Abstract
Orthognathic surgery leaves the intrinsic volume of the facial soft tissues untouched, sometimes resulting in unsatisfactory improvements in aesthetics. The aim of this study was to evaluate the aesthetic outcomes and patient satisfaction following bimaxillary orthognathic surgery with or without simultaneous facial lipofilling procedures. The preoperative and postoperative facial appearances of 210 patients were compared through analysis of photographs and postoperative clinical evaluation. A patient questionnaire was used to assess the perceived improvement in aesthetics. One hundred and twenty patients (mean age 20.3 years) underwent bimaxillary orthognathic surgery and simultaneous facial lipofilling procedures (group I). The remaining 90 patients (mean age 19.8 years) underwent skeletal procedures only (group II). The overall aesthetic improvement was similar in the two groups (group I 92.5%, group II 91.1%). Greater higher-level aesthetic improvement scores were recorded for group I (group I 80%, group II 55.6%). The overall patient satisfaction was 98.3% for group I and 97.8% for group II. Greater higher-level satisfaction scores were recorded for group I (group I 14.2%, group II 6.7%). The simultaneous use of the autologous fat micrograft is a promising technique that may improve the aesthetic outcomes of orthognathic surgery, leading to greater patient satisfaction.
Corrective jaw surgery, termed orthognathic surgery, is used to treat a variety of facial and jaws abnormalities in which the upper and lower jaws and the teeth are not in an acceptable relationship. In most cases, orthognathic surgery is carried out not only to correct the malocclusion and related stomatognathic function, but also to improve facial aesthetics. O’Ryan and Lassetter reported that, from the patient’s perspective, the success or failure of the orthognathic surgical procedure depends mainly on the resulting facial beauty. Orthognathic surgery changes the skeletal framework providing well-balanced support for the facial soft tissues, but leaves the intrinsic volume of the soft tissues untouched. In daily practice, we experience how these surgical movements of the hard framework can sometimes highlight and even worsen the intrinsic lack of volume of the soft tissues. The fullness of the soft tissues is a key component of a youthful and attractive facial appearance. The autotransplantation of fat micrografts is a well-known technique in facial aesthetics and reconstructive surgery recontouring. However, structural fat micrografting represents a novel application in orthognathic surgery.
The autologous fat micrograft technique is relatively easy to perform, but there is as yet no agreement on the methods that should be used for harvesting, processing, and injecting the fat. Moreover, some disadvantages of the strict usage of Coleman’s principles and tools have been revealed recently, such as unpredictable fat resorption, facial contour irregularities, and long-term asymmetries. Therefore, new operative protocols have introduced several modifications to the original technique of Coleman in order to obtain more predictable results. Currently, the harvesting procedure is carried out using small cannulae (2 or 2.4 mm) with very small holes (1.0-mm diameter). The material harvested is then processed and purified by washing and cleaning, by decanting, or by centrifugation. The injection is performed using very small, smooth probes (0.9-mm diameter).
The purpose of this study was to evaluate the aesthetic outcomes and patient satisfaction following bimaxillary orthognathic surgery with or without simultaneous facial lipofilling procedures. Performing the autologous fat micrograft technique in conjunction with orthognathic surgery during a single operation may result in an increased volume of the facial soft tissue envelope, thus leading to improved aesthetic outcomes and patient satisfaction. The specific aims of the study were to clinically evaluate the pre- and postoperative facial appearances of patients who had undergone bimaxillary orthognathic surgery with or without simultaneous facial lipofilling procedures, to score the aesthetic outcomes achieved, and to assess the postoperative patient satisfaction with the aesthetic outcomes.
Patients and methods
An analysis of 210 patients who underwent bimaxillary orthognathic surgery between January 2007 and June 2010 was performed. This study was carried out in accordance with the guidelines of the Declaration of Helsinki and was approved by the local ethics committee. The patients included in this study were treated consecutively; there was no patient selection. Patients were divided into two groups: those who underwent bimaxillary orthognathic surgery in conjunction with a facial lipofilling procedure (120 patients) and those who underwent bimaxillary orthognathic surgery performed alone without adjunctive facial lipofilling procedures (90 patients). All patients had requested orthognathic surgery for functional and aesthetic complaints. None of the patients received a secondary jaw surgery or had undergone a previous facial lipofilling procedure. Furthermore, none of the patients underwent genioplasty and/or inferior border reshaping and/or rhinoplasty. All procedures were performed by the same surgeon. The maxillary surgery was performed using a Le Fort I maxillary osteotomy, and the mandibular surgery was performed using the bilateral sagittal split osteotomy technique with rigid fixation of the bone segments.
Group I comprised 120 patients (90 females and 30 males), with a mean age of 20.3 years (range 17.2–31.6 years). The patients’ dentoskeletal deformities were distributed as follows: 45 cases of class II skeletal malocclusion (37.5%), 40 cases of class III skeletal malocclusion (33.3%), 18 cases of skeletal asymmetry (15%), 9 cases of hyperdivergent facial pattern (7.5%), and 8 cases of hypodivergent facial pattern (6.7%). All 120 patients underwent bimaxillary orthognathic surgery with simultaneous facial lipofilling procedures. In each case, the same lipofilling protocol was performed at the end of the skeletal surgery.
Group II comprised 90 patients (53 females and 37 males), with a mean age of 19.8 years (range 16.0–38.6 years). All 90 patients underwent bimaxillary orthognathic surgery performed alone, without additional facial lipofilling procedures. The patients’ dentoskeletal deformities were distributed as follows: 33 cases of class II skeletal malocclusion (36.7%), 25 cases of class III skeletal malocclusion (27.8%), 16 cases of skeletal asymmetry (17.8%), 10 cases of hyperdivergent facial pattern (11.1%), and 6 cases of hypodivergent facial pattern (6.7%).
The modified Coleman’s technique was adopted, with slight modification, and was updated by the authors for use in the autologous fat transfer. For the patients in group I, various areas of the face were injected, such as the temple, orbit and lids, malar and submalar areas, cheek, lips, chin, mandibular borders, mandibular angles, and any other part of the face requiring augmentation. The fat grafting sites were defined preoperatively for each patient, based on a clinical evaluation performed by the surgical team; these sites were marked on a sheet depicting a reproduction of a face. Complete photographic documentation was obtained preoperatively, including the three-quarters facial view, in order to plan the optimal midfacial contour and mandibular border enhancement.
Fat graft harvesting, processing, and injecting procedures were performed after all of the orthognathic surgical incisions had been sutured. The lateral thigh and lower lateral abdomen were chosen as donor sites for fat graft harvesting. No infiltration or tumescent technique was used. A 3-mm blunt suction cannula (custom-made) was connected to a 10-ml syringe. An adequate amount of fat was gently aspirated using finger pressure on the plunger of the syringe to minimize trauma to the fat particles. The aspirated material was then processed under sterile conditions, and the fat was purified free of blood and oil. Centrifugation was avoided. The material was placed in a tea ball with a very fine filter (holes smaller than 0.4 mm) and plunged into serum at 30–35 °C for 15–20 s. For the injections, the cannulae used were of several different lengths (from 5 to 7 cm) and cross-sections (0.5 and 0.7 mm (custom-made) or 0.9 and 1.2 mm (Tulip Medical, a Division of Black Tie Medical Inc., San Diego, CA, USA)).
Table 1 shows the sites of injection, levels of injection, corresponding recommended cannula types, and ranges of fat amounts injected into the patients in group I. For these patients, the surgical team determined the amount of fluid fat to inject using the extent of the deficiencies in terms of volume or thickness at each facial site. At many sites, the smallest smooth cannula (with a diameter between 0.5 and 0.9 mm, referred to as ‘micro’ in Table 1 ) was used, but a larger cannula (with a diameter of 1.2 mm, referred to as ‘macro’ in Table 1 ) was preferred for the deeper, malar, or mandibular areas.
| Facial site of fat injection | Anatomical level of fat injection a | Type of cannula used for fat injection | Amount of fat injected (ml) |
|---|---|---|---|
| Cheek and submalar | Intermediate | Macro | 2.0–5.0 |
| Medial suborbital | Periosteal | Micro | 1.5–3.0 |
| Lateral orbital and suborbital | Periosteal | Micro | 1.0–3.0 |
| Malar and zygomatic arch | Intermediate, SubQ, periosteal | Micro–macro | 3.0–10.0 |
| Temple and front | SubQ | Micro | 2.0–5.0 |
| Mentum/submentum | SubQ and periosteal | Micro–macro | 2.0–5.0 |
| Superficial tear trough | Periosteal | Micro | 0.3–1.0 |
| Brow roll and upper orbit | Periosteal | Micro | 0.5–3.0 |
| Glabella | SubQ | Micro | 0.5–1.5 |
| White rolls (upper lip) | SubQ and dermal | Micro | 0.3–1.0 |
| Philtral columns | SubQ and dermal | Micro sharp | 0.3–0.6 |
| Upper vermilion | Submucosal | Micro | 0.3–3.0 |
| Lower vermilion | Submucosal | Micro | 0.5–2.0 |
| Mandibular angle prominence | SubQ and periosteal | Macro | 3.0–10.0 |
| Mandibular borders and contours | Intermediate and periosteal | Micro–macro | 3.0–10.0 |
| Paranasal and nasolabial fold | Intermediate and SubQ | Micro–macro | 1.0–3.0 |
| Nasal dorsum | Periosteal | Micro | 0.5–1.5 |
a The ‘intermediate’ level corresponds to virtual spaces. The ‘periosteal’ level could be injected if the periosteum had not been detached to perform the skeletal procedures. Subcutaneous compartments injected with fat are listed as ‘SubQ’.
Three levels of injection were considered: periosteal or deeper, intermediate, and superficial. The periosteal level is above the periosteum in areas not related to the surgical dissection resulting from the jaw osteotomies. The intermediate plane corresponds to virtual spaces. For example, the malar and buccal fat pads underlying the superficial musculo-aponeurotic system or the intermuscular or interligamentous virtual spaces, represent an intermediate level of injection. Fat micrografts were intentionally not injected inside the muscles so that the muscular dynamics were not disrupted and the amount of resorption due to muscular pump activity was reduced. The most superficial anatomical plane of injection corresponds to subcutaneous fat compartments, which have been well described. The fluid status of the injected material allowed for very superficial grafting, such as in the dermal layers of the labial philtral crest or in the white roll border to accentuate the Cupid’s bow. To fill the dermis and define philtral crests, the use of a sharp needle was necessary. Increased lip volumes were obtained by injection into the submucosal level using microcannulae.
Postoperatively, the following were prescribed for all patients: antibiotic therapy for 1 week, 4–8 mg of steroids once a day for 4 days, nonsteroidal anti-inflammatory drugs (NSAIDs) twice a day for 5 days, and calcium and vitamin D3 for 2 months. For patients in group I, the grafted sites of the face were taped with minimal compression for 3–4 days; moreover, these patients were instructed to reduce or avoid movements of the facial muscles and, if possible, to minimize any trauma to the newly formed blood vessels around the injected fat grafts. Patients in both groups followed a liquid diet for 3–4 days and then a soft diet for 6 weeks. In all cases the post-surgery follow-up included assessments at 1 day, 1 week, 2 weeks, 5 weeks, and 6 months, and a long-term assessment at 18 to 48 months.
An evaluation of the pre- and post-surgery facial appearances of each patient was performed by two surgeons and two orthodontists at the end of the follow-up period (18 to 48 months after surgery). By that time any residual swelling had disappeared and the fat and adipose-derived stem cell (ADSC) grafts had definitively taken in the patients in group I. Facial appearance was evaluated through clinical examination and analysis of photographs. In all cases, the clinical evaluation included the occlusal and aesthetic outcomes of the orthognathic surgery and the appearance of the soft tissue envelope. The clinical evaluation included an accurate analysis of the aesthetic improvements to the facial sites usually affected minimally by the hard tissue changes, such as the lips, malar prominence, and parasymphyseal areas. Following this, the patients who had undergone a facial lipofilling procedure were identified (group I), and particular attention was given to the volumetric soft tissue increase, to facial contour definition, and to the areas of fat injection (the midface contour, neck, mandible contour, lips, and chin profile). To assess the surgical aesthetic outcomes achieved for each patient, the medical team defined a simple scale from 1 to 5, with 1 indicating no aesthetic improvement with some imperfections and drawbacks (‘mild drawbacks’) and 5 indicating a major aesthetic improvement (‘very beautiful’). Furthermore, the clinicians investigated the side effects related to the autologous fat micrograft procedure, paying particular attention to swelling, morbidity, possible fat resorption, tissue irregularities, and postoperative complications.
During the follow-up assessment at 18 to 48 months after surgery, all patients were asked to complete a questionnaire to assess the discomfort that they had experienced. Moreover, an aesthetic judgement numerical scale, similar to the Wong–Baker FACES Pain Rating Scale and the 11-Point Box Scale, was administered to the patients to determine whether they perceived postoperative improvements in their facial appearance. This scale was introduced recently by Funk et al. as the Aesthetic Numeric Analogue scale (ANA Scale) for aesthetic assessment purposes. The ANA Scale is scored from 0 to 10, with 0 indicating no perceived aesthetic improvement (‘insufficient’) and 10 indicating the highest degree of perceived aesthetic improvement after surgery (‘perfect’).
Results
After orthognathic surgery, all patients had their dentoskeletal deformities corrected to a class I occlusion, and their chief complaint was fully addressed.
According to the clinicians’ evaluation, patients in both group I and group II showed a noticeable postoperative facial aesthetic improvement. In group I patients, the percentage of aesthetic improvement overall was 92.5% (111 of the total 120 patients), similar to that achieved in group II (91.1%; 82 of the total 90 patients). With respect to higher-level aesthetic improvements scoring 4 (‘evident improvement’) and 5 (‘very beautiful’), the percentage was 80% for patients in group I and 55.6% for patients in group II.
The clinicians considered the aesthetic outcomes of the patients in group I to be ‘very beautiful’ in 52 cases (43.3%), with a remarkable improvement achieved due to the fat micrografting; the results were considered ‘beautiful’ in 44 cases (36.7%), with an evident improvement related to the fat augmentation. Moreover, 15 cases were evaluated as partially improved due to the lipofilling and volumetric increase in facial soft tissues (12.5%). However, seven patients (5.8%) exhibited no noticeable aesthetic improvements due to the lipofilling, and two patients (1.7%) showed some residual imperfections due to the lipofilling. In these latter two groups of patients who did not achieve a noticeable improvement in the soft tissue facial envelope, a repeated lipofilling procedure or some type of corrective procedure was advised. The long-term persistence of tissue irregularities related to defective fat distribution occurred in our sample, but this was rare (two patients, 1.7%). This was due to the use of small clusters, which allowed an easier and well-balanced distribution of the graft materials. Overfilling of the lower lip was noted in three cases, which was treated with targeted microliposuction after several months (2.5%).
The clinicians considered the aesthetic outcomes of the patients in group II to be very beautiful in two cases (2.2%); the results were considered beautiful in 48 cases (53.3%), with evident improvement. Moreover, 32 cases were evaluated as partially improved (35.6%), with a moderate improvement. However, seven patients (7.8%) in group II exhibited no noticeable aesthetic improvements, and one patient (1.1%) showed no noticeable improvements with some residual aesthetic imperfections. The postoperative aesthetic outcomes of all patients, as assessed by the clinicians at 18 to 48 months after surgery, are shown in Fig. 1 .
