The jaws and teeth are important components of the facial profile and significantly affect facial balance and aesthetics. If the positioning of the upper jaw and the lower jaw is out of balance with one another or with other facial structures, the appearance of the teeth, lips, chin-neck, nose, cheeks and forehead is affected.
Vertical imbalance of the jaws may create cosmetic concerns such as having a "toothless smile" or a "gummy smile" when speaking, resting or smiling. Horizontal imbalance of the jaws may cause cosmetic concerns by creating a facial profile with an exaggerated convex "weak chin" or concave "strong chin." Malpositioning of the jaws also causes an "underbite" or "overbite" condition.
Prior to gum and jaw treatment at the Mayo Aesthetic Surgery Center, patients are evaluated by an orthodontist and an oral-maxillofacial surgeon. The goal of treatment is to shorten or lengthen the horizontal, vertical or transverse dimensions of the jaw so that the facial soft tissue, the teeth and the other facial structures are in proper functional and aesthetic balance. Other surgical and medical evaluations also may be required to assess associated cosmetic (skin, nose and neck) and functional (speech, airway, sleep) problems.
Patients will begin treatment with orthodontic management. Most patients will need to wear braces for six months to two years to properly straighten the teeth. After the first portion of orthodontic work is complete, jaw surgery is performed to produce normal tooth function and aesthetics.
Jaw surgery (osteotomy) is performed through mouth incisions with power bone instrumentation. The repositioned bone is held in position during healing with various small internal metal devices. These devices, except on rare occasions, are retained indefinitely.
Patients undergo general anesthesia and a one-to-three-day hospitalization following surgery. A liquid/soft diet is prescribed for four to six weeks, and lower jaw function is restricted during this period of bone healing. The patient, however, is able to talk and open the mouth.
Orthognathic surgical procedures are safe and predictable. Surgical complications are minor and uncommon. Patients should expect significant swelling and bruising during the first two weeks following surgery. When the lower jaw is repositioned, a period of lower-lip numbness or tingling is present and may last for weeks or months. On rare occasions, this altered lip feeling may persist indefinitely.
Orthodontic treatment will resume six to eight weeks after jaw surgery and frequently last six to 12 months (for a total surgery and orthodontic treatment time of 12 to 24 months). Following removal of the orthodontic braces, the patient can expect a stable cosmetic and functional improvement. Additional cosmetic procedures, such as rhinoplasty and face-lift, can be considered because the internal structures (jaws and teeth) are now positioned for potential maximum aesthetic enhancement of the remainder of the face.
Because of the complexity and length of the surgical and orthodontic treatment, patients must be highly motivated and well-informed about the importance of their participation in treatment.
Saturday, August 5, 2006
The Face: Chin Augmentation or Chin Refinement
The chin is an important component of the overall facial profile. A large or small chin may create a proportional imbalance with other facial structures such as the neck, lips, nose and forehead. A chin that is too large in the horizontal, vertical or transverse dimension can be reduced, and the chin that is too small in the same dimensions can be augmented. These chin surgical procedures can be done alone or in concert with other cosmetic surgical procedures. Local anesthesia with intravenous sedation or general anesthesia is required.
A patient's chin may be reduced in size through a mouth incision made behind the lower lip. Surgeons then do bone reduction (genioplasty) with power bone instruments. Following surgery, patients must wear a chin dressing and eat soft foods for two to three weeks. Patients will experience a brief period of lower-lip swelling, discoloration, and a numbness or tingling sensation.
It is more common for patients to seek chin augmentation. This is accomplished by advancing the chinbone or placing an onlay of artificial implant material. The type and complexity of this procedure is dictated by the degree of chin deformity and the patient's treatment goals.
If the patient needs an artificial implant for a minor horizontal or transverse deficiency, surgeons create a pocket by making an incision in the mouth or chin skin. Then, an appropriately sized implant is placed. Following surgery, patients must wear a firm chin dressing and eat soft foods for two to three weeks. Patients will experience a brief period of lower-lip swelling, discoloration, and a numbness or tingling sensation.
Patients with major chin deficiency will require bone surgery (osteotomy) in which the bone of the chin is moved forward following various oblique bone incisions. Using power bone instruments, surgeons perform the procedure through a mouth incision made behind the lower lip. General anesthesia is frequently required. Patients must follow a soft diet for two to three weeks, and the lower-lip swelling, discoloration, and altered lip sensation may last longer than previously described.
The cosmetic chin procedures are safe and offer good results. Surgical complications are minor and uncommon. Wound infection is rare. However, if it occurs, a patient may have to have the artificial chin implant or internal metal devices removed. It is also possible to experience permanent altered sensation of the chin.
Aesthetic procedures of the chin may be combined with orthognathic surgical procedures in which the teeth and jaws are simultaneously repositioned to achieve facial balance. Additional cosmetic procedures such as face-lift or rhinoplasty also may be combined with the chin surgery.
A patient's chin may be reduced in size through a mouth incision made behind the lower lip. Surgeons then do bone reduction (genioplasty) with power bone instruments. Following surgery, patients must wear a chin dressing and eat soft foods for two to three weeks. Patients will experience a brief period of lower-lip swelling, discoloration, and a numbness or tingling sensation.
It is more common for patients to seek chin augmentation. This is accomplished by advancing the chinbone or placing an onlay of artificial implant material. The type and complexity of this procedure is dictated by the degree of chin deformity and the patient's treatment goals.
If the patient needs an artificial implant for a minor horizontal or transverse deficiency, surgeons create a pocket by making an incision in the mouth or chin skin. Then, an appropriately sized implant is placed. Following surgery, patients must wear a firm chin dressing and eat soft foods for two to three weeks. Patients will experience a brief period of lower-lip swelling, discoloration, and a numbness or tingling sensation.
Patients with major chin deficiency will require bone surgery (osteotomy) in which the bone of the chin is moved forward following various oblique bone incisions. Using power bone instruments, surgeons perform the procedure through a mouth incision made behind the lower lip. General anesthesia is frequently required. Patients must follow a soft diet for two to three weeks, and the lower-lip swelling, discoloration, and altered lip sensation may last longer than previously described.
The cosmetic chin procedures are safe and offer good results. Surgical complications are minor and uncommon. Wound infection is rare. However, if it occurs, a patient may have to have the artificial chin implant or internal metal devices removed. It is also possible to experience permanent altered sensation of the chin.
Aesthetic procedures of the chin may be combined with orthognathic surgical procedures in which the teeth and jaws are simultaneously repositioned to achieve facial balance. Additional cosmetic procedures such as face-lift or rhinoplasty also may be combined with the chin surgery.
The Face: Facial Implant Surgery or Facial Contour Refinement
The contours of the face are affected by the skin and underlying structures, including subcutaneous tissue, muscle, fat and bone. Occasionally, problems exist that cannot be addressed by altering the skin alone. For example, deficiencies in the cheekbones, jawbone, nasolabial creases and lips significantly affect a person's appearance. Many patients want to change these areas.
Most commonly, patients seek to augment one or more of the facial regions mentioned above to give a more youthful and defined appearance to the face. For augmentation procedures, we at Mayo use synthetic materials that have a track record of safety and efficacy. The nasolabial creases and lips usually are augmented with small, soft implants that are placed deeply in the skin and the underlying subcutaneous tissue.
Mayo surgeons typically perform the chin and cheekbone augmentation surgery through intraoral incisions. Occasionally, however, surgeons will do the surgery through a small incision under the chin. The material to augment these specific regions is then placed and fixed with internal sutures and, occasionally, external sutures.
The surgery for each of these regions takes from 30 minutes to 1 1/2 hours. Most are performed using local anesthesia with sedation or general anesthesia. Following surgery, the patient remains in the recovery room for a period of time and then may return home with a responsible adult. If the surgery is performed with other procedures, overnight observation may be required.
The main risk to patients with synthetic implants is postoperative infection. Meticulous surgical technique is used to help prevent this complication. When synthetic material is implanted, the patient is usually placed on antibiotics after surgery to prevent infection.
Intraoral sutures dissolve on their own five to 14 days after surgery. Any external sutures are removed after surgery. There may be some swelling and bruising in the augmented region. Discoloration takes about one to three weeks to resolve. The swelling may take a total of several months to entirely resolve. Rarely, the implants will shift during the healing phase and need slight repositioning.
Some studies have shown slight bone erosion under some implants placed on the cheekbones or chin. However, this has not been shown to be of significance to the patient over the long term. There have been no reports of any systemic disorders or medical abnormalities caused by using synthetic materials for facial contouring, although there may be associated numbness in the surgical region. This resolves over a period of months. Permanent numbness is an extremely rare complication of these procedures.
Less often, a patient seeks reduction of the cheekbones, jawbone, or lips. This is usually done by contouring the underlying bone or removing excessive skin and subcutaneous tissue. In reduction procedures, there is no associated placement of augmentation material.
Most commonly, patients seek to augment one or more of the facial regions mentioned above to give a more youthful and defined appearance to the face. For augmentation procedures, we at Mayo use synthetic materials that have a track record of safety and efficacy. The nasolabial creases and lips usually are augmented with small, soft implants that are placed deeply in the skin and the underlying subcutaneous tissue.
Mayo surgeons typically perform the chin and cheekbone augmentation surgery through intraoral incisions. Occasionally, however, surgeons will do the surgery through a small incision under the chin. The material to augment these specific regions is then placed and fixed with internal sutures and, occasionally, external sutures.
The surgery for each of these regions takes from 30 minutes to 1 1/2 hours. Most are performed using local anesthesia with sedation or general anesthesia. Following surgery, the patient remains in the recovery room for a period of time and then may return home with a responsible adult. If the surgery is performed with other procedures, overnight observation may be required.
The main risk to patients with synthetic implants is postoperative infection. Meticulous surgical technique is used to help prevent this complication. When synthetic material is implanted, the patient is usually placed on antibiotics after surgery to prevent infection.
Intraoral sutures dissolve on their own five to 14 days after surgery. Any external sutures are removed after surgery. There may be some swelling and bruising in the augmented region. Discoloration takes about one to three weeks to resolve. The swelling may take a total of several months to entirely resolve. Rarely, the implants will shift during the healing phase and need slight repositioning.
Some studies have shown slight bone erosion under some implants placed on the cheekbones or chin. However, this has not been shown to be of significance to the patient over the long term. There have been no reports of any systemic disorders or medical abnormalities caused by using synthetic materials for facial contouring, although there may be associated numbness in the surgical region. This resolves over a period of months. Permanent numbness is an extremely rare complication of these procedures.
Less often, a patient seeks reduction of the cheekbones, jawbone, or lips. This is usually done by contouring the underlying bone or removing excessive skin and subcutaneous tissue. In reduction procedures, there is no associated placement of augmentation material.
The Face: Otoplasty or Ear Refinement
Ear surgery (otoplasty) is a procedure performed to reshape the ear and give it a more normal appearance. The surgery usually is done on ears that are too large or that protrude from the head. Many times, the problem is caused by an undeveloped middle fold of the ear. In addition to the lack of a fold, there may be other deformities. For this reason, it may be necessary to perform several procedures on the ear at the same time. In most cases, patients need surgery on both ears so that they will be similar. Rarely, only one ear may require surgery.
Otoplasty is done under general anesthesia in children, while adults may have the procedure under either general anesthesia, or local anesthesia with intravenous sedation. Otoplasty can be performed in the outpatient facility, and the patient can return home the day of surgery.
During the procedure, the surgeon makes an incision behind the ear and weakens the cartilage, which is folded into the proper position and held with sutures. Sometimes, the surgeon will remove cartilage and skin. Rarely, the surgeon will make the incision in the front of the ear. Upon healing, scarring barely shows. Following surgery, a head dressing is applied. After removal of the dressing, the patient must wear a headband at night for a few weeks to keep from pulling out the sutures during sleep. Swelling and discoloration will subside in a few weeks.
In most cases, the results of ear surgery are very pleasing. However, the ears may not be perfectly symmetrical since even normal ears are not exactly the same. In a small number of patients, the ear may return toward the old position and require a second operation. Rarely, one of the nondissolving sutures left in the ear will work its way to the surface and have to be removed.
Once the ears have healed, they are in a more normal position that complements the patient's overall appearance.
Otoplasty is done under general anesthesia in children, while adults may have the procedure under either general anesthesia, or local anesthesia with intravenous sedation. Otoplasty can be performed in the outpatient facility, and the patient can return home the day of surgery.
During the procedure, the surgeon makes an incision behind the ear and weakens the cartilage, which is folded into the proper position and held with sutures. Sometimes, the surgeon will remove cartilage and skin. Rarely, the surgeon will make the incision in the front of the ear. Upon healing, scarring barely shows. Following surgery, a head dressing is applied. After removal of the dressing, the patient must wear a headband at night for a few weeks to keep from pulling out the sutures during sleep. Swelling and discoloration will subside in a few weeks.
In most cases, the results of ear surgery are very pleasing. However, the ears may not be perfectly symmetrical since even normal ears are not exactly the same. In a small number of patients, the ear may return toward the old position and require a second operation. Rarely, one of the nondissolving sutures left in the ear will work its way to the surface and have to be removed.
Once the ears have healed, they are in a more normal position that complements the patient's overall appearance.
The Face: Rhinoplasty or Refinement of the Nose
Cosmetic nasal surgery (rhinoplasty) is performed to bring the nose into harmony with the face, thereby improving overall appearance. There is no standard procedure for rhinoplasty. It is important for the surgeon to take into account those nasal features the patient would like changed and then to carefully examine the nose and overlying skin. With this information, the surgeon and the patient can discuss the nasal features that can be realistically modified to obtain the desired result. Often there is an underlying deviation of the nasal septum (the cartilage and bony structure that support the nose and separate it internally into two sides), which causes difficulty in breathing. If this condition is present, it is corrected at the time of surgery.
The surgery is performed primarily through incisions inside the nose. If external incisions are necessary, the scars are small and inconspicuously placed. During the procedure, the surgeon separates the skin of the nose from the underlying bone and cartilage, reshapes the bone and cartilage, and allows the natural elasticity of the skin to reshape over the new framework.
The surgery can be done under local anesthesia with intravenous sedation or general anesthesia in the outpatient facility. The patient can return home or to a hotel the day of surgery, provided he or she is under the care of a responsible adult.
Commonly performed procedures include removing a hump on the bridge of the nose, narrowing the nose, refining the nasal tip, and correcting a deviated septum. Chin augmentation may be suggested to further enhance the facial profile in selected patients. (See facial contour section.)
At the conclusion of the procedure, a small splint is placed over the nose for support and to reduce swelling. The external splint is removed on the fifth to seventh postoperative day. Rarely packing is needed for one to two days.
Swelling and bruising around the nose and eyes is expected for three weeks. Although most of the swelling subsides in four to six weeks, there continues to be some swelling that may take six months or longer to subside. Swelling inside the nose can persist for several weeks and cause nasal stuffiness.
In rare cases, an infection can occur and delay the healing process or result in the development of scar tissue. Other problems that can temporarily occur during the postoperative healing phase include bleeding and a diminished sense of smell. It is important to remember that healing continues for some time following surgery as the skin shrinks and adjusts to the new framework.
Rarely, the final result may not be what the patient and surgeon anticipated. Minor irregularities usually can be corrected with a revision procedure. The quality of the skin overlying the nasal cartilage is an important factor in the final appearance of the nose. Thick and oily skin does not conform as well and may compromise the result. Older skin does not possess the elastic properties of younger skin and may preclude an optimal result.
Following rhinoplasty, the nose has an improved aesthetic appearance as it blends into the face. The improved appearance of the nose is long-lasting.
The surgery is performed primarily through incisions inside the nose. If external incisions are necessary, the scars are small and inconspicuously placed. During the procedure, the surgeon separates the skin of the nose from the underlying bone and cartilage, reshapes the bone and cartilage, and allows the natural elasticity of the skin to reshape over the new framework.
The surgery can be done under local anesthesia with intravenous sedation or general anesthesia in the outpatient facility. The patient can return home or to a hotel the day of surgery, provided he or she is under the care of a responsible adult.
Commonly performed procedures include removing a hump on the bridge of the nose, narrowing the nose, refining the nasal tip, and correcting a deviated septum. Chin augmentation may be suggested to further enhance the facial profile in selected patients. (See facial contour section.)
At the conclusion of the procedure, a small splint is placed over the nose for support and to reduce swelling. The external splint is removed on the fifth to seventh postoperative day. Rarely packing is needed for one to two days.
Swelling and bruising around the nose and eyes is expected for three weeks. Although most of the swelling subsides in four to six weeks, there continues to be some swelling that may take six months or longer to subside. Swelling inside the nose can persist for several weeks and cause nasal stuffiness.
In rare cases, an infection can occur and delay the healing process or result in the development of scar tissue. Other problems that can temporarily occur during the postoperative healing phase include bleeding and a diminished sense of smell. It is important to remember that healing continues for some time following surgery as the skin shrinks and adjusts to the new framework.
Rarely, the final result may not be what the patient and surgeon anticipated. Minor irregularities usually can be corrected with a revision procedure. The quality of the skin overlying the nasal cartilage is an important factor in the final appearance of the nose. Thick and oily skin does not conform as well and may compromise the result. Older skin does not possess the elastic properties of younger skin and may preclude an optimal result.
Following rhinoplasty, the nose has an improved aesthetic appearance as it blends into the face. The improved appearance of the nose is long-lasting.
The Face: Submental Liposuction or Chin and Neck Fat Removal
People sometimes accumulate a focal deposit of fatty material in the area between the chin and neck that detracts from the profile contour. This often happens as a result of aging. However, the deformity can also be seen in younger faces as well, long before other signs of aging have begun. Under these circumstances, patients are bothered by the rounding influence and lack of definition along the jawline and neck.
In submental lipectomy, the surgeon removes this fat by suction techniques or by excision, and often tightens the underlying neck muscles. When sufficiently resilient, the skin then can recoil and have a more toned appearance. For some patients the procedure is a less extensive precursor to a formal face-lift perhaps done at a later time. Younger patients generally have good skin elasticity which permits a more focused approach to the problem without formal face-lifting.
Fat removal from under the chin can result in irregularities of the facial contour or "dimpling" that appears unnatural. Temporary numbness or weakness in the chin and mouth can result from the procedure, but permanent problems are very unusual. Submental lipectomy causes swelling and bruising that can extend into the front of the neck and requires two to three weeks to resolve.
In submental lipectomy, the surgeon removes this fat by suction techniques or by excision, and often tightens the underlying neck muscles. When sufficiently resilient, the skin then can recoil and have a more toned appearance. For some patients the procedure is a less extensive precursor to a formal face-lift perhaps done at a later time. Younger patients generally have good skin elasticity which permits a more focused approach to the problem without formal face-lifting.
Fat removal from under the chin can result in irregularities of the facial contour or "dimpling" that appears unnatural. Temporary numbness or weakness in the chin and mouth can result from the procedure, but permanent problems are very unusual. Submental lipectomy causes swelling and bruising that can extend into the front of the neck and requires two to three weeks to resolve.
The Face: Eyebrow and Forehead Rejuvenation
Progressive drooping of the eyebrows and wrinkling of the forehead are some of the earliest and most recognizable aspects of facial aging. Sagging eyebrows and forehead skin, when advanced, is recognized by contact between the hairs of the eyebrow and eyelash. This phenomenon often prompts patients to comment that their eyes seem to be "shrinking" and that make-up smears on the upper eyelid easily.
This redundancy of tissue also heaps up on the eyelid region itself, creating accordion-like wrinkles. Wrinkles develop in both a transverse and horizontal orientation and fail to disappear even when the eyebrows are at rest. The results of these changes can falsely create a visual image of exhaustion or anger in an individual's face.
The browlift procedure, also called the forehead lift, allows for elevation of the eyebrows and tightening of the forehead skin, giving the eye region a more refreshed and well-rested appearance. Wrinkles are reduced or eliminated by removing the underlying muscles which create them. Excess skin accounting for the laxity is redistributed or removed from the scalp above.
The browlift procedure usually is performed through an incision at or in the hairline, which permits camouflage of the healing scars. In cases where the skin has retained some elastic tone, the forehead and eyebrows can be repositioned using small incisions and a lighted rod called an endoscope. This approach has the additional advantage of minimizing scalp scars, lessening the backward movement of the hairline and decreasing numbness in the central upper scalp, which are common problems associated with traditional approaches. However, both techniques create some swelling and bruising that can last a few weeks before subsiding.
Although the browlift will redrape skin and reduce wrinkling in the upper eyelid and "crow's feet" region, eyelid surgery or a skin resurfacing technique also may be needed to treat these areas most effectively. Puffiness around the eyes, particularly in the lower eyelid region, is also not treated by a browlift procedure. However, if you are looking to optimally rejuvenate aging changes about the eyes, the browlift and eyelid surgery procedures are often mutually complementary and frequently performed simultaneously. In addition, because a face-lift primarily addresses aging changes visible along the jawline and in the neck, a browlift done in conjunction with a face-lift will help to more completely revitalize all regions of the face.
This redundancy of tissue also heaps up on the eyelid region itself, creating accordion-like wrinkles. Wrinkles develop in both a transverse and horizontal orientation and fail to disappear even when the eyebrows are at rest. The results of these changes can falsely create a visual image of exhaustion or anger in an individual's face.
The browlift procedure, also called the forehead lift, allows for elevation of the eyebrows and tightening of the forehead skin, giving the eye region a more refreshed and well-rested appearance. Wrinkles are reduced or eliminated by removing the underlying muscles which create them. Excess skin accounting for the laxity is redistributed or removed from the scalp above.
The browlift procedure usually is performed through an incision at or in the hairline, which permits camouflage of the healing scars. In cases where the skin has retained some elastic tone, the forehead and eyebrows can be repositioned using small incisions and a lighted rod called an endoscope. This approach has the additional advantage of minimizing scalp scars, lessening the backward movement of the hairline and decreasing numbness in the central upper scalp, which are common problems associated with traditional approaches. However, both techniques create some swelling and bruising that can last a few weeks before subsiding.
Although the browlift will redrape skin and reduce wrinkling in the upper eyelid and "crow's feet" region, eyelid surgery or a skin resurfacing technique also may be needed to treat these areas most effectively. Puffiness around the eyes, particularly in the lower eyelid region, is also not treated by a browlift procedure. However, if you are looking to optimally rejuvenate aging changes about the eyes, the browlift and eyelid surgery procedures are often mutually complementary and frequently performed simultaneously. In addition, because a face-lift primarily addresses aging changes visible along the jawline and in the neck, a browlift done in conjunction with a face-lift will help to more completely revitalize all regions of the face.
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