An important aesthetic goal in orthognathic planning is to improve facial balance, harmony, volume, and symmetry. It is therefore logical that adjunctive aesthetic procedures become a part of the overall orthognathic treatment plan and that their possibilities are discussed with orthognathic candidates. Such procedures help to improve the final outcome of the orthognathic treatment and enhance patient satisfaction. Training and experience are of utmost importance when offering and performing aesthetic facial surgery. This article discusses various facial aesthetic procedures that can be combined with orthognathic surgery, to the patient’s benefit, to help them become the most beautiful version of themselves.
Key points
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To reach the best outcome of orthognathic surgery it is of importance to have knowledge not only of correct occlusion but also of facial balance, beauty, and harmony.
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To improve facial balance, harmony, and beauty, surgeons should have knowledge of adjunctive facial aesthetic procedures and their possible outcomes.
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The ability to combine aesthetic procedures with orthognathic planning and surgery may enhance patient satisfaction and will make one a more complete surgeon.
Introduction
Aesthetics play an important role in the planning and performance of orthognathic surgery, along with function, occlusion, and airway. An important aesthetic goal in orthognathic planning is to improve facial balance, harmony, volume, and symmetry. It is therefore logical that adjunctive aesthetic procedures become a part of the overall orthognathic treatment plan and that their possibilities are discussed with orthognathic candidates. There is no consensus on what facial beauty is because it differs with time, between cultures, and between people. Professionals like to develop and use all kinds of measurements and analyses to try to objectively determine facial beauty and facial harmony, and thereby to provide guidelines for the planning of orthognathic and other types of facial surgery ( Fig. 1 ). Although there are different analyses at clinicians’ disposal, it is preferred not to treat patients by numbers but rather try to help them become the most beautiful version of themselves. Despite the paradigm shift from two-dimensional orthognathic planning in profile view to more advanced three-dimensional (3D) virtual planning, clinical experience and artistry are still helpful in this respect.
Facial beauty and/or facial rejuvenation enhancement are the two most important reasons for opting for aesthetic facial surgery. These also apply to orthognathic surgery, along with functional improvement. The aim of many aesthetic procedures is to increase or change the volume in different regions of the face (eg, fat grafting, osteotomies of the malar region, alloplastic implants, liposuction), whereas for some it is to change the shape of certain facial parts (eg, rhinoplasty, otoplasty, lip fillers). Facial aging is a process that starts after the age of 25 and generally follows a standard pattern ( Fig. 2 ). Individual variations and the severity of the aging process are not only influenced by genetic factors but also by environmental factors, such as smoking habits and sunlight exposure. There are roughly four factors involved in facial aging: (1) loss of volume (deflation), (2) displacement of tissues, (3) loss of elasticity, and (4) skin changes. Orthognathic advancement surgery of either jaw increases the facial volume, thus having an antiaging effect on younger patients and a rejuvenating effect on older individuals. Advancement of the maxillomandibular complex can enhance lip support, reduce nasolabial folds, and reduce jowling. Bimaxillary advancement, with or without genioplasty, is therefore often referred to as a reversed facelift ( Fig. 3 ). Some aesthetic volumizing procedures can help with enhancing the volume further in different aesthetic regions of the face (eg, by fat grafting and malar augmentation), whereas those procedures aimed at removing redundant tissue can also create a more youthful appearance (eg, lip lift, blepharoplasty, and liposuction).
Aesthetic procedures are categorized as: (1) procedures that enhance the results of orthognathic surgery, and can be performed concomitantly; (2) procedures performed secondarily after a soft tissue edema has resolved and healing is complete; (3) procedures that can address undesired aesthetic changes that have occurred after orthognathic surgery; and (4) procedures that are performed to camouflage certain aspects in patients not desiring optimal orthognathic surgery.
In this article, we discuss different facial aesthetic procedures that are combined with orthognathic surgery, to the patient’s benefit, to help them become the most beautiful version of themselves. This overview is not extensive because certain procedures are covered elsewhere in this issue.
Facial fat grafting
Autologous facial fat transplantation, a commonly applied procedure in aesthetic surgery since the 1980s, is an easy to use, effective, and safe technique with a low complication rate and minimal donor-site morbidity. The latter is because subcutaneous fat is abundantly available in most patients, and is fully biocompatible and conceivably permanent. However, fat grafting studies have reported between 25% and 80% long-term volume retention. This variable amount of volume retention is one of the major disadvantages of the technique and often necessitates repeated surgical procedures, so called touch-up procedures. Nevertheless, the volumizing effect of lipofilling is subtle and soft, creating a more youthful appearance, especially in the periorbital and zygomatic area ( Fig. 4 ). Before starting the procedure, the patient should be examined in an upright position and markings should be made on the area of the skin with a volume deficit to accentuate the area of the planned correction. A series of preoperatively made patient photographs should be available during the process to help in evaluating the plan and the progress of the correction. The procedure starts with injecting the donor site with an infiltration solution (Ringer solution or sodium nitrate combined with lidocaine 2%) followed by gentle manual liposuction, usually using a 10-mL Luer lock syringe, 2-mL negative pressure, and a blunt cannula with a small diameter (2.4 mm) and small holes. The fat is then processed with centrifugation, washing, or decantation techniques. Recent research points to a slightly beneficial outcome, regarding fat cell viability, from the washing method. The fat is subsequently injected into the subcutaneous tissues of the target areas of the face using a small blunt cannula (0.9–1.2 mm diameter). According to a recent study, there is site-dependent variation in volumetric retention after facial fat grafting, with the zygoma area showing a 40% volumetric effect 1 year posttreatment compared with an unmeasurable volumetric effect in the lip area using a 3D measuring method.
To enhance volume retention of the grafted fat, several fat enrichment strategies are being investigated, including adding: adipose tissue–derived stromal cells; tissue stromal vascular fraction; cellular stromal vascular fraction; and nanofat, microfat, and platelet-rich plasma or fibrin to the grafted fat. Even though some studies show a promising beneficial effect of these additives regarding volume retention, high-quality research, with proper volumetric measurements, is lacking. Fat grafting results in excellent soft volume enhancement, which is beautiful. However, fat grafting does not always provide enough projection, for instance to enhance the cheekbone area. In such situations, the fat can be too soft in its augmenting effect. Facial implants, or an intraoral zygoma osteotomy, can then be indicated. Fat grafting can also be used as an adjunctive procedure to implant placement or zygoma osteotomy to create more projection and softness. When combined with an osteotomy, the fat grafting procedure should, preferably, be performed immediately after the osteotomy so the apparent effect of the osteotomy on the face can then be taken into account and swelling has not yet occurred.
Soft tissue fillers
The use of soft tissue fillers has increased tremendously. In 2019, almost three-quarters of a million procedures were performed in the United States alone. Soft tissue fillers are predominantly resorbable and basically have two variations: hyaluronic acid (HA) fillers and biostimulatory fillers. Since the Food and Drug Administration approved Restylane (Q-med, Uppsala, Sweden) as an HA filler in 2003, most of the currently used fillers consist of HAs. HA fillers are based on glycosaminoglycan chains that coil in on themselves, resulting in a viscous and elastic matrix that is hydrophilic in nature. These fillers are easy to apply, not time consuming, and inexpensive. HA fillers also have an overall low rate of adverse events. The filler degrades over time, with the amount of cross-linking between the glycosaminoglycan chains theoretically changing the clinical half-life. Hence, the volumetric effect of HA fillers varies from 1 to 3 years, depending on the amount of cross-linking and other aspects of the filler, with the maximum effect occurring 1 to 3 months posttreatment. Soft tissue fillers are, in general, applied under local anesthesia in a precise manner using a needle or a cannula varying from 23 to 30 gauge. In the beginning, fillers were predominantly used to smooth out wrinkles but, over the last decade they have evolved into contour and shape defining fillers. The disadvantage of HA fillers, compared with fat grafting, is that the volumetric effect is not permanent, even though some authors claim a collagen stimulatory effect. The advantage over fat grafting is the constant and predictable volumetric effect, which is fairly equivalent in all the soft tissue layers. Therefore, HA fillers are indicated more for the lips than fat grafting ( Fig. 5 ) and may be more effective for subtle defects, such as an A-frame deformity of the upper eyelid, marionette lines, prejowl depression, and mental creases. However, a too superficial injection, such as under the thin skin of the lower eyelid, can cause a blue discoloration of the skin called Tyndall effect, which is thought to occur because of stronger scattering of the blue light spectrum through the colloid particles.
Even though the volumizing effect of some HA fillers lasts for several years, it usually decreases over time, necessitating, as sometimes with fat grafting, touch-up treatments to maintain the desired result. HA filler treatment can be done immediately following an osteotomy, but it is generally performed postoperatively because the procedure is tolerated well and usually smaller volumes are applied compared with lipofilling. Therefore, applying the HA filler 3 to 6 months postoperatively when the edema has largely resolved, and the result of the osteotomy is examined while the patient is in an upright position, is usually preferred. It can even be beneficial to wait with lip augmentation until the orthodontic procedure has been completed and the orthodontic appliances taken out to rule out any projection caused by the appliance on the lips. Application of a lip filler can also compensate for the lack of dental lip support. Small imperfections that remain after, or are caused by the orthognathic surgery, can also be corrected in this manner.
Facial implants
Alloplastic facial implants are easily combined with orthognathic surgery, especially because most implants can be placed subperiosteally through the intraoral incisions that are being used for the orthognathic procedure. Implants can correct bony deficits in a rigid manner, giving a firm projection that mimics the projection of bone and simulates a bony feeling when palpated. Off-the-shelf facial implants are available in different shapes and sizes corresponding to various areas of the face lacking projection. They are modified, if needed, in the operating room using a scalpel. Mandibular angle, chin, and zygoma are especially popular regions to augment. Facial implants are often made of solid silicone rubber, porous polyethylene, titanium, or polyether ether ketone (PEEK). These implants, preferably fixated with screws, have stood the test of time and have proven to be safe. Complications are rare, mainly caused by bacterial biofilm formation and infection, usually leading to removal of the implant. Also, implant displacement can occur and, in time, resorption of the bone underlying the implant may result in loss of projection. Sterilizable 3D-printed bony models of the patient are helpful intraoperatively to estimate how and where the implant has to be modified. This is hard to judge in the patient during the surgery. The evolution of 3D planning has also led to more attention to patient-specific implants (PSIs). PSIs are made from several materials but are mostly made from polyether ether ketone. When combined with 3D osteotomy planning, PSIs give excellent opportunities to correct, for instance, bony asymmetries and shapes in individuals in a precise way. Despite orthognathic surgery being well planned and executed, and correcting asymmetries to a large extent, some asymmetries can remain, especially in the mandible because it is not symmetric. It has proven to be helpful to correct the remaining asymmetries by placing a PSI of the mandibular angle and inferior border. Such implants are fabricated based on mirroring the image of a computed tomography scan that is made around 6 months after the orthognathic procedure ( Fig. 6 ). Nevertheless, soft tissue asymmetries are hard to correct fully with implants and one should consider addressing them with additional fat grafting or filler injections either during implant placement or at a later stage.
