physical examination and radio-
graphic examination should be performed to determine
32

PARANASAL AUGMENTATION WITH IMPLANT
314
the patient’s condition. The surgeon should thoroughly
consult the patient before deciding to proceed with the
operation. The procedure is contraindicated in patients
who wear dentures because edentulous patients develop
alveolar ridge erosion that will eventually lead to the
denture becoming positioned up against the implant and
causing extrusion through the thin skin mucosa.8 An
explanation of the procedure and its complications should
be given to the patient.
On the day of surgery, the patient should not apply facial
cosmetics. Usually an intravenous solution of cefazolin or
clindamycin is given 30 minutes before the start of the
operation.
Anesthesia
Paranasal augmentation can also be performed under local
anesthesia or in an outpatient setting with good results.
However, general anesthesia is commonly used with a
combined procedure such as paranasal augmentation with
orthognatic sugery or chin surgery.
Instruments
The following instruments are used for the procedure:
1. Periosteal elevator
2. Surgical round burr
3. Vulcanite burr
4. Downward and upward retractors
5. Microscrew
6. Drill bit
Procedure
The face and mouth are prepped. Local anesthesia using
2% lidocaine with 1:100.000 epinephrine (2 ampules per
side) is injected into the upper vestibule, moving from the
left canine to the right canine. The midline is marked at
the maxillary vestibule with a suture. This procedure might
be omitted when Gore-Tex is used. In this case, two
separate incisions are made. Approximately 10 minutes
after the anesthesia is injected, the incision is made
through the maxillary vestibule, and the dissection is
continued deep to the orbicularis oculi muscle and through
the subperiosteum. The subperiosteal dissection is then
carried medially using the periosteal elevator, but remain-
ing lateral to the infraorbital nerve, toward the piriform
rim of the nose. A wide dissection is necessary for fixation
of Medpor. If Gore-Tex is used, the pocket should be
formed only large enough to hold it, and fixation is not
required. Medpor is contoured according to the form of
the bony surface. For Gore-Tex, a 2 × 4 fold of a 1 × 1-cm
rectangular sheet should be used. The fold should be made
on the left and right sides and then separated. Medpor is
fixated with microscrews around the pryiform aperture.
As previously stated, fixation is not necessary when Gore-
Tex is used. The intraoral wound is closed with 3-0 or
4-0 VicrylTM sutures (Ethicon, Inc., Somerville, NJ) after
irrigation. In most cases, drains are unnecessary (Figures
32-1 to 32-6).
Recovery
Soft tissue edema may resolve within 1 to 2 weeks after
paranasal augmentation. An external pressure dressing is
applied for a minimum of 3 days. Because surgery usually
exposes the infraorbital nerve, patients sometimes
expensory a sensory deficit in the upper lip and cheek after
surgery. Sensation generally returns within 1 to 2 months
and recovers more rapidly than does the mental nerve.
Complications
Provided that care is taken to prevent postoperative infec-
tion, minimal complications are seen with this procedure.
Only a small number of patients have an altered sensation
in the upper lip and paranasal area immediately after
paranasal augmentation surgery.
Possible complications include the following:
• Bone resorption
• Infection
• Dehiscence
• Overprojection or underprojection
• Asymmetry
• Displacement
• Upper-lip retraction
Case Study
Figures 32-7 to 32-10.

COMPLICATIONS
315
Figure 32-1
Medpor used for paranasal augmentation.
Figure 32-4
Gore-Tex used for paranasal augmentation.
Figure 32-3
The incision for Gore-Tex implantation.
Figure 32-2
Fixation of Medpor.
Figure 32-5
Placement of Gore-Tex.

PARANASAL AUGMENTATION WITH IMPLANT
316
Figure 32-6
Interrupted sutures with 3-0 or 4-0 Vicryl.
Figure 32-7
Preoperative facial view (case 1).
Figure 32-8
Postoperative facial view (case 1).
Figure 32-9
Preoperative facial view (case 2).
Figure 32-10
Postoperative facial view (case 2).

COMPLICATIONS
317
References
1. Proffit WR, White RP, Sarver DM: Contemporary treatment
of dentofacial surgery, St Louis, 2002, Mosby, p 193.
2. Jung DH: Rhinoplasty, Seoul, 2002, Greenbook, p 251.
3. Watanabe T, Matsuo K: Augmentation with cartilage grafts
around the pyriform aperture to improve the midface profile
in Binder’s syndrome, Ann Plast Surg 36:206-211, 1996.
4. Fanous N, Yoskovitch A: Premaxillary augmentation: adjunct
to rhinoplasty, Plast Reconstr Surg 106:707-711, 2000.
5. Byrd HS, Hobar CP, Shwemake K: Augmentation of the
craniofacial skeleton with porous hydroxyapatite granules,
Plast Reconstr Surg 91:15-26, 1993.
6. Aufricht G: Rhinoplasty and the face, Plast Reconstr Surg
43(3):219-230, 1969.
7. Hinderer UT: Nasal base, maxillary, and infraorbital
implants—alloplastic, Clin Plast Surg 18(1):87-105, 1991.
8. Brink RR: Premaxillary augmentation. In Terino EO, Flowers
RS, eds: The art of alloplastic facial contouring, St Louis,
2002, Mosby, pp 119-127.
9. Ellenbogen R: Improvement of the gummy smile using the
implant spacer technique, Ann Plast Surg 12:16-24, 1984.

319
It is sometimes difficult to determine whether a Class III
malocclusion is primarily the result of mandibular excess,
maxillary deficiency, or both. The dentofacial deformity is
evaluated not only from a cephalometric standpoint but
also on the basis of facial aesthetic features.
Maxillary deficiency can exist in any of three planes: the
anteroposterior, vertical, or transverse dimensions. When
maxillary deficiency exists, the maxilla is typically deficient
in two or even all three dimensions. When advancement of
the deficient maxilla is planned and a co-existing transverse
deficiency is present, the deficiency is generally corrected
simultaneously by surgical expansion of the maxilla.
When the maxillary deficiency is primarily in the vertical
direction, inferior repositioning of the maxilla with
interpositional grafting should be done. When a transverse
maxillary deficiency exists, it may be best corrected with
surgical expansion of the maxilla.
Preoperative Care
Immediate presurgical model surgery is performed, and
the splint is constructed. Occlusal overcorrection is
important. If the amount of advancement at the occlusal
level in the individual who has completed bone maturation
is greater than 5 mm, 1- to 2-mm overcorrection of the
maxillary advancement is advised. An informed operative
consent is obtained. Bed rest, no fluid or food intake after
midnight, and full urine voiding are advised. Skin and hair
preparation are done immediately before the operation,
and the patient is not allowed to wear facial cosmetics.
A prophylactic antibiotic with intravenous cefazolin or
clindamycin is given 30 minutes before the operation.
Correction of Dish Face
Jin-Young Choi
Anesthesia
The nasotracheal tube is used to provide optimal access to
the entire midface and is fixed to the septum with a suture.
Hypotensive anesthesia reduces intraoperative bleeding,
which facilitates surgical dissection.
Instruments
The following instruments are used:
1. Periosteal elevator (small, medium, and large)
2. Surgical round burr
3. Oscillating saw
4. Reciprocating saw
5. Bone rongeur
6. Right angled retractor (Obwegeser retractor): short,
middle, and long arms; and downward and upward
7. Nasal septal osteotome
8. Chisel (small, medium, and large)
9. Curved osteotome
10. Bone hook
11. Tessier maxilla mobilizer
Procedure
The face and mouth are prepped and draped in sterile
fashion, and tarsorrahaphy sutures are placed.
External reference measurements are recorded as follows:
• The distance from the medial canthus to the ipsilateral
maxillary canine orthodontic bracket
• The distance from the midcanthus to the ipsilateral
maxillary first molar orthodontic bracket
33

CORRECTION OF DISH FACE
320
• The distance from the nasion to the ipsilateral tragus
• The distance from the midline of the orthodontic
archwire to the ipsilateral tragus
It is critical to document these distances before mobiliza-
tion of the midface so that optimal control of the facial
relationships can be achieved. When the midface is later
stabilized, the position of the midface is reflected by the
change in this external reference. Typically, this reference
point remains unchanged, but it can be changed by as
much as 4 mm.
Supplementary local anesthesia of 2% lidocaine with
1:100.000 epinephrine (2 ampules per side) is infiltrated
into the periosteal plane to achieve a bloodless dissection
field. The upper anterior vestibule, anterior nasal spine
area, infraorbital area, and maxillary tuberosity are
infiltrated through an intraoral approach. A #15 blade is
used to make a horizontal incision in the maxillary vestibule
above the mucogingival junction. At the labial frenulum, a
notched incision is used to identify the midline, and a V-Y
closure is made to avoid alar base broadening. The incision
is extended from the second molar region of one side
to that on the contralateral side. The periosteum is now
reflected from the lower maxilla. Superiorly, the subperi-
osteal dissection is completed to expose the lateral aspect
of the maxillary and zygomatic crest, anterior nasal floor,
pyriform aperture, and pterygoid maxillary junction. A
right angled retractor (positioned downward) is placed
anteriorly to help visualize the anterolateral portion of
the maxilla. A curved Freer elevator or small periosteal
elevator is used to detach the mucoperiosteum from the
nasal floor, base of the nasal septum, and the lateral nasal
wall. The mucoperiosteum is detached all the way to the
posterior aspect of the hard palate and to the base of nasal
septum approximately 5 mm above the nasal floor, as
well as to the inferior turbinate on the lateral nasal wall. At
that time, cartilage on the anterior nasal spine is separated
from the bony anterior nasal spine using a #15 blade. It is
important to avoid tearing the nasal mucosa. A pencil is
used to draw a horizontal ostectomy line is drawn on the
maxilla. The horizontal line is generally 4 to 5 mm above
the apices of the teeth. The length of the root of the teeth
is assessed by direct visualization and palpation of the bone
that encases the apices of the teeth. The anterior and
posterior vertical reference points are etched into the bone.
A long, vertically positioned, right-angled retractor is
placed into the pterygomaxillary fissure, and a periosteal
elevator or malleable retractor is placed along the lateral
nasal wall. A reciprocating saw is then used to make the
horizontal ostectomy from the lateral side to the medial
side. The posterior portion of the lateral nasal wall and the
posterior wall of the maxillary antrum are sectioned with a
thin osteotome such as a spatula. A nasal septal osteotome
is positioned above the anterior nasal spine and parallel to
the hard palate. The osteotome is malleted to the posterior
edge of the nasal septum. Care is taken to direct the
osteotome slightly inferiorly so as to continue along the
nasal floor and not tear the nasal mucoperiosteum. A sharp
pterygoid osteotome or curved osteotome is malleted into
the pterygoid maxillary suture to separate the maxilla from
the pterygoid plate. With the osteotome positioned at the
inferior portion of the suture to minimize the danger to
the vascular structures in the pterygoidmaxillary fissure,
the osteotome is malleted so that the force is medially and
anteriorly directed. Use of digital pressure on the palatal
mucosa in the region of the hamulus allows the operator to
feel the osteotome as it transects the bone without traumat-
izing the underlying mucoperiosteum. A bone hook is
placed on the nasal floor, and inferior pressure is applied
on the anterior portions of the maxilla to separate the
maxilla from the remaining skull. If the previous bone cut
is not adequate, then the maxilla is not mobilized. The
usual areas in which the bone is not sectioned include the
posterior portion of lateral nasal wall and the posterior
portion of the maxillary sinus. These areas are carefully
sectioned with a thin chisel. During this time, the
descending palatine artery can be accidentally ruptured.
After the maxilla is downfractured, excellent access is
available to the principal problem areas, which include the
perpendicular plate of the palatine bone and the pterygoid
tuberosity interface. A Tessier maxilla mobilizer is applied
to the posterior surface of the maxilla, and the maxilla is
pulled forward. Bony interferences in any area can be
readily identified and removed with a burr, rongeur, or
osteotome under direct visualization. After the maxilla is
mobilized, an intermediate wafer is inserted, and maxillo-
mandibular fixation is done. The occlusal wafer splint is
delivered to the mandible. Intermaxillary fixation is then
accomplished by looping 26-gauge stainless steel wires
around the maxillary orthodontic brackets and the occlusal
splint. The condyle position is checked, and the distances
are measured as follows:
• The distance of the external reference point from the
medial canthus to the ipsilateral maxillary canine
orthodontic bracket
• The distance from midcanthus to the ipsilateral
maxillary first molar orthodontic bracket

COMPLICATIONS
321
• The distance from the nasion to the ipsilateral tragus
• The distance from themidline of orthodontic archwire
to the ipsilateral tragus
Plates (usually L-type, 4-hole) are used for internal fixation.
One plate is used for the pyriform aperture, and another is
used for the zygomatic buttress area. After contouring the
plate according to the surface of the bone, the plate on the
maxilla area is fixated and then the upper portion is fixated.
Four plates, two on each side, will firmly hold the maxilla.
This author personally uses the M3 plate system. Finally,
after hemostasis has been accomplished, a cinch suture
and V-Y–type closure of the wound are made to prevent
alar broadening. When rigid fixation with bone plates has
been completed, the maxillomandibular fixation should be
removed. When the maxilla is positioned in such a way
that the pyriform rim and zygomatic buttress are not in
contact with the plate and thus do not leave a significant
(e.g., >3 mm) defect, bone grafts should be placed to bridge
the defects and stabilize the new position of the maxilla.
Bone grafting will promote faster healing of the bone at the
ostectomy sites. The grafts should be mechanically locked
between bone segments or supported with wire or screw
fixation. Approximation of the muscle, especially including
the transverse nasalis, and V-Y closure of the mucosa will
maintain lip length, alar width, and the vermilion height of
the lip. The muscle suturing is done through the musculo-
periosteal tissue using 3-0 or 4-0 VicrylTM (Ethicon, Inc.,
Somerville, NJ) sutures (two on each side). The posterior
suture begins at the first molar region in the superior part
of the wound where the needle is passed through the
periosteum and the muscle. A skin hook is placed in the
midline of the upper wound edge to provide traction
during the closure. A single V-Y suture is effective, but a
bulky lip develops in the midline at the expense of the loss
of the vermilion surface in the lateral lip areas. Surgeons
have employed a double V-Y mucosal closure to minimize
this problem for patients with very thin lips (Figures 33-1
to 33-5).
Recovery
Every effort must be made to keep the nasal airway clear
immediately after the surgery. Nasal topical medications
(e.g., xylometazoline nasal spray) can be helpful. On rare
occasions, a nasopharyngeal airway is needed. Patients
develop a considerable facial edema. Often the edema is
not correlated with the degree of difficulty of the proce-
dure. Surgical edema usually peaks on the second or third
postoperative day and mostly resolves within 2 weeks.
However, the soft tissues of the face, including the lips, take
6 to 12 months to adapt to their new positions. An external
pressure dressing is kept in place for a minimum of 5 days.
Almost all patients will experience an altered sensation in
the upper lip and paranasal areas. Mild oozing of blood
from the nose is common, but significant bleeding is
unusual. In most instances, the bleeding is from the base of
the septum or the posterior lateral wall. The application
of simple pressure across the alar base (i.e., pinching the
nostril) can stop the bleeding from the anterior septum.
Although posterior bleeding may require packing, the
initial step should be the use of a topical vasoconstrictor
spray (e.g., phenylephrine 0.5%) or intranasal application of
solution on a cotton-tipped applicator or contoured nasal
sponges. If a rigid internal fixation with small bone plates
has been applied, maxillomandibular fixation should be
maintained overnight to allow early, undisturbed soft-
tissue healing. Guiding elastics are applied after releasing
the maxillomandibular fixation to help the patient function
with the occlusal splint, which dictates the new occlusal
relationship.
Complications
The risks and complications associated with the surgery
are as follows:
• Airway obstruction
• Bleeding
• Hematoma
• Midfacial bruise
• Numbness of the cheek and upper lip
• Asymmetry
• Postoperative wound infection
• Dehiscence
Case Study
See Figures 33-6 to 33-9.

CORRECTION OF DISH FACE
322
Figure 33-1
Illustration of the mucosal incision for the Le Fort I osteotomy.
Figure 33-2
Illustration of the Le Fort I osteotomy.
Figure 33-3
Separation of the maxilla using a bone hook.
Figure 33-4
Mobilization of the maxilla into the desired position.
Figure 33-5
Fixation of the maxilla with miniplates and screws.

COMPLICATIONS
323
A
B
Figure 33-6
Part 1. A to C, Preoperative facial views. D, Preoperative cephaoradiography.
Figure 33-7
Part 1. A to C, Postoperative facial views. D, Postoperative cephaoloradiography.
C
D
A
B
C
D

CORRECTION OF DISH FACE
324
Figure 33-8
Part 2. A to C, Preoperative facial views. D, Preoperative cephaoradiography.
Figure 33-9
Part 2. A to C, Postoperative facial views. D, Postoperative cephaoloradiography.
A
B
C
D
A
B
C
D

COMPLICATIONS
325
References
1. Bell WH, White WR, Proffit RP: Surgical correction of
dentofacial deformity, Philadelphia, 1980, Saunders, p 234.
2. Henderson D: A color atlas and textbook of orthognathic
surgery. The surgery of facial deformity, London, 1987,
Wolfe Medical, p 109.

327
Malar prominence is a major determining factor of the
overall facial form, which may be classified as round, oval,
long, or quadrangular. Among the various facial forms,
the oval face is considered the most aesthetically pleasing
facial contour.1 Recontouring of the malar eminence and
establishment of an oval facial contour may affect the
overall facial balance and harmony.2 The Caucasian facial
skeleton tends to be longer in the vertical dimension and
narrower in width and has a relatively greater anterior
projection with considerable prominence in the center.
It gives an impression of a well-balanced oval contour with
prominent malar complexes. However, the typical Asian
facial skeleton tends to be wider and shorter and has less
anterior projection and a flat midface compared with the
Caucasian face. Malar prominence creates a flat, wide, and
masculine facial appearance. Requests for malar reduction
are fairly common in Asia, whereas demands for malar
augmentation are predominant in the West.
Reduction malarplasty consists of anterior and posterior
(temporal) malar osteotomies, repositioning of the
mobilized malar complex, and bony fixation.3
The potential merits of malar osteotomy and repositioning
techniques are as follows:
1. Precise, predictable malar reduction is possible when
accurate osteotomies are performed and the exact
amount of bone is excised as planned.
2. Symmetry is easily maintained under direct vision.
3. In addition to reducing the projection of the malar
complex, malar osteotomy also allows the cheekbone to
be moved to a more attractive position.
4. The natural curvature and contour of the malar
complex are not disturbed. It is well known that the
Reduction Malarplasty
Rong-Min Baek and Chan-Yeong Heo
natural contour of the anterolateral malar eminence is
difficult to reproduce surgically. Preservation of the
natural malar contour and curvature is valuable.
5. Postoperative cheek droop is less likely when the facial
soft tissues are completely redraped.
6. A forehead-brow lift or subperiosteal face lift can be
performed concomitantly.
Patient Selection and Preparation
Because the reduction malarplasty is a purely cosmetic
procedure, the patient’s motivation for the surgery should
be evaluated. The patient’s expectations must be within the
realm of the surgeon’s capabilities.
The patient must be informed of the use of anesthesia, the
surgical procedure, and the limitations of this procedure.
Potential complications should be thoroughly discussed.
Use of vitamin E, aspirin, and estrogen compounds are
forbidden for 10 days preoperatively.
Analytical one-to-one planimetric photographs (i.e.,
frontal, left and right profiles, and submental views),
cephalograms, and submentovertex radiographs are taken
preoperatively. These studies, in addition to clinical
assessments and the surgeon’s sense of beauty, determine
the amount of the malar reduction and the final position of
the mobilized malar complex.
The night before the surgery, the patient’s hair should be
shampooed with an appropriate antiseptic solution (e.g.,
Phisohex [Sanofi-Synthelabo, New York, NY]) and braided
along the predetermined incision line. The line should
follow the frontal hair pattern in the middle portion of the
34

REDUCTION MALARPLASTY
328
forehead and turn posteriorly 8 cm behind and parallel to
the frontal hairline before it curves acutely downward in
the temple area to the junction of the superior helix of the
ear within the temporal scalp (Figure 34-1).
Operative Procedure
The procedure is performed under general endotracheal
anesthesia. The patient is placed on the operation table in
a reclined position with flexion of the hips, minimal knee
8 cm
Figure 34-1
Coronal incision for reduction malarplasty.

OPERATIVE PROCEDURE
329
flexion, and head elevation. Good illumination is essential.
A fiberoptic headlight provides the best illumination of
the malar area beneath the coronal flap. A solution of 1%
lidocaine hydrochloride with 1:2000,000 epinephrine is
infiltrated into the subcutaneous layer along the proposed
line to promote hemostasis. After a 5-minute wait,
a coronal incision is made from the upper attachment of
the auricular helix to the other side. However, instead of
cutting in a straight line, the surgeon performs a Z-plasty
by making a V-cut behind the ear and back to points B and
C (see Figure 34-1). The incision is made through skin,
subcutaneous tissue, and galea parallel to the hair shaft as
the hairs are pulled anteriorly and posteriorly simultan-
eously until the loose areolar connective tissue of the
subgaleal plane is revealed. Subgaleal dissection is carried
down gently with the scalpel to the supraorbital rims.
Meticulous sharp dissection with a scalpel and bipolar
electrocoagulator is recommended during subgaleal dis-
section because the use of a monopolar electrocoagulator
may cause nerve injury from the heat. The incision line is
made through periosteum and into the subperiosteal layer,
approximately 1 cm superior to the superior orbital rim, so
that the supraorbital neurovascular bundle can be safely
visualized and preserved. The lateral portion of the flap is
dissected inferiorly along the superior border of the
temporalis fascia overlying the temporalis muscle, which
fuses with the pericranium above the superior temporal
line. The temporal dissection follows the plane under the
superficial layer of the deep temporalis fascia to the
zygomatic arch (Figure 34-2). Subperiosteal dissection is
then performed to expose the entire malar complex,
including the zygomatic arch, lateral orbital wall, and
anterolateral maxillary wall (Figure 34-3). The temporalis
fascial insertion and the masseteric attachment to the
malar complex are left intact and provide balanced pulling
forces to preserve the blood supply to the zygomatic bone,
except at the osteotomy site.
Anterior (maxillary) and posterior (temporal) malar
osteotomy mobilize the entire malar complex (Figures
34-4 and 34-5). The anterior malar osteotomy starts at the
maxillary notch, which is located approximately 5 to 8 mm
medial to the inferior end of the zygomaticomaxillary
suture, goes upward, and ends near the frontozygomatic
suture, preserving the lateral orbital rim. The cut is made
with a reciprocating saw as the soft tissue is protected with
a retractor (Figure 34-6). The posterior malar osteotomy is
performed just anterior to the zygomatic tubercle. The cut
is made obliquely from posterior to anterior with a small
Figure 34-2
Schematic cross-sectional diagram of the dissection toward the zygomatic arch (thick
line with arrow).
Figure 34-3
The right zygomatic arch with incised periosteum on the superior surface and the
intact superficial layer of the temporal fascia.

REDUCTION MALARPLASTY
330
reciprocating saw (Figure 34-7). After the malar complex is
completely mobilized (Figure 34-8), it can be repositioned
medially (Figure 34-9), superiorly (Figure 34-10), and/or
posteriorly (Figure 34-11) as planned, and it is stabilized
with interosseous wires or plates and screws (Figures 34-12
and 34-13).
Before flap closure, closed suction drainage is placed
superficially to the pericranium. It is important to
thoroughly wash away bone dust. The galea is closed with
interrupted 3-0 VicrylTM sutures (Ethicon, Inc., Somerville,
NJ), and the skin is reapproximated with surgical staples.
The surgeon should bear in mind that to prevent hair loss,
the subcutaneous tissue of the scalp should not be sutured
during the closure of the scalp incision. The postauricular
Figure 34-4
Cephalic view of the malar complex. The osteotomy site is illustrated. Dissection must
extend to the maxilla and the lateral orbital wall.
Figure 34-5
Lateral view of the osteotomy line.
Figure 34-6
Anterior malar osteotomy line (left side).
Figure 34-7
Posterior (temporal) malar osteotomy (left side).
Figure 34-8
Mobilization of the malar complex (right side). Note the use of Kelly forceps.

CAUTIONS
331
incision is closed in two layers, using absorbable 6-0
sutures for the subcutaneous tissue and nonabsorbable
6-0 interrupted sutures for the skin. If hemostasis is
meticulous, blood transfusions are unnecessary in most
cases. An elastic net dressing that opens in the front to
expose the face and eyes is placed over the head.
Postoperative Course
Prophylactic antibiotics are administered for 5 days. The
dressing and suction drains are removed within 48 hours
postoperatively. Swelling and subconjunctival hemorrhage
may continue for a few weeks, and the patient should be
reassured that this is normal. The hair can be washed on
the third postoperative day. Postauricular skin sutures and
scalp staples are removed after 7 to 10 days.
Complications
Reduction malarplasty techniques have their short-
comings. The patient needs to be hospitalized and placed
under general anesthesia. Careful attention must be paid to
the branches of the facial nerve during the procedure.
Potential complications include asymmetry, inadequate
reduction, wide scalp scar, hematoma, infection, and facial
nerve injury, which can be completely avoided by pre-
operative planning and strict adherence to basic surgical
principles and techniques.4
Cautions
When the patient has a prominent mandibular angle or a
square face, reduction malarplasty may accentuate the
strong mandibular contour. In such cases, malar reduction
Figure 34-9
A to B, Medial repositioning of the mobilized malar complex. Note that a strip of the
bone can be excised to reduce lateral excess when necessary.
Figure 34-10
A to B, Superior repositioning of the mobilized malar complex. The superior
protrusion of the lateral orbital rim can be removed with a rotary burr when
necessary.

REDUCTION MALARPLASTY
332
is not recommended unless concomitant contouring of the
prominent mandibular angle is planned. Patients should be
aware of the possibility of postoperative malar asymmetry.
The maxillary sinus may be opened during the medial
malar osteotomy; however, this has not caused any
significant problems such as infection, sinusitis, or
bleeding. Fear of injury to the orbit and its contents may
lead the surgeon to place the medial malar osteotomy line
too far laterally. This can cause undercorrection and a
palpable step deformity in the anterior cheek area. A saw
blade placed in the proper axis and direction should never
enter the orbit or cut any vital structures.
Case Studies
Selected case studies are illustrated in Figure 34-14.
Figure 34-11
A to B, Posterior repositioning of the mobilized malar complex. Note the direction of
the posterior (temporal) malar osteotomy. Bone Z-plasty on the zygomatic arch
maximizes the effect of malar reduction and provides bony contact between the
repositioned zygomatic arch segments.
Figure 34-13
The position of malar complex is checked and then stabilized using interosseous
wires (left side).
Figure 34-12
A comparative view of the zygomatic arch after reduction malarplasty.

CASE STUDIES
333
Figure 34-14
A to C, Preoperative views of a 23-year-old male with severe prominent and asymmetric malar complexes. B to D, Postoperative view after reduction malarplasty with the
malar ostectomy and repositioning technique.
A
B
C
D

REDUCTION MALARPLASTY
334
References
1. Brennan HG: Augmentation malarplasty, Arch Otolaryngol
Head Neck Surg 108:441, 1982.
2. Powell NB, Riley RW, Laub DR: A new approach to
evaluation and surgery of the malar complex, Ann Plast Surg
20:206, 1988.
3. Baek SM, Chung YD, Kim SS: Reduction malarplasty, Plast
Reconst Surg 88:53-61, 1991.
4. Baek SM, Baek RM: Problems in aesthetic contouring of the
facial skeleton in Orientals, Prob Plast Recon Surg 1:667-682,
1991.

335
The convex face is more common in Asians because of the
position of the dental and skeletal structures (i.e., a more
procumbent dentition and a more acute interincisal
angle).1 These conditions lead to convex profiles and
protrusions and may contribute to a person’s inferiority
complex.2-4 An aesthetically acceptable profile can be
achieved by maxillary and mandibular anterior segmental
osteotomies. A successful application of these techniques
for the correction of lower facial disharmony are facilitated
by the continuing evolution and refinements in aesthetic
facial bone surgery.5
Preoperative Evaluation
A careful medical history should be obtained. Complaints
include facial convexity, an acute nasolabial angle,
protruding lips, lip incompetence, procumbent teeth,
gummy smile, a retropositioned and deficient chin, and
open bite deformity. Preoperative facial and occlusal
photodocumentation is taken. A standard cephalogram,
orthopanogram, and dental models are obtained. The
majority of patients have maxillary protrusion or prognath-
ism with or without concomitant mandibular deformity.
However, the most prominent and constant features are an
acute interincisal angle and a procumbent dentition. The
amount and direction of movement needed for the bone
segment is estimated by reestablishing the correct occlusal
relationship and attaining a satisfactory facial contour from
cephalometric predictions and mock surgeries of study
casts. Prediction tracings are necessary, and occlusal
acrylic splints should be made during the week preceding
Maxillary and Mandibular
Anterior Segmental
Osteotomy
Rong-Min Baek and Chan-Yeong Heo
the surgery. Although they are not essential in every case,
it is quite helpful to have both an intermediate and a final
splint.
Anesthesia
Nasotracheal intubation is generally used because inter-
maxillary fixation or at least intraoperative confirmation
of the occlusal pattern is necessary. Hypotensive anesthesia
is used to minimize blood loss and facilitate a clear opera-
tive field. When RAE nasotracheal intubation (Mallincrodt,
Inc., St. Louis, MO) is used, the use of a Mayo stand for
intraoral surgery is recommended for convenience6
(Figure 35-1).
35
Figure 35-1
The Mayo stand is suitable for supporting the nasotracheal tube by filling the space
between the nasotracheal tube and the ventilator.

MAXILLARY AND MANDIBULAR ANTERIOR SEGMENTAL OSTEOTOMY
336
Operative Procedure
Maxillary Anterior Segmental Osteotomy
Extraction of maxillary first premolar teeth is usually
required to facilitate the alignment and make the anterior
teeth upright (Figure 35-2, A). Two vertical buccal
mucoperiosteal incisions in the first premolar area, plus
a transverse incision 3 to 5 mm above the labiogingival
sulcus and connecting the two vertical incisions, are made
to expose the buccal osteotomy site and nasal floor (see
A
B
Figure 35-2
A, Extraction of the maxillary first premolar teeth and incision line (dashed line).
B, Line of the osteotomy in the maxilla. C to E,The osteotomy is performed while
the palatal mucoperiosteum is protected by a thin malleable retractor inserted
through the palatal submucoperiosteal tunnel.
Continued
C
D

OPERATIVE PROCEDURE
337
Figure 35-2, B). The nasal septal framework is exposed, and
the nasal septal cartilage is elevated from its insertion
in the vomer groove to a point that reaches the osteotomy
through the vomer. A subperiosteal tunnel is created from
the lingual surface of each maxillary first premolar site
to the midline of the palate over the area of the proposed
osteotomy for the resection of the palatal bone and vomer.
No palatal incision is made so that the palatal blood supply
is preserved. With an oscillating saw, a small round burr,
and a thin tapered osteotome, the maxillary osteotomy is
performed from the edge of the piriform aperture along the
line that extends upward from the first premolar sites (see
Figure 35-2, C and D). The osteotomy is deepened down
to the hard palate while the palatal mucoperiosteum is
protected with a thin malleable retractor that is inserted
through the palatal submucoperiosteal tunnel (see Figure
35-2, E). The required amount of bone is resected from
the alveolar process and hard palate. After complete and
adequate mobilization of the maxillary anterior segment,
the bone is aligned and held in the desired position and
guided by the interim occlusal wafer splint during the
fixation (see Figure 35-2, F). The repositioned maxillary
anterior segment is stabilized with miniplates, screws, and
interdental wires between the canines and the second
premolar teeth (see Figure 35-2, G). Intermaxillary fixation
is usually not necessary. When the mobilized anterior
segment of the maxilla needs to be advanced and rotated
downward or laterally, calvarial bone or a bone fragment
obtained from the concomitant facial bone surgery is
wedged between the bone gaps. A well-preserved and
protected lingual mucoperiosteal flap is sufficient for the
survival of the mobilized segment of either the maxilla or
the mandible. In the maxillary osteotomy, the palatal
mucoperiosteal flap technique provides a better exposure
of the anterior maxillary surface and helps reposition and
fixate the segment more efficiently.
Mandibular Anterior Segmental Osteotomy
The mandibular first premolars are extracted as required
(Figure 35-3, A). Two vertical buccal mucoperiosteal
incisions from the mandibular first premolar sites, plus a
transverse incision slightly out of the buccal sulcus that
connects the two vertical incisions, are made (see Figure
35-3, B). Keeping the inferior alveolar nerves in mind, the
mucoperiosteum of the anterior portion of the mandible is
reflected to expose the proposed osteotomy site (see Figure
35-3, C). An oscillating saw and a thin tapered osteotome
Figure 35-2, cont’d
C to E,The osteotomy is performed while the palatal mucoperiosteum is protected
by a thin malleable retractor inserted through the palatal submucoperiosteal tunnel.
F, An interim occlusal splint used during the fixation. G, After the maxillary anterior
segmental osteotomy, anterior jaw segments are stabilized in the desired position
using miniplates and interdental wires. (Note: In these images, the extended
transverse maxillary mucosal incision has been added for the reader’s appreciation.)
F
G
E

MAXILLARY AND MANDIBULAR ANTERIOR SEGMENTAL OSTEOTOMY
338
Figure 35-3
A, Extraction of the mandibular first premolar teeth and the incision line. Dashed
lines represent the mucosal incision lines. B, Line of the osteotomy in the mandible.
C to E, After bimaxillary anterior segmental osteotomy, the anterior jaw segments
are stabilized in the desired position using miniplates and interdental wires guided by
the interim occlusal splint. (In these images, the extended transverse mandibular
mucosal incision has been added for the reader’s appreciation.)
A
B
C
D
E

COMPLICATIONS
339
are used to perform a vertical osteotomy to a level below
the apices of the teeth. The two vertical osteotomies are
joined by a horizontal osteotomy. If necessary, the required
amount of bone is resected as planned. The anterior
segment of the mandible is moved to its proper position,
guided by the interim occlusal wafer splint, and fixed with
miniplates and screws and interdental wiring (see Figure
35-3, D and E). Intermaxillary fixation is usually not
necessary. If a bone graft is necessary, calvarial bone or
bone fragments obtained from the concomitant facial bone
surgery are used. When premolar removal is not required,
an interdental osteotomy is performed.
Postoperative Course
Transfusion is usually unnecessary. Oral feeding is avoided
for the first 24 hours except for clear water. A liquid diet is
initiated based on the patient’s tolerance. Oral hygiene with
a soft toothbrush and water-pick is begun within a few days
of surgery. The soft-diet formula is continued at least 2
weeks postoperatively. The patient routinely receives
antibiotics for 7 days. The interdental wires are removed 6
weeks after the operation. If intermaxillary fixation was
done, it is removed 6 to 8 weeks postoperatively.
Complications
Potential complications include a poor aesthetic result,
bony necrosis, misalignments, teeth devitalization, infec-
tions, septal deviations, inferior alveolar nerve injuries, and
mucogingival flap necrosis. However, these complications
are rare in well-planned surgery performed by experienced
surgeons.
If the flap shows signs of compromised capillary perfusion
(i.e., flap congestion), then immediate and intensive
hyperbaric oxygen therapy may salvage the flap.
Combined Operative Procedures
Other combined operative procedures may be used for
more favorable results, such as LeFort I osteotomy,
bilateral mandibular ramus osteotomy, genioplasty,
mandibular angle ostectomy or contouring, reduction
malarplasty, paranasal augmentation with bone graft, face
lift, rhinoplasty, or orbital reconstruction. These techniques
can be performed simultaneously to correct aesthetic or
functional deformities such as a long or an asymmetric
face, severe malocclusion, microgenia, piriform recession,
prominent mandibular angles, prominent malar eminences,
or an aging face. When Le Fort osteotomy or mandibular
ramus osteotomy is done concurrently with segmental
osteotomy, intermaxillary fixation using the occlusal wafer
splint is maintained for 6 weeks postoperatively.
Orthodontic Considerations
In a growing number of patients, successful treatment of
such facial disharmony has been accomplished in part by
orthodontists using the extraction philosophies of Tweed
and Begg. However, in adult patients, surgical-orthodontic
procedures may offer a distinct advantage compared with
orthodontic therapy alone when the improvement in facial
balance cannot be achieved through conventional therapy
or the adult patient is unwilling to accept the appliance
therapy. Additionally, with surgical-orthodontic procedures,
treatment time and possible adverse effects of lengthy
and extensive orthodontic therapy may be reduced, and
optimal aesthetic improvement may be facilitated.7 More-
over, in those cases complicated by other skeletal or
soft-tissue deformities (e.g., vertical excess of the maxilla
or mandible, symmetrical or asymmetrical transverse
deviation, or any sagittal skeletal discrepancies), the
surgical-orthodontic procedure provides the only effective
modality that yields successful results with regards to both
aesthetics and stability.
Technical Considerations and Cautions
When bimaxillary surgery is performed, the three-
dimensional free rotation of the upper and lower jaw must
be considered. In these situations, a temporary occlusal
wafer splint is of great help when fixing the mobilized
segments. Rigid fixation using miniplates, screws, and
interdental wires eliminates the necessity for intermaxillary
fixation even when bimaxillary anterior segmental osteo-
tomy is performed. Rigid fixation greatly diminishes the
patient’s discomfort and enhances an early return to a
normal social life. However, concomitant LeFort osteotomy
or mandibular ramus osteotomies require intermaxillary
fixation with an occlusal splint. When the vertical
dimension of the anterior portion of mandible is too short,
advancement genioplasty cannot be done simultaneously

MAXILLARY AND MANDIBULAR ANTERIOR SEGMENTAL OSTEOTOMY
340
with the mandibular anterior segmental osteotomy. A
minimal 5-mm bridge of bone should be maintained to
preserve the vertical continuity. The aesthetic contouring
of facial bones can bring about a subtle but dramatic
change of the face. Proper surgical planning for aesthetic
facial skeletal surgery requires the surgeon to not only
possess an intimate knowledge of the available techniques
but also have a proper understanding of how and when to
apply those techniques. Opinions may differ for surgical
indications because of differences in cultural backgrounds.
However, the surgeon’s main goal for “aesthetic and
physical harmony, balance, and symmetry” is universal. If
the surgical technique can be modified to achieve the
desired effect, there is no doubt that the patient will be
satisfied.
Case Studies
Selected case studies are illustrated in Figures 35-4 and
35-5.
Figure 35-4
A, Preoperative frontal and lateral view of a 25-year-old female with lip protrusion. B, Postoperative view 13 months after bimaxillary anterior segmental osteotomy.
A
B

TECHNICAL CONSIDERATIONS AND CAUTIONS
341
References
1. Cox NH, Van Der Linden FGH: Facial harmony, Am J Orthod
60:175, 1971.
2. Ohmori K, Kamiji T: Segmental osteotomy of the upper and
lower jaw, Clin Plast Surg 18(1):163-169, 1991.
3. Lamberton CM, Reichart PA, Triatananimit P: Bimaxillary
protrusion as a pathologic problem in the Thai, Am J Orthod
77:320, 1980.
4. Miura F, Inoue N, Suzuki K: Cephalometric standards for
Japanese according to the Steiner analysis, Am J Orthod
51:288, 1965.
5. Baek SM, Baek RM: Profiloplasty of the lower face by
maxillary and mandibular anterior segmental osteotomies,
Aesthetic Plast Surg 17(2):129-137, 1993.
6. Baek RM, Song YT: A practical method of surgical draping
using the preformed RAE (Ring-Adair-Elwyn) nasotracheal
tube and the Mayo table in maxillofacial surgery, Plast
Reconstr Surg 112(5):1484-1485, 2003.
7. Jacobs JD, Bell WH: Combined surgical and orthodontic
treatment of bimaxillary protrusion, Am J Orthod
83(4):321-333, 1983.
8. Baek SM, Baek RM: Problems in aesthetic contouring of the
facial skeleton in Orientals, Probl Plast Reconst Surg 1:667,
1991.
A
B
Figure 35-5
Comparative preoperative (A) and postoperative (B) lateral cephalometric views.

343
Consultation
The intraoral versus submental approach should be
discussed. The submental scar is small, well camouflaged,
and well accepted by the patient. If the patient has a
tendency to form a keloid or hypertrophic scar, the
intraoral approach is advised. The degree of projection is
determined by computer morphing or by placing a sample-
sized implant on the chin and viewing it in front of the
mirror. The vertical dimension of the chin should be
evaluated. Alloplastic implants should not be used to
camouflage an excessively long and retrusive chin.1
Although some surgeons use Mersilene® (Ethicon, Inc.,
Somerville, NJ) or Supramid® (S. Jackson Co., Alexandria,
VA) mesh implants, the overwhelming majority use
silicone rubber implants. An anatomic chin implant with
mandibular extension is used widely and provides a more
natural contour. Pre-jowl implants provide augmentation
under the geniomandibular groove and are used to
enhance the pre-jowl depression more commonly seen in
older patients. The possibility of implant mobility, migra-
tion, or asymmetry should be discussed, although these
complications are not likely to occur with a careful sub-
periosteal placement of the implant. Temporary numbness
and the potentially permanent loss of lip sensation should
also be discussed.
Anesthesia
For the regional block of the chin below the labiomental
groove, bilateral inferior alveolar nerve blocks can be
achieved by injecting 2 mL of 1% lidocaine with 1:100,000
Chin Augmentation with
Silicone Implant
Jung I. Park and Adolfo Napolez
epinephrine solution on each side. The nerve is blocked at
the midpoint between the anterior and posterior border of
the ramus of the mandible at the level of the upper surface
of the molar teeth. Approximately 1 mL of the same local
anesthetic solution may be injected into the area below the
canine teeth on each side to ensure that the mental nerve
is adequately blocked. Additional local anesthesia is
infiltrated just above the periosteum of the chin and along
the lower aspect of the mandibular body area.
Procedure
The standard sterile prepping and draping is applied.
Before touching the implant, the surgeon should rinse the
gloves with sterile saline solution to remove powder. The
chosen implant is placed on the chin with the patient in
the supine position. The midline is marked with a sterile
marking pen. The ideal location of the implant is
determined. It is important to place the implant over the
hard and resistant bone of the mental symphysis.
The lower edge of the implant should be located slightly
above the lower margin of the midline mandible to prevent
the appearance of a ptotic chin. The boundary of the
implant is then drawn on the chin with the marking pen.
The main body and mandibular extension of the implant is
placed in line with the lower border of the mandible
(Figure 36-1). Next, a 1.5-cm incision is made in the
midline submental region along the natural crease (if
present). The incision is deepened to the mandibular
periosteum on its inferior surface. The periosteum is
elevated with a broad, sharp-edged periosteal elevator.
36

CHIN AUGMENTATION WITH SILICONE IMPLANT
344
First, the elevation is done over the chin area in an upward
direction to the upper margin of the marking. A slightly
higher dissection is made to allow for comfortable
placement of the implant. The tendency is to develop a
midline pocket that is too high during intraoral approaches
and too low during submental approaches. Next, the sub-
periosteal dissection is continued laterally along the
inferior border of the mandible. A low dissection best
protects the mental nerve. The tendency is to develop a
tunnel that gradually slants upward as the dissection
progress laterally. This is the most common cause for an
upward migration of the lateral mandibular extension of
the implant. The pocket size is just large enough to accept
the implant. The opposite pocket is created in a similar
fashion along the skin markings. A slightly longer pocket is
created at the lateral end of the first side to provide room
for the insertion of the opposite end of the implant through
a rather small incision. A forceful misdirected insertion at
this stage creates a false pocket into the soft tissue outside
the subperiosteal pocket. Once the false pocket is formed,
the implant tends to find this pocket on repeated insertion.
The false pocket may even become larger during successive
implant placement attempts. The key to success is to
maintain the pocket in the subperiosteal plane during the
initial dissection. The surgeon should constantly
remember to follow the lower border of the mandible
throughout the dissection. After one side is completely
inserted (Figure 36-2), the implant is partially folded to
bring the opposite end of the implant to the incision. While
maintaining a steady position of the main body of the
implant at the midline, the end of the opposite side of
the implant is pushed into the tunnel (Figure 36-3). The
implant should be directed in such a way that it passes the
dissected subperiosteal tunnel without creating a false
pocket. Once the lateral extension is placed halfway, the
main part of the implant can be easily pushed into the
pocket (Figure 36-4). One common error involves a failure
to create the midpocket high enough to allow the implant
to settle in comfortably. Because repeated attempts at
insertion cause a false pocket, it is crucial to make an
adequate pocket before any insertion is attempted. The
positioning of the implant is conformed by palpation. The
midline notch of the implant is located in the center of
the chin (Figure 36-5). The incision site is closed in layers
with 4-0 VicrylTM (Ethicon, Inc., Somerville, NJ) and the
skin is closed with 6-0 nylon. Hemostasis is usually not
necessary. The wound is covered with an antibiotic
ointment. The wound is dressed in a sterile manner.
Compression dressings are neither effective nor necessary.
Postoperative Care
Oral antibiotics are prescribed for 1 week. Cold com-
presses are applied for 2 days. Showering is allowed in 3
Figure 36-1
The anticipated location of the chin implant is determined and marked on the chin. A
precise pocket that matches the marking is then created.
Figure 36-2
The implant is inserted into the right-sided pocket.
Figure 36-3
The implant is bent, and the opposite end is introduced into the left-sided pocket.

POSTOPERATIVE CARE
345
Figure 36-4
The midportion of the implant is advanced into the pocket.
Figure 36-5
The midline notch of the implant is located precisely in the midline.
A
B
Figure 36-6
A, Preoperative view. B, Postoperative view. The patient also had nasal augmentation.

CHIN AUGMENTATION WITH SILICONE IMPLANT
346
days. Full physical activity may be resumed in 2 weeks.
Sports activities that may have an impact on the chin
should be avoided for at least 1 month.
Recovery
The patients are often alarmed by the roundness and large
size of the chin due to swelling. A preoperative warning
will prepare the patients ahead of time. The size of the chin
is significantly reduced within 1 year. Numbness may last
for several weeks.
Complications
Almost all the complications related to an unfavorable
result are due to a poorly executed pocket formation. A
precise subperiosteal pocket ensures a rigid and stable
implant. Symmetric pocket development along the lower
border of the mandible is a certain way to avoid a slanted
implant position. Accidental dissection into the muscle
plane and disruption of the mentalis muscle may cause
an unsightly and distorted chin muscle contraction post-
operatively. If the implant is placed too low, then flattening
and ptotic changes may occur after the swelling has com-
pletely subsided. Although demineralization is common, it
does not manifest itself as a contour deformity.2 Superior
migration of the implant may cause an erosion of the
dentoalveolar bone and the loss of teeth. Implant extru-
sion, wound dehiscence, and infection are potential
complications that are found more often when using a
sublabial incision.3
Case Studies
See Figures 36-6 and 36-7.
A
B
Figure 36-7
A, Preoperative view. B, Postoperative view.

CASE STUDIES
347
References
1. McCarthy JG, Ruff GL: The chin, Clin Plast Surg 15:125,
1988.
2. Friedland JA, Coccaro PJ, Converse JM: Retrospective
cephalometric analysis of mandibular bone absorption under
silicone rubber chin implants, Plast Reconstr Surg 57:144,
1976.
3. McCarthy JG, Kawamoto H, Grayson BH, et al: Surgery of
the jaws. In McCarthy JG, ed: Plastic surgery, vol 2,
Philadelphia, 1990, Saunders, p 1309.

349
If a patient shows signs of a retruded chin, alloplastic
implant materials such as silicone or MedporTM (Porex
Surgical, Inc., Fairburn, GA) can be inserted for chin re-
inforcement. Alloplastic implant augmentation is excellent
for minor abnormalities. This is a well-accepted technique
for the chin that has only mild to moderate microgenia and a
shallow labiomental fold. However, treatment of advanced
chin retrusion requires an osseous genioplasty technique
such as a sliding genioplasty procedure. More complex
anterior mandible abnormalities can be corrected by alter-
ing the vertical, transverse, or anteroposterior dimensions.
Preoperative Care
The amount of repositioning is planned before surgery
to meet the needs of the individual patient. An informed
operative consent is obtained, and the patient is advised to
have adequate sleep and no fluids or foods after midnight,
and the patient is not allowed to wear facial cosmetics on
the day of the surgery. A prophylactic antibiotic such as
intravenous cefazolin or clindamycin is given 30 minutes
before the operation, and the bladder is emptied.
Anesthesia
Although sliding genioplasty can be performed under local
anesthesia in an outpatient setting, general anesthesia is
most commonly used in this procedure. The patient is
more comfortable and the airway is better protected under
general anesthesia. Unless a rhinoplasty is performed
concurrently, nasotracheal intubation is preferred.
Genioplasty
Jin-Young Choi
Instruments
The following instruments are used in this procedure:
• Periosteal elevator
• Surgical round burr
• Oscillating saw
• Reciprocating saw
• Retractor: downward and upward
• Vein retractor
• Chin retractor
Procedure
The mouth and face are prepped. The midline and canine
and premolar interdental mucosa are tagged with sutures
to aid in accurate realignment of the wound margin.
Supplementary local anesthesia of 2% lidocaine with
1:100.000 epinephrine (2 ampules per side) is infiltrated
into the periosteal plane to achieve a bloodless dissection
field. Before the incision is made, 10 minutes are allowed to
elapse after injection of the local anesthetic. The initial
incision, from canine to canine, is made through mucosa.
The dissection is continued through the submucosal
tissues and muscle and down to the periosteum. The
periosteum is sharply incised, and the periosteum is
reflected from the anterior mandible to the inferior border.
During this dissection, care is taken to identify the mental
foramen and protect the emerging mental nerve bundles.
Because the inferior border osteotomy usually extends
posterior to the mental foramen, the periosteum at the
inferior border must be freed to at least the anterior third
of the body of the mandible. The nerve emerges at the
37

GENIOPLASTY
350
foramen, which is generally found between the first and
second premolar teeth and at the level of the origin of
the mentalis muscle or 2 to 4 mm below the level of the
bicuspid tooth apices. The foramen is situated deep to
the midportion of the depressor anguli oris. The midline
should be scored vertically with a burr or saw to mark the
correct position in case the inferior border is moved
(Figure 37-1).
A horizontal osteotomy with an oscillating saw or recipro-
cating saw or burr must be done just above the inferior
border. A sagittal saw with a 30-degree bend should be
used to facilitate an even cut while minimizing soft tissue
trauma. The lateral cuts should be 4 to 5 mm below the
foramina to protect the path of the inferior alveolar nerve.
At its posterior limit, the osteotomy should taper into the
body to prevent a vertical step deformity on the inferior
border. After the inferior border has been freed, it should
remain pedicled to the digastric muscle insertions and
sometimes to a portion of the geniohyoid muscle (Figure
37-2). For a vertical reduction, a measured amount of
bone must be removed from the anterior mandible with a
second horizontal bone cut, and the inferior border must
be repositioned superiorly.
Occasionally the facial surface of the mandible loses its
normal contour when the inferior border is repositioned
posteriorly and superiorly. A facial-lingual concavity in the
anterior mandible must be developed above the inferior
border to provide a depression for optimal lip function and
a good aesthetic appearance. The concavity is carefully
sculptured into the bone with a burr. During horizontal
advancement, the opposing osteotomy surface of the facial
plate of the mandible above lies in contact with the lingual
plate of the inferior border segment and usually remains
thus. If additional bone contour is desired after advancing
the inferior border, an onlay bone graft of autogenous or
allogenic bone is placed over the step area. If required, the
inferior border can be advanced even farther in a
horizontal plane, leaving a gap between the lingual surface
of the advanced segment and the facial surface of the intact
mandible. When such an extensive advancement is made,
the defect is filled with autogenous bone after the segments
have been stabilized and fixed. The freed inferior border
segment can be shifted to allow correction in all these
dimensions and then held exactly in the new position with
rigid internal fixation (usually a 4-hole chin plate and screw
and 1 or 2 long screws [14 to 16 mm long]) (Figure 37-3).
Defects then can be grafted as required. After the
osteotomy has been completed and fixated, the incision is
closed in layers with deep 4-0 VicrylTM sutures (Ethicon,
Inc., Somerville, NJ) to approximate the severed muscles
and interrupted 3-0 or 4-0 chromic catgut sutures to close
the mucosa. An external pressure dressing is almost man-
datory to provide wound support. Adequate hemostasis
greatly reduces the danger of hematoma formation and
subsequent wound breakdown.
Recovery
Soft tissue edema can take several weeks to resolve after
inferior border osteotomy. Often the lips are also
Figure 37-1
Intraoral finding before the circumvestibular mucosal incision is made.
Figure 37-2
The horizontal osteotomy is completed.

COMPLICATIONS
351
repositioned with the procedure and may require 3 to 6
months to adapt and function in this new position.
Occasionally, active lip exercises are prescribed to improve
lip tone if it does not improve with normal daily activity.
The external pressure dressing or elastic tape is kept in
place for a minimum of 3 days.
Because surgery usually exposes the mental nerve, patients
experience a sensory deficit in the lower lip after surgery.
Sensation generally returns within 3 to 6 months.
Complications
Provided that care is taken during the initial soft tissue
dissection and subsequent bony cuts, minimal complica-
tions are seen. Complications may include the following:
• Bone resorption
• Infection
• Extrusion
• Dehiscence
• Overprojection or underprojection
• Asymmetry
• Displacement
• Capsular contraction
• Lower-lip retraction
• Chin ptosis
Because dead spaces are nearly always created after
segments are repositioned, wound dehiscence is more
likely with this procedure than with other orthognathic
surgical procedures. If dehiscence occurs, meticulous
wound care with frequent irrigation to prevent the accu-
mulation of food debris allows wound closure by secondary
intention.
Case Studies
See Figures 37-4 to 37-7.
A
B
C
Figure 37-3
A to C, The chin fragment is fixated with a miniplate and screws after the segment is
moved to the desired position.

GENIOPLASTY
352
A
B
C
Figure 37-5
A to C, Postoperative facial views after genioplasty (4 mm advancement).
A
B
C
Figure 37-4
A to C, Preoperative facial views of a patient with a retruded chin.

CASE STUDIES
353
References
1. Bell WH, Profitt WR, White RP: Surgical correction of
dentofacial deformity, vol 1, Philadelphia, 1980, Saunders,
p 1210.
2. Lessin ME: Considerations for genioplasty. In Shelton DW,
Irby WB: Current advances in oral and maxillofacial surgery:
orthognathic surgery, volume V, St Louis, Mosby-Year Book,
1986, p 100.
A
B
C
Figure 37-6
A to C, Preoperative facial views of a patient with a retruded chin.
A
B
C
Figure 37-7
A to C, Postoperative facial views after genioplasty (4 mm advancement).

355
Mandibular angle resection to soften the square jaw is done
by removing the bone posterolateral to the course of the
mandibular canal. Knowing the anatomy of the mandibular
canal allows a surgeon to perform a maximal resection
of the mandibular angle. The mandibulogram assists a
surgeon to draw a mandibular angle osteotomy line close to
the mandibular canal without danger of injuring it.
Construction on X-Ray Film
A panorex view of the mandible is obtained. The x-ray may
be repeated until a clear view of the mandibular canal is
achieved (Figure 38-1). A line is drawn that connects
the most prominent point of the mandibular angle and the
upper posterior corner of the existing last molar tooth.
This line is described as an angle-molar tooth line (Figure
38-2). The mandibular canal is traced on the radiograph
Mandibulogram
Jung Park
with a marking pen. A point on the angle-molar line 5 mm
posterior and inferior to the tracing of the mandibular
canal is marked as point A. Then a line passing through
point A and parallel to the mandibular canal is drawn.
This line crosses the posterior border of the ramus of
the mandible and the inferior border of the body of the
mandible. This line is the osteotomy line for the mandi-
bular angle ostectomy. The point at which the mandibular
osteotomy line crosses the inferior border is marked as
point B (Figure 38-3). A line is drawn up toward the teeth
from point B. This line is at a right angle to the inferior
mandibular border, and it crosses the upper surface of
the mandible or one of the molar teeth. This point on the
upper border of the mandible or a molar tooth is marked as
point C (Figures 38-4 and 38-5). The distance between the
upper posterior corner of the last molar tooth and point A
on the angle-molar line is measured and recorded for
future use (Figure 38-6).
38
A
B
Figure 38-1
The mandibular canal is seen distinctively running obliquely. The canal is marked as two short parallel lines.

MANDIBULOGRAM
356
A
B
Figure 38-2
The line connecting the posterior superior corner of the last molar tooth and the farthest point of the angle of the mandible (angle tooth line).
A
B
5 mm
Figure 38-3
A line running parallel to the direction of the mandibular canal is drawn. The line is 5 mm from the mandibular canal. This is the line for the mandibular angle ostectomy (angle
ostectomy line). The cross point between these two lines is designated as point A. Point B is the cross point between the angle ostectomy line and the inferior border of the
mandible.
A
B

RECONSTRUCTION
357
A
B
90˚
Figure 38-4
A line at a 90-degree angle to the lower border of the mandible, passing point B, is drawn vertically. Point C is where the vertical line crosses the upper border of the mandible.
A
B
B
Figure 38-5
This point C could be on the surface of the molar tooth, depending on the orientation of the mandibular canal.
A
B

MANDIBULOGRAM
358
Reconstruction
A reversal of the construction process is carried out on the
lateral surface of the exposed mandible. The angle-molar
line is drawn on the mandible. Point A is plotted on this
line based on the measurement made on the Panorex view
(Figure 38-7). The distance measured on the Panorex view
was 30 mm. However, the Panorex view of the mandible
has 20% magnification of the mandible at the mandibular
angle/ramus area. Point A on the mandible itself should
be closer to the molar tooth than the one based on the
radiograph. Point A should then be marked by calculating
a prorated distance from the last molar tooth. The follow-
ing formula could be used to calculate the actual distance
from the radiograph distance:
(actual distance) × 120% = 30 mm
(actual distance) = 30 mm ÷ 120% = 30 ÷ 1.2 = 25 mm
Based on this calculation, point A on the actual mandibular
surface is located 25 mm from the molar tooth. However,
the author uses the 30-mm figure to ensure further safety.
Next, point C is marked either on the surface of the molar
tooth or on the postmolar gum area based on the finding
of the mandibulogram (Figure 38-8). A vertical line is
drawn from point C to the inferior border of the mandible
that crosses the border at a 90-degree angle. The point B
is then marked on the inferior border of the mandible
(Figure 38-9). A line is drawn through point B and point A.
Continuation of this line passes the posterior border of
the ramus of the mandible. This line B–A becomes the
mandibular angle osteotomy line (Figure 38-10). The
extracted mandibular angle piece matches the dimension
of the radiograph quite nicely, and the mandibular nerve is
preserved (Figure 38-11).
30mm
B
A
C
Figure 38-6
The distance between the molar tooth and point A is measured. On this mandible, it is 30 mm.
A
B

RECONSTRUCTION
359
A
30 mm
A
C
30 mm
Figure 38-7
The angle tooth line is drawn between the upper posterior corner of the molar tooth and the mandibular angle on the exposed mandible. Point A is marked by measuring the
distance from the last molar tooth. Based on the calculation, point A on the actual mandibular surface is 25 mm from the last molar tooth. However, the author uses the
unprorated 30-mm figure to ensure further safety.
Figure 38-8
Point C is marked either on the post molar gum area or on the surface of the molar tooth based on the mandibulogram.
A
B
A
B

MANDIBULOGRAM
360
90˚
A
C
B
A
B
C
Angle osteotomy line
A
B
A
B
Figure 38-9
A vertical line at a right angle to the inferior border of the mandible is drawn. Point B is marked on the inferior broader cross point.
Figure 38-10
A line that connects points B and A and extends to the posterior of the mandible becomes the angle ostectomy line.

RECONSTRUCTION
361
References
1. Carter RB, Keen EN: The intramandibular course of the
inferior alveolar nerve, J Anat 108(3):433-440, 1971.
2. Nortje CJ, Farmon AG, Grotepass FW: Variations in the
normal anatomy of the inferior dental (mandibular) canal: a
retrospective study of panoramic radiographs from 3612
routine dental patients, Br J Oral Surg 15:55-63, 1978.
3. Jin H, Kim BG: Mandibular osteotomies after drawing out
the inferior alveolar nerve along the canal, Aesth Plast Surg
27:126-129, 2003.
Figure 38-11
Precise extraction of the mandibular angle based on the mandibulogram.

363
The Asian facial bone structure is brachycephalic, and the
mandibular arch is broad. The traditional concept of Asian
beauty is an oval, “egg-shaped” face. The lower face should
gently slope downward in a smooth line from the ear lobe
to the mandibular body. A prominent mandibular angle is
considered to be harsh and masculine. Women often try
to conceal it with long straight hair. The mandibular angle
is surgically manageable when it is caused by either
mandibular bony hypertrophy, a flared-out mandibular
angle, or masseteric muscle hypertrophy.1-3 However,
cosmetic surgery cannot manage a wide lower face caused
by a wide mandibular arch or parotid hypertrophy.
The recent development of BotoxTM (Allergan, Inc., Irvine,
CA) injections has allowed for temporary improvement
of a wide mandible secondary to masseteric muscle
hypertrophy.4,5
Consultation
Although the surgery is recommended to achieve a
softening of the angle and rounding of the lower facial
curve, its limitations should be clearly explained to the
patient before surgery. The patient needs to be informed
that improvement is often more visible on the lateral or
oblique view and less obvious on the frontal view.
Preoperative Care
The condition of the teeth and the occlusal pattern should
be evaluated and documented. Dental hygienic treatment
is recommended before the surgery. A Panorex view of the
mandible should be ordered. The Panorex view allows a
surgeon to evaluate the dimension of the mandible and the
Mandibular Angle
Ostectomy
Jung I. Park
feasibility of resection. A surgeon should be confident
that the remaining mandibular body after the surgery
would be sufficient to withstand any future accidental
impact on the mandible. The course of the mandibular
canal is highlighted on the radiograph of the Panorex view,
and a mandibular angle osteotomy line is constructed
based on the mandibulogram (see Chapter 38).4 The facial
nerve function should be evaluated and documented.
Mouthwash is recommended using a 26.9 % alcohol-based
solution (e.g., ListerineTM) for 10 minutes the night before
and the morning of surgery. Postoperative instructions
are given during the preoperative period. A preoperative
history and general physical examination are obtained. The
patient is not allowed to wear facial cosmetics on the day
of surgery and is asked to wash the face and hair with
Phisohex shampoo on both the night before and the
morning of the surgery. Intravenous
cefazolin or
clindamycin is administered preoperatively.
Anesthesia
General nasotracheal intubation is preferred. However, if
this is not feasible, orotracheal intubation is acceptable.
Supplementary local anesthesia of diluted 0.1% lidocaine
with 1:1,000,000 epinephrine (40 mL per side) is infiltrated
in the periosteal plane to achieve a bloodless dissection
field. The posterior border of the ramus, the medial sur-
face, and the inferior border of the mandible are infiltrated
through the neck, posteroinferior to the mandibular angle
(15 mL). The lateral surface of the mandible is infiltrated
through the gingivobuccal sulcus (15 mL). The medial
mandibular periosteal infiltration is added through the
floor of the mouth (10 mL).
39

MANDIBULAR ANGLE OSTECTOMY
364
Instruments
The following instruments are used (Figures 39-1 and
39-2):
• Periosteal elevator
• Intraoral vertical osteotomy retractor
• Obwegeser inferior border retractor
• Obwegeser mandibular inferior border stripper (right
and left)
• Right-angled oscillating saw
• MicroAireTM hand engine adapter (MicroAire Surgical
Instrument LLC, Charlottesville, VA)
• MicroAire oscillating blade, 11.2 × 7 × 0.5 mm
• Blake suction drains (Fr. #10) (quantity: 2)
• Large cutting rotating burr
Procedure
The oropharyngeal cavity is packed with a large single
gauze pack. The mucosal incision is made with a #10 Bard-
Parker blade. The incision is made along the anterior
border of the mandible and the alveolar ridge through the
gingivobuccal sulcus. At least 1.5 cm of gingival mucosal
cuff should remain attached to the gingiva to ensure a
watertight mucosal closure and prevent avascular loss of
the teeth. The incision begins at the midpoint of the
anterior border of the ramus and ends at the level of
the first molar tooth (Figure 39-3). The incision is carried
downward to the periosteum. Identification of the mental
foramen may help to prevent injury to the mental nerve
and identify the mandibular canal, especially during the
inferior border shaving procedure. The periosteal elevation
is easily accomplished with a heavy periosteal elevator
over the lateral surface of the mandibular ramus and the
posterior half of the mandibular body. Periosteal elevation
over the mandibular angle is more difficult because of the
tendinous attachment of the masseteric muscle. The
periosteal elevation of the lower border of the mandible
is accomplished using an inferior border stripper (Figures
39-4 and 39-5). The surgeon should constantly survey the
location of the facial nerve and artery during this stage of
dissection. Accidental slippage of the sharp instrument can
be detrimental. Cheek retraction is achieved with the
use of an Obwegeser inferior border and intraoral vertical
osteotomy retractor (Figures 39-6 to 39-8). For a wider
exposure, two retractors may be used, one engaged on the
posterior border of the ramus and another on the lower
Figure 39-1
Instruments.
Figure 39-2
MicroAire angled oscillating saw adapted to the special handpiece.
Figure 39-3
The green line on the mandible indicates the gingivobuccal incision, the blue line
indicates the mandibular canal, and the red triangle represents angle ostectomy.