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

Traditional orthognathic surgery aligns the patient’s bony jaws into a desired, more appropriate po-
sition but may leave other cosmetic issues unaddressed.

Soft tissue deformities may be treated concomitantly with orthognathic surgery, including soft tis-
sue augmentation (fillers), reduction (liposuction), hard tissue augmentation, cosmetic lip proce-
dures, 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.

INTRODUCTION tissues, which are more fixed in their ultimate posi-

tion. Orthognathic surgical treatment planning
Orthognathic surgery, although serving to correct may be limited to isolated maxillary or mandibular
functional skeletal and dental discrepancies, osteotomies (single jaw), or combined maxillary
should be based on the maximal aesthetic and mandibular surgery (double or 2-jaw) when
outcome achievable for the patient. Patients are appropriate. Regardless, a vigilant surgeon should
generally referred by the orthodontist or primary- consider additional aesthetic adjuncts that may
level care provider to evaluate and correct a dramatically improve patient appearance (Box 1).
skeletal and/or dental malocclusion. However, ap- These changes are ideally based on achieving
proaching these patients with aesthetic concerns symmetry, balance, proportion, and overall facial
in mind maximizes the overall benefit of orthog- harmony. It is important to prioritize this outcome
nathic surgery. First introduced by Worms and col- from the initial consultation, thus providing the
leagues,1 and further modified by McCollum and philosophic framework for surgical optimization
Evans,2 treatment planning was suggested pri- and a final aesthetic result.
marily to establish the most favorable contours of Using this approach, multiple adjunctive proce-
the soft tissue facial profile. Once assessed, these dures exist that can improve on the outcomes
data could then be used to determine the amount achieved with skeletal movements alone. The
and direction of tooth and skeletal movement to skeletal and soft tissue discrepancies that are pre-
achieve the specific soft tissue contours. This sent, the specific surgical treatment planned, and
approach directs importance to the soft tissues, the personal desires of the patient dictate these
oralmaxsurgery.theclinics.com

because they introduce greater variability to the options.

final result, followed by manipulation of the hard

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: jperen@lsuhsc.edu

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.
2 Mohamed & Perenack

Box 1 Box 2
Orthognathic procedures 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
Malar osteotomies/implants
Jones and Smith3 described the sequencing of
Piriform augmentation
cosmetic surgery to be based on orthognathic sur-
gery. A similar method to categorize procedures is Soft tissue augmentation
described as: Lip augmentation/shortening

1. Procedures that enhance the result of orthog- Rhinoplasty

nathic surgery, performed concomitantly. Lower face procedures
2. Procedures performed perioperatively that
Chin augmentation/reduction
supplement the orthognathic surgery result.
Typically performed 3 to 6 months after orthog- Mandibular angle modification
nathic surgery. Submental/jowl liposculpting
3. Procedures performed at a distant time from Lower face/neck rhytidectomy
orthognathic surgery, often to correct unfavor-
able orthognathic surgery sequelae.
4. Camouflage cosmetic surgery performed on
patients not desiring optimal orthognathic sur- unpredictable changes at the time of surgery,
gery but still desiring some aspect of favorable which include:
soft tissue improvement. This route should be
Complex or drastic changes to the nasal
discussed with the patient’s orthodontist to structures
determine whether a functional and stable oc-
Compromises to the vascularity of the
clusion can be obtained with orthodontic ther- epithelium
apy alone (Box 2).

Procedures Performed Temporally Distant to

Procedures Performed at the Time of Orthognathic Surgery
Orthognathic Surgery
Correcting soft and hard tissue deformities
Simultaneous augmentation/alteration of the skin, created iatrogenically during orthognathic surgery
submentum, and nasal tissues offers the advan- is in the category of delayed treatment. These de-
tage of cost-effective, convenient, and compre- formities include mandibular inferior border
hensive treatment of the patient and minimizes notching caused by a sagittal split osteotomy or
the risk of anesthesia to a single surgery. Disad- sliding anterior segmental osteotomy, and so-
vantages include soft tissue edema secondary to called winging of the mandible caused by a verti-
orthognathic surgical manipulation, variation in cal ramus osteotomy. Hard and soft tissue facial
the soft tissue drape, and increased operating asymmetry may need to be camouflaged if control
time.4 of yaw movements during 2-jaw surgery or genio-
plasty was lost. Common iatrogenic soft tissue
Procedures Performed Perioperatively to
deformities include an unaesthetic labiomental
Orthognathic Surgery
crease, malar or submalar asymmetry or defi-
Delayed adjunctive aesthetic procedures are rec- ciency, and unaesthetic changes to the nasal
ommended in cases that create a higher risk of appearance.
 Aesthetic Adjuncts to Orthognathic Surgery 3

Camouflage Cosmetic Surgery Box 3

Camouflage cosmetic surgeries typically involve Goals of cosmetic maxillofacial surgery
creating changes to the skin–soft tissue envelope Correction of functional deformities that affect
without osteotomies and repositioning of the appearance
underlying skeletal structures. These surgeries
Enhancement of the patient’s self-esteem and
classically include the use of facial implants, soft
quality of life
tissue augmentation or reduction/liposuction,
and rhinoplasty. Achievement of the patient’s desire for
improved maxillofacial contour
INITIAL EVALUATION Achievement of the desired change in bone
and/or soft tissue maxillofacial contour
Patients should be directed to provide both written Stable clinical results
and verbal rationales for their desire to seek or-
Satisfaction of the patient’s desire for change in
thognathic and/or cosmetic surgery. A thorough
maxillofacial contour
history of previous trauma and cosmetic or orthog-
nathic surgery should be documented. Medical Appropriate understanding by patient (and
history and the appropriate consults need to be family) of treatment options and acceptance
of the treatment plan
established before any procedures are performed.
Appropriate understanding and acceptance by
Physical Examination and Diagnosis patient (and family) of favorable outcomes
and known risks and complications
Skeletal discrepancy
Adapted from Fattahi T. 2012 AAOMS parameters of
Soft tissue discrepancy
care. AAOMS ParCare 2012. J Oral Maxillofac Surg
Combined deficiencies 2012;70(Suppl 3):e1–11.

A finalized treatment plan involving both the or-

thognathic and cosmetic adjuncts should be es-
tablished and presented to the patient.
possibly prolapsed orbital contents.5 Traditional
For patients interested in adjunctive cosmetic
Le Fort I advancements do not address these de-
surgery related to orthognathic surgery, a classic
ficiencies. A high Le Fort I (or level II–III) may be
orthognathic surgery examination and analysis
treatment planned, or the use of facial cheek or
should be performed. Orthognathic evaluation
rim implants may obviate the more aggressive os-
should reveal and categorize hard tissue defor-
teotomy. The skeletal correction often completely
mities. In addition, an appropriate examination of
corrects the soft tissue deformity, eliminating a
the skin–soft tissue envelope includes evaluation
need for soft tissue surgery. These same patients
of solar damage, skin elasticity, skin thickness,
may also present with nasal deformities secondary
skin glandularity, and the presence of any existing
to a deficient nasal pedestal. The deformities
scars. These aspects of skin health and resiliency
associated with maxillary deficiency and the pre-
may dramatically affect how the skin–soft tissue
dictable changes as a result of Le Fort I correction
envelope redrapes after a procedure. Systematic
are well described in the literature.4,6,7 A ptotic
evaluation of sites amenable to recontouring
nasal tip or relative nasal dorsal hump may be
should also be performed. Contour deficiencies
apparent on presentation; however, once the
are typically categorized as being caused by
maxillary position is optimized, a rhinoplasty may
hard tissue, soft tissue, or combined deficiencies
or may not be indicated.8,9 Mandibular hypoplasia
(Box 3).
similarly may coexist with chin hypoplasia and an
obtuse cervicomental angle.10 This combination
Hard Tissue Deformity Only: Soft Tissue
may require genioplasty and cervicoplasty with
Deformities Primarily Caused by Skeletal
submental lipectomy, in addition to mandibular
Deformities
advancement.
Certain orthognathic skeletal discrepancies are Knowledge of the combined or associated dis-
highly associated with predictable aesthetic soft crepancies aids in an accurate diagnosis and en-
tissue deformities, with no true soft tissue deficit ables the surgeon to present the appropriate
or excess present. Maxillary anterior-posterior hy- treatment options to the patient. For patients in
poplasia often coexists with malar hypoplasia whom a soft tissue deformity is suspected, but is
involving deficiency of the infraorbital rims in single not certain, it is appropriate to plan a delayed peri-
or multiple dimensions. This condition in turn pre- operative approach to soft tissue corrective
sents as a soft tissue tear trough deformity and surgery.
4 Mohamed & Perenack

Soft Tissue Deformities right, profile left and right) In addition, when under-
taking rhinoplasty, obtaining worm’s-eye and
Areas of soft tissue deficiency/excess should be
bird’s-eye view photographs is recommended.
further categorized in relation to the deep fat pad
When treating deformities of the ear, a true sub-
layer or superficial fat pad layer. Areas of muscle
mental view revealing the conchal-mastoid and
hypertrophy or atrophy should be noted. Any
conchal-scaphoid angles should be obtained.12
motion-related abnormalities of facial expression
Imaging of the planned contour changes allows
should be explored for cause. In the aged patient,
a dialogue between the surgeon and patient of the
atrophy of the deep fat pads often dictates areas
intended surgical goals. Imaging should be con-
for soft tissue augmentation. For these patients
servative to prevent overpromising and should al-
soft tissue volume loss may present in the temple
ways be accompanied by the caveat that there is
(temporal fat pad and temporal extension of
no implied guarantee of results.
buccal fat pad), the anterior cheek (suborbital oculi
As a standard, the primary goal when ap-
fat [SOOF] layer), the submalar region (buccal fat
proaching orthognathic patients is to determine
pad), and occasionally in the subplatysmal region
both the hard and soft tissue discrepancies that
(subplatysmal fat pad). Contour deformities of
exist, to ask the patients their specific goals
the orbit, nasolabial fold, marionette line, and
and desires (nonsurgical vs surgical adjuncts),
prejowl may be developmental or age related
and to establish realistic expectations. The limita-
because the bony lateral orbit, pyriform rim,
tions of what orthognathic surgery can achieve
mandibular angle, and prejowl all undergo remod-
need to be explained and the adjunctive proce-
eling and resorption with age.11 In the previously
dures should be clearly defined. This approach
operated mandibular orthognathic patient partic-
not only fully informs the patient but also allows
ular attention should be paid to the integrity of
a better decision to be made by all parties
the line of the inferior border. Overlying superficial
involved (see Box 3).
fat pad atrophy or hypertrophy may add to a con-
It is ideal to obtain both preoperative and post-
tour deformity and need to be addressed. Defor-
operative photographs, at least 3 months after
mities associated with hypertrophy of the
surgery and after any debanding. Careful evalua-
superficial fat pad are most noticeable in the areas
tion of achieved versus predicted results is critical
of the nasolabial fold, the jowls, and submentum.
for cosmetic facial/orthognathic surgeons to
Atrophy of the superficial fat pad is often seen in
improve their diagnosis, treatment planning, and
the aged patient and contributes to a deflated
technique.
look to the face with loss of overlying skin resil-
iency. Superficial fat pad hypertrophy is often
ANATOMY
best addressed with some type of liposuction. At-
Facial Adipose
rophy in this layer may dictate that soft tissue
augmentation be performed. Chin position, height, The facial/neck adipose tissue is present in super-
and symmetry should be evaluated along with the ficial and deep planes. The face represents
associated labiomental crease. Cervicomental approximately 80% of adipose tissue with the
angle and hyoid bone position should be neck assuming the remaining 20%. Superficial
documented. fat is a continuous layer intertwined in a dense
weblike network of fascia extending from superfi-
Combined Hard and Soft Tissue Deformities cial fascia to dermis, making up more than half of
the facial fat. The deep fat (44%) is contained in
In the presence of a severe skeletal deformity, the loosely supported fascia and is divided into
degree of soft tissue deformity may be particularly discreet fat pads.13
difficult to quantify or plan treatment for. In these
situations, a delayed or sequenced cosmetic pro- Retaining Ligaments of the Face
cedure should be considered. The patient should
be informed of the possible need for adjunctive The true and false ligaments represent the soft tis-
perioperative cosmetic surgery to achieve an sue support structures of the face. These
optimal, predictable aesthetic result. anchorage points aid in resisting facial aging. Un-
derstanding the anatomy and manipulating these
anchorage points is important in achieving
Photography
aesthetic outcomes.5 The true ligaments of the
Photographs are an essential part of the consulta- face extend from the periosteum to dermis and
tion process and the medical legal record. Stan- are made up of the orbital, zygomatic, mandibular,
dard, 6-view photographs are generally taken and buccomaxillary ligaments. The false ligaments
(front-repose, front-smile, three-quarters left and extend between the fascial structures and consist
 Aesthetic Adjuncts to Orthognathic Surgery 5

of the platysma-auricular, masseteric-cutaneous, Table 2

and buccal-maxillary (Table 1). Skeletal and soft tissue remodeling with age
Changes Associated with the Aging Face Women Men
Predictable skeletal remodeling takes place Upper Face
among men and women with aging. Women lose Less Decrease in More decrease in
more soft tissue volume and experience a skeletal width skeletal width
decrease in facial height with age, whereas men More decrease in soft More stable soft
retain a more stable soft tissue envelope and tissue envelope than tissue envelope
have greater changes in skeletal width (Table 2). men than women
Therefore, soft tissue augmentation being per- More loss of height —
formed with orthognathic surgery must consider (convexity)
these likely changes.14,15 Midface
Stable Stable width
TREATMENT PLANNING More decrease in soft —
tissue envelope
Treatment planning adjunctive cosmetic proce- Lower Face
dures to occur simultaneously or perioperatively Width decreases Increase in width
with orthognathic surgery should take into account Downward and More forward
predictable soft tissue changes that occur with backward rotation of the
skeletal realignment. mandibular rotation mandible and
increased
Soft Tissue Changes Associated with prominence
Orthognathic Surgery
The soft tissue changes associated with orthog-
an airspace between the maxillary central incisors
nathic surgery have been well described.6,7,9,16
and the upper lip may introduce some variability.
Mandibular Surgery Stella and colleagues18 determined that
completely accurate predictions cannot be made
Mandibular surgery produces close to a 0.9:1 soft/ as a result of variation in lip thickness among indi-
hard tissue change regarding pogonion to point B, viduals. Changes in the display of the upper cen-
when minimal changes of soft tissue thinning tral incisors with maxillary superior or inferior
occur. Less predictability of this ratio occurs in pa- repositioning approaches a 1:1 ratio. Advance-
tients with a significantly thick soft tissue chin ment of the maxilla may increase incisal display
prominence. Lower lip changes of up to a 0.75:1 at a ratio approaching 0.5:1. With maxillary retru-
ratio, with considerable variation, is present in ad- sion, the soft tissue follows the maxillary incisor
vancements versus setbacks. Bell and Dann17 re- approximately 0.76:1 in a horizontal plane and
ported results of patients undergoing genioplasty 0.38:1 in a vertical plane, as described by
(both ASO and silicone implants) finding a mean Schendel and colleagues.19 The nasolabial angle
ratio of soft tissue response to advancement at changes approximately 1.2 for every 1 mm of
pogonion of 0.6:1.6,10,16 change in hard tissue, with increases in advance-
ments and inferior repositioning, and decreases
Maxillary Surgery in impaction and maxillary retrusion. Vasudavan
Maxillary advancements in which V-Y closure is and colleagues8 reported that maxillary advance-
involved show consistent lip and soft tissue to ment elevates the nasal tip, increases nasal tip
hard tissue ratios of 0.9:1.6 The presence of protrusion, and reduces the nasofrontal angle.
The effect of maxillary surgery on alar base
widening has been largely corrected with alar
Table 1 cinch procedures.
True and false ligaments of the face

True Retaining False Retaining TREATMENT PLANNING RHINOPLASTY

Ligaments Ligaments
Addressing a nasal deformity, whether functional
Orbital Platysma-auricular or cosmetic, deserves particular attention. The
Zygomatic Masseteric-cutaneous central position of the nose relative to the face cre-
Buccal-maxillary Buccal-maxillary
ates a situation in which even minor asymmetries
Mandibular —
or deformities of 1 mm or less are readily apparent.
6 Mohamed & Perenack

Mandibular osteotomies show minimal change nasal to an oral intubation after the mandibular os-
to the nasal structures; however, advancing or ret- teotomy is completed (Fig. 1).
ruding the mandible increases or decreases the Maxillary movements are reported to affect
prominence of the chin, respectively. The percep- nasal tip rotation by 20% to 30%. Maxillary ad-
tion of a more or less prominent chin creates the vancements create several predictable changes
illusion of a smaller or larger nose respectively. to the nose, which include increases in nasolabial
Therefore, the mandibular movement should be angle, alar base widening, and an increase in tip
taken into consideration when shaping the nose. projection. Maxillary superior repositioning de-
Nonetheless, Waite and colleagues20 reported no creases the appearance of a dorsal hump through
absolute contraindications for concomitant nasal increases in nasal projection and superior rotation
surgery with mandibular osteotomies, citing the of the nasal tip. A decrease in nasolabial angle and
high predictability of the soft tissue response. alar base widening also occurs. The amount of
Placement of the endotracheal tube dictates nasal tip change in 3 dimensions is difficult to pre-
sequencing the mandibular osteotomies before dict accurately, because nasal tip projection de-
rhinoplasty. It is recommended to change from a pends 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 7

maxillary position.9 Long-term scar contracture at the time of maxillary surgery or, more optimally,
and healing of the tip adds to the unpredictability at a perioperative date allows the reduction of up-
of tip procedures. Controversy surrounds whether per lip length and increased incisal display
simultaneous rhinoplasty with maxillary orthog- (Fig. 2). This procedure is especially useful in
nathic surgery should be performed. Waite and older patients, in whom longer lips are generally
colleagues20 described simultaneous rhinoplasty present. Predictable changes that occur with ag-
with maxillary and mandibular osteotomies as hav- ing include loss of lip volume and architecture,
ing a positive patient response. The indications for lip lengthening and inversion, and rhytid formation
simultaneous rhinoplasty are moderate dorsal de- secondary to accumulated actinic damage and
formities and minor abnormalities of tip muscle mimetics. Liplift surgery is indicated for
morphology and alar base. The contraindications any patient with a longer upper lip, inadequate
are patient-directed minor changes in the nasal vermillion display/eversion, and inadequate
tip position and shape. These parameters depend maxillary incisal display. It may be performed
on the degree of maxillary movements. Rigid fixa- simultaneously with mandibular surgery or as a
tion of the maxilla is emphasized along with alar camouflage procedure.22
cinching sutures and V-Y closure of the lip.20,21
For the discerning (picky) rhinoplasty patient, it Excess Gingival Display
is ideal to separate the maxillary and nasal sur-
geries. If the decision is made to perform the rhino- Patients with vertical maxillary excess may show
plasty at some point after a maxillary surgery, it is some residual degree of excess gingiva when
important to allow most soft tissue edema and smiling after maxillary superior repositioning. Add-
scar contracture to occur before proceeding. A ing volume to the body of the upper lip typically
minimum of at least 3 to 6 months is recommen- displaces the margin inferiorly, gaining 1 to 2 mm
ded depending on the degree of maxillary surgery. of gingival coverage (Fig. 3). Lip volumizing is
When maxillary surgery is performed before nasal most easily achieved with 0.5 to 1.0 mL of hyal-
surgery, it is important to maintain as much septal uronic acid (HA) injection into the body of the
cartilage as possible to provide building materials vermillion. Injectable HA is also effective in
for the rhinoplasty. creating more defined lip architecture, roll, and
pout. At present there are no permanent US
TREATMENT PLANNING ADJUNCTIVE LIP Food and Drug Administration (FDA)–approved in-
SURGERY jectables for lip augmentation. For body volumiz-
Long Lip/Inadequate Incisal Display ing of the lips, free fat transfer has been used
with some success, as has translip placement of
Maxillary movements are largely dictated by the rolls of autologous fascia, dermis, acellular cadav-
desired amount of tooth display at repose. Excess eric dermis, and polytetrafluoroethylene (PTFE)
or inadequate incisal display may be secondary to implants. For patients with a very thin display of
vertical skeletal deformities in the maxilla or the upper lip vermillion, a subnasal liplift is recommen-
soft tissue length of the upper lip. If a patient pre- ded to achieve greater lip eversion before
sents with a long upper lip, obtaining the optimal augmentation of the body of the lip.22
incisal display may cause the maxilla to be placed
more inferiorly than is ideal, which can create
Facial Augmentation or Recontouring
more patient morbidity because a bone graft
may be required to support an inherently less sta- In augmenting the angle of the mandible, chin, or
ble movement. A subnasal liplift performed either cheek, several options exist. The areas can be

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

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

addressed with an osteotomy, a solid implantable Solid Implant Materials

device, or an injectable material.
Solid silicone rubber
As previously discussed, modifications in os-
Silastic (silicone rubber) facial implants are avail-
teotomy design allow favorable changes to areas
able in multiple sizes and can be used in multiple
of concern. The advantages of using modified os-
areas of the face, including temples, orbital rims,
teotomies are versatility, permanence, and no
malar, submalar, piriform aperture, nasal dorsum,
foreign material being introduced, excepting fixa-
chin, and mandibular angles. Silastic implants
tion. The disadvantages include the permanency
are easily modified during surgery to the desired
of change; the unpredictability of the soft tissue
shape and conformation. The implants do not
response, particularly in the midface region; pro-
contain any pores, eliminating fibrous ingrowth
longed recovery; asymmetry; sensory distur-
and reducing the inflammatory response. Custom
bance; and inferior border notching.
Silastic implants may be created using virtual
Solid implantable devices are able to address
surgical planning. A soft tissue pocket is created
most hard tissue augmentation goals. The
slightly larger than the implant, which is then
advantages of implantable devices include a pre-
secured either with a screw or suture. Bony
determined size, minimal chance of sensory
resorption, implant infection, and implant
disturbance, ability to modify the implant or cus-
displacement have been noted. Silastic implants
tomizable implants, and ability to remove the
are soft and inherently unstable when cantilevered
implant at a later time. The disadvantages are
and unsupported by bone, and thus are prone to
related to the small possibility of a foreign body
shifting and/or bony resorption.
reaction, early or late implant infection, move-
ment of the implant or shift over time, difficulty
in correcting large vertical deficiencies, scar, Porous polyethylene
and asymmetry between implant positions. Preformed implants are available in the form of a
Peri-implant bone resorption has also been high-density polyethylene that contains pores
documented. Several materials are currently sized at 100 mm. The pore volume constitutes
FDA-approved for implantable devices. more than 50% of the product. Implants are avail-
Many FDA-approved nonpermanent injectable able in preformed or custom-shaped sizes similar
fillers (and 1 permanent filler) are currently avail- to Silastic implants. The preformed product is
able for recontouring in the face. Advantages of easily carved to the desired shape during surgery.
injectable fillers include ease of application Placement is in a subperiosteal plane and the im-
with little to no patient downtime; exceptional plants can be secured with titanium screws to
precision with small augmentations; and versa- inhibit migration. Tissue ingrowth occurs through
tility. Disadvantages include lack of permanence the large pore size. The complication rate associ-
with additional cost incurred over the lifetime of ated with the use of porous polyethylene (PPE) is
the patient; difficulty in creating large hard and low, with fracture and infection being reported. Ap-
soft tissue augmentations; and limited ability to plications that have been reported for PPE include
cantilever small hard tissue augmentations. orbital reconstruction, rhinoplasty, midfacial skel-
Injectable fillers present an optimal option for eton augmentation, cranioplasty, and auricular
correcting small bony defects or notching after reconstruction. The solid nature of the PPE implant
osteotomy. better allows it to cantilever from bone, unlike
 Aesthetic Adjuncts to Orthognathic Surgery 9

Silastic. However, because of this same charac- fat transfer offers another option for semiperma-
teristic, PPE implants do not as easily conform to nent or permanent soft tissue augmentation, but
irregular surfaces and are more prone to postoper- is considered a surgical procedure. The variety of
ative asymmetries. handling characteristics found in injectable mate-
rials currently offers the surgeon a remarkable
Polytetrafluoroethylene versatility in correcting soft tissue deformities.
Expanded PTFE (Gore-Tex) is a less commonly The ideal filler possesses safety, efficacy, and is
used implantable device that has a long history practical. The different G0 of fillers allows layering
of medical application. Gore-Tex has pores of of material such that less viscoelastic materials
approximately 22 mm. The pores allow fibrous are placed more superficially, mimicking fat, and
ingrowth and incorporation into the implant. firmer fillers are placed deeply, mimicking hard
PTFE is extremely biocompatible, with low compli- tissue.23
cation rates documented. Implant hardening and
fracture are the most common complications. Hyaluronic acid
HA is present in all organisms. It is found in the
Injectable materials proteoglycan portion of mesenchymal tissues.
Injectable fillers allow the surgeon to precisely The introduction of HA fillers has allowed quick
augment the face in a nonsurgical technique with and reversible modification of many soft tissue de-
minimal downtime. The use of soft tissue fillers formities. The advantages of HA fillers are minimal
can be categorized by their degree of permanence to no downtime, immediate results, and revers-
and the viscoelasticity (G0 ). HA is the most ibility. Disadvantages include technique sensi-
commonly used filler material in the United States tivity, lack of permanence, and the possibility of
and offers good versatility, with several viscosities asymmetry. Cost per unit volume also represents
available. A high degree of cross-linking in HAs a significant disadvantage. Several forms of HA
creates a viscous injectable material. Because a are available in the United States (Table 3).
gel resists movement it is better able to displace The primary areas for HA include nasojugal folds
overlying tissue. More viscous fillers are currently (tear trough), malar region, nasolabial folds, perio-
available than the hyaluronics, principally calcium ral rhytids, marionette lines, jowls and angles of
hydroxyapatite. At present only 1 FDA-approved the mandible, and the lips.
synthetic permanent injectable is available. Meth- If HA filler is placed injudiciously, or evidence of
ylmethacrylate spheres contained within a degrad- clumping exists, hyaluronidase can be injected
able bovine collagen carrier create a firm collagen directly into the site, which effectively degrades
response that mimics hard tissue. Autologous free the filler.23,24

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

Delivery
Source Trade Name Use Duration Technique Approved
Bacterial Restylane Moderate depth 12 mo Mid-dermal FDA and HPB
cultured and
stabilized
Bacterial Perlane Deep defects, 12 mo Deep dermal FDA and HPB
cultured and shaping facial
stabilized contours
Bacterial Juvederm Ultra Ultra: moderate 12–18 mo Mid-dermal to FDA
cultured and and Ultra Plus depth deep dermal
stabilized Ultra Plus: deep,
shaping facial
contours
Bacterial Belotero Superficial, 12 mo Mid-dermal to FDA
cultured and moderate, and deep dermal
stabilized deep
Bacterial Voluma Deep 12–24 mo Deep dermal to FDA
cultured and supraperiosteal
stabilized

Abbreviation: HPB, Health Protection Branch.

10 Mohamed & Perenack

Calcium hydroxyapatite rim. Augmentation is in the submuscular plane

Calcium hydroxyapatite is a bioceramic semiper- above the periosteum, often in the SOOF pad, to
manent material that is nonirritating to tissues. prevent visible clumping or nodule formation.27
Radiesse (Radiesse, Bioform, San Mateo, CA) is Once injected, the area is gently massaged. Re-
supplied as a single-use sterile, ready to use paste sults are immediate (Fig. 4).
in 0.8-mL and 1.5-mL syringes. The calcium hy-
droxyapatite is suspended in an aqueous gel and Malar region: dermal and subdermal planes.
contains glycerin and sodium carboxycellulose. Higher G0 injectables provide results that rival
When injected, there is a 1:1 immediate product solid implantable devices.
to soft tissue response. At present it is used for Nasolabial folds: dermal and subdermal planes.
soft and hard tissue facial augmentation, the mate- Marionette lines: dermal and subdermal planes.
rial is degraded by macrophages over time, and Prejowl: layering of filler through dermal, sub-
lasts 1 to 2 years. Because of the material’s high dermal, and supraperiosteal planes.
G0 and robust collagen-stimulating response, it Angle/inferior border: placed beneath masseter
represents a particularly useful filler for hard tissue muscle and immediately supraperiosteal.
augmentation of angles, cheeks, and bony defects Lips: placement of the filler can be to recreate lip
that are seen after osteotomies. It is not recom- architecture or to restore fullness. In recreat-
mended for lip augmentation.25,26 ing lip architecture, the area injected follows
the vermillion border and defines the shape
Polymethyl methacrylate of the lip. Restoring fullness requires place-
The polymethyl methacrylate (PMMA) that is used ment into the body of the lip deep to the sub-
in the United States is marketed as Artefil. It con- mucosa. Injecting into the body of the lip has
sists of homogeneous PMMA microspheres shown decreases in incisal show ranging from
(20%), evenly suspended in a solution of partly de- 1 to 3 mm, which benefits individuals with
natured 3.5% bovine collagen (80%), thus requiring excess gingival show but may create a nega-
skin testing for hypersensitivity. The product is tive result for patients with optimal or subopti-
premixed with lidocaine. The collagen contained mal incisor display.11,28
in the product is absorbed over 3 months and is re-
placed with native collagen. The PMMA micro-
spheres serve as a collagen stimulus, resulting in
Cervicoplasty, Platysmaplasty, and
encapsulation of the individual spheres by collagen.
Rhytidectomy
After completion of the remodeling process, the Lipomatosis in the submental region may coexist
augmented area consists of 80% native collagen with mandibular skeletal deformities. Undesirable
and 20% PMMA microspheres to form a pliable overcontoured nasolabial and jowl fat may also
implant. As an injectable filler, it is ideal for perma- be present. In cases of a mandibular setback, pre-
nent correction of minor (1–2 mL) hard tissue viously minor problems may become exacer-
defects.24 bated. Jaw advancement or chin augmentation
may improve the contours of these fat pads.
The submentum can be addressed with lipos-
PLACEMENT OF INJECTABLES
culpting, skin tightening, and platysma tightening.
Tear Trough
Although mandibular advancements positively
Placement of the filler is in the nasojugal folds and alter the cervicomental relationship, to appropri-
in areas of fat atrophy just below the inferior orbital ately address submental lipomatosis, platysmal

Fig. 4. Tear trough deficiency reduction with an injectable HA filler and simultaneous lower blepharoplasty.
 Aesthetic Adjuncts to Orthognathic Surgery 11

banding, and platysma ptosis with the associated Iatrogenic Deformities Created as a Result of
skin, additional cervical alterations must be Orthognathic Surgery
accomplished.
Orthognathic surgery occasionally creates an un-
The predictability of soft to hard tissue changes
desired cosmetic result that requires attention
favors simultaneous modification of the chin.
either perioperatively or at a distant time.
Epker and Stella29 describe simultaneous lipec-
tomy with orthognathic surgery with favorable re-
sults to patients. Fattahi5 describes addressing Facial asymmetries
the submental liposuction and/or platysmaplasty Facial asymmetries may be noticed periopera-
simultaneously with mandibular osteotomies with tively or at a later date. Asymmetries may be the
safety (Fig. 5).5,30–35 result of an inadequate or flawed orthognathic
Submental liposuction can be performed with treatment plan and surgical work-up, or intraoper-
ease before or after advancement or setback of ative error in technique. Patients who have pro-
the mandible. If platysmal banding or ptosis is be- found facial asymmetries at consultation often
ing addressed, an approximately 1.5-cm incision cannot be completely corrected even by the
is placed in the submental crease and the pla- most skilled of surgeons. If a surgical error is
tysma is incised and reapproximated in a running apparent, reoperation and correction of the os-
fashion. In situations involving excess skin, the teotomies is optimal. However, when this is not
appropriate avenue may involve a necklift proce- feasible or agreeable to the patient, camouflage
dure or lower traditional facelifting. Appropriate re- procedures may be attempted. The deficient
covery time from the osteotomy before soft tissue side of the face may be augmented with any or
augmentation may yield superior results in these all of an implantable device, injectable filler, or
cases. fat transfer, depending on the nature of the defi-
ciency. The overcontoured side of the face may
be reduced by surgically reducing bone or selec-
Sequence for Closed Submental Liposuction tive liposuction.
The patient is placed in the upright position for skin
marking. Tumescent infiltration with a dilute lido- Bony notching
caine solution containing epinephrine is injected Bony notching can be seen at the site of osteoto-
in the subcutaneous plane. Stab incisions are mies of the mandible most notably after bilateral
created at the earlobes and submentum and, if na- sagittal split osteotomy (BSSO) and genioplasty.
solabial folds are added, incisions are made at These notches may be addressed either by injec-
each ala. Lipodissection (1.5-mm to 2-mm can- tion of permanent filler immediately supraperios-
nulas) followed by closed liposuction using teally, with a solid implantable device, or through
increasing diameter (2–3 mm) cannulas with feath- bone grafting. PMMA injectable filler offers a sim-
ering is ultimately performed. For liposuction per- ple resolution to this problem (Fig. 6).
formed above the mandibular border, use of
smaller cannulas (1.0–2.0 mm) is preferred. If a Motion abnormalities
large midline submental fat deposit is noted, it is Motion abnormalities related to hyperfunction are
recommended that the area is opened in the sub- rarely seen in patients after orthognathic surgery.
cutaneous plane using facelift scissors, and lipo- These conditions may be addressed by intramus-
suction under direct vision is performed. A cular injection of botulinum toxin A. Patients are
simultaneous platysmal plication can then easily typically injected in the hyperfunctioning muscle
be performed if desired. 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.
12 Mohamed & Perenack

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 hard tissue anatomy, as well as the changes that
and no further treatment is needed. result from orthognathic surgery, is imperative in
achieving optimal results for patients.
DISCUSSION
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