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160. Tokgöz, E., Carola, N., Levitt, S., Patel, V., & Sosa, D. (2023). Robotics applications in total
knee arthroplasty. In Total knee arthroplasty: Medical and biomedical engineering and science
concepts. Springer. ISBN #: 978-3-031-31099-7.
161. Tokgöz, E., Sosa, D., Carola, N., Levitt, S., & Patel, V. (2023). Impact of manufacturing on
total knee arthroplasty. In Total knee arthroplasty: Medical and biomedical engineering and
science concepts. Springer. ISBN #: 978-3-031-31099-7.
162. Tokgöz, E., Patel, V., Carola, N., Sosa, D., & Levitt, S. (2023). Optimization investigations on
total knee arthroplasty. In Total knee arthroplasty: Medical and biomedical engineering and
science concepts. Springer. ISBN #: 978-3-031-31099-7.
163. Tokgöz, E., Patel, V., Sosa, D., Levitt, S., & Carola, N. (2023). Artificial intelligence, deep
learning, and machine learning applications in total knee arthroplasty. In Total knee
arthroplasty: Medical and biomedical engineering and science concepts. Springer. ISBN #:
978-3-031-31099-7.
164. Tokgöz, E. (2023). Advancing engineering of total knee arthroplasty. In Total knee
arthroplasty: Medical and biomedical engineering and science concepts. Springer. ISBN #:
978-3-031-31099-7.
165. Tokgöz, E., & Marina, A. C. (2023). Biomechanics of facial plastic surgery applications. In
Cosmetic and reconstructive facial plastic surgery: A review of medical and biomedical
engineering and science concepts. Springer. ISBN #: 978-3031311673.
166. Tokgöz, E., & Marina, A. C. (2023). Applications of artificial intelligence, machine learning,
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169. Tokgöz, E. (2023). Technological improvements on facial plastic, head and neck procedures. In
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engineering and science concepts. Springer. ISBN #: 978-3031311673.
170. Levitt, S., Patel, V., Sosa, D., Carola, N., & Tokgöz, E. (2023). Preexisting conditions leading
to total knee arthroplasty. In Total knee arthroplasty: Medical and biomedical engineering and
science concepts. Springer. ISBN #: 978-3-031-31099-7.
171.
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in total knee arthroplasty. In Total knee arthroplasty: Medical and biomedical engineering and
science concepts. Springer. ISBN #: 978-3-031-31099-7.
172. Sosa, D., Carola, N., Patel, V., Levitt, S., & Tokgöz, E. (2023). Perioperative patient care for
total knee arthroplasty. In Total knee arthroplasty: Medical and biomedical engineering and
science concepts. Springer. ISBN #: 978-3-031-31099-7.
173. Levitt, S., Patel, V., Carola, N., Sosa, D., & Tokgöz, E. (2023). Complications of total knee
arthroplasty. In Total knee arthroplasty: Medical and biomedical engineering and science
concepts. Springer. ISBN #: 978-3-031-31099-7.
174. Carola, N., Patel, V., Levitt, S., Sosa, D., & Tokgöz, E. (2023). Ergonomics of total knee
arthroplasty. In Total knee arthroplasty: Medical and biomedical engineering and science
concepts. Springer. ISBN #: 978-3-031-31099-7.
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reconstructive facial plastic surgery: A review of medical and biomedical engineering and
science concepts. Springer. ISBN #: 978-3031311673.
176. Marina, A. C., & Tokgöz, E. (2023). Aesthetic surgery of the upper face and cheeks. In
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malformations. In Cosmetic and reconstructive facial plastic surgery: A review of medical and
biomedical engineering and science concepts. Springer. ISBN #: 978-3031311673.
179. Marina, A. C., & Tokgöz, E. (2023). Surgical reconstruction of craniofacial trauma and burns.
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engineering and science concepts. Springer. ISBN #: 978-3031311673.
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(1)
(2)
©The Author(s), under exclusive license to Springer Nature Switzerland AG2023
E. Tokgöz, M. A. Carro, Cosmetic and Reconstructive Facial Plastic Surgery
https://doi.org/10.1007/978-3-031-31168-0_8
Biomechanics of Facial Plastic Surgery
Applications
EmreTokgöz1 and MarinaA.Carro
2
Whiting School of Engineering, Johns Hopkins University, Baltimore,
MD, USA
The Frank H. Netter M.D. School of Medicine, Quinnipiac University,
North Haven, CT, USA
MarinaA.Carro
Email: Marina.Carro@quinnipiac.edu
Keywords Biomechanics of facial plastic – Biomechanical basics of skull
& facial bones – Mandible bone biomechanics – Nasal bone biomechanics
– Biomechanics of maxillofacial reconstructions – Biomechanics of
mandibular reconstructions – Biomechanics of craniofacial surgery –
Biomechanics of rhinoplasty
Emre Tokgöz completed two Ph.D. degrees, one in Mathematics and
another one in Industrial Engineering, at the University of Oklahoma along
with a master’s degree in Computer Science and two master’s degrees in
Mathematics. Due to his interest in biomedical engineering applications of
mathematics and engineering, he pursued an online biomedical engineering
master’s degree for professionals at Johns Hopkins University. His other
research interests include nonlinear optimization, game theory,
deep/machine learning, financial engineering, facility allocation problems,
vehicle routing problems, systems’ design and improvement, network
theory and analysis, inventory systems, and Riemannian geometry.
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Marina A. Carro is a second-year medical student at the Frank H. Netter
School of Medicine (Quinnipiac University). Prior to medical school, she
worked as a project manager at Clínica Esperanza Hope Clinic in
Providence, Rhode Island, where she organized and managed a satellite
COVID-19 vaccination clinic for underserved populations in the area.
Additionally, she has worked as a certified nursing assistant for 3 years in
the emergency department and intensive care unit at South County Hospital
in Kingston, Rhode Island. Currently, she is on the board for the Frank H.
Netter Wellness Committee, ENT Surgical Interest Group, and American
Medical Student Association at Netter. She hopes to continue exploring her
interests in clinical procedural research, healthcare business and
administration, and provide equitable healthcare for marginalized patients
throughout the rest of her career.
1 Introduction
The biomechanics of the facial region requires an extensive understanding
of the boney and soft tissues’ nature and the associated mechanical
phenomena. A possible partition of the facial skeleton into three regions
[59] is as follows:
The lower third consisting of rigid bone (mandible with its condylar
articulation to base of skull).
The upper thirds of it to be the part with cranial vault and frontal bone.
The middle third consisting of central midfacial bone (the maxilla, the
nasoethmoid, and lateral midfacial bone—zygoma).
The forces to the facial skeleton can be applied from an anteroposterior,
superior, inferior, and lateral directions. Pattern of an injury can be
determined by the point of contact and level of forces. For instance,
cranium fractures rarely extend into the region of facial skeleton. On the
contrary, fractures originating in the facial skeleton can extend into the
cranium.
Significance of the displacement of forces is one way to measure the
impact of accidents [60]. Forces applied on facial skeleton can be
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transmitted to the base of skull with the effect ranging from transient loss of
consciousness to dangerous cerebral laceration [61]:
Minimal nasal bone fracture tolerance level range: 25–75 lbs
Maxilla’s (anterior wall) fracture tolerance level range: 140–445 lbs
Zygomatic arch tolerance range: 208–475 Ibs
Body of the zygoma tolerance level: 200–450 lbs
Frontal bone: 800–1600 lbs
Figure 1 displays these regions and the associated tolerance amounts in
pounds.
Fig. 1 Force tolerances based on resistance to impact classification on the facial region [62]
Biomechanical properties of facial skeleton depend on a variety of
factors, including anatomical structures, attachment of muscles, forces
applied on bones, and additional mechanical factors. Healing, repairment,
and surgical applications are highly dependent on the biomechanics of the
maxillofacial skeleton [23]. Differential levels of osteoblasts, osteoclasts,
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and osteocytes have roles in the biomechanics properties of the facial bone;
however, these factors and other physiological factors are assumed to be
known for an “average person” in calculations.
Material properties of the bone can be technically considered as a fiberreinforced polymer (composite). Tensile strength is derived mainly from
Type 1 collagen fibers. The compressive strength is provided by the mineral
matrix. Fiber bundles’ length and orientation along with specific loading
conditions are location dependent; this is one of the main reasons for
directionality dependence of bone’s mechanical properties based on its
anisotropic structure [38].
Cancellous tissue with its light weight and low density and lamellar
tissue with its compact and dense structure are the two types of tissue
composers of the facial skeleton. The natural design of the face reflects the
perfection of cancellous and lamellar tissues’ distribution throughout the
facial skeleton depending on functionality and demand. Facial bone’s
generation is layer dependent. The cranial vault’s bone structure has a
middle layer of cancellous bone and an outer and inner layer of compact
bone with the protection provided to the brain from external forces. The
mandible is mainly consisting of cortical bone with cancellous bone in the
body, angle, and condyle region. The midface bones have a thin layer of
compact bone as well as cancellous bone, which helps with shock
absorbance [24]. Metabolic differentiability of the facial bone of a person
with its dynamic remodeling ability makes aging and time as biomechanical
variables [23].
Organic matrices form the structure of the bone that also contains
inorganic substances that are loaded in small crystal forms into the matrices.
Calcium, chlorine, magnesium, iron, potassium, and carbonate are present
in the bone. Collagenous and noncollagenous proteins and lipids exist in the
organic component of the bone. Formation of organic component is about
90% collagenous proteins with dominancy of Type 1 collagen, while
noncollagenous proteins and lipids are in the rest of the formation. Different
regions of the skull are reported to have different biomechanical properties.
For instance, significantly different minimum and maximum elastic
modulus are found between the inner and outer cortical plates in [13].
The performance indicators that can be evaluated for facial plastic
surgery biomechanics are plenty, and their interactions generate the
complexity of the design. Facial skin, nerves, bones, soft tissue, natural
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forces such as forces generated by blood, pressures existing under the skin,
and the correlation of all these factors play a significant role on the overall
inner workings of the facial biomechanical considerations. Noting the
limited ability to observe all these indicators and their correlations along
with their variability over time, age, disease status, and mineral density
causes challenges associated with implementation of facial plastic surgeries.
It is also important to note here that the physiological issues and diseases
throughout the body also impact the head region, which also impacts the
operations that can take place in facial plastic surgeries [13, 23]. Externally
caused factors for treating head and neck malignancies, such as radiation
therapy, can change the physical, biological, and biomechanical properties
of bone significantly. Radiation therapy can decrease the ultimate tensile
stress by a factor of four while reducing the elastic modulus in tension by
fivefold, even in demineralized bone [91]. The bone’s ability to heal
fractures and vascularity is dramatically reduced upon radiation treatment
[92, 93].
2 Biomechanical Basics of Skull and Facial Bones
The bone structure of the skull plays an important role in the biomechanics
of facial plastic surgeries. Given that the surgical procedures focus on
certain areas of interest, such as the mandible, nasal, maxilla, and parietal
sections, we will be covering these sections of the bone.
A bone is subject to deformation due to loading and unloading, and the
variability of deformation impacts the bone’s material properties. Strain is
used for measuring deformation per unit of length used [1], which also
helps to identify percentage of bone deformation. Deformation occurring on
the bone tissue naturally causes tension, which is quantified by the force
applied to the bone. The force per unit area of the bone is defined to be the
stress. Additional biomechanical features of the bone include, but are not
limited to, compression, tension, shear, strength, rigidity, torsion, elastic
moduli, and bending. In this section, we will cover the basic biomechanical
properties of several different bone structures of the skull.
The brittle nature of the bone doesn’t allow it to withstand elongation
for too long, before it breaks. The bone breaks first on the tension side
when subjected to bending forces, noting that compressive forces don’t
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