Aesthetic Male Facial Skeletal Surgery

Muzaffer Celik, M.D., Michael T. Longaker, M.D., and Henry K. Kawamoto, M.D., D.D.S.

Los Angeles, California, USA

Abstract. Craniofacial surgery concepts developed originallyfor reconstruction may also be applied to aesthetic surgery. Thefacial skeleton is an important component of appearance andmay be modified using common craniofacial surgery tech-niques. Three representative male patients are presented, whoeach desired an improvement in his appearance. The techniquesused were different and combined orthognathic and remodelingprocedures. Aesthetic male facial skeletal surgery was benefi-cial in these selected cases. The results were well received andwithout complications. Surprisingly, we have found that maleskeletal aesthetic patients did not have unrealistic expectationsand were pleasant to manage pre- and postoperatively.

Key words: Males—Facial skeletal surgery

Facial contour is a reflection of bony skeleton and over-lying soft tissues. A number of facial anomalies and dis-proportions result from skeletal deformities, while inother cases the problem lies with soft tissue [3,7,8,13,14]. The facial skeleton should have a balanced pro-portional relationship for an aesthetic appearance [1,4,5].Cephalometric analyses can be helpful in understandingthe source of facial disharmony because in some cases,patients’ concerns about their appearance may be ob-scure.

Traditionally, aesthetic surgery procedures have fo-cused on soft tissues rather than the facial skeleton. How-ever, the osseous foundation has important implicationsfor surgeons evaluating male patients who want tochange their appearance, as the skeleton provides a majorcomponent of the facial form.

In recent years, more male patients have consideredaesthetic skeletal surgery. It is known that the male face

and facial skeleton have different contours compared totheir female counterparts. Larger bone volumes in thezygoma, mandibular angle, and chin are some of themale facial bony characteristics in the lower face [2]. Inthe upper facial skeleton the orbits, frontal bone, andsupraorbital ridge are different in males and females.These distinct characteristics are key points of male ver-sus female facial aesthetics.

The spectrum of male facial appearance ranges froman exaggerated to a less masculine look. It has been ourexperience that males whose appearance falls into eitherextreme of this spectrum are seeking surgical consulta-tion at an increasing frequency. In addition, abnormalcontours, malocclusions, asymmetries, and acquiredanomalies are other reasons to perform aesthetic facialskeletal surgery.

Craniofacial techniques have been shown to be bothsafe and reliable. Thus, one of the current applications ofcraniofacial surgery may be aesthetic craniofacial sur-gery [9–12].

Case Reports

Case 1

A 24-year-old man presented in consultation with max-illary hypoplasia, a shortened distance from the anteriornasal spine to the supradentale, and an acute nasolabialangle (Fig. 1A). He had a lip-to-tooth ratio of −2 mm andClass I occlusion. He desired to show more teeth whenhe smiled. Although cephalometric analysis was per-formed, the clinical assessment dictated the amount ofinferior maxillary movement. The patient underwent aLeFort I osteotomy with a 7-mm inferior repositioning ofthe maxilla with internal rigid fixation. In addition, cra-nial bone grafts across the osteotomy lines were per-formed to augment the anterior maxilla and stabilize thenew maxillary position. Because of the use of internal

Correspondence to Henry K. Kawamoto, M.D., D.D.S., 130120th Street, Suite 460, Santa Monica, CA 90404, USA

Aesth. Plast. Surg. 23:81–85, 1999

© 1999 Springer-Verlag New York Inc.

rigid fixation, postoperative intermaxillary fixation wasavoided. The patient was pleased with the result. Hismidface was lengthened, with a planned new incisalshow of +2 mm in repose (Fig. 1B).

Case 2

A young man presented in consultation because he feltthat his face was too wide. Elsewhere, he had previouslyhad genioplasty, otoplasty, and forehead reduction tocorrect what he felt was an excessively masculine ap-pearance. On examination, he had a prominent zygo-matic arch on the left compared to the right, absence ofincisal show, and fullness in the mandibular angle areasbilaterally (Figs. 2A and B). He had a lip-to-tooth ratio of−2 mm and Class I occlusion. The patient underwent aLeFort I osteotomy and a 7-mm inferior repositioning ofthe maxilla with internal rigid fixation. He also had cra-nial bone grafts placed across the osteotomy lines toaugment the anterior maxilla and stabilize the new max-illary position. In addition, bilateral zygomatic arch re-duction through a postauricular incision and bilateral in-traoral reduction of the mandibular angles were per-formed (Fig. 2C). Because of the use of rigid internalfixation, postoperative intermaxillary fixation wasavoided. Postoperatively, the patient was pleased withhis more narrow and elongated face, with +1 mm ofincisal show in repose (Figs. 2D and E).

Case 3

A 20-year-old young man was seen in consultation com-plaining of facial asymmetry. He had been evaluatedseveral years earlier for the same complaint, but declinedreconstruction at that time. On physical exam and cepha-lograms, he had a right-sided hemihypertrophy of themandible with a severe occlusal cant (Figs. 3A–C).There was an associated maxillary deformation second-ary to the mandibular hemihypertrophy. Following ceph-alometric analysis, dental models and mock surgery were

used to plan orthognathic movements and prefabricatedental splints. The patient underwent two jaw surgeriesconsisting of mandibular bilateral sagittal osteotomiesand a leveling LeFort I osteotomy, both with rigid inter-nal fixation. In addition, the height of the right mandibu-lar body was reduced via intraoral shaving (Figs. 3D andE). Postoperatively intermaxillary fixation was not re-quired. The patient had Class I occlusion and his changein facial appearance was dramatic (Figs. 3F–H).

Discussion

Aesthetic considerations of the face play an importantrole in social interactions of both male and females.Many congenital or acquired soft tissue defects causefacial deformities, while others may be secondary toskeletal changes. For example, fibrous dysplasia, vascu-lar malformations, and some bone tumors can adverselyaffect facial appearance [3,7,8,13,14]. Some of these fa-cial deformities may be corrected by craniofacial tech-niques altering the anatomy and contour of the facialskeleton [10–12,14]. In these cases an operation is donefor both therapeutic and aesthetic reasons.

Craniofacial approaches have been shown to be safeand reliable. As such, these techniques are also helpful infacial aesthetic surgery. For example, subperiosteal dis-section is an integral component of craniofacial surgeryand now subperiosteal facelifting is done routinely[9–12].

Aesthetic surgery has traditionally focused on facialsoft tissue, while almost ignoring the underlying facialskeleton. This is surprising, as both structures can bealtered to change the facial appearance. When youngmale patients request a change in facial form, the skel-eton must be examined carefully. If present, facial skel-etal disharmony can be corrected using craniofacial tech-niques for aesthetic considerations. Depending on theanatomy, surgical procedures will be different for everypatient and can be modified and/or combined.

Fig. 1. A 24-year-old man who desired moreincisal show.(A) Preoperative frontalphotograph.(B) Postoperative frontalphotograph. Note the change in thelip-to-tooth relationship and the increasedincisal show.

82 Aesthetic Male Facial Skeletal Surgery

One important aspect of male aesthetic surgery thatdeserves emphasis is the psychological condition of thepatient. It is generally accepted that male aesthetic pa-tients can be more difficult to manage than their femalecounterparts. In contrast, it has been our experience thatmale patients seeking aesthetic facial skeletal surgery fortrue facial skeletal disharmony do not have unrealisticexpectations. We do, however, repeatedly emphasize thata complete correction of their facial skeleton is often notpossible. Thus, the patient who has marked disproportionof his facial skeleton should be counseled preoperativelyin a different way than patients who have minimal ormoderate deformities.

It is interesting that two of three patients presented inthis series had Class I occlusion preoperatively. Thesepatients underwent orthognathic surgery without preop-erative orthodontic treatment. As such, they had intraop-erative placement of arch bars, temporary intraoperativeintermaxillary fixation with elastics, and maxillary repo-sitioning without a surgical splint. With the advance ofrigid internal fixation, postoperative intermaxillary fixa-tion is rarely needed, a point welcomed by patients seek-ing aesthetic surgery. Although it is considered uncom-mon, the senior author (H.K.K.) has a large experiencewith orthognathic surgery on patients with Class I occlu-sion, mainly to enhance vertical facial proportions. We

Fig. 2. A male patient who felt that his facewas too wide and desired an increased incisalshow.(A) Preoperative frontal photograph.(B) Preoperative right lateral photograph.(C)Line drawing of the surgical procedure.Left:Preoperative skeleton with proposedosteotomies.Right: Postoperative facialskeleton: LeFort I osteotomy with a 7-mminferior repositioning of the maxilla, cranialbone grafts across the osteotomies, bilateralzygomatic arch reduction through apostauricular incision, and bilateral intraoralreduction of the mandibular angles.(D)Postoperative frontal photograph. Thepatient’s face appears less wide.(E)Postoperative right lateral photograph.

83M. Celik et al.

Fig. 3. A 20-year-old man with right-sidedmandibular hemihypertrophy causing markedfacial asymmetry.(A) Preoperative frontalphotograph.(B) Preoperative inferior-viewphotograph.(C) Preoperative photographshowing occlusal cant.(D) Line drawing ofthe preoperative facial skeleton withproposed osteotomies.(E) Line drawing ofleveling two jaw maxillary LeFort I andmandibular bilateral sagittal splitosteotomies, sliding osseous genioplasty, anda reduction of the right inferior mandibularbody. (F) Postoperative frontal photograph.Note the dramatic change in facialappearance.(G) Postoperative inferior-viewphotograph.(H) Postoperative photographshowing the improvement in the occlusalcant.

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feel that 2–3 mm of incisal show is important aestheti-cally because the alternative is an aged appearance whenit is lacking. Finally, when dealing with male patientsrequesting facial skeletal surgery, it is important to listento patients’ concerns when planning the operation ratherthan relying solely on cephalometrics.

In conclusion, aesthetic male facial skeleton surgery isa surgical practice that includes the comprehensiveevaluation, diagnoses, and surgical treatment of aestheticskeletal conditions of the craniofacial region [1,4,6]. Thisis an area of increasing interest, since a number of malepatients seeking cosmetic facial enhancement, whencarefully evaluated, have both skeletal and soft tissueabnormalities. Thus, surgeons performing aesthetic fa-cial surgery should have a broad-based understanding ofthe evaluation, diagnosis, and treatment of both the softand the skeletal components of facial disharmony.

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