Cosmetic Facial Surgery

Long term complications include relapse, which may occur if the jaw is advanced or if the jaw is retracted. The cause is controversial. It is thought to be related to continued growth in some patients - seen when the jaw is pushed back, and muscle pull - when the jaw is advanced large distances to accentuate a small chin. It is therefore important to carry out such operations when growth has ceased. Muscles inserted into the chin may be divided in the floor of mouth in cases of large jaw advancement - circa 1cm (myotomy). The majority of cases of relapse are noticed by slight changes in the dental occlusion only noticed by the clinician. It is very rare for relapse to adversely affect the cosmetic improvement achieved.

b) Chin Surgery – Genioplasty

The position of the chin is critical and influences the facial height, facial centre-lines and cosmetic appearance of the nose. Patients seeking rhinoplasty may discover that their perceived cosmetic problem lies elsewhere – the chin. The effect of both rhinoplasty and/or genioplasty may be demonstrated to the patient on screen during the initial consultation using computer technology.

The chin may be moved backward / forwards / upwards / downwards with an intraoral incision behind the lower lip, to correct an abnormal position. It may also be moved to the facial centre line in cases of facial asymmetry.

Post surgery a pressure dressing is applied to the chin for about 72 hours. This reduces bruising which may sometimes travel down the tissue planes into the neck and even onto the chest. Such bruising is not necessarily related to surgical technique and may be related to a tendency for blood vessels to ooze following surgery.

c) Liposuction and Liposculpture

A “double chin” is a common feature and may be treated alone or in combination with the chin and lower jaw. Liposuction may be carried out through a tiny skin incision under the chin. The removal of fatty tissue is carried out using suction (Liposuction) which may be carried out laterally in the neck to provide a better jaw line and for the treatment of jowling (Liposculpture), through additional skin incisions near the angle of the jaw.

The effects pf liposuction / liposculpture may be simulated on screen with computer technology at the time of initial consultation.

d) Upper Jaw - Maxilla

Maxillary osteotomy surgery may be advised when an abnormally positioned jaw is giving rise to cosmetic problems. The jaw can be moved upwards / downwards / forwards and rarely backwards.

The critical aspect of where to place the maxilla in the anteroposterior plane is determined by computer analysis of skull x-rays and computer simulation using digital photography (photomorphanalysis™). This illustrates the movement and its permits effect on other structures to be calculated e.g. the nose.

The position of the maxilla in the vertical plane is determined by the amount of upper incisor tooth visible below the upper lip at rest and when smiling.

Rotation of the maxilla may be required on occasion to centralise the position of the front teeth. This has a temporary effect on the central position of the nose, which initially looks “off centre” – this usually corrects itself over a 3 month period.

Surgery to the maxilla is carried out at three levels named after a French Surgeon René Le Fort.

The Le Fort I osteotomy involves separating the maxilla and the palate from the skull above the roots of the upper teeth through an incision inside the upper lip. The maxilla is fixed in its new position with titanium screws and plates. Surgery time is around three hours. The operation is frequently carried out with the mandibular Sagittal split osteotomy when it is termed a Bimaxillary Osteotomy.

Bimaxillary osteotomies take around five hours to complete and may be carried out in conjunction with chin surgery and liposuction/liposculpture. Blood transfusion is required. On occasions bone grafting is required in the Le Fort I osteotomy to ensure bone healing and union across the bone cuts. The graft is frequently harvested from the hip. Bone graft material may be harvested from the chin or lower jaw in bimaxillary cases – leaving the hip intact.

Cosmetic improvement is startling for those individuals requiring these procedures, and with proper planning it is unusual for patients not to be delighted with outcome.

The Le Fort II Osteotomy is an uncommon procedure used when there has been a problem with growth in the centre of the face and the upper jaw and nose requires movement together. This is a major surgical operation, and involves incisions in the mouth, cosmetic incisions behind the lower eyelids (transconjunctival) or through the skin below the lower eyelids (blepharoplasty). The nose is approached with a cosmetic incision over the top of the head from ear to ear (bicoronal approach) and the scalp is raised forwards to get access to the nasal bones. Sensory nerves to the forehead require to be freed from bony canals (illustrated). Hip grafts (illustrated in red) are needed to fill in any gaps after the upper jaw and nose have been moved (usually forwards).

Surgery time is around 8 hours; blood transfusions are required and the patient is nursed in a high dependency unit overnight following the operation. Suction drains are placed in the scalp to reduce bruising. Patients may have considerable facial swelling and black eyes following this procedure. Aesthetic improvement is startling for those patients requiring this type of surgery.

The Le Fort III Osteotomy is used to correct generalised growth failure of the midface involving the upper jaw nose and cheek bones (zygomas). The surgical approach and post operative management is similar as for the Le Fort II procedure.

Brow lift procedures may be carried out at the same time as Le Fort II and Le Fort III osteotomies.