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Consideration inTreatment
ofLong Face
SanghoonPark
12
12.1 Pearls
1. The concept of a “long face” is subjective and
not a specic medical diagnosis. Yet, the number of patients seeking treatment for what
they perceive as a long face, in pursuit of more
balanced facial proportions, is noticeably
increasing.
2. The characteristics of a long face are varied
and can include features like prognathism,
vertical maxillary excess, chin hyperplasia, or
a long face with normal vertical proportions.
3. The treatment approach for a long face
depends on its underlying causes. In cases
where the long face is due to elongated maxilla and mandible coupled with malocclusion,
the most effective solution often involves twojaw surgery alongside facial bone contouring
procedures. However, many patients prefer
simpler and less invasive options. Hence, this
chapter primarily explores enhancements
achievable through facial bone contouring
surgeries and soft tissue management.
4. Facial bone contouring surgeries, such as mini
V-line and V-line surgeries employing
T- osteotomy for vertical reduction, offer
straightforward and effective methods for
S. Park (*)
Center for Facial Bone Surgery, Department of
Plastic Surgery, ID Hospital, Seoul, South Korea
e-mail: spark@idhospital.com
addressing a long lower face, with or without
prognathism.
5. Addressing sagging and excess soft tissue is
as critical as bone reduction for effectively
shortening the face. Techniques like muscle
suspension, or liposuction, can be applied
independently or in combination to enhance
the outcomes of bone reduction.
6. For addressing a long midface, the simplest
and most effective approach is shortening the
upper lip. Philtrum reduction can be an ideal
solution for patients who have an excessive
incisor show, as it effectively shortens the
midface without disrupting the overall soft
tissue balance in this region.
12.2 Introduction
The term “long face” is subjective and difcult to
describe scientically. However, to understand
the series of conditions referred to as a “long
face,” we should start from the scientic proportion of the face. Traditionally, the face is vertically segmented into three equal parts: the upper
face extends from the hairline to the glabella, the
midface from the glabella to the subnasale, and
the lower face from the subnasale to the menton
(Fig. 12.1). These proportions, while varying
globally, are crucial in determining the long face.
The width-to-height ratio, generally accepted as
3:4, also plays a crucial role in the aesthetic judg-
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
S. Park (ed.), Facial Bone Contouring Surgery, https://doi.org/10.1007/978-981-97-4992-8_12
t.me/Dr_Mouayyad_AlbtousH
113
114
Fig. 12.1 Face is divided into horizontal thirds. The
upper third extends from the hairline to glabella, the middle third from glabella to subnasale, and lower third from
subnasale to menton
ment of facial length, with an oval-shaped face
often seen as the ideal [1, 2].
The perception of facial length extends beyond
just the vertical proportions of the skeleton. For
instance, an anteroposterior (AP) disproportion
between the maxilla and mandible can create an
illusion of a longer face. Additionally, the skin
and soft tissues play a signicant role in this perception. Sagging or thinning of facial soft tissues
can also contribute to the impression of an elongated face, highlighting the importance of
considering both skeletal and soft tissue factors
in the overall aesthetic evaluation.
Facial proportions, a fundamental aspect in
aesthetic evaluation, vary signicantly across different races, genders, and cultural preferences, as
do their aesthetic standards. In some Asian cultures, for example, a shorter lower face is often
associated with youthfulness, leading some individuals with proportionate chins to desire reduction surgeries [3, 4]. Understanding the patient’s
desired outcome through meticulous consultation
S. Park
is vital, as it allows for a comprehensive approach
to effectively and harmoniously address their
concerns.
This chapter focuses on managing a perceived
“long face” through surgical interventions involving the maxilla and mandible.
For the lower face, the basic principle is vertical reduction genioplasty. Popular contouring
surgeries like the mini V-line surgery and V-line
surgery, which utilize a T-shaped osteotomy, are
effective. However, addressing accompanying
soft tissue issues is equally important. Despite
bone shortening through facial contouring surgery, redundant soft tissue can still give the
appearance of a longer lower face. Therefore,
procedures such as muscle suspension (e.g.,
geniohyoid/digastric muscle), liposuction, and
face lifting should be considered to comprehensively manage the lower face’s appearance.
For midface shortening, vertical maxillary
reduction may be indicated but is beyond the
scope of this chapter. When less invasive options
are preferred, philtrum reduction surgery can
effectively create the illusion of a shorter midface. This approach is particularly suitable for
patients with normal or near-normal occlusion,
those seeking quicker recovery, or those with
redundant soft tissue in the philtrum area.
12.3 Patient Assessment
andConsultation
To plan facial contouring surgeries effectively,
especially for patients thought to have a “long
face,” it’s crucial to start with a thorough physical
examination and detailed clinical photographs.
This is supplemented with essential imaging like
cephalometric and panoramic X-rays, along with
3D CT scans. A key tool in this evaluation is the
lateral cephalogram. It’s a prole X-ray that helps
us understand the relationship between the jawbones and soft tissues, which is crucial for assessing facial proportions.
While the denition of a “long face” can vary,
using known aesthetic ideals as a guide in our
pre-surgical planning is very useful. In particular,
those with a long and thin upper lip, minimal
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12 Consideration inTreatment ofLong Face
incisor show less than 2 mm, and prominent
hooding of the lateral lip, often benet from philtrum reduction surgery. The choice of surgery for
reducing facial length depends on matching these
ideal standards with what the patient hopes to
achieve.
12.4 Surgical Techniques
As mentioned above, surgery includes skeletal
surgery for mandible and soft tissue surgery for
maxilla. The basic surgical procedure for mandible is reduction genioplasty. After reduction genioplasty, neighboring inferior mandible border
can be reduced to match the lower jaw line. These
surgical procedures are not far different from
prevalent facial bone contouring surgeries
described at V-line surgery or mini V-line
surgery.
Philtrum shortening is indicated only in
patients with an excessive incisor show; otherwise it breaks the overall soft tissue balance in
this region.
12.4.1 Reduction Genioplasty
Various osteotomy designs can be considered
depending on the position of the nerve, the
amount of reduction, and the patients’ needs.
12.4.1.1 Two-Parallel Osteotomy
The technique of chin shortening through twoparallel osteotomy lines is frequently utilized,
especially when the inferior alveolar nerve is
positioned higher, or when only a modest reduction is required (Fig.12.2). This approach is both
straightforward and efcient, as surgeons can
easily create two-parallel cuts using doublebladed saws. These osteotomy lines are most frequently used and favored. It’s prudent for
surgeons to explore safer, alternative osteotomy
techniques, if necessary.
12.4.1.2 Inverted V-Shaped Osteotomy
In cases where the inferior alveolar nerve is positioned low, or if there is limited space due to pre-
115
Fig. 12.2 Two-parallel osteotomy. It is most commonly
used reduction technique
vious surgeries, an alternative approach can be
used. This involves adjusting the two-parallel
osteotomy line obliquely (Fig.12.3). Removing
central slip and moving it centrally augment the
reduction effect in vertical dimension of the chin.
12.4.1.3 Spade-Shaped Osteotomy
In instances where a patient seeks substantial
reduction in chin length but opts for a round chin
over a pointed one, the primary objective of the
osteotomy is to concentrate on shortening. This
technique involves removing a signicant amount
of bone from the central part of the chin while
only minimally adjusting the bone at both ends
(Fig.12.4). This approach ensures that even when
the inferior alveolar nerve is situated low, the
chin length can still be effectively and sufciently
reduced.
12.4.1.4 Bow Tie-Shaped Osteotomy
When a patient opt for more pointed chin with
shortening and the existing chin length isn’t
excessively long, this can be accomplished
through a combination of transverse and oblique
osteotomy lines (Fig. 12.5). This osteotomy
design, which is essentially the reverse of the
spade-shaped osteotomy, involves minimal bone
removal from the central portion and maximal
removal at both ends. This approach achieves a
more pointed chin prole, though the extent of
chin length reduction is somewhat constrained.
t.me/Dr_Mouayyad_AlbtousH
116
Fig. 12.3 Inverted V-shaped osteotomy. Length of the chin can be reduced through oblique deformation of the osteotomy line either with or without removal of the bone
S. Park
Fig. 12.4 Spade-shaped osteotomy. It enables maximum
length reduction
However, it’s important to note that adequate
space below the nerve line is necessary when
employing this bow tie-shaped osteotomy, due to
the signicant bony steps created at both ends.
While reducing the length of chin, surgeons
also can control projection of the chin. In the
case of long and protruding chin, the degree of
protrusion can be improved by reducing the
length itself. When additional control of protrusion is required, setback genioplasty can be
considered.
Furthermore, surgeons have to control overlying soft tissue for more effective shortening of
t.me/Dr_Mouayyad_AlbtousH
Fig. 12.5 Bow-tie-shaped osteotomy. The shape of the
tip of the chin can be made more sharp while reducing the
length of the chin
the chin as soft tissue sagging makes the face
look longer even after bone contouring surgeries.
Basic procedure is maintaining as much soft tissue as possible to the genioplasty segments.
Adjunctive methods include liposuction of the
lower cheek and double chin and suspension of
geniohyoid/digastric muscle. When removing
central segment of bone, check the muscle attachment in the posterior surface and reattach it to
medial portion of two lateral chin segments via
small hole.
12 Consideration inTreatment ofLong Face
117
12.5 Philtrum Reduction
Philtrum reduction can be performed either under
intravenous sedation or general anesthesia. Local
anesthetic, specically 2% lidocaine with
1:100,000 epinephrine, is administered to the
upper lip, nasal mucosa, and nasal tip skin under
sedation. The surgical approach involves modifying the conventional trans-columella incision to
locate along the subalar crease, complemented by
two intranasal incisions (Figs. 12.6 and 12.7a).
The procedure utilizes tenotomy scissors through
the incision to identify the caudal septal end, proceeding with dissection in the subcutaneous
plane just above the orbicularis oris muscle in the
upper lip (Fig.12.7b). This ensures the preservation of the muscle’s functionality. The dissection
is conned within the limits of the nasal base’s
width and extends halfway toward the lip’s white
roll. Limited dissection of the nasal tip and dorsum is accessed through the infracartilaginous
part of the same incision (Fig.12.7c). After lifting the skin and subcutaneous tissue from the
orbicularis oris, the columellar subunit becomes
freely mobile. A crucial 3-0 nylon suspension
suture is passed through the intranasal incision
into the dissected subcutaneous layer, securing
the supercial orbicularis oris muscle and fascia
about halfway up the upper lip. This suture is
anchored to the lower caudal septum, enabling
controlled shortening of the central upper lip
without compromising the muscle’s function
(Fig.12.7d). For patients with specic nasal tip
conditions, adjustments like tip plasty with a
plumping graft for increased projection, or caudal septum shortening for a hanging columella,
are considered. The excess skin over the columella is not removed but repositioned around the
nasal tip. Excess tissue in the upper lip area is
redistributed into the nasal vestibule for excision.
Key anchoring sutures are placed to secure the
endonasal aps to the immobile supraperiosteal
tissue of the vestibular oors, which helps relieve
tension. In cases where additional lateral lifting is
desired, a more caudal subalar resection is performed. This comprehensive approach ensures a
harmonious and aesthetically pleasing outcome,
considering both the reduction of the philtrum
and the subtle nuances of nasal tip adjustment.
Each step of the procedure, from the precise
placement of sutures to the meticulous handling
of soft tissues, is executed with the goal of
enhancing facial symmetry and balance
(Figs.12.6 and 12.7a–d).
Fig. 12.6 Incision design and extent of dissection of philtrum reduction
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118
S. Park
Fig. 12.7 Surgical procedures
12.6 Key Technical Points
1. The choice of osteotomy technique is inu-
enced by several factors, including the position
of the nerve, the desired extent of reduction,
pointedness of chin and the patient’s preferences for chin shape. Each approach is tailored
to achieve optimal outcomes while ensuring the
safety and satisfaction of the patient.
t.me/Dr_Mouayyad_AlbtousH
2. In facial contouring, the management of soft
tissue is equally critical as the bone surgery
itself. Techniques like muscle suspension,
liposuction, or face lifting play a signicant
role in ensuring a smooth and proportionate
facial contour. These procedures help address
any residual soft tissue that might otherwise
lead to an irregular or elongated appearance
of the face.
ab
12 Consideration inTreatment ofLong Face
119
3. For patients seeking midface shortening without extensive surgical intervention, philtrum
reduction emerges as an effective alternative.
scar camouage, making it a favorable option
for patients concerned about visible post-
surgical marks.
This technique, when executed properly, can
achieve up to a 6 mm lift in the midface.
Moreover, it offers the advantage of excellent
Case 1 Reduction Genioplasty
12.7 Case Study
A 25-year-old female patient presented with concerns about her long, asymmetric, and prognathic chin (Fig.12.8). To address these issues, a reduction genioplasty was performed, employing
a spade- shaped osteotomy technique. This procedure achieved a 5mm reduction in the length
of the chin and a 2mm setback, reducing the chin’s projection. The setback was facilitated using
a prebent plate, with additional xation applied to ensure optimal bone contact at both ends of
the bone segment (Fig.12.9). To counter potential soft tissue sagging, a suspension suture was
placed using PDS 3-0. At the 5-month postoperative mark, signicant improvements were noted
in both the length and projection of the chin (Fig.12.10).
Fig. 12.8 Case 1.
Preoperative frontal (a)
and lateral (b)
photographs of the
patient
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120
S. Park
a
b
Fig. 12.9 Case 1. Preoperative (a) and postoperative (b) radiographs showing length reduction and improve-
ment of prognathism
Fig. 12.10 Case 1.
Five-month frontal (a)
and lateral (b)
postoperative
photographs
a b
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12 Consideration inTreatment ofLong Face
Case 2 Philtrum Reduction
A 20-year-old woman visited ID hospital to improve her long face. She underwent forehead
reduction, mandible contouring surgery, and philtrum reduction. The philtrum was reduced by
5mm. Two months after the operation, the patient’s facial contour appears short and more balanced (Fig.12.11).
121
Fig. 12.11 Case 2.
Comparison of
preoperative and
postoperative frontal (a)
and oblique (b)
photographs of the
patient
a
b
t.me/Dr_Mouayyad_AlbtousH
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