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14 Secondary Mandibular Contouring Surgery
(E) Irregular and Uneven Jawline
During a conventional mandibular angle reduction surgery, the bony resection should be precisely done in a uniform fashion. When performing the V-line surgery, the bony steps at the
chin-mandible junction should be smoothened out. If these are not guaranteed during the mandible contouring surgery, the resultant jawlines will be irregular and uneven. The irregular bone
contours may be noticeable externally and may be a reason for patient complaint. An additional
bone contouring should be done to correct this contour irregularity, with an extra caution by the
surgeon on the path of the inferior alveolar nerve [1, 4].
Figures 14.6 and 14.7 show a 35-year- old female who underwent a two-jaw surgery and a
concomitant mandibular V-line surgery. She complained on the irregular, uneven jawlines of the
lower face contour. As the hardwares in the mandible were removed, further mandibular contouring was performed 1year after the previous surgery. As seen on the postoperative panoramic radiograph and medical photographs, the lower face contours were smoothened.
141
Fig. 14.6 Preoperative and postoperative panoramic radiograph of a 35-year-old female. The irregular, uneven
jawlines resulting from a prior two-jaw and V-line surgery were smoothened by a secondary mandibular
contouring
Fig. 14.7 As seen on
the oblique view of the
preoperative medical
photographs, the
previous jaw surgery
resulted in an irregular
contour. After the
secondary mandibular
contouring surgery, the
uneven jawlines were
much smoothened, and a
natural contour was
achieved
t.me/Dr_Mouayyad_AlbtousH
142
(F) Unnatural Alloplastic Implant
Alloplastic implant and articial ller are popular procedures for chin shaping.
Figure 14.8 shows a 30-year-old female who underwent a mandibular angle reduction and a
concomitant chin implant insertion. She wanted to remove the implant and make a smooth and
slimmer jawline. As the chin implant was removed, secondary mandibular contouring was performed. As seen on the postoperative panoramic radiograph and cephalograms, the mandible
contours were slimmer and smoothened.
J. Lee
Fig. 14.8 (Above, left) Preoperative posteroanterior (P-A) cephalometric radiograph. (Above, right)
Postoperative posteroanterior (P-A) cephalometric radiograph. (Below, left) Preoperative lateral cephalometric
radiograph. (Below, right) Postoperative lateral cephalometric radiograph
t.me/Dr_Mouayyad_AlbtousH
14 Secondary Mandibular Contouring Surgery
143
References
1. Lee TS.Standardization of surgical techniques used in
facial bone contouring. J Plast Reconstr Aesthet Surg.
2015;68:1694–700.
2. Lee SW, Ahn SH.Angloplasty revision: importance
of genioplasty for narrowing of the lower face. Plast
Reconstr Surg. 2013;132:435–42.
3. Lee TS, Kim HY, Kim TH, Lee JH, Park S.Contouring
of the lower face by a novel method of narrowing
and lengthening genioplasty. Plast Reconstr Surg.
2014;133:274e–82e; discussion 283e.
4. Lee TS, Kim HY, Kim T, Lee JH, Park S.Importance
of the chin in achieving a feminine lower face: narrowing the chin by the “mini V-line” surgery. J Craniofac
Surg. 2014;25:2180–3.
5. Park S, Noh JH. Importance of the chin in lower
facial contour: narrowing genioplasty to achieve a
feminine and slim lower face. Plast Reconstr Surg.
2008;122:261–8.
6. Chen T, Khadka A, Hsu Y, etal. How to achieve a balanced and delicate lower third of the face in orientals
by mandibular contouring. J Plast Reconstr Aesthet
Surg. 2013;66:47–56.
7. Choi BK, Goh RC, Moaveni Z, Lo LJ.Patient satisfaction after zygoma and mandible reduction surgery:
an outcome assessment. J Plast Reconstr Aesthet Surg.
2010;63:1260–4.
8. Kang M.Incidence of complications associated with
mandibuloplasty: a review of 588 cases over 5 years.
Plast Reconstr Surg Glob Open. 2014;2:e139.
t.me/Dr_Mouayyad_AlbtousH
t.me/Dr_Mouayyad_AlbtousH
Soft Tissue Surgery Combined
withtheMandible Contouring
Surgery
SanghoonPark andJooYongKwon
15
15.1 Pearls
1. Soft tissue management post-mandibular
reduction surgery is crucial due to the potential for sagging in patients with abundant soft
tissue, which could diminish the effects of the
surgery.
2. Various lifting procedures, such as laserassisted liposuction, absorbable barbed thread
lifting, nonabsorbable elastic thread lifting,
and traditional facelifts, are applied based on
the patient’s soft tissue status.
3. The choice of lifting procedure should be tailored to each patient, considering their specic needs and desired outcomes.
4. Laser-assisted liposuction not only improves
facial contour through effective fat removal
but also enhances thread lifting efcacy by
reducing the weight of the lifted soft tissue.
However, caution is needed to avoid thermal
damage to nerves, vessels, and salivary
glands, and excessive suction can lead to surface irregularities.
S. Park (*)
Center for Facial Bone Surgery, Department of
Plastic Surgery, ID Hospital, Seoul, South Korea
e-mail: spark@idhospital.com
J. Y. Kwon
Center for Lifting Surgery, Department of Plastic
Surgery, ID Hospital, Seoul, South Korea
5. Barbed thread lift, known for its ease of application and minimally invasive nature, has
limitations like early recurrence rates and
minimal long-term efcacy.
6. Elastic lift, offering advantages like longevity,
elasticity, impalpability, and ease of removal,
is an effective alternative to barbed thread lift.
However, patient apprehensions about nonabsorbable materials and the learning curve for
surgeons are notable challenges.
7. Facelift surgery is one of the most effective
methods for lifting sagging tissues. However,
it necessitates a signicant recovery period
after surgery and leaves long scars, so patients
should be informed about these aspects before
undergoing the procedure.
15.2 Introduction
Facial bone contouring surgeries, while successful in achieving a slender V-line facial structure,
often lead to a reduction in bony support and volume. This change can result in soft tissue complications, such as cheek drooping and the formation
of a double chin [1–3]. Consequently, addressing
soft tissue sagging following bony reduction surgery is frequently necessary.
It’s important to recognize that the nature of
sagging in patients who have undergone facial
bone surgery differs from the gradual sagging seen
in naturally aged patients. Post-surgery sagging is
more acute in the subperiosteal layer, requiring
© 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_15
t.me/Dr_Mouayyad_AlbtousH
145
146
S. Park and J. Y. Kwon
stronger lifting and supporting techniques to counterbalance the weight of the skin. Fortunately, if
well executed, the results tend to be durable, as the
quality of the overlying skin remains intact.
Patients undergoing facial bone contouring
surgeries are generally young, are scar-sensitive,
have relatively good skin tension, and have abundant subcutaneous fat tissue. They tend to prefer
minimally invasive procedures over conventional
facelifts. The barbed suture lift has emerged as a
minimally invasive option for facial rejuvenation
and correcting soft tissue ptosis [4–11]. Yet, its
long-term effects are sometimes questioned due
to early recurrence rates [12–14]. Laser-assisted
liposuction offers an effective solution for facial
contouring and rejuvenation [15–20], but it might
not be optimal for signicant soft tissue sagging
due to its relatively weak lifting effect. The recent
popularity of nonabsorbable thread lifting, especially using elastic thread (Elasticum®, Korpo
SRL, Genova, Italy) in the “elastic lift,” is attributed to its efcacy and durability.
For the removal of fat in sagging soft tissue
areas, techniques like conventional liposuction or
laser-assisted liposuction with a 1444 nm
Nd-YAG laser are employed. Dermatologic
lasers and energy devices also play a role in
achieving a lifting effect by promoting collagen
regeneration. The choice of technique is tailored
to the patient’s condition and the desired results.
In aged patients desiring facial bone contouring, surgeons must undertake a comprehensive
assessment of their skin condition. This includes
evaluating the skin’s fairness, color, degree of
sagging, and any existing skin damages. It’s
essential to discuss the potential for additional
sagging post-surgery and the necessity for corrective measures.
The decision to opt for a conventional facelift
technique should be tailored to the patient’s
unique sagging status and personal requirements.
A variety of facelift procedures have been developed and rened to effectively address soft tissue
sagging issues in older patients. These procedures are chosen based on their ability to harmonize with the patient’s overall facial structure
while mitigating the effects of aging and postsurgical changes.
15.3 Patient Assessment
andConsultation
Patient assessment should be performed in an
upright sitting position before surgery because
once the patient lies on a bed, there can be
changes in soft tissue distribution. Then, surgeons mark the areas for fat removal, identify the
areas of soft tissue sagging, and draw a design of
lifting plan on the patient’s face (Fig.15.1).
The primary areas targeted for fat removal are
the lower cheeks and the submental area. Excess
fat in these regions, particularly on the jowls and
cheeks, can deepen marionette lines and nasolabial folds following mandible and malar reduction surgery. Similarly, excessive fat in the
submental area can contribute to a double chin
Fig. 15.1 Illustration of the laser-assisted liposuction
and barbed thread lift. Shaded area indicates the major
liposuction area, lower cheek and submental areas. Dotted
lines indicate the course of barbed threads insertion. Note
that the anchoring point for nasolabial fold and lower
cheek is deep temporal fascia and Lore’s fascia,
respectively
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15 Soft Tissue Surgery Combined withtheMandible Contouring Surgery
147
appearance, which may be exacerbated by genioplasty, especially procedures involving vertical
reduction and/or narrowing. It’s also important to
consider fat removal along the mandible-neck
line and below to better dene the cervical neck
line, even though these areas may not have signicant fat accumulation.
Soft tissue sagging is predominantly noticed
in the jowls, cheeks, and submandibular areas.
Post facial bone contouring surgery, existing sagging tends to worsen, and new sagging may occur
due to the reduction in facial bone and extensive
soft tissue elevation during dissection. Key factors that indicate a high risk of sagging post mandible reduction surgery include abundant soft
tissue in the cheek area, which can lead to sagging due to its weight, and loose skin, particularly in older patients. Thus, indications for
lifting procedures in conjunction with mandible
reduction surgery include excess soft tissue in the
cheek area, reduced skin elasticity, older age
(over 40years), a long face, or a Class II prole.
In cases with any of these high-risk factors,
surgeons should consider incorporating simultaneous lifting procedures with mandible reduction
surgery. The decision to perform these procedures simultaneously with facial bone contouring
surgery or at intervals thereafter depends on various factors such as the likelihood of drooping,
patient’s age, personal preferences, and economic
considerations.
When conducting lifting procedures simultaneously with facial bone contouring surgery, surgeons must exercise caution to avoid disrupting
the layers involved in the bone surgery, which
could heighten the risk of subcutaneous infection. The choice of lifting procedure and its timing should be meticulously planned to ensure
optimal aesthetic outcomes while minimizing
potential complications.
15.4 Surgical Techniques
15.4.1 Laser-Assisted Liposuction
The surgical procedure was performed under
local anesthesia, supplemented by propofol seda-
tion. For the chin area, two entry points for the
cannula were created using an 18 gauge needle.
A tumescent solution containing 0.5% lidocaine
and epinephrine was injected into the designated
fat removal areas using an 18 gauge cannula. The
typical volume of tumescent uid administered
ranged between 5 and 10cc for both the cheek
and chin regions. The fat reduction process
involved the use of a 1444 nm Nd-YAG laser
(AccuSculpt; Lutronic, Goyang, Korea), which
was employed across multiple layers including
the subdermal, supercial subcutaneous, and
deep subcutaneous layers for effective laser lipolysis. Energy delivery was carefully managed,
with 500–800 Joules directed into each cheek
and 500–1000 Joules into the chin area. To mitigate any thermal damage post-laser treatment,
cold wet gauze was applied to the treated areas.
Subsequent liposuction was performed using a
16 gauge cannula, facilitated by the laser’s prior
breakdown of fatty tissue into smaller fragments.
Liposuction was continued until the desired
reduction in fat thickness was achieved, with the
suction volume typically being twice that of the
injected tumescent uid, generally in the range of
10–20cc. Post-liposuction, the cannula insertion
sites were closed using 6-0 nylon sutures. These
sutures were scheduled to be removed 7 days
after the surgery. This meticulous approach
ensured effective fat reduction while minimizing
potential complications and promoting optimal
recovery.
15.4.2 Barbed Suture Lift
The procedure for the barbed suture lift involved
the use of 0-0 bidirectional cogged polydioxanone sutures. These sutures were initially
anchored beneath the deep temporal fascia and
tympanoparotid fascia using an anchoring device
known as owl. Following this, each end of the
barbed suture was reinserted and passed into the
targeted lift areas, such as the paranasal and chin
regions (Fig.15.1) using a straight cannula. The
sutures were strategically passed into the deep
subcutaneous layer, located just above the supercial musculoaponeurotic system (SMAS) layer,
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148
which was the primary focus for lifting. Typically,
six to ten threads were used for each cheek,
anchored securely to the deep temporal fascia.
Four to six threads were inserted to improve
cheek drooping and deep nasolabial folds, and
two to four threads were inserted to improve the
jowl. Post-insertion, any exposed threads were
carefully removed to mitigate the risk of postoperative thread exposure. To ensure no skin dimpling occurred, the skin was stretched while the
patient was in a sitting-up position, as dimpling is
not easily detectable in a supine position. This
step is crucial for achieving a smooth and even
lifting effect. Dimple, if found later in the postoperative period, should be relieved by stretching
the overlying skin before it becomes permanent.
Upon completion of the lift procedure, elastic
bandages were applied to both the neck and
cheek areas. These bandages served to maintain
the lift’s effectiveness and to reduce postoperative swelling. The bandages were scheduled for
removal on the third postoperative day, while the
sutures were removed after a week.
S. Park and J. Y. Kwon
15.4.3 Elastic Lift
The initial step involves outlining the area of soft
tissue bulge in the cheek. The point of maximal
bulging is then marked, indicating the engagement of elastic thread to the soft tissue. Following
this, the exit point is identied, which is situated
distally to the maximal bulge. Determination of
the exit point and the thread returning point is of
paramount importance. During this process, careful consideration is given to the depth of subcutaneous needle penetration and the intended
direction of tissue pull.
The elastic lifting procedure can be performed
under conscious sedation for standalone cases, or
under general anesthesia when conducted simultaneously with facial bone contouring surgeries.
For the procedure, the incision sites at both scalps
are inltrated with a mixture of 2% lidocaine and
1:100,000 epinephrine. Two vertical stab incisions are made with a No.15 blade at the level of
the highest point of the ear helix and earlobe
(Fig.15.2). A sharp mosquito clamp is then used
Fig. 15.2 Illustration of the elastic lift procedure
to create a pathway down to the deep temporal
fascia. An anchoring device called an owl is
employed to secure an elastic thread at the deep
temporal fascia. The free end of the elastic thread
is held with a mosquito clamp to prevent it from
retracting inside. The Jano needle® is then
inserted through the incision site opposite the
free end. As the needle moves through the deep
subcutaneous tissue plane, it emerges at the targeted exit point. It’s crucial not to fully pull out
the needle during this process. With ve depth
marks on the needle, each at 5mm intervals, the
surgeon can adjust the needle’s exit distance from
the actual lift site. The needle is pulled back until
only the last one or two depth marks are visible.
The elastic thread is then drawn through the needle exit site as much as possible. Surgeons can
locate the center of Jano needel in mind and make
it return at desired maximal bulging point.
Subsequently, the needle is rotated toward the
incision, passing through the deep subcutaneous
layer and fully extracted at the incision site.
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15 Soft Tissue Surgery Combined withtheMandible Contouring Surgery
149
At this stage, the surgeon assesses the appropriateness of the lifting layer, ensuring that the
lifting does not cause any dimpling, depression,
or soft tissue bunching. This is done by applying
adequate tension to the elastic thread. Once
satised, the thread is tied under tension and
positioned deeply to prevent exposure. The procedure is then repeated from the opposite incision site, using the Owl in the reverse direction.
The two stab incisions are nally sutured closed
using 6-0 nylon (Fig.15.2). This careful and precise approach ensures effective lifting while minimizing the risk of visible scarring and other
potential complications.
15.5 Facelift
Facelift is the most powerful method for lifting
sagging tissues. Since most patients undergoing
facial bone contouring surgery are relatively
young, the need for facelift surgery is not great.
Traditionally, facelifts become more pertinent for
individuals in their mid-40s or older, especially
after bone contouring surgery; however, some
patients in mid-20 may seek for additional lifting
after their initial bone surgery.
Facelift surgery encompasses a spectrum of
techniques ranging from those requiring minimal
access to those involving multiplane and deep
dissections. Among the prevalent methods are
SMAS plication, lateral SMAS-ectomy, extended
SMAS, high SMAS, and deep plane techniques,
each targeting different planes and engaging various manipulations of the supercial musculoaponeurotic system (SMAS). These approaches
present distinct benets and limitations. Author’s
preferred method is the extended deep plane
facelift technique [21], which facilitates control
over the volume of the posterior mandible region,
contributing to the sculpting of a more youthful
jawline.
The surgical procedure can be performed
under local anesthesia, supplemented by propofol sedation for standalone cases, or under general anesthesia when conducted simultaneously
with facial bone contouring surgeries. Incisions
commence with a 15 blade, elevating the skin to
the deep-plane entry point, which is a arbitrary
line from the mandibular angle to the lateral canthus (Fig.15.3). A composite facial ap of skin,
subcutaneous fat, SMAS, and malar fat is raised
antero-medially from this point. Sharp entry into
the deep-plane ap is performed from inferior to
superior with a 15 blade. Then a blunt dissection
with a facelift scissors releases the masseteric
cutaneous ligaments inferiorly. Near the lateral
canthus, the same blunt dissection technique is
used to identify a plane supercial to the orbicularis oculi muscle. Malar elevation is facilitated
Fig. 15.3 Illustration of
the deep-plane entry
point
t.me/Dr_Mouayyad_AlbtousH
150
S. Park and J. Y. Kwon
by nger assistance, directing a composite skin
and malar fat ap toward the nasofacial sulcus.
The zygomatic cutaneous ligaments are dissected
free sharply with a 15 blade, staying on the surface of the zygomaticus muscle.
In the neck area, the skin is elevated, and the
junction of the platysma and sternocleidomastoid
muscle (SCM) is marked from the gonial angle
and extends 5 cm inferiorly along the anterior
border of the SCM.
The platysma is sharply elevated in the submuscular fascia plane with blade and then
advanced anteriorly with facelift scissors. This
connects to the sub-SMAS plane previously
established in facial dissection, extending anteriorly to the facial artery’s mandibular crossing. A
horizontal platysmal myotomy below the mandibular margin facilitates superior and posterior
rotation of the composite ap over the gonial
area, secured with 3-0 ethibond. The inferior
limb of the platysmal ap is then pulled just
below the mandibular border and suspended posteriorly to mastoid fascia with 3-0 ethibond.
Finally the skin incisions are sutured using 4-0
vicryl and 5-0 and 6-0 nylon.
15.6 Key Technical Points
1. During laser-assisted liposuction, it’s crucial
to avoid harming normal anatomical structures such as the marginal mandibular nerve,
facial vessels, and salivary glands. The surgeon must have a thorough understanding of
anatomy and exercise caution, especially
when applying energy around these critical
structures. Excessive suction should also be
avoided as it can lead to excessive swelling,
bleeding, and, in rare cases, inammation.
The amount of suction should be carefully
controlled to prevent complications like
depression or surface irregularities. It’s important to determine the appropriate target
amount of suction to achieve the desired
results without causing adverse effects.
2. When performing a barbed thread lift, placing
the thread at the correct depth is essential. If
the thread is inserted too supercially, the
barbs may be palpable under the skin, leading
to dimpling, especially in patients with thin
skin. In procedures combining barbed thread
lifting with facial bone contouring surgery,
the surgeon must be vigilant to avoid placing
the thread too deep beneath the dissected
plane, which could increase the risk of infection. Precise insertion at the optimal depth is
key to achieving the desired lifting effect
while minimizing the risk of complications.
3. The success of an elastic lift depends on the
careful selection of target points and the insertion plane. Optimal placement is critical for
maximizing the lift’s effectiveness and minimizing side effects like dimpling, depression,
and soft tissue bunching. Due to the bidirectional sharp tips of the Jano needle, the surgeon must gently advance the needle to
prevent bleeding and bruising. The most crucial aspect of the procedure is controlling the
traction force and securing the tie properly.
This ensures that the lift is effective and the
results are long-lasting, with minimal risk of
adverse outcomes.
4. Facelift surgery is a potent intervention for
correcting sagging facial tissues. As it, inherently involves the creation of extensive scars
and necessitates a substantial postoperative
recovery period, its application in younger
demographics is relatively rare, necessitating
careful deliberation regarding its necessity.
During facelift surgery, it’s crucial to avoid
damaging branches of the facial nerve, highlighting the importance of the surgeon’s comprehensive understanding of anatomy.
Complete release of the retaining ligaments is
essential for achieving lasting surgical outcomes in facelift procedures.
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