Invited Discussion on: Advanced Facial Rejuvenation after Bimaxillary Surgery in Three Different Facial Types

Abstract

It is with great interest that we read the authors’ manuscript on aesthetic facial rejuvenation after orthognathic surgery [1], having long recognized the influence of skeletal support on both the development and correction of facial ageing [2]. The authors critically evaluate a single surgeon’s postoperative results of doubleand triple-jaw surgery over the course of five years. They include both independent reviewer assessment of postoperative patient images in addition to patient-reported outcomes data. Of the 85 patients evaluated, the authors demonstrate excellent improvement in signs of facial ageing across all age groups included, with and without premorbid orthodontic pathology. Facial ageing is characterized by global soft tissue volume loss in addition to loss of midfacial support of the soft tissue envelope. Signs of premature ageing include jowling, sullen or angry facial expression in repose, downturned oral commissures, premature loss of jawline definition, and perioral strain. Myriad approaches and techniques are available to address facial ageing via face and neck lift, grafting, and skin tightening. Too often at conferences and in publications, these ‘‘modern’’ facelift approaches are shown with definite improvement, but usually leaving a deficient skeletal substructure untouched. In such scenarios, the results could have been even better coupled with some bony augmentation and/or orthognathic intervention. A hypoplastic or underdeveloped skeletal framework can exacerbate an aged and haggard appearance secondary to progressive laxity of ligamentous tissues and deflation of soft tissue bulk. Orthognathic strategies to address these concerns are aimed at expanding the craniofacial skeleton to counteract skeletal disproportion and improve the height and projection of the middle and lower thirds of the face [3, 4]. By restoring structural harmony, the soft-tissue envelope can be resuspended and tension on ligamentous facial support can be better restored (Fig. 1a, b). The authors demonstrated excellent improvement in facial aesthetics and patient-reported outcomes in patients under the age of 50. In our own surgical experience, these observed benefits extend to patients over 50 years old as well (Fig. 2a, b). While an increasing number of younger patients seek orthognathic surgery for primary aesthetic concerns compared to their older counterparts [5], orthognathic surgery is safe and effective for improving both functional and aesthetic outcomes for patients over the age of 50. That said, patients over the age of 30 may be at higher risk of prolonged or permanent neurosensory loss [6]. Osteoporosis, primarily a comorbidity affecting an older population, may also be a risk factor for osteotomy propagation and/or bone healing [7]. Older patients should be appropriately counseled about these perioperative risks at the time of initial consultation. In our surgical & Derek M. Steinbacher [email protected]