Orthognathic surgery is mostly performed to correct developmental or acquired oral and maxillofacial skeletal deformities (OMSDs). During the past three decades, significant advances in surgical osteotomy techniques and instrumentation have been developed and carried out in orthognathic surgery. However, the basic surgical principles have more or less remained unchanged. At the same time, numerous surgical techniques have been developed and refined and used by surgeons in the field of oral and maxillofacial surgery. These techniques have treatment of the most complex dentofacial deformities with confidence. Additionally, it has been possible to predict the results of the treatment. Although the initial surgical techniques for correction of anterior mandibular open bite were reported as early as the late 1800s, widespread use of currently acceptable techniques began in the middle of the last century. Detailed surgical planning is essential for a successful outcome. The treatment involves an accurate treatment plan, correct type of instruments for a specific procedure, a thorough surgical routine, and adherence to the guidelines for each routine. Although similar orthognathic surgical techniques are used, there are multiple important differences related to each osteotomy. It is essential for the surgeon to understand these differen‐ ces in order to provide an effective and safe surgical care for the patient with facial anomalies. Choosing an optimal method of osteotomy depends on many factors, including the indication for treatment, the goal of therapy, patient profile, underlying medical conditions, and the magnitude of surgical movement. The major objective of this chapter is to provide practical guidelines and principles of osteotomies and commonly used techniques. These guidelines are based on a review of the current literature and the author's personal experience. The chapter focuses on the history of orthognathic surgery, anatomical considerations, indications for different osteoto‐ mies, and the surgical technique for each osteotomy. Techniques such as the Le Fort I, II, III osteotomies, segmental osteotomies of the maxilla, bilateral sagittal split osteotomy (BSSO), bilateral vertical osteotomy (BVO) genioplasty, segmental osteoto‐ my of the mandible, and the chin wing osteotomy are described.

**Keywords:** osteotomy, maxilla, mandible, chin, segmentation

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **1. Introduction**

During the last three decades, remarkable advances have been made in surgical techniques and instrumentation for dentofacial surgery. Our knowledge and understanding of all aspects of orthognathic surgery have also grown over time. However, the basic surgical principles have more or less remained unchanged, despite technical innovations. Oral and maxillofacial surgery plays a central role in many aesthetic and functional procedures affecting the face and oral cavity. Since the first reported osteotomy performed on the mandible in the USA in 1849 [1], a large number of improvements have been published in the fields of orthognathic surgery. A well‐defined treatment plan is required to ensure a successful treatment outcome. The surgeon should develop and adopt a proper technique for each procedure; using the same surgical sequence enables assisting residents to anticipate each step, thus adopting skills and developing a routine. The leading surgeon should have explicit knowledge on each surgical step. The most common surgical techniques currently used for the correction of dentofacial deformities, with various modifications, are the bilateral sagittal split osteotomy (BSSO) of the mandible, the oblique ramus osteotomy of the mandible, genioplasty, and the Le Fort I osteotomy of the maxilla. Osteotomies of jaw must be performed in a safe way and preferably intraorally to avoid scars on the face and at the same time provide adequate exposure to the skeleton. Essential structures must be preserved, and provision for appropriate nutrition postoperatively should be considered.

### **2. History**

The first reported operation to correct malocclusion was performed in the USA in 1849 by Simon P. Hullihen [1] (**Figure 1**), in a patient with an open‐bite deformity secondary to scar contractures of the neck and chest.

**Figure 1.** Simon P. Hullihen [1] first reported an operation to correct the malocclusion.

**1. Introduction**

618 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3

postoperatively should be considered.

contractures of the neck and chest.

**2. History**

During the last three decades, remarkable advances have been made in surgical techniques and instrumentation for dentofacial surgery. Our knowledge and understanding of all aspects of orthognathic surgery have also grown over time. However, the basic surgical principles have more or less remained unchanged, despite technical innovations. Oral and maxillofacial surgery plays a central role in many aesthetic and functional procedures affecting the face and oral cavity. Since the first reported osteotomy performed on the mandible in the USA in 1849 [1], a large number of improvements have been published in the fields of orthognathic surgery. A well‐defined treatment plan is required to ensure a successful treatment outcome. The surgeon should develop and adopt a proper technique for each procedure; using the same surgical sequence enables assisting residents to anticipate each step, thus adopting skills and developing a routine. The leading surgeon should have explicit knowledge on each surgical step. The most common surgical techniques currently used for the correction of dentofacial deformities, with various modifications, are the bilateral sagittal split osteotomy (BSSO) of the mandible, the oblique ramus osteotomy of the mandible, genioplasty, and the Le Fort I osteotomy of the maxilla. Osteotomies of jaw must be performed in a safe way and preferably intraorally to avoid scars on the face and at the same time provide adequate exposure to the skeleton. Essential structures must be preserved, and provision for appropriate nutrition

The first reported operation to correct malocclusion was performed in the USA in 1849 by Simon P. Hullihen [1] (**Figure 1**), in a patient with an open‐bite deformity secondary to scar

**Figure 1.** Simon P. Hullihen [1] first reported an operation to correct the malocclusion.

**Figure 2.** A 20‐year‐old woman severely burned on the neck at the age of 5 years operated by Hullihen [1] in 1849.

The cicatrix caused a deformity, and her head was drawn forward and downward with the chin frowsy close to the chest. Hullihen [1] performed an operation on the front section of the mandible and removed a wedge‐shaped section from the anterior portion of the mandible, by sawing out a V‐shaped segment, repositioned it, and fixed it with wire ligatures (**Figure 2**). Although the operation was performed primarily to correct the grotesque facial deformity, Hullihen [1], without formal dental training, had enough vision to reduce the class III maloc‐ clusion with bilateral subapical osteotomies. This was performed without having access to anaesthesia, antibiotics, or sophisticated instruments [2]. The development of orthognathic surgery continued in the USA when Steinhäuser and Berger 1897 described osteotomy of the condyle for the correction of prognathism.

Vilray Blair performed the first osteotomy of the mandibular body for the correction of horizontal mandibular excess, in 1907 [3]. He described three distinct problems: (1) cutting of the bone, (2) replacing the segment to a new position, and (3) fixation of the segments. This chapter was written more than 100 years ago but is still of great value.

In 1925, Limberg reported the first subcondylar osteotomy as an extraoral technique; later it was modified into the intraoral vertical subcondylar osteotomy. In the 1950s, mandibular osteotomies were routinely used with more or less predictable results, and publications came subsequently by Blair, Bruhn, Ascher, Obwegeser, Caldwell, and Letterman [4, 5]. Wassmund 1927 suggested a variation of the different subcondylar cuts similar to what is now known as the inverted L osteotomy. An anterior mandibular alveolar osteotomy was proposed by Hofer in 1963 to advance anterior teeth to correct mandibular dentoalveolar retrusion. Caldwell and Letterman developed a vertical ramus osteotomy technique that had the advantage of minimizing traumatic injury to the inferior alveolar neurovascular bundle [6].

A tremendous improvement in cutting the vertical ramus was the sagittal split osteotomy, described by Obwegeser in 1955 [7]. Trauner and Obwegeser published a modification of the same technique in 1957 [8]. Delpont made significant changes in osteotomy design in 1961 [9]. Later, Hunsuck 1968 [10] suggested a minor modification, which decreased trauma to overlying soft tissues. In 1965, Obwegeser [11] performed complete mobilization of the maxilla for the first time. Relocating the maxilla could be done without tension. Until 1960, a pedicle of the soft tissue of buccal side was still preserved. Bell in 1970 published a paper and stressed that as long as the maxilla is attached to the palatal mucosa, the down fracture of the maxilla including the labial gingiva with complete mobilization can be done with adequate vascular supply [12].

Kent and Hinds, in 1971, presented the use of single tooth osteotomies of the mandible. Macintosh followed this technique with his description of total mandibular alveolar osteotomy in 1974 [13].

David Cheever reported the very first maxillary osteotomy in the USA in 1867 [14], for the treatment of complete nasal obstruction due to a sinus tumour for which a right hemimaxillary downfracture was used. The first time that an entire Le Fort I osteotomy was used for surgical correction of a facial deformity was by Wassmund in 1927. Wassmund introduced Le Fort I, or total maxillary osteotomy, for the treatment of an open bite. The early maxillary osteotomies that were performed in the 1950s were regarded with scepticism because of unpredictable results. After the successful mobilization and repositioning of the maxilla, presented by Wassmund, surgical correction of the maxilla appeared to be accepted from the early 1960s.

Schuchardt advocated the separation of pterygomaxillary junction in 1942. Bell 1975 stated that Le Fort I osteotomy has become a routine procedure in orthognathic surgery. Its simplicity, its broad application to resolve many functional and aesthetic problems, and the dependability of its results support this evolution. The applicability of the osteotomy makes it possible to reposition the maxilla in several directions; however, the setback of the maxilla is difficult because of the pterygoid plates. In the case where elongation of the maxilla is desired, a bone graft is often needed since bone contact will be lost. In modern protocols this can, however, be avoided if a pyramidal osteotomy is performed in the lateral walls of the maxillary complex, making the maxilla slide inferio‐anteriorly. In 1949, Moore and Ward [15] recommended horizontal transection of the pterygoid plates for maxillary advancement. However, this technique was abandoned due to the incidence of severe bleeding in most cases. In 1959, Köle [16] suggested interproximal bone segmentation to expedite mobility between tooth bearing segments. He suggested that teeth could be segmented and moved as 'small boxes' through bone remodelling without involving the periodontal ligament. In the 1960s, Obwegeser suggested that the maxilla/maxillary segments should be fully mobilized so that they could be brought into the desired position without tissue resistance. This proved to be a significant advancement in stabilization, as documented by Hogemann and Willmar, De Haller, and Perko, respectively [17].

### **3. Anatomical considerations**

### **3.1. Blood supply**

Blood supply is essential for the healing of osteotomies. Bell and Levey 1969 18] and 1970 have shown in a study that periosteum is necessary for maintaining the blood supply to the teeth of a mobile jaw segment [12, 18]. Even when the labial periosteum is raised, care should be taken not to cause any tension or tears. A subapical osteotomy needs to be carefully planned to ensure as large a vascular pedicle as possible. In the lower jaw, the proximal segment of the vertical osteotomy is attached by the lateral pterygoid muscle and temporomandibular joint capsule. In some recent studies, stripping of the muscle attached to the medial segment has been suggested. However, in older literature, it was recommended to keep this muscle attachment intact. Apparently, either approach when used does not show any significant differences in clinical outcomes. However, it is important that the distance between the osteotomy and apices of the teeth is at least 5 mm. Keeping this distance minimizes tooth and pulpal injury, and a mobile segment will have greater vitality to survive by increased vascular supply.

It is advised to handle the soft tissues with care so that adequate collateral blood supply to the osteotomized segment is maintained and injury to other vital structures is avoided.

Prominent vessels to consider when planning orthognathic surgery are the posterior superior alveolar (PSA) artery, greater palatine artery, maxillary artery, pterygoid venous plexus, inferior alveolar artery, and buccal artery (**Figure 3**).

**Figure 3.** Prominent vessels to consider in orthognathic surgery are the posterior superior alveolar (PSA) artery, great‐ er palatine artery, maxillary artery, pterygoid venous plexus, inferior alveolar artery, and buccal artery.

#### **3.2. Nerves**

overlying soft tissues. In 1965, Obwegeser [11] performed complete mobilization of the maxilla for the first time. Relocating the maxilla could be done without tension. Until 1960, a pedicle of the soft tissue of buccal side was still preserved. Bell in 1970 published a paper and stressed that as long as the maxilla is attached to the palatal mucosa, the down fracture of the maxilla including the labial gingiva with complete mobilization can be done with adequate vascular

Kent and Hinds, in 1971, presented the use of single tooth osteotomies of the mandible. Macintosh followed this technique with his description of total mandibular alveolar osteotomy

David Cheever reported the very first maxillary osteotomy in the USA in 1867 [14], for the treatment of complete nasal obstruction due to a sinus tumour for which a right hemimaxillary downfracture was used. The first time that an entire Le Fort I osteotomy was used for surgical correction of a facial deformity was by Wassmund in 1927. Wassmund introduced Le Fort I, or total maxillary osteotomy, for the treatment of an open bite. The early maxillary osteotomies that were performed in the 1950s were regarded with scepticism because of unpredictable results. After the successful mobilization and repositioning of the maxilla, presented by Wassmund, surgical correction of the maxilla appeared to be accepted from the early 1960s. Schuchardt advocated the separation of pterygomaxillary junction in 1942. Bell 1975 stated that Le Fort I osteotomy has become a routine procedure in orthognathic surgery. Its simplicity, its broad application to resolve many functional and aesthetic problems, and the dependability of its results support this evolution. The applicability of the osteotomy makes it possible to reposition the maxilla in several directions; however, the setback of the maxilla is difficult because of the pterygoid plates. In the case where elongation of the maxilla is desired, a bone graft is often needed since bone contact will be lost. In modern protocols this can, however, be avoided if a pyramidal osteotomy is performed in the lateral walls of the maxillary complex, making the maxilla slide inferio‐anteriorly. In 1949, Moore and Ward [15] recommended horizontal transection of the pterygoid plates for maxillary advancement. However, this technique was abandoned due to the incidence of severe bleeding in most cases. In 1959, Köle [16] suggested interproximal bone segmentation to expedite mobility between tooth bearing segments. He suggested that teeth could be segmented and moved as 'small boxes' through bone remodelling without involving the periodontal ligament. In the 1960s, Obwegeser suggested that the maxilla/maxillary segments should be fully mobilized so that they could be brought into the desired position without tissue resistance. This proved to be a significant advancement in stabilization, as documented by Hogemann and Willmar, De Haller, and

Blood supply is essential for the healing of osteotomies. Bell and Levey 1969 18] and 1970 have shown in a study that periosteum is necessary for maintaining the blood supply to the teeth

supply [12].

620 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3

in 1974 [13].

Perko, respectively [17].

**3.1. Blood supply**

**3. Anatomical considerations**

Facial nerve branches are rarely damaged in orthognathic surgery, but great care should be taken when, for example, an extraoral vertical ramus osteotomy is performed. The course of the inferior alveolar nerve through the mandibular canal is at increased risk of injury when any osteotomy is carried out in the mandible. Bradycardia and asystole may occur during downfracture or mobilization of the maxilla due to the trigeminal‐cardiac reflex. This can happen as a result of manipulation of the central or peripheral portions of the trigeminal nerve during mobilization of the maxilla [19]. All patients can experience varying degrees of dysesthesia some months postoperatively such as numbness, hypaesthesia, or tingling, most commonly after BSSO [20]. Patients who undergo Le Fort II and III osteotomies may experience infraorbital nerve sensory dysfunction.

### **3.3. Muscles**

Muscles are, as mentioned earlier, important in orthognathic surgery. On the one hand, they are essential for blood supply to the segments, and on the other, they have an impact on relapse. Surgery can affect muscles in two different ways; they can change the length and direction of function. The muscles that can be affected by orthognathic surgery are the suprahyoid group of muscles and the masticatory muscles.

### **4. Osteotomies in the maxilla**

### **4.1. Le Fort I**

Wassmund 1927 [21] described this osteotomy. In 1969, Obwegeser reviewed and modified the technique [22]. An intraoral incision, 3–4 mm above the attached gingiva at maxillary vestibular fornix, is made from the second premolar of one side to the opposite side. A mucoperiosteal flap is raised exposing maxillary walls. Modern protocols [23–26], however, advocate a less extended incision with an opening in the incisor region only. The infraorbital nerve must be identified, and the dissection will then extend to the level of infraorbital nerve to simplify the following osteotomies and to achieve direct control of periorbital tissues. During the exposure, great care should be taken not to expose the buccal fat pad. Before the bone osteotomy, a nasal mucosa mobilization is performed from the wall of the nasal cavity. The osteotomy is carried out with a burr, saw, or piezo machine, starting from the lateral aspect of the piriform aperture and extended to the posterior aspect of the maxilla towards the zygomatic buttress as backwards as possible and inferiorly (**Figures 4** and **5**).

**Figure 4.** Schematic picture of a Le fort I Osteotomy

**Figure 5.** Frontal view of a Le Fort I osteotomy performed by a piezo saw with a nice cut.

The same is done on the opposite side. These osteotomies are completed with a chisel, to detach the nasal septum and lateral wall of the nasal cavity. The osteotomy of the nasal septum and separation of septal cartilage from the anterior nasal spine is usually made by chisel. Finally, it is important to separate the pterygomaxillary junction by using a curved chisel laterome‐ dially to simplify the mobilization of the maxilla. After the last detachment of the maxilla is done, downfracture can be performed. The advantages of this osteotomy are full mobilization, speed, simplicity, direct vision, the safety of segmentation, and reduced risk for relapse. An alternative to the separation of the pterygomaxillary junction is a vertical osteotomy in the tuber region of the alveolar crest. This method will, however, not enable the same degree of mobility. It is fixated using miniplates.

Over many years, the precision of the operative technique and establishment of a scientific and biological basis for the procedure has been established. The Le Fort I osteotomy has become an essential procedure in the surgical armamentarium for correction of dentofacial deformities.

### **4.2. Segmented Le Fort I osteotomy**

commonly after BSSO [20]. Patients who undergo Le Fort II and III osteotomies may experience

Muscles are, as mentioned earlier, important in orthognathic surgery. On the one hand, they are essential for blood supply to the segments, and on the other, they have an impact on relapse. Surgery can affect muscles in two different ways; they can change the length and direction of function. The muscles that can be affected by orthognathic surgery are the suprahyoid group

Wassmund 1927 [21] described this osteotomy. In 1969, Obwegeser reviewed and modified the technique [22]. An intraoral incision, 3–4 mm above the attached gingiva at maxillary vestibular fornix, is made from the second premolar of one side to the opposite side. A mucoperiosteal flap is raised exposing maxillary walls. Modern protocols [23–26], however, advocate a less extended incision with an opening in the incisor region only. The infraorbital nerve must be identified, and the dissection will then extend to the level of infraorbital nerve to simplify the following osteotomies and to achieve direct control of periorbital tissues. During the exposure, great care should be taken not to expose the buccal fat pad. Before the bone osteotomy, a nasal mucosa mobilization is performed from the wall of the nasal cavity. The osteotomy is carried out with a burr, saw, or piezo machine, starting from the lateral aspect of the piriform aperture and extended to the posterior aspect of the maxilla towards the

zygomatic buttress as backwards as possible and inferiorly (**Figures 4** and **5**).

infraorbital nerve sensory dysfunction.

622 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3

of muscles and the masticatory muscles.

**4. Osteotomies in the maxilla**

**Figure 4.** Schematic picture of a Le fort I Osteotomy

**3.3. Muscles**

**4.1. Le Fort I**

In cases of open bite or when a transversal expansion is required in the maxilla, a Le Fort I osteotomy approach can be combined with a multiple‐piece osteotomy to correct an unfav‐ ourable curve of Spee or a transverse discrepancy. The maxilla can be sectioned into 2, 3, 4, 5, or 6 segments depending on the indications (**Figures 6**–**8**).

**Figure 6.** Segmentation of maxilla into 4 pieces.

**Figure 7.** Segmentation of maxilla into 6 pieces.

**Figure 8.** Clinical view of segmented maxilla.

A median osteotomy is made by a Lindeman burr or piezo at the lateral aspect of the median palatal suture. When a two‐segment osteotomy is planned, one median cut is performed only on the side of the palatal suture. This cut will be connected consequently to a vertical inter‐ dental osteotomy that will be placed between the canine and first bicuspid teeth on the same side (**Figure 9**).

**Figure 9.** A vertical interdental osteotomy placed between the canine and first bicuspid teeth on the same side.

Another option of vertical osteotomy is to place the vertical interdental osteotomy between the lateral incisor and canine [23-30]. In both cases, the interdental osteotomies are combined with palatal osteotomies but from a superior angle without raising a palatal flap. When a four‐ piece segmentation is required, two parallel osteotomies are performed on each side (**Fig‐ ure 6**). These osteotomies will consequently be connected to each other by an oblique osteotomy and subsequently to the vertical interdental osteotomy placed between the canine and first bicuspid or between the lateral incisor and canine. It is essential to keep the palatal mucosa intact. Careful sectioning when performing the interdental osteotomies is mandatory to avoid injury to the tooth roots and their blood supply. This approach allows placement of the maxillary segments in different directions since they are detached.

In some cases, a high Le Fort I osteotomy is required for advancement of the entire midface to improve the extraoral profile of the facial skeleton (**Figure 10**).

**Figure 10.** In some cases, a high Le Fort I osteotomy is required for advancement of the entire midface to improve the extraoral profile.

#### **4.3. Le Fort II**

**Figure 7.** Segmentation of maxilla into 6 pieces.

624 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3

**Figure 8.** Clinical view of segmented maxilla.

side (**Figure 9**).

A median osteotomy is made by a Lindeman burr or piezo at the lateral aspect of the median palatal suture. When a two‐segment osteotomy is planned, one median cut is performed only on the side of the palatal suture. This cut will be connected consequently to a vertical inter‐ dental osteotomy that will be placed between the canine and first bicuspid teeth on the same

**Figure 9.** A vertical interdental osteotomy placed between the canine and first bicuspid teeth on the same side.

The indication for this osteotomy is when a forward, downward movement of the nasal and maxillary complex is necessary for correction of the midface. This osteotomy is performed in the upper midface, between the frontal facial unit and above Le Fort I (**Figure 11**).

**Figure 11.** Le Fort II osteotomy is performed in the upper midface, between the frontal facial unit and above Le Fort I.

The approach has its place where there is a need for the correction of nasomaxillary hypoplasia [31, 32]. This osteotomy is also called a pyramidal naso‐orbital maxillary osteotomy. The Le Fort II osteotomy includes the naso‐orbital ethmoidal (NOE) fracture line, the zygoma laterally, and internal part of the orbit. This osteotomy was first presented by Henderson and Jackson in 1973. Surgically, an incision is performed obliquely to the paranasal region extending to the infraorbital rim to the medial canthus and over the nasal bone. The Le Fort II osteotomy is relatively rare because it is not required as often (only in 2% of dentofacial anomalies cases, such as in Apert, Crouzon Treacher Collins syndromes). Other indications are a skeletal class III malocclusion in combination with maxillary‐zygomatic deficiency, maxillary‐alveolar‐ palatal cleft deformity, and nasomaxillary deficiency [28]. The osteotomy allows lengthening of the nose along with the movement of the upper jaw in selected cases where this effect is desired.

Steinhauser, 1980, described three different surgical approaches namely anterio‐, pyramidal, and quadrangular osteotomies [33].

To get surgical access for the Le Fort II osteotomy, a V‐shaped incision with the apex at the glabella is made to extend bilaterally along both sides of the nose to reach just above the alar base. The columella of the nose is pulled down, and the cartilaginous and bony part is separated. Osteotomy starts at the bottom of the nasal bone towards the medial wall of orbit towards the floor of orbit posterior to the nasolacrimal apparatus. Then it continues to the infraorbital margin medial to the infraorbital nerve and extends to the alveolar bone posterior to the second premolar. A flap in the posterior buccal area is raised. The osteotomy is completed through the intra oral incision towards the pterygoid plates. In cases with deficiency in the infraorbital area, the cut can be continued to the zygomatic buttress before going down towards the pterygoid plates. Downfracture of the midface can be done. The segment can be advanced after mobilization. Fixation can be done either by an acrylic splint or by fixation plates. In this approach, bone grafts should be used to restore the bone deficiencies. It is crucial to have skin coverage, and nasal lining must be provided. The nasolacrimal apparatus must not be damaged.

### **4.4. Le Fort III**

**Figure 11.** Le Fort II osteotomy is performed in the upper midface, between the frontal facial unit and above Le Fort I.

The approach has its place where there is a need for the correction of nasomaxillary hypoplasia [31, 32]. This osteotomy is also called a pyramidal naso‐orbital maxillary osteotomy. The Le Fort II osteotomy includes the naso‐orbital ethmoidal (NOE) fracture line, the zygoma laterally, and internal part of the orbit. This osteotomy was first presented by Henderson and Jackson in 1973. Surgically, an incision is performed obliquely to the paranasal region extending to the infraorbital rim to the medial canthus and over the nasal bone. The Le Fort II osteotomy is relatively rare because it is not required as often (only in 2% of dentofacial anomalies cases, such as in Apert, Crouzon Treacher Collins syndromes). Other indications are a skeletal class III malocclusion in combination with maxillary‐zygomatic deficiency, maxillary‐alveolar‐ palatal cleft deformity, and nasomaxillary deficiency [28]. The osteotomy allows lengthening of the nose along with the movement of the upper jaw in selected cases where this effect is

Steinhauser, 1980, described three different surgical approaches namely anterio‐, pyramidal,

To get surgical access for the Le Fort II osteotomy, a V‐shaped incision with the apex at the glabella is made to extend bilaterally along both sides of the nose to reach just above the alar base. The columella of the nose is pulled down, and the cartilaginous and bony part is separated. Osteotomy starts at the bottom of the nasal bone towards the medial wall of orbit towards the floor of orbit posterior to the nasolacrimal apparatus. Then it continues to the infraorbital margin medial to the infraorbital nerve and extends to the alveolar bone posterior to the second premolar. A flap in the posterior buccal area is raised. The osteotomy is completed through the intra oral incision towards the pterygoid plates. In cases with deficiency in the infraorbital area, the cut can be continued to the zygomatic buttress before going down towards the pterygoid plates. Downfracture of the midface can be done. The segment can be advanced after mobilization. Fixation can be done either by an acrylic splint or by fixation plates. In this approach, bone grafts should be used to restore the bone deficiencies. It is crucial to have skin coverage, and nasal lining must be provided. The nasolacrimal apparatus must not be

desired.

damaged.

and quadrangular osteotomies [33].

626 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3

Sir Harold Gillies and colleagues presented the Le Fort III osteotomy for the first time in 1951. The technique was improved by Paul Tessier in 1967 making five different variations mainly regarding the osteotomy of the lateral wall of the orbit [34]. The Le Fort III procedure is designed to move the entire midface forward including the portions of the eye sockets to get a more balanced appearance in whom facial disharmony results from panfacial hypoplasia. This technique is used in various craniofacial syndromes such as Apert, Crouzon, Treacher Collins, etc.

Those patients who have a total retrusion of the midface often have a retrusion of the nose, cheeks, inferior orbital rims, and upper lip. Patients with Crouzon, Apert's, and Pfeiffer's syndrome often have a hypoplastic nose. In some cases, it will be necessary to complete a Le Fort III with a Le Fort I osteotomy to make the appropriate adjustment for optimal aesthetics and occlusion. One more detail to keep in mind is the intercanthal distance and level of attachment of the medial and lateral canthal tendons. Epker et al. 1980 [35] suggested that this method is more aesthetic, and function of the lacrimal sac is better when dystopia of the medial canthal tendons or telecantism does not exist.

The bicoronal approach is preferred and often utilized in Le Fort III osteotomies. The incision is a coronal flap to lift the full‐face skin combined with subciliary, subtarsal or transconjunctival incision, and intraoral vestibular incisions. The dissection of the supraorbital rim includes decompression of the supraorbital nerve by an osteotomy on the supraorbital rim to release the nerve (**Figure 12**).

**Figure 12.** The dissection of the supraorbital rim includes decompression of the supraorbital nerve by an osteotomy on the supraorbital rim to release the nerve. The incision extended to the lateral orbital rim, nasion, and through the zygo‐ matic arch via a coronal incision.

After releasing the nerve, nasal bone, medial canthal tendons, and superior part of the lacrimal sac, the lateral and inferior orbital rims are exposed.

The osteotomies start at the glabella using a horizontal cut (**Figure 12**). The medial canthal tendons should be either left intact or reflected off or reached with a suture. The lacrimal fossa is exposed below this area with the accompanying lacrimal sac. Care should be taken not to interfere with the ethmoidal artery that is located about 25 mm back in the orbit. Thus, the cut can be applied only 12–15 mm posteriorly avoiding the ethmoidal artery. If the medial canthal distance is average, the cut can be placed anterior to the medial canthal tendon, leaving the tendon untouched. If any subciliary or subconjunctival incision is made, the cut of the medial wall can be done via a chisel. A horizontal cut is then performed across the orbital floor extending to the lateral orbital rim. At the lateral orbital rim, the cut of the lateral wall can be carried out in the middle, but depending on the deficiency of the lateral rim it can be more superior or inferiorly placed according to Tessier I, II, and III. By elevating the anterior part of the temporal muscle, direct access to the retro‐orbital and infratemporal space is gained. To detach the pterygomaxillary junction, an intraoral gingivobuccal incision as described for Le Fort I is used. It is also possible to separate the junction via bicoronal approach.

In some cases, a glabella incision together with bilateral subciliary incisions and oral vestibular incisions is utilized. With that approach, the osteotomies start at the glabella section through a horizontal incision in the skin. This cut continues to the middle part of the orbital rim with the same care mentioned earlier at the medial section of the orbit, downwards to the inferior orbital rim through the subciliary incision. The incision is then extended to the lateral orbital rim and finally through the zygomatic arch through an intraoral incision back to the ptery‐ goidomaxillary junction that is detached by a chisel (**Figure 13**).

**Figure 13.** *Le Fort III* The incision extended to the lateral orbital rim, nasion, and through the zygomatic arch via a coro‐ nal incision, through an intraoral incision back to the pterygoidomaxillary junction that is detached using a chisel.

Rowe's forceps are then used to mobilize Le Fort III. Garcia and colleagues recently suggested some changes in this technique [36]. This method can be used in combination with distraction osteogenesis resulting in a very good outcome (**Figures 14**–**16**).

**Figure 14.** Le Fort I osteotomy cab be used in combination with distraction osteogenesis resulting in a very good out‐ come. The mobilized midface is at the zygomatic region and paranasal bony anchored to the distractor. At the end of distraction, the midface is advanced. Note the increase of pharyngeal volume compared with the preoperative situa‐ tion.

**Figure 15.** Lateral radiographic projection showing the preoperative view

tendon untouched. If any subciliary or subconjunctival incision is made, the cut of the medial wall can be done via a chisel. A horizontal cut is then performed across the orbital floor extending to the lateral orbital rim. At the lateral orbital rim, the cut of the lateral wall can be carried out in the middle, but depending on the deficiency of the lateral rim it can be more superior or inferiorly placed according to Tessier I, II, and III. By elevating the anterior part of the temporal muscle, direct access to the retro‐orbital and infratemporal space is gained. To detach the pterygomaxillary junction, an intraoral gingivobuccal incision as described for Le

In some cases, a glabella incision together with bilateral subciliary incisions and oral vestibular incisions is utilized. With that approach, the osteotomies start at the glabella section through a horizontal incision in the skin. This cut continues to the middle part of the orbital rim with the same care mentioned earlier at the medial section of the orbit, downwards to the inferior orbital rim through the subciliary incision. The incision is then extended to the lateral orbital rim and finally through the zygomatic arch through an intraoral incision back to the ptery‐

**Figure 13.** *Le Fort III* The incision extended to the lateral orbital rim, nasion, and through the zygomatic arch via a coro‐ nal incision, through an intraoral incision back to the pterygoidomaxillary junction that is detached using a chisel.

Rowe's forceps are then used to mobilize Le Fort III. Garcia and colleagues recently suggested some changes in this technique [36]. This method can be used in combination with distraction

osteogenesis resulting in a very good outcome (**Figures 14**–**16**).

Fort I is used. It is also possible to separate the junction via bicoronal approach.

goidomaxillary junction that is detached by a chisel (**Figure 13**).

628 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3

**Figure 16.** Lateral view after surgical correction with large anterior movement of the maxilla with distraction

#### **4.5. Monobloc**

The so‐called monobloc craniofacial surgery is used for craniofacial advancement in combi‐ nation with distraction osteogenesis and is used for children with complex craniosynostosis syndromes. A bicoronal incision will be used, following a standard fronto‐orbital osteotomy. After separating the frontal bone flap, a forceful forward protrusion of the frontal lobe is noticed suggesting high intracranial pressure from the craniosynostosis. After that, the orbital bandeau is separated by the aid of a piezo saw. A Le Fort III osteotomy should then be performed. The osteotomy line should pass the arch of zygomatic, from the spheno‐zygomatic suture across the floor of the orbit, continuing behind the nasolacrimal duct. After that, it should continue along the lacrimomaxillary suture to the nasal bone (**Figures 17** and **18**). The nasal septum must be separated from the perpendicular plate of the ethmoid bone with a chisel or straight osteotome. Next, the pterygoid plates must be separated with a chisel as described in Le Fort I osteotomy at pterygomaxillary fissure. The viscerocranium can then be mobilized. Rowe's forceps can be used for mobilization of the viscerocranium for rotation downwards.

**Figure 17.** *Monobloc* The forehead, superior orbital rims when a monobloc approach is performed from a frontal point of view.

**Figure 18.** The monobloc approach seen from a sagittal point of view.

#### **4.6. SARME**

**4.5. Monobloc**

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of view.

The so‐called monobloc craniofacial surgery is used for craniofacial advancement in combi‐ nation with distraction osteogenesis and is used for children with complex craniosynostosis syndromes. A bicoronal incision will be used, following a standard fronto‐orbital osteotomy. After separating the frontal bone flap, a forceful forward protrusion of the frontal lobe is noticed suggesting high intracranial pressure from the craniosynostosis. After that, the orbital bandeau is separated by the aid of a piezo saw. A Le Fort III osteotomy should then be performed. The osteotomy line should pass the arch of zygomatic, from the spheno‐zygomatic suture across the floor of the orbit, continuing behind the nasolacrimal duct. After that, it should continue along the lacrimomaxillary suture to the nasal bone (**Figures 17** and **18**). The nasal septum must be separated from the perpendicular plate of the ethmoid bone with a chisel or straight osteotome. Next, the pterygoid plates must be separated with a chisel as described in Le Fort I osteotomy at pterygomaxillary fissure. The viscerocranium can then be mobilized. Rowe's forceps can be used for mobilization of the viscerocranium for rotation downwards.

**Figure 17.** *Monobloc* The forehead, superior orbital rims when a monobloc approach is performed from a frontal point

Surgical assisted rapid maxillary expansion osteotomy (SARME) or surgical assisted rapid palatal expansion osteotomy (SARPE) (SARME/SARPE expressions are used interchangeably) is one of the most commonly performed orthognathic techniques. The terminology is somehow confusing since this approach includes both maxillary and palatal expansions. The terminol‐ ogy includes only one part and is, therefore, inaccurate [37]. It was used and described first by

**Figure 19. Important to avoid orthodontic tilting of molar teeth**. When the median suture is fused, attempting to wi‐ den the palatal suture by orthodontic treatment only cause buccal displacement of teeth with a very high risk of re‐ lapse. A widening of the dental arch without tilting of the teeth is only possible by a surgery.

Brown in 1938. The most common indications for SARME are a transverse discrepancy in the maxilla, failed orthodontic expansion, significant nasal stenosis, and widening of the arch following collapse associated with the cleft palate deformity. This procedure is often used for patients between 16–20 years when the median sutures of the palate are fused. When the median suture is fused, attempting to widen the palatal suture by orthodontic treatment only causes buccal displacement of teeth with a very high risk of relapse (**Figure 19**). Therefore, in those patients, a widening of the dental arch without tilting of the teeth is only possible by a surgically assisted osteotomy together with orthodontic expansion.

The approach is similar to Le Fort I osteotomy as described above. A medial osteotomy is performed carefully with an osteotome following the suture. The activation of the expansion device is preferably done so the expansion can occur quickly. Proper care must be taken not to perforate the soft tissue in the gum with a chisel and not to damage the central incisor roots. Once the separation is done, the expansion device deactivates again. The activation of the device for expansion of the palatal can first be started one week post‐operatively. In some cases, an anterior expansion is needed, only then the pterygoid‐maxilla junction can be kept un‐ touched. If posterior expansion is planned, a similar detachment between the posterior maxilla and pterygoid plate is done as described previously for a traditional Le Fort I osteotomy (**Figure 20**).

**Figure 20.** If the posterior expansion is planned, a similar detachment between the posterior maxilla and pterygoid plate is done as described previously for a traditional Le Fort I osteotomy.

The expansion device extends over the palate with an attachment, and by the use of a screw‐ driver it can spread the bony segments (**Figure 20**). The expansion of the maxilla may take some weeks depending on how far the plate needs to be expanded. The expansion is 1 mm per day. Transversal expansion of the mandible is possible in the same way but is a very unusual approach.

### **4.7. Anterior segmental maxillary osteotomy**

Brown in 1938. The most common indications for SARME are a transverse discrepancy in the maxilla, failed orthodontic expansion, significant nasal stenosis, and widening of the arch following collapse associated with the cleft palate deformity. This procedure is often used for patients between 16–20 years when the median sutures of the palate are fused. When the median suture is fused, attempting to widen the palatal suture by orthodontic treatment only causes buccal displacement of teeth with a very high risk of relapse (**Figure 19**). Therefore, in those patients, a widening of the dental arch without tilting of the teeth is only possible by a

The approach is similar to Le Fort I osteotomy as described above. A medial osteotomy is performed carefully with an osteotome following the suture. The activation of the expansion device is preferably done so the expansion can occur quickly. Proper care must be taken not to perforate the soft tissue in the gum with a chisel and not to damage the central incisor roots. Once the separation is done, the expansion device deactivates again. The activation of the device for expansion of the palatal can first be started one week post‐operatively. In some cases, an anterior expansion is needed, only then the pterygoid‐maxilla junction can be kept un‐ touched. If posterior expansion is planned, a similar detachment between the posterior maxilla and pterygoid plate is done as described previously for a traditional Le Fort I osteotomy

**Figure 20.** If the posterior expansion is planned, a similar detachment between the posterior maxilla and pterygoid

plate is done as described previously for a traditional Le Fort I osteotomy.

surgically assisted osteotomy together with orthodontic expansion.

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(**Figure 20**).

This technique is applied when repositioning of the premaxilla in a vertical plan is required such as for frontal open bite, to retract the anterior teeth, when orthodontic treatment cannot accomplish the desired movement (e.g., when teeth are ankylotic or when a deep bite is present). Cohn‐stock (1921) [38] was the first surgeon who reported this technique. A mucosal incision is applied in the buccal side of the maxilla above the roots of the incisors. This incision is extended to the distal section of the first bicuspid bilaterally. It is common to use a micro saw or piezoelectric device, followed by chisel since a high risk of injury to tooth roots exists. Consequently, osteotomies are performed after extraction of first bicuspids. After that, a transverse palatal incision is made following a wedge‐shaped osteotomy to provide a green stick fracture. This osteotomy can be done either by performing a Le Fort I osteotomy or by a restricted buccal vestibular incision, allowing direct access to the anterior lateral maxillary walls, piriform aperture, nasal floor, and septum (**Figure 21**).

**Figure 21.** Anterior segmental maxillary osteotomy can be done either by performing a Le Fort I osteotomy or by a restricted buccal vestibular incision, allowing direct access to the anterior lateral maxillary walls, piriform aperture, nasal floor, and septum.

The anterior segmental maxillary osteotomy can cause some complications such as oronasal or oroantral fistula, damage to the teeth, loss of vitality of teeth, complication with the maxillary sinus and nasal cavity, unfavourable nasolabial aesthetics, and nasal septal deviation. The most common complication with anterior segmentation is a retraction of gingiva in the anterior segment and relapse during the early healing phase. This method has been revised and discussed widely in the literature by Epker 1977 [39], Epker and Wolford 1980 [35], and Wunderer 1985 [40].

#### **4.8. Posterior maxillary segmental osteotomy**

The technical difficulties concerning approaches to the posterior maxillary segmental osteot‐ omy have been emphasized. The indications are mainly uni‐ or bilateral posterior open bite. The cut is performed at the buccal vestibular section of the posterior maxilla 5 mm above the root apices (**Figure 22**).

**Figure 22.** The cut is performed at the buccal vestibular section of the posterior maxilla 5 mm above the root apices.

The access to the bone is made through a horizontal cut in the buccal vestibule extending from the second molar to the distal aspect of the canine. The incision continues vertically to the papillae at the distal aspect of canine and distal aspect of the second molar. It is preferable to extract the molar in advance some months before this approach. After a horizontal cut, if an interdental vertical osteotomy through the extraction sites (in cases extraction is needed) and also a posterior vertical osteotomy at the pterygomaxillary junction is done, the palate will remain in original position, but the dentoalveolar complex will be separated and moved to the planned position. After a buccal vestibular incision, a parasagittal palatal incision is performed without any vertical interdental incisions (**Figure 22**).

The method is somewhat complicated since multiple areas of bony contacts may interfere. A Le Fort I osteotomy is more often used for correction of the posterior maxillary deficiency. There are, however, a number of indications for this approach namely maxillary hyperplasia, distal replacement of the posterior maxillary alveolar fragment to provide space for proper eruption of an impacted canine or bicuspid posterior open bite, posterior cross bite or scissors bite, and anterior open bite correction through bilateral impaction of the posterior parts.

Complications related to this approach are the loss of teeth vitality, relapse, necrosis of segment, and periodontal defects.

### **4.9. Combination of anterior and posterior maxillary osteotomy (Horseshoe osteotomy)**

Paul Tessier in 1969 [34] reported this procedure for midface hypoplasia. It has also been described and further developed by West and Epker 1972, Hall and Roddy 1975, Wolford and Epker 1975, West and McNeil 1975, Hall and West 1976, and Maloney 1982. Palatal parasagittal osteotomies are performed with a piezoelectric device. The hard palate is untouched staying in position. The method creates a three‐piece maxilla with the central nasal portion left undisturbed. This is a complicated technique since multiple areas of bone contacts exist. The indication is maxillary alveolar hyperplasia or transverse hypoplasia without a vertical component. The method has more or less been replaced by the traditional Le Fort I osteotomy (**Figure 23**).

**Figure 23.** The horseshoe osteotomy; this method has more or less been replaced by the traditional Le Fort I osteotomy.

### **5. Osteotomies of mandible**

The cut is performed at the buccal vestibular section of the posterior maxilla 5 mm above the

**Figure 22.** The cut is performed at the buccal vestibular section of the posterior maxilla 5 mm above the root apices.

without any vertical interdental incisions (**Figure 22**).

segment, and periodontal defects.

(**Figure 23**).

The access to the bone is made through a horizontal cut in the buccal vestibule extending from the second molar to the distal aspect of the canine. The incision continues vertically to the papillae at the distal aspect of canine and distal aspect of the second molar. It is preferable to extract the molar in advance some months before this approach. After a horizontal cut, if an interdental vertical osteotomy through the extraction sites (in cases extraction is needed) and also a posterior vertical osteotomy at the pterygomaxillary junction is done, the palate will remain in original position, but the dentoalveolar complex will be separated and moved to the planned position. After a buccal vestibular incision, a parasagittal palatal incision is performed

The method is somewhat complicated since multiple areas of bony contacts may interfere. A Le Fort I osteotomy is more often used for correction of the posterior maxillary deficiency. There are, however, a number of indications for this approach namely maxillary hyperplasia, distal replacement of the posterior maxillary alveolar fragment to provide space for proper eruption of an impacted canine or bicuspid posterior open bite, posterior cross bite or scissors bite, and anterior open bite correction through bilateral impaction of the posterior parts.

Complications related to this approach are the loss of teeth vitality, relapse, necrosis of

**4.9. Combination of anterior and posterior maxillary osteotomy (Horseshoe osteotomy)**

Paul Tessier in 1969 [34] reported this procedure for midface hypoplasia. It has also been described and further developed by West and Epker 1972, Hall and Roddy 1975, Wolford and Epker 1975, West and McNeil 1975, Hall and West 1976, and Maloney 1982. Palatal parasagittal osteotomies are performed with a piezoelectric device. The hard palate is untouched staying in position. The method creates a three‐piece maxilla with the central nasal portion left undisturbed. This is a complicated technique since multiple areas of bone contacts exist. The indication is maxillary alveolar hyperplasia or transverse hypoplasia without a vertical component. The method has more or less been replaced by the traditional Le Fort I osteotomy

root apices (**Figure 22**).

634 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3

### **5.1. Bilateral sagittal split osteotomy (BSSO)**

The original bilateral ramus osteotomy by Trauner and Obwegeser [41] is performed in the ramus above the mandibular foramen. Dal Pont et al. [42] in 1961 modified this to the vertical osteotomy of the body of the mandible combined with lower horizontal osteotomy with an advantage of easy splitting. Hunsuck [10] in 1968 recommended the shorter horizontal cut that should only extend to the mandibular foramen at the medial ramus (**Figure 24**).

**Figure 24.** Hunsuck's shorter horizontal cut only extends to the mandibular foramen in the medial ramus.

This procedure is used to correct retrognathism and mandibular prognathism. Mandible advancement, setback, rotation, and in some cases closing of the an open bite is possible. The incision is made through the mucosa, muscle, and periosteum, down to the bone on the lateral aspect of the anterior border of the ramus midway up to the ascending ramus and downwards into the depth of the vestibule ending mesial to the second molar. It is advisable to leave 7–8 mm of non‐keratinized buccal epithelium for ease of suturing [10, 43].

Dissection of the periosteum starts subperiosteally along the anterior border of the ramus upwards the coronoid process. Dissection should be limited only to areas where the osteoto‐ mies will be performed and muscle attachments that need to be separated from the bone. No lateral dissection of the ascending ramus is needed. By using a coronoid notch retractor, soft tissue over the ascending ramus can be elevated. At medial section, the soft tissue is retracted gently to avoid damaging the inferior alveolar nerve. The inferior alveolar neurovascular bundle as it enters the mandibular foramen should be identified and supported by a medial retractor. The stylomandibular ligament and the medial pterygoid muscle can be stripped from the angle of the medial aspect.

The sagittal osteotomies can then be started by using a Lindeman fissure bur through only the medial cortex and extended just posterior and superior to the lingual about 2 mm above the inferior alveolar neurovascular bundle. It is advised that the horizontal cut at the medial section of the mandible is made through the whole length of the lingual cortex to avoid an unfortunate split (**Figure 24**). But it is still possible to extend the horizontal cut in the medial section of the mandible just some mm behind the inferior alveolar neurovascular bundle.

When the osteotomy is completed on the medial aspect of the mandible, the next cut is performed on the lateral aspect of the anterior ramus posterior to the second molar. This cut is made parallel and directly adjacent to the lateral cortex. Finally, the osteotomy is extended from approximately the first to second molar downwards vertically just inside the buccal cortex and ends at the base of the mandible [10, 43, 44]

The medial section of the mandible base should be included in the osteotomy. Chisels are then used to control the cut through all osteotomies. Usually, two osteotomes are used as levers to separate the segments: one of the osteotomes places in the vertical osteotomy and the other one in the horizontal osteotomy site behind the second molar. It is important to keep in mind that in cases where the separation does not proceed favourably, it is better to stop the procedure and identify the problem. The problem should be diagnosed and solved to avoid an unfortu‐ nate split. It is important that when the split is done, it will in effect separate the lateral proximal section from the cancellous bone, and the inferior alveolar nerve will remain in the distal segment, and the nerve should not be injured.

If the alveolar canal (including the nerve) is attached to the proximal segment during the splitting procedure, the canal should be carefully dissected from the proximal part, but this will increase the sensory morbidity of the inferior alveolar nerve. The separation of nerve from proximal section of the ramus is debated in the literature. In our experience, the nerve can be left in the proximal segment if the fixation material does not pinch it, and if the movement of the fragments is not too much. Thus, the nerve must be easily moveable in the mandibular canal. As soon as the separation of the layers is done, the surgeon should check that the osteotomy is done accurately, and the neurovascular bundle is intact and separate from the proximal segment (**Figure 25**).

**Figure 25.** Rigid fixation of the segments by lag screws or plating.

#### **5.2. Vertical ramus osteotomy**

### *5.2.1. Extraoral*

into the depth of the vestibule ending mesial to the second molar. It is advisable to leave 7–8

Dissection of the periosteum starts subperiosteally along the anterior border of the ramus upwards the coronoid process. Dissection should be limited only to areas where the osteoto‐ mies will be performed and muscle attachments that need to be separated from the bone. No lateral dissection of the ascending ramus is needed. By using a coronoid notch retractor, soft tissue over the ascending ramus can be elevated. At medial section, the soft tissue is retracted gently to avoid damaging the inferior alveolar nerve. The inferior alveolar neurovascular bundle as it enters the mandibular foramen should be identified and supported by a medial retractor. The stylomandibular ligament and the medial pterygoid muscle can be stripped from

The sagittal osteotomies can then be started by using a Lindeman fissure bur through only the medial cortex and extended just posterior and superior to the lingual about 2 mm above the inferior alveolar neurovascular bundle. It is advised that the horizontal cut at the medial section of the mandible is made through the whole length of the lingual cortex to avoid an unfortunate split (**Figure 24**). But it is still possible to extend the horizontal cut in the medial section of the mandible just some mm behind the inferior alveolar neurovascular bundle.

When the osteotomy is completed on the medial aspect of the mandible, the next cut is performed on the lateral aspect of the anterior ramus posterior to the second molar. This cut is made parallel and directly adjacent to the lateral cortex. Finally, the osteotomy is extended from approximately the first to second molar downwards vertically just inside the buccal

The medial section of the mandible base should be included in the osteotomy. Chisels are then used to control the cut through all osteotomies. Usually, two osteotomes are used as levers to separate the segments: one of the osteotomes places in the vertical osteotomy and the other one in the horizontal osteotomy site behind the second molar. It is important to keep in mind that in cases where the separation does not proceed favourably, it is better to stop the procedure and identify the problem. The problem should be diagnosed and solved to avoid an unfortu‐ nate split. It is important that when the split is done, it will in effect separate the lateral proximal section from the cancellous bone, and the inferior alveolar nerve will remain in the distal

If the alveolar canal (including the nerve) is attached to the proximal segment during the splitting procedure, the canal should be carefully dissected from the proximal part, but this will increase the sensory morbidity of the inferior alveolar nerve. The separation of nerve from proximal section of the ramus is debated in the literature. In our experience, the nerve can be left in the proximal segment if the fixation material does not pinch it, and if the movement of the fragments is not too much. Thus, the nerve must be easily moveable in the mandibular canal. As soon as the separation of the layers is done, the surgeon should check that the osteotomy is done accurately, and the neurovascular bundle is intact and separate from the

mm of non‐keratinized buccal epithelium for ease of suturing [10, 43].

636 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3

the angle of the medial aspect.

cortex and ends at the base of the mandible [10, 43, 44]

segment, and the nerve should not be injured.

proximal segment (**Figure 25**).

In the early 1950s, Caldwell and Letterman [6] popularized an osteotomy performed in the ramus of the mandible for the correction of mandibular excess. This technique is mainly used for the correction of asymmetry of the mandible [37, 45-47]. In this procedure, the lateral aspect of the ramus is exposed through a submandibular incision. The incision is marked about 2 cm below the inferior border of the mandible base, in the angle region. The length of the skin incision is about 4 cm long. Dissection is made through the skin and all the covering soft tissues over the platysma are carefully undermined. An incision is then performed on the platysma to the next layer as deep as to the superficial layer of the deep cervical facia. The marginal mandibular branch of the facial nerve passes through this layer. Thus, extreme care should be taken. As soon as this layer is dissected, the masseter muscle will be exposed which can be cut

**Figure 26.** Vertical ramus osteotomy is suitable for posterior repositioning of the mandible.

with a knife. From here, dissection can be continued posteriorly to the gonial notch and superiorly subperiosteally to expose the ascending ramus laterally. Before starting the osteotomy, the medial pterygoid muscle should be released from the medial part of the angle. The ramus is osteotomized in a vertical direction, posterior to the foramen where the man‐ dibular inferior nerve enters. The cut can be done superiorly from the sigmoid notch to the angle of the mandible. This osteotomy is suitable for posterior repositioning of the mandible (**Figure 26**).

It is also possible to perform an inverted L osteotomy, where a horizontal cut from the anterior section of the ascending ramus is made just below the coronoid process extending to the vertical osteotomy from the angle of the mandible. The entire body and anterior ramus section of the mandible are moved posteriorly, which places the teeth in proper occlusion. The proximal segment of the ramus that is attached to the condyle will overlap the anterior part of the jaw that includes the teeth and will be stabilized during the healing phase with wiring or plating of the bone segments combined with using elastic mandibulomaxillary fixation.

### *5.2.2. Intraoral*

A similar technique can be done through an intraoral incision and an angulated oscillating saw or piezo saw. The design of the osteotomy is identical to that performed through an extraoral incision. The incision is performed via an intraoral entrance. This procedure has, at least, two advantages namely elimination of the risk of damage to the facial nerve and elimination of the risk of a visible scar postoperatively. The main disadvantage with the intraoral approach is that it is difficult to perform since visibility is limited (Hall et al. 1975) [48]. Additionally, fixation of the fragments is difficult.

Previously, it was common to use mandibulomaxillary fixation (MMF) for 5–7 weeks postop‐ eratively when this approach was used. A rigid, internal fixation can be used but MMF must be considered for a short period.

### **5.3. Genioplasty**

The chin is a critical part of the face. A disharmony in the chin is very noticeable and should be corrected in an artistic way [49]. Each of the different skeletal deficiencies (e.g., class II and III deep bite or open bite) can cause a morphology change of the chin that is very different between individuals even if the dentofacial deformities are similar.

Correction of a chin deficiency can be performed by reducing or augmenting in three different dimensions namely vertically, transversely, and sagittally. This correction can be combined with any operation in both maxilla and mandible. Augmentation genioplasty, reduction genioplasty, straightening genioplasty, and lengthening genioplasty are some procedures that can be used (**Figures 27**–**30**).

**Figure 27.** It is highly important to mark the midline of the chin before any osteotomy is performed.

with a knife. From here, dissection can be continued posteriorly to the gonial notch and superiorly subperiosteally to expose the ascending ramus laterally. Before starting the osteotomy, the medial pterygoid muscle should be released from the medial part of the angle. The ramus is osteotomized in a vertical direction, posterior to the foramen where the man‐ dibular inferior nerve enters. The cut can be done superiorly from the sigmoid notch to the angle of the mandible. This osteotomy is suitable for posterior repositioning of the mandible

It is also possible to perform an inverted L osteotomy, where a horizontal cut from the anterior section of the ascending ramus is made just below the coronoid process extending to the vertical osteotomy from the angle of the mandible. The entire body and anterior ramus section of the mandible are moved posteriorly, which places the teeth in proper occlusion. The proximal segment of the ramus that is attached to the condyle will overlap the anterior part of the jaw that includes the teeth and will be stabilized during the healing phase with wiring or plating of the bone segments combined with using elastic mandibulomaxillary fixation.

A similar technique can be done through an intraoral incision and an angulated oscillating saw or piezo saw. The design of the osteotomy is identical to that performed through an extraoral incision. The incision is performed via an intraoral entrance. This procedure has, at least, two advantages namely elimination of the risk of damage to the facial nerve and elimination of the risk of a visible scar postoperatively. The main disadvantage with the intraoral approach is that it is difficult to perform since visibility is limited (Hall et al. 1975) [48]. Additionally,

Previously, it was common to use mandibulomaxillary fixation (MMF) for 5–7 weeks postop‐ eratively when this approach was used. A rigid, internal fixation can be used but MMF must

The chin is a critical part of the face. A disharmony in the chin is very noticeable and should be corrected in an artistic way [49]. Each of the different skeletal deficiencies (e.g., class II and III deep bite or open bite) can cause a morphology change of the chin that is very different

Correction of a chin deficiency can be performed by reducing or augmenting in three different dimensions namely vertically, transversely, and sagittally. This correction can be combined with any operation in both maxilla and mandible. Augmentation genioplasty, reduction genioplasty, straightening genioplasty, and lengthening genioplasty are some procedures that

between individuals even if the dentofacial deformities are similar.

(**Figure 26**).

*5.2.2. Intraoral*

fixation of the fragments is difficult.

638 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3

be considered for a short period.

can be used (**Figures 27**–**30**).

**5.3. Genioplasty**

**Figure 28.** The midline can be marked as a reference point using a burr or saw. A plus (+) sign can be used to mark the bone in the centre of the buccal cortex.

**Figure 29.** Lengthening or reduction of the chin by the so‐called sliding osteotomy. In the case of reduction, a slice of the bone is removed and in the event of augmentation, the chin is pulled forward and sometimes downwards. Addi‐ tional bonegraft material may be used to improve the augmentation.

**Figure 30.** Augmentation genioplasty, reduction genioplasty, straightening genioplasty, and lengthening genioplasty are some procedures commonly used.

The most common osteotomy is sliding horizontal osteotomy [49, 50]. However, double horizontal osteotomy, hinge sliding osteotomy, oblique osteotomy for advancement, jumping genioplasty, wedge osteotomy, propeller genioplasty, triple osteotomy, quadruple osteotomy, and genioplasty using grafts or implants are also used.

A transoral incision is performed in the mucosa from the canine to canine with a good margin from the attached gingiva to make suturing easier. The mental muscles must be exposed and dissected to expose the bone. The second incision is made through the periosteum on to the bone. The periosteal attachment will be released, but the inferior anterior border should be untouched to keep the soft tissue contour unchanged and also keep the blood circulation intact. It is crucial to identify the mental foramen bilaterally. Then, the midline should be marked as a reference point, e.g., by using a burr or saw. A plus (+) sign can be used to mark the bone in the centre of the buccal cortex (**Figure 28**).

The osteotomy starts below the apical level of the roots (**Figure 28**), with a piezo ultrasonic or reciprocating saw. The osteotomy should be well planned with regard to chin shape and type of deficiency. Posteriorly, the angulation of the osteotomy can be altered depending on the treatment demands. This angulation results in the changes in vertical dimension of the anterior mandible. The posterior osteotomy must end at least 7–8 mm below the mental foramen (**Figure 30**) to avoid injury to the nerve bundle. The nerve canal is at about 5 mm below the mental foramen. When increasing the vertical dimension of the chin, bone can be applied to the gap. When reduction of the vertical dimension is planned, a parallel osteotomy to the first one can be performed and the segment in the middle can be pulled out (**Figure 29**).

The transverse dimension of the chin can be altered by segmentation of the symphysis area (**Figure 27**). If reducing the transverse dimension of the chin is planned, two parallel vertical osteotomies are performed laterally to the midline. The wound should be sutured in two layers. It is important to ensure the accurate position of the mental muscles before suturing the mucosa [49, 50].

#### **5.4. Chin‐wing osteotomy**

In 2009, Albino Triaca described a different osteotomy, called chin wing osteotomy, for the correction of aesthetic dislocation of the lower face, either in the anterior part of the mandible or for the entire border of the mandible base [51]. The name of the approach was coined due to the fact that the shape of the mandible base is like a wing (**Figure 31**).

**Figure 31** . Chin‐wing osteotomy.

**Figure 30.** Augmentation genioplasty, reduction genioplasty, straightening genioplasty, and lengthening genioplasty

The most common osteotomy is sliding horizontal osteotomy [49, 50]. However, double horizontal osteotomy, hinge sliding osteotomy, oblique osteotomy for advancement, jumping genioplasty, wedge osteotomy, propeller genioplasty, triple osteotomy, quadruple osteotomy,

A transoral incision is performed in the mucosa from the canine to canine with a good margin from the attached gingiva to make suturing easier. The mental muscles must be exposed and dissected to expose the bone. The second incision is made through the periosteum on to the bone. The periosteal attachment will be released, but the inferior anterior border should be untouched to keep the soft tissue contour unchanged and also keep the blood circulation intact. It is crucial to identify the mental foramen bilaterally. Then, the midline should be marked as a reference point, e.g., by using a burr or saw. A plus (+) sign can be used to mark the bone in

The osteotomy starts below the apical level of the roots (**Figure 28**), with a piezo ultrasonic or reciprocating saw. The osteotomy should be well planned with regard to chin shape and type of deficiency. Posteriorly, the angulation of the osteotomy can be altered depending on the treatment demands. This angulation results in the changes in vertical dimension of the anterior mandible. The posterior osteotomy must end at least 7–8 mm below the mental foramen (**Figure 30**) to avoid injury to the nerve bundle. The nerve canal is at about 5 mm below the mental foramen. When increasing the vertical dimension of the chin, bone can be applied to the gap. When reduction of the vertical dimension is planned, a parallel osteotomy to the first

one can be performed and the segment in the middle can be pulled out (**Figure 29**).

The transverse dimension of the chin can be altered by segmentation of the symphysis area (**Figure 27**). If reducing the transverse dimension of the chin is planned, two parallel vertical osteotomies are performed laterally to the midline. The wound should be sutured in two layers. It is important to ensure the accurate position of the mental muscles before suturing the mucosa

In 2009, Albino Triaca described a different osteotomy, called chin wing osteotomy, for the correction of aesthetic dislocation of the lower face, either in the anterior part of the mandible

are some procedures commonly used.

and genioplasty using grafts or implants are also used.

640 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3

the centre of the buccal cortex (**Figure 28**).

[49, 50].

**5.4. Chin‐wing osteotomy**

The incision is always intraoral and along the entire border of the mandible from the mandib‐ ular ramus to the opposite site below the dental arch. The mucoperiosteum will be raised to the same level of the cortex where the Chin‐wing osteotomy is planned. It is important not to strip the periosteum caudally to allow a new blood circulation to the mandible. Particular care is taken near the mental foramen. Before performing this osteotomy, careful examination and identification of the location of the nerve bundle and canal is required by CBCT examination. The inferior mandibular nerve should not be placed buccally because the osteotomy is performed from the buccal cortex, and angulation of the osteotomy is in a somewhat sloping direction from superior to inferior below the nerve canal. A horizontal bicortical mandibular cut is then done with piezo‐ultrasonic, reciprocating saw or a Mayfair bur (Maillefer Instru‐ ments, Ballaigues, Switzerland). The anterior region of the mandible can be cut in one or two segments. After osteotomy of the entire mandible, mobilization should be carried out very carefully not to fracture the mandible. The most dangerous place for fracture is around the mental foramen. Using this method, a change of the base of the mandible is possible, and the shape of the chin prominence can be adjusted sagittally and transversely without changing the tooth‐bearing mandible and without influence on the Temporomandibular joint (TMJ). The method can also be combined with other osteotomies of the face [52, 53].

#### **5.5. Lateral body osteotomy of the mandible**

This osteotomy is widely used in selected cases of mandibular prognathism. This method is used especially when first or second premolars are missing or are planned to be extracted, and by using this method, a prosthetic reparation of intact teeth can be avoided. It is also desirable to use this method in the case of an anterior open bite, excess growth of the mandible with negative overjet located in the anterior dentoalveolar area of the mandible, to treat mandibular dental arch asymmetry.

This method can be used to reposition the anterior section of the mandible in every desirable direction, such as for posterior and superior repositioning. The method can be used for a block osteotomy or segmental or total alveolar osteotomy (**Figure 32**).

**Figure 32.** Lateral body osteotomy can be used for a block or segmental osteotomy or total alveolar osteotomy.

**Figure 33.** Fixation is performed with miniplates.

A transoral circumvestibular incision is performed following the extraction of the first premolars. The periosteal attachment will be released, but the inferior anterior border should be untouched to keep the soft tissue contour unchanged, and also keep the blood circulation undisturbed. An incision is made distally to the second premolar. The flap should be extended behind the second premolar to give sufficient access to the area. Care should be taken not to cause any unnecessary soft tissue stripping. The subapical area will then be exposed enough to achieve proper exposure for osteotomy. The osteotomy is horizontally placed subapical about 5 mm from the root apices and then will be connected with two vertical osteotomies at the extracted first premolars. The horizontal osteotomy ends about 2–3 mm anteriorly to the mental foramen. The vertical osteotomies are preferably positioned at the extraction sites. Often, the vertical incision is performed with an anterior step osteotomy to avoid the inferior alveolar neurovascular bundle (**Figure 33**).

In this osteotomy, removal of premolar teeth and bone in the area of extraction sites is desired. After downfracture and separation, the anterior segment is repositioned posteriorly, at the same time extraction sites are closed. If no extraction is planned, the anterior section can be repositioned upwards to close an anterior open bite. The bone graft should be placed into the gap. It is important to remember to keep the excessive interdental bone to avoid periodontal problems.

### **5.6. Anterior subapical osteotomy**

This method can be used to reposition the anterior section of the mandible in every desirable direction, such as for posterior and superior repositioning. The method can be used for a block

**Figure 32.** Lateral body osteotomy can be used for a block or segmental osteotomy or total alveolar osteotomy.

A transoral circumvestibular incision is performed following the extraction of the first premolars. The periosteal attachment will be released, but the inferior anterior border should be untouched to keep the soft tissue contour unchanged, and also keep the blood circulation undisturbed. An incision is made distally to the second premolar. The flap should be extended behind the second premolar to give sufficient access to the area. Care should be taken not to cause any unnecessary soft tissue stripping. The subapical area will then be exposed enough to achieve proper exposure for osteotomy. The osteotomy is horizontally placed subapical about 5 mm from the root apices and then will be connected with two vertical osteotomies at

osteotomy or segmental or total alveolar osteotomy (**Figure 32**).

642 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3

**Figure 33.** Fixation is performed with miniplates.

Anterior subapical osteotomy is suggested when the skeletal class I relation exists, and deformities in the front part of the mandible cannot be treated by orthodontic treatment. Some of the indications are as follows:

– Excess growth of the mandible with negative overjet located in the anterior dentoalveolar process of the mandible,

**Figure 34.** The subapical area is exposed far enough to provide sufficient access for the osteotomy.

Anterior subapical osteotomy method can be used to reposition the anterior section of the mandible in every desirable direction, such as posterior and superior repositioning.

A transoral circumvestibular incision is performed in the mucosa from canine to the canine with a good margin of attached gingiva. The periosteal attachment will be released, but the inferior anterior border should be untouched to keep the soft tissue contour unchanged, and also to keep the blood circulation undisturbed. After identifying the neurovascular bundle, the incision is extended carefully in the posterior direction to the premolar area. The flap should be extended behind the first premolar to give sufficient access to the area. The mental muscles are identified and dissected to expose the bone. Care should be taken not to cause unnecessary soft tissue stripping. The subapical area will then be exposed far enough to provide sufficient access for the osteotomy (**Figure 34**).

The osteotomy is horizontally placed subapical, about 5 mm from the root apices and then connected with two vertical osteotomies between the canines and first premolars. Interdental osteotomy is performed with care to avoid injury to the roots. The anterior segment is subsequently repositioned superiorly to close the anterior open bite, and a bone graft is placed into the gap area. It should be kept in mind that interdental bone is essential to avoid perio‐ dontal problems.

### **5.7. Posterior subapical osteotomy**

This method can be used for the correction of supereruption of mandibular posterior teeth or ankylosis of the posterior teeth.

A transoral incision is performed at the anterior border of the vertical ramus and is carried forward to the canine area. The incision is made around the margins of the teeth with starts one tooth behind the proposed osteotomy anteriorly and posteriorly. Two vertical, oblique incisions are connected to the horizontal. The periosteal attachment is released, but the inferior border is untouched to keep the soft tissue contour unchanged, and also to keep the blood circulation undisturbed. Again, the neurovascular bundle is identified and the incision is extended carefully in an anterior direction to the premolar area (**Figure 35**).

**Figure 35.** The neurovascular bundle is identified and preserved.

The osteotomy is horizontally placed subapical, about 5 mm from the root apices, and special care must be taken to preserve the mandibular canal. The horizontal osteotomy is connected with two vertical osteotomies between the first molar and second premolars. Interdental cuts should as always be done carefully with a chisel to avoid injury to the roots. The vertical interdental cut is to be made from the buccal after downfracture and separation. The posterior segment can then be repositioned superiorly.

### **5.8. Inverted L and C ramus osteotomies**

be extended behind the first premolar to give sufficient access to the area. The mental muscles are identified and dissected to expose the bone. Care should be taken not to cause unnecessary soft tissue stripping. The subapical area will then be exposed far enough to provide sufficient

The osteotomy is horizontally placed subapical, about 5 mm from the root apices and then connected with two vertical osteotomies between the canines and first premolars. Interdental osteotomy is performed with care to avoid injury to the roots. The anterior segment is subsequently repositioned superiorly to close the anterior open bite, and a bone graft is placed into the gap area. It should be kept in mind that interdental bone is essential to avoid perio‐

This method can be used for the correction of supereruption of mandibular posterior teeth or

A transoral incision is performed at the anterior border of the vertical ramus and is carried forward to the canine area. The incision is made around the margins of the teeth with starts one tooth behind the proposed osteotomy anteriorly and posteriorly. Two vertical, oblique incisions are connected to the horizontal. The periosteal attachment is released, but the inferior border is untouched to keep the soft tissue contour unchanged, and also to keep the blood circulation undisturbed. Again, the neurovascular bundle is identified and the incision is

The osteotomy is horizontally placed subapical, about 5 mm from the root apices, and special care must be taken to preserve the mandibular canal. The horizontal osteotomy is connected with two vertical osteotomies between the first molar and second premolars. Interdental cuts should as always be done carefully with a chisel to avoid injury to the roots. The vertical

extended carefully in an anterior direction to the premolar area (**Figure 35**).

**Figure 35.** The neurovascular bundle is identified and preserved.

access for the osteotomy (**Figure 34**).

644 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3

**5.7. Posterior subapical osteotomy**

ankylosis of the posterior teeth.

dontal problems.

Trauner and Obwegeser presented inverted L and C ramus osteotomies in 1957 [35]. Indica‐ tions for this osteotomy are horizontal mandibular deficiencies. This approach can be per‐ formed extraorally in the same way as vertical ramus osteotomy (**Figure 36**).

**Figure 36.** Extraoral inverted L ramus osteotomy.

The incision is very much like bilateral vertical ramus osteotomy. It starts with a 6 cm sub‐ mandibular cut 2 cm below the angle of the mandible in the inferior border. Exposure of the entire ramus is done very carefully by dissection through the different layers of soft tissues.

A vertical osteotomy is placed behind the mandibular foramen to avoid nerve damage. This vertical osteotomy starts at the base of the mandible and is connected to a horizontal osteotomy that is placed above the mandibular foramen and below the sigmoid notch. For setback of the mandible, the proximal segment is placed laterally. The segments can be fixed rigidly by plates, or left without fixation, but then maxillomandibular fixation (MMF) for 6 weeks will be needed.

If an increasing of the vertical height or horizontal direction is planned, a bone graft can be placed in the osteotomy.

### **Acknowledgements**

Thanks to Mr. Farat Kanat for the contribution of hand‐drawing figures in this chapter and Mr Fredrik Persson, Pixlar.se for all computerized drawings.

### **Author details**

Hossein Kashani\* and Lars Rasmusson

\*Address all correspondence to<EMAIL_ADDRESS>
Department of Oral and Maxillofacial Surgery, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

### **References**

**Author details**

Hossein Kashani\*

**References**

and Lars Rasmusson

Department of Oral and Maxillofacial Surgery, The Sahlgrenska Academy, University of

[1] Hullihen SP. Case of elongation of the under jaw and distortion of the face and neck,

[2] Kruger G. Textbook of oral and maxillofacial surgery. The CV Mosby Company. St

[4] Ascher F. Zum problem der chirurgis chen obilisierung des prognathen oberkie fer.mit.telstuckes in kieferoothopaedischer sincht. Fortschritte der kiefer und Gesichts‐

[5] Bruhn C. The surgical‐orthopedical removal of the deformations of the jaws. Int. J.

[6] Caldwell JB, Letterman GS. Vertical osteotomy in the mandibular rami for correction

[7] Obwegeser H, Trauner R. Zur operationstechnik bei der progenie und anderen

[8] Trauner R, Obwegeser H. The surgical correction of mandibular. Oral Surgery, Oral medicine, Oral Pathology, 1957 (Elsevier, Volume 10, issue 10, July 1957, p 677–689.

[9] Dal Pont G. Retromolar osteotomy for the correction of prognatism. J. Oral Surg.

[10] Hunshuck EE. A modified intra‐oral sagittal splitting technique for the correction of

[11] Obwegeser H.Surgery of the Maxilla for the correction of prognatism.. SSO Schweiz

[12] Bell WH, Levy BN. Revascularization and bon regeneration after anterior mandibu‐

unterkieferanomalien. Dtsch Zahn Mund Kiefer–heikd. 1955; 23:H1–2.

Chirurgie, vol–1. Stuttgart; 1955. Chirurgie, vol‐1. Stuttgart; 1955. 16(1):81–8.

caused by burn, successfully treated. Am. J. Dent. Sci. 1849; 9:157.

[3] Blair VP. Operations on the jaw bone and face. J. Oral Surg. 1907; 4: 67–78.

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Gothenburg, Gothenburg, Sweden

Louis, Toronto, London 1979

Orthod. 1927; 13:65.

of prognatism. J. Oral. Surg. 1954; 12:185.

Anesth. Hosp. Dent. Serv. 1961;19:42.

mandibular prognathism. J. Oral Surg. 1968; 26:250–3.

Monatsschr Zahnheilkd. 1965 Apr;75:365–74.

larosteotomy. J. Oral Surg. 1970; 28:196–203.

[42] Dal Pont G. Retromolar osteotomy for the correction of prognathism. J. Oral Surg. 1961; 19: 42–7.

[28] Epker BN, Wolford LM. Middle third facial osteotomies: their use in correction of acquired and developmental dentofacial and craniofacial deformities. J. Oral Surg.1975;

[29] Epker BN, Wolford LM. Middle third facial osteotomies: their use in correction of congenital dentofacial and craniofacial deformities. J. Oral Surg. 1976; 34:324.

[30] Reyneke JP, Ferretti C. Oral diagnosis and treatment planning for orthognathic surgery textbook. In: Andersson L, Kahnberg K–E, Anthony (Tony) Pogrel M (Ed.), Oral and maxillofacial surgery. 2010, Chapter 46. Mosby 1980, ISBN 10:0801616069, ISBN 13:

[31] Mathijssen IM. Guideline for care of patients with the diagnoses of craniosynostosis: working Group on Craniosynostosis. J. Craniofac. Surg. 2015; 26(6):1735–807.

[32] Tahiri Y, Taylor J. An Update on midface advancement using Le Fort II and III distrac‐ tion osteogenesis. Semin. Plast. Surg. Clavadelerstrasse 8, CH 7270, Davos Platz 2014;

[33] Steinhauser EW. Variations of Le Fort II osteotomies for correction of midfacial

[34] Tessier P, Guiot G, Rougerie J, Delbet JP, Pastoriza J. Cranio-naso-orbito-facial osteot‐

[35] Epker BN, Wolford LM. Textbook. Dentofacial deformities, surgical‐ orthodontic

[36] García Y Sánchez JM, Gómez Rodríguez CL, Romero Flores J. Surgical guides for modified oblique Le Fort III osteotomy. J. Maxillofac. J Oral Surg Anesth Hosp Dent

[37] Ehrenfeld M, Manson PN, Prein J. Textbook. Principles of internal fixation of the craniomaxillofacial skeleton. Trauma and orthognatic surgery.  A modified anterior maxillary ostectomy. J. Maxillofac. Surg. 1977; 5(1):35–

[40] Wunderer S, Watzke I. Complications in prognathism operations (following the method of labial pedicled anterior maxilla fragment and their prevention. Fortschr

[41] Trauner R, Obwegeser H. The surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty. Oral Surg. Oral Med. Oral Pathol. 1957;

AO Foundation, 2012. Osteotomies of the Maxillofacial Skeleton 29.

Kiefer Gesichtschir. 1985; 30:96–8. German. No abstract available.

behandlung der prognathie vjschr zabneik 37:320, 1921.

deformities. J. Maxillofac. Surg. 1980; 8(4):258–65.

omies. Hypertelorism, Ann Chir Plast. 1967 Jun;12(2):103–18.

33:491.

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9780801616068

28(4):184–92.

correction. 1980.

Serv. 1961;19:42–47

8.

10:677–89.

**Section 14**

## **Facial Lifting**

## **Facelift: Current Concepts, Techniques, and Principles**

Fereydoun Pourdanesh, Mohammad Esmaeelinejad, Seyed Mehrshad Jafari and Zahra Nematollahi

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/63150

#### **Abstract**

The effects of aging on skin, including thinning and loss of muscle tone, result in a flabby or drooping appearance of the face. The demands of an attractive appearance and smooth skin are wanted all around the world. There are a lot of factors which influence the choice of rejuvenation techniques, including anatomy of the facial skeleton, the severity of aging changes, social and economic status of the patient, and structure of the skin. Facelifting is a facial rejuvenation procedure in which by dissection of subcutane‐ ous layers and different suturing techniques we are able to stretch the skin and make the patient look younger. This chapter presents the technique, current concepts, complications, and indications of facelift surgery.

**Keywords:** aging, lifting, rhytidectomy, rhytidoplasty

### **1. Introduction**

**Facelifting**, also known as a **rhytidectomy,** technically means removal of wrinkles by surgery to give a more youthful appearance to the face. Although the history of this surgery goes back to more than one hundred years ago, in recent decades it has become more popular because demands of being youthful in middle and senile ages have increased among people. Due to contemporary improvements in medical care and increased common knowledge about the importance of healthcare, the life‐span of people all around the world, especially in the first world countries, has been significantly increased. As a result, the common problems associ‐ ated with senility have gained more attention.

One of the main concerns is facial rejuvenation of wrinkles.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**A wrinkle** or **rhytide** is a crease in the skin. Skin wrinkles typically appear as a result of aging processes such as glycation 1 . There are other factors such as age spots, sun ray effects, tissue sagging, and volume loss, which may also lead to an aged face. The major role of each factor depends on the skin type of the patient. Sagging or drooping is more prominent in patients with thick skin whereas patients with thin skin usually manifest aging with wrinkles and volume loss.

Asian people have thicker skins than Caucasians; therefore, their chief problem is tissue drooping and have less wrinkles in their face. Due to their relatively thick skin, the weight of their tissue is considerably more than other groups and performing facelift surgery is more difficult. Wrinkles begin to form in the early 30s. They usually start in anatomic regions with the thinnest skin such as the periorbital area. As the body gets older, skin and subcutaneous fat loses its volume and the collagen and elastic fibers lose their elasticity, which results in superficial wrinkles.

This chapter briefly explains different approaches of facelifting as well as indications, advan‐ tages, and disadvantages of various modifications of facelift surgery, complications, and post‐ operative care.

### **2. History of facelift surgery**

In early 1900, Hollander introduced the basic facelift surgery which only involved removal of excessive tissue along the hairline. In 1920, surgeons undermined the subcutaneous layer, which became the preferred technique. This method improved skin laxity, but it was unable to address the underlying soft tissues ptosis. Surgeons found that increased skin redundancy is not the only factor involved in aging processes and there are other factors such as ptosis of the deep soft tissues, skeletal deformities, and changes in skin texture which play a significant role.

In 1974, Skoog developed a technique which elevated a subdermal flap in continuity with the subplatysmal plane in the neck in order to address the deeper tissues. The skin and platysma muscle were elevated together as a unit to develop a more youthful jawline for the patient. Although Skoog's technique did not gain acceptance, it was a turning point in facelift surgery.

In 1976, Mitz and Peyronie defined the superficial musculoaponeurotic system (SMAS) [1]. In the late 1980s and early 1990s, based on Skoog's technique, Hamra introduced the deep plane rhytidectomy followed by composite facelift in order to improve the periorbital and nasolabial regions [2]. Owsley made this technique even better by describing the malar fat pad dissection and suspension to improve the nasolabial crease [3]. Ramirez introduced the subperiosteal rhytidectomy technique to improve the cheek, forehead, jowls, lateral canthus, and eyebrows [4].

<sup>1</sup> Non-enzymatic glycosylation is the result of typically covalent bonding of a protein or lipid molecule with a sugar molecule, such as glucose, without the controlling action of an enzyme.

There have been a lot of comparisons between the risks and benefits of these methods. Less invasive methods which only included the superficial plane dissection showed decreased risk, reduced complications, lower morbidity, decreased convalescence, and more patient satisfac‐ tion.

More invasive methods, which included deeper plane dissections, showed more stable long‐ term results, better control of the midface and similar risks and complication rates as less invasive techniques. During the past decade, surgeons tend to reduce the complexity of facelift procedure and patients demanded less invasive and less complicated surgeries. Nowadays, due to younger age of facelift procedure, less invasive methods such as endoscopic technique, minimal incision facelift surgery and suspension sutures have gained popularity.

### **3. Facelift anatomy**

**A wrinkle** or **rhytide** is a crease in the skin. Skin wrinkles typically appear as a result of aging

sagging, and volume loss, which may also lead to an aged face. The major role of each factor depends on the skin type of the patient. Sagging or drooping is more prominent in patients with thick skin whereas patients with thin skin usually manifest aging with wrinkles and

Asian people have thicker skins than Caucasians; therefore, their chief problem is tissue drooping and have less wrinkles in their face. Due to their relatively thick skin, the weight of their tissue is considerably more than other groups and performing facelift surgery is more difficult. Wrinkles begin to form in the early 30s. They usually start in anatomic regions with the thinnest skin such as the periorbital area. As the body gets older, skin and subcutaneous fat loses its volume and the collagen and elastic fibers lose their elasticity, which results in

This chapter briefly explains different approaches of facelifting as well as indications, advan‐ tages, and disadvantages of various modifications of facelift surgery, complications, and post‐

In early 1900, Hollander introduced the basic facelift surgery which only involved removal of excessive tissue along the hairline. In 1920, surgeons undermined the subcutaneous layer, which became the preferred technique. This method improved skin laxity, but it was unable to address the underlying soft tissues ptosis. Surgeons found that increased skin redundancy is not the only factor involved in aging processes and there are other factors such as ptosis of the deep soft tissues, skeletal deformities, and changes in skin texture which play a significant

In 1974, Skoog developed a technique which elevated a subdermal flap in continuity with the subplatysmal plane in the neck in order to address the deeper tissues. The skin and platysma muscle were elevated together as a unit to develop a more youthful jawline for the patient. Although Skoog's technique did not gain acceptance, it was a turning point in facelift surgery.

In 1976, Mitz and Peyronie defined the superficial musculoaponeurotic system (SMAS) [1]. In the late 1980s and early 1990s, based on Skoog's technique, Hamra introduced the deep plane rhytidectomy followed by composite facelift in order to improve the periorbital and nasolabial regions [2]. Owsley made this technique even better by describing the malar fat pad dissection and suspension to improve the nasolabial crease [3]. Ramirez introduced the subperiosteal rhytidectomy technique to improve the cheek, forehead, jowls, lateral canthus, and eyebrows

Non-enzymatic glycosylation is the result of typically covalent bonding of a protein or lipid molecule with a sugar

molecule, such as glucose, without the controlling action of an enzyme.

. There are other factors such as age spots, sun ray effects, tissue

processes such as glycation 1

654 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 3

volume loss.

superficial wrinkles.

**2. History of facelift surgery**

operative care.

role.

[4].

1

Any surgeon who wants to perform a facelift procedure must know the anatomy of the face. The first layer in facelift anatomy is the skin. The dermal plexus of blood vessels is responsible for the skin and facelift flap blood supply. Usually, fat is left adherent to the dermal under surface of the flap to enhance its viability.

**Figure 1.** Anatomy of layers of the face. (A) Skin; (B) subcutaneous; (C) SMAS; (D) retaining ligaments; (E) deep fascia; (F) nerve.

The next layer is the subcutaneous layer. The fat in this layer is in close contact with deeper SMAS and superficial dermis. This layer can be safely undermined without damaging the anatomic structures. The subcutaneous layer has different thicknesses based on the location and patient. It becomes thickened over the malar region and is attached to it by ligaments running from the underlying periosteum through the malar pad and insert into the dermis. This area, also referred to as McGregor's patch, provides resistance when dissecting because of its fibrous nature.

The third layer is the SMAS layer. This layer separates the subcutaneous fat from the parotid‐ masseteric fascia and facial nerve branches. The SMAS layer is continuous with the galea in the scalp, the temporoparietal fascia in the temples, and the superior cervical fascia in the neck. SMAS is continuous with the platysma and separates two layers of fat in the face into super‐ ficial and deep layers. All of the facial muscle motor nerves are deep to this plane (**Figure 1**). When this layer is stretched or pulled, it moves the entire lateral face in the desired vector. In theory, this would allow the face to move more as a unit, thus making expression more efficient.

The fourth surgical plane is the sub‐SMAS plane. It contains the facial nerve motor branches and the parotid duct. The parotidomasseteric fascia is the layer over the parotid gland and masseter muscle. By operating superior to this layer, the facial nerve branches are protected. Just as the SMAS is an extension of the superficial cervical fascia, parotidomasseteric fascia is also an extension of the superficial layer of the deep cervical fascia into the face and the deep temporal fascia above the zygomatic arch. By deeper and more anterior dissection beneath this layer, the chance of injury to the facial nerve branches increases.

There is a sub‐SMAS loose areolar tissue plane extending from the anterior border of the parotid to the anterior border of the masseter. Blunt dissection in this plane gives the deep plane facelift (DPFL) dissection the ability to proceed safely even though it is almost intimate with the underlying facial nerve branches.

As the facial nerve branches move further anteriorly, they pass over the buccal fat pad and innervate the mimetic muscles. Facial nerve branches, parotid duct, buccal fat pad, and facial artery and vein are all part of the plane under the parotidomasseteric fascia. Dissection over the parotid gland must be done with great caution because although it is a safe plane, it may damage the facial nerve branches as they course out of the parotid gland and cross the masseter muscle.

Several other structures may be damaged in a routine facelift procedure. The greater auricular nerve and external jugular vein are in close contact with sternocleidomastoid muscle. The greater auricular nerve innervates the earlobe and cheek. These two are always superficial to the SMAS layer; hence, dissecting in the subcutaneous layer may preserve these structures.

### **4. Patient selection and evaluation**

As any other cosmetic procedure, patient evaluation and selection are very important in the whole treatment plan. The surgeon should keep in mind that failing to plan is planning to fail. During the asking of chief complaint and taking case history, evaluation of psychological aspect of the patient must be done carefully. Never treat a SIMON2 patient.

At first, the surgeon and the patient must have complete understanding of the procedure and the risk and benefits. Second of all, the surgeon must know the chief complaint of the patient. Next, a thorough medical and habitual history must be taken from the patient. Some drugs such as isotretinoin and vitamin E have adverse effects on healing and must be noted in the patient's history. Vitamin E supplements and NSAIDs or aspirin should be avoided at least 2 weeks before the surgery. Smoking and alcohol consumption can further delay the healing period and increase the skin flap necrosis. The patient must be persuaded to quit smoking 2 months before surgery.

 Thorough examination of these regions gives valuable clues about the treatment plan.

The face is divided into thirds. The upper third consists of the forehead and upper and lower eyelids, which are not typically addressed in superficial plane rhytidectomy. The middle third includes ears and cheeks. The surgeon must assess the amount of skin laxity in this region. The initial position of the earlobe must be noted because there may be a displacement after closure. The lower third includes chin, jawline, and neck [5].

Dedo classified neck profiles into the following subtypes [6]:

The next layer is the subcutaneous layer. The fat in this layer is in close contact with deeper SMAS and superficial dermis. This layer can be safely undermined without damaging the anatomic structures. The subcutaneous layer has different thicknesses based on the location and patient. It becomes thickened over the malar region and is attached to it by ligaments running from the underlying periosteum through the malar pad and insert into the dermis. This area, also referred to as McGregor's patch, provides resistance when dissecting because

The third layer is the SMAS layer. This layer separates the subcutaneous fat from the parotid‐ masseteric fascia and facial nerve branches. The SMAS layer is continuous with the galea in the scalp, the temporoparietal fascia in the temples, and the superior cervical fascia in the neck. SMAS is continuous with the platysma and separates two layers of fat in the face into super‐ ficial and deep layers. All of the facial muscle motor nerves are deep to this plane (**Figure 1**). When this layer is stretched or pulled, it moves the entire lateral face in the desired vector. In theory, this would allow the face to move more as a unit, thus making expression more efficient. The fourth surgical plane is the sub‐SMAS plane. It contains the facial nerve motor branches and the parotid duct. The parotidomasseteric fascia is the layer over the parotid gland and masseter muscle. By operating superior to this layer, the facial nerve branches are protected. Just as the SMAS is an extension of the superficial cervical fascia, parotidomasseteric fascia is also an extension of the superficial layer of the deep cervical fascia into the face and the deep temporal fascia above the zygomatic arch. By deeper and more anterior dissection beneath this

There is a sub‐SMAS loose areolar tissue plane extending from the anterior border of the parotid to the anterior border of the masseter. Blunt dissection in this plane gives the deep plane facelift (DPFL) dissection the ability to proceed safely even though it is almost intimate

As the facial nerve branches move further anteriorly, they pass over the buccal fat pad and innervate the mimetic muscles. Facial nerve branches, parotid duct, buccal fat pad, and facial artery and vein are all part of the plane under the parotidomasseteric fascia. Dissection over the parotid gland must be done with great caution because although it is a safe plane, it may damage the facial nerve branches as they course out of the parotid gland and cross the masseter

Several other structures may be damaged in a routine facelift procedure. The greater auricular nerve and external jugular vein are in close contact with sternocleidomastoid muscle. The greater auricular nerve innervates the earlobe and cheek. These two are always superficial to the SMAS layer; hence, dissecting in the subcutaneous layer may preserve these structures.

As any other cosmetic procedure, patient evaluation and selection are very important in the whole treatment plan. The surgeon should keep in mind that failing to plan is planning to fail.

layer, the chance of injury to the facial nerve branches increases.

with the underlying facial nerve branches.

**4. Patient selection and evaluation**

muscle.

of its fibrous nature.

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Based on this classification, the surgeon chooses the best treatment modality possible. In some cases, facelift surgery alone is not enough for attaining proper results, so other resurfacing procedures must be discussed with the patient that might be needed in future. Good marking of the patient's face and neck in upright position before scheduling for anesthesia has an important role in facelift surgery.

#### **4.1. Indications for facelift surgery**

The appearance of wrinkles, folds, and creases on an individual's face is the primary basis for a surgeon to agree to the operation. Skin drooping of the cheeks and jowls are among the factors indicating a person as a prime candidate for the facelift procedure. Other factors include

<sup>2</sup> Single, immature, male, overly expectant, narcissistic is a patient with excessive concern of their surgery and usually exaggerates a minor physical defect.

predominant eye bags, folds in the eye area (crow's feet and laugh lines), and a permanent crease above the bridge of the nasal region and folds in the forehead. Ideally, the patient should be around the age of fifty or below. Above this age may not be ideal anymore, because the work may be more extensive than for younger individuals. This means that more surgeries may be needed.

Another indication for rhytidectomy is the state of skin in the surgical site. Sun exposure is one of the main reasons of wrinkles. The sun basically makes the skin look older and constant exposure of skin to sun exacerbates this matter. Facelift can rejuvenate patients. It is important to remember that normal looking appearance is one of the primary goals after this kind of surgery.

### **4.2. Contraindications of facelift surgery**

Relative contraindications are poor medical health, patients who continuously consume blood‐ thinning medications, patients with unrealistic expectations, and heavy smokers. Fine wrinkles which can be managed by nonsurgical or conservative treatment very well are contraindications of facelift surgery. Secondary facelifts should also be done with caution because the scar from the primary procedure may disrupt the original tissue planes and increase the risk of facial nerve damage.

### **5. Facelift techniques**

### **5.1. Subcutaneous facelift**

### *5.1.1. Procedure*

Subcutaneous facelift or skin‐only facelift was initially the major concept of the facelift procedure. Lexer presented skin‐only facelift as a procedure in which the dissection is in a subcutaneous plane [7]. Subcutaneous dissection is needed in this technique so that muscular structure and SMAS remain intact. Facelift in this technique is consisted mainly of skin excision with primary closure. This method was the most popular modification of facelift for a long time. Although the role of subcutaneous facelift has diminished after deep layer (i.e., SMAS layer) was presented, the skin‐only facelift is still suggested in selected patients.

This procedure is indicated in thin women with good facial skeleton as well as appropriate skin tone. Actually, this technique is suitable when the surgeon needs to only reduce the facial skin excess. Previous facelift surgery with SMAS plication is an indication for subcutaneous facelift procedure. The results of skin‐only facelift are limited because of not addressing other senile facial structures. This technique is contraindicated in obese patients, especially with a non‐ideal facial skeleton. Besides, this procedure is not appropriate in elderlies with severe aging changes and sagging of deep facial structures [8]. It is also important to consider that excessive subcutaneous dissection medially especially in smokers make the skin flap at the risk of ischemia [9].

### *5.1.2. Advantages*

predominant eye bags, folds in the eye area (crow's feet and laugh lines), and a permanent crease above the bridge of the nasal region and folds in the forehead. Ideally, the patient should be around the age of fifty or below. Above this age may not be ideal anymore, because the work may be more extensive than for younger individuals. This means that more surgeries

Another indication for rhytidectomy is the state of skin in the surgical site. Sun exposure is one of the main reasons of wrinkles. The sun basically makes the skin look older and constant exposure of skin to sun exacerbates this matter. Facelift can rejuvenate patients. It is important to remember that normal looking appearance is one of the primary goals after this kind of

Relative contraindications are poor medical health, patients who continuously consume blood‐ thinning medications, patients with unrealistic expectations, and heavy smokers. Fine wrinkles which can be managed by nonsurgical or conservative treatment very well are contraindications of facelift surgery. Secondary facelifts should also be done with caution because the scar from the primary procedure may disrupt the original tissue planes and

Subcutaneous facelift or skin‐only facelift was initially the major concept of the facelift procedure. Lexer presented skin‐only facelift as a procedure in which the dissection is in a subcutaneous plane [7]. Subcutaneous dissection is needed in this technique so that muscular structure and SMAS remain intact. Facelift in this technique is consisted mainly of skin excision with primary closure. This method was the most popular modification of facelift for a long time. Although the role of subcutaneous facelift has diminished after deep layer (i.e., SMAS

This procedure is indicated in thin women with good facial skeleton as well as appropriate skin tone. Actually, this technique is suitable when the surgeon needs to only reduce the facial skin excess. Previous facelift surgery with SMAS plication is an indication for subcutaneous facelift procedure. The results of skin‐only facelift are limited because of not addressing other senile facial structures. This technique is contraindicated in obese patients, especially with a non‐ideal facial skeleton. Besides, this procedure is not appropriate in elderlies with severe aging changes and sagging of deep facial structures [8]. It is also important to consider that excessive subcutaneous dissection medially especially in smokers make the skin flap at the

layer) was presented, the skin‐only facelift is still suggested in selected patients.

may be needed.

**4.2. Contraindications of facelift surgery**

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increase the risk of facial nerve damage.

**5. Facelift techniques**

**5.1. Subcutaneous facelift**

*5.1.1. Procedure*

risk of ischemia [9].

surgery.

This procedure is very simple and suitable for beginners. The dissection plane is above the SMAS layer which contains the facial nerve, so it decreases the risk of nerve injury in this technique. This procedure is associated with good recovery and is an appropriate technique in secondary facelift and after that [10]. The complications of this method are not significantly higher than other DPFL [10, 11].

### *5.1.3. Disadvantages*

The long‐term results of skin‐only facelifts are not very good. This is a major concern for surgeons. This issue results from two reasons. First, skin viscoelasticity property causes loosening of tightened skin after a while [12]. Second, intact subcutaneous tissues are suscep‐ tible to ptosis after a period of time because they are not manipulated in this technique.

### **5.2. SMAS plication facelift**

### *5.2.1. Procedure*

Introducing and describing SMAS by Mitz changed the concepts of facelift [1]. This technique was suggested as a new method to manipulate the subcutaneous tissues to solve the senile changes of the face including skin wrinkles and deep soft tissue sagging simultaneously. The fibro‐fatty composition of SMAS layer gives it greater strength against gravity than skin. The concept of SMAS plication technique was manipulating a stronger layer which can bear more loads than skin.

The dissection plane in this technique is supra‐SMAS. After dissecting in the subcutaneous plane, SMAS layer is exposed. The mobile segment of SMAS layer is fixed to the posterior relatively immobile layer (i.e., parotidomasseteric fascia) by mainly three sutures in a vertical direction. The excess of SMAS layer could be trimmed after suturing to prevent bulging. This technique is indicated in middle‐aged patients with thin skins and moderate to severe laxity. Obese patients with thick skin types are not candidates for this technique.

### *5.2.2. Advantages*

SMAS plication seems to be an easy procedure with little risk for facial nerve damage. Despite manipulation of SMAS layer, the dissection plane is above this layer and the facial nerve plane which let this method to be a relatively safe procedure. The surgery time is short and the recovery would be good in this technique. This technique may have a better esthetic result in midface area than DPFL [13]. On the other hand, the surgeon may be able to manipulate skin movements by SMAS plication procedure comparing to MACS lift and less invasive than sub‐ SMAS procedures [14, 15].

### *5.2.3. Disadvantages*

Resolving neck aging is more difficult by this technique than DPFL. This issue is related to the inadequate release of platysma facial attachments [16]. SMAS plication is more invasive than some other lifting methods such as MACS lift [14]. The surgeon is not able to manipulate deeply positioned soft tissues under SMAS layer, which results in relatively short‐term outcomes comparing to DPFLs.

### **5.3. Minimal access cranial suspension (MACS) lift**

### *5.3.1. Procedure*

The main concept of MACS lift was the difference in vector of traction. The skin is re‐draped in an oblique direction in traditional face lifting. In MACS procedure, the horizontal vector of traction is avoided and skins simultaneously with under soft tissues are moved vertically [17] (**Figure 2**). MACS procedure is mainly divided into two types: simple and extended. The simple variation of MACS technique is used to correct the lower third of the face and aging appearance of the neck including jowling and the cervicomental angle by using two purse‐ string sutures. Extended MACS lift was presented to correct nasolabial groove and midface and lower eyelid senile changes [18]. The incision in the latter form of MACS technique is

**Figure 2.** (A) The wrong direction of facelifting forms a large dog ear under the ear lobe. (B) The correct direction of lifting in MACS technique omits the dog ear.

extended along the temporal hairline and a third purse‐string suture is used to suspend the malar fat pad (**Figure 3**).

**Figure 3.** (A) Incision line in MACS technique. (B) Undermining area in MACS technique.

Submental liposuction is performed before starting MACS lift. The incision is made from lower limit of the lobule going through the pre‐auricular crease upwards. The upper limits of the incisions in simple and extended variations are at the level of the lateral canthus and the level of the tail of the eyebrow, respectively. This procedure is performed in the pre‐SMAS plane above the plane of facial nerve path. Dissection is performed two fingers below the angle of mandible. The purse‐string sutures are used to fix the deep temporal fascia in the simple variation. In the extended variation, the third u‐shaped purse‐string suture is placed between the anterior part of the deep temporal fascia and the malar fat pad. The skin is excised after re‐ draping in a vertical direction.

### *5.3.2. Advantages*

*5.2.3. Disadvantages*

comparing to DPFLs.

lifting in MACS technique omits the dog ear.

*5.3.1. Procedure*

**5.3. Minimal access cranial suspension (MACS) lift**

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Resolving neck aging is more difficult by this technique than DPFL. This issue is related to the inadequate release of platysma facial attachments [16]. SMAS plication is more invasive than some other lifting methods such as MACS lift [14]. The surgeon is not able to manipulate deeply positioned soft tissues under SMAS layer, which results in relatively short‐term outcomes

The main concept of MACS lift was the difference in vector of traction. The skin is re‐draped in an oblique direction in traditional face lifting. In MACS procedure, the horizontal vector of traction is avoided and skins simultaneously with under soft tissues are moved vertically [17] (**Figure 2**). MACS procedure is mainly divided into two types: simple and extended. The simple variation of MACS technique is used to correct the lower third of the face and aging appearance of the neck including jowling and the cervicomental angle by using two purse‐ string sutures. Extended MACS lift was presented to correct nasolabial groove and midface and lower eyelid senile changes [18]. The incision in the latter form of MACS technique is

**Figure 2.** (A) The wrong direction of facelifting forms a large dog ear under the ear lobe. (B) The correct direction of

There are several advantages of MACS procedure suggested in the literature. Small skin incisions and limited subcutaneous dissection are the major advantages of this technique. The risk of facial nerve damage is low due to supra‐SMAS dissection. The results are good and the recovery is rapid in this technique. The surgeon is able to re‐drape the skin of the lower third of the face, correct the senile changes of the neck, and correct the cervicomental angle [19].

The MACS lift is a shorter procedure than SMAS imbrication with high patient satisfaction and low morbidity. The short incision in MACS lift is a major advantage in this technique, especially in young patients. Avoiding the postauricualr incision in this method makes this procedure acceptable in young patients who usually pull their hair up. The risk of hematoma is low in this technique. Besides, hematoma is easily evacuated and usually does not track into the neck. The dog ear formation under the ear lobe is prevented in this technique, owing to the vector of traction [20].

### *5.3.3. Disadvantages*

The limitations of MACS lift procedure are mainly associated with the anatomy of the patient. The results of this technique are not very good in patients with a bulky neck and significant skin laxity [21]. The final neck contour is unsatisfactory in bulky neck patients due to limited skin excision and pure vertical vector of skin re‐draping. The improvement would be less optimal in the latter group. There is a chance of skin flap irregularity regarding to the excessive bunching of the purse‐string sutures. Avoiding the ligamentous lysis in this technique prevents the long‐term results of MACS lift, especially if the sutures pull through. The cheese wiring effect is also more probable in this facelift modification.

### **5.4. Deep plane facelift (DPFL)**

### *5.4.1. Procedure*

Deep plane rhytidectomy was suggested in place of traditional face lifting to correct aging changes of midface (i.e., malar fat pad) and nasolabial grooves. The deep plane modification was presented by Hamra for the first time [2]. The main concept of this technique was based on reversing gravity's effect by manipulating deep soft tissues to make more satisfying changes in older patients.

In the beginning of the procedure, subcutaneous dissection is performed 2 to 3 mm anterior to the tragus. SMAS layer is then incised after a few millimeters exposure. The dissection plane is the sub‐SMAS plane. There are three main reference points during dissection of DPFL (**Figure 4**). Orbicularis oris is the first reference point which should not considered as a part of the flap in deep plane dissection. Good esthetic results would be achieved by incorporating most of the soft tissue into the flap. The zygomatic major muscle is the second important reference point. Deep plane dissection is continued superiorly to the border of this muscle. The last reference point is the zygomatic minor muscle. Zygomatic cutaneous ligament as a major facial retaining ligament is lysed directly. It is necessary to release this ligament to mobilize the midface completely. The final flap consists of skin, subcutaneous tissue, and malar fat pad [22].

Patients with significant aging changes of midface and mentolabial fold are good candidates for this procedure. This method is not suggested for patients with irrational expectations and with poor medical health. This procedure is not suitable in secondary facelift unless the first one was not a sub‐SMAS procedure. Although DPFL is indicated for smokers in some investigations [23], the surgeon should be aware of increased risk of wound‐healing compli‐ cations.

especially in young patients. Avoiding the postauricualr incision in this method makes this procedure acceptable in young patients who usually pull their hair up. The risk of hematoma is low in this technique. Besides, hematoma is easily evacuated and usually does not track into the neck. The dog ear formation under the ear lobe is prevented in this technique, owing to

The limitations of MACS lift procedure are mainly associated with the anatomy of the patient. The results of this technique are not very good in patients with a bulky neck and significant skin laxity [21]. The final neck contour is unsatisfactory in bulky neck patients due to limited skin excision and pure vertical vector of skin re‐draping. The improvement would be less optimal in the latter group. There is a chance of skin flap irregularity regarding to the excessive bunching of the purse‐string sutures. Avoiding the ligamentous lysis in this technique prevents the long‐term results of MACS lift, especially if the sutures pull through. The cheese wiring

Deep plane rhytidectomy was suggested in place of traditional face lifting to correct aging changes of midface (i.e., malar fat pad) and nasolabial grooves. The deep plane modification was presented by Hamra for the first time [2]. The main concept of this technique was based on reversing gravity's effect by manipulating deep soft tissues to make more satisfying changes