reading

This edition first published 2019

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

The right of Derek M. Steinbacher to be identified as the author of this work has been asserted in accordance with law.

Registered Office(s)

John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA

Editorial Office

111 River Street, Hoboken, NJ 07030, USA

For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com.

Wiley also publishes its books in a variety of electronic formats and by print-on-demand. Some content that appears in standard print versions of this book may not be available in other formats.

Limit of Liability/Disclaimer of Warranty The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

Library of Congress Cataloging-in-Publication Data

Names: Steinbacher, Derek M. (Derek Matthew), editor.

Title: Aesthetic orthognathic surgery and rhinoplasty [electronic resource] /

[edited by] Derek M. Steinbacher.

Description: Hoboken, NJ : Wiley-Blackwell, 2019. | Includes bibliographical

references and index. |

Identifiers: LCCN 2018047520 (print) | LCCN 2018048604 (ebook) | ISBN

9781119187110 (Adobe PDF) | ISBN 9781119186984 (ePub) | ISBN

9781119186977 (hardback)

Subjects: | MESH: Orthognathic Surgical Procedures--methods |

Rhinoplasty--methods | Esthetics, Dental, Plastic Surgery, Orthodontics, Otolaryngology, Surgery

Classification: LCC RD119.5.N67 (ebook) | LCC RD119.5.N67 (print) | NLM WU

600 | DDC 617.5/230592--dc23

LC record available at https://lccn.loc.gov/2018047520

Cover image: © Derek Steinbacher

Cover design by Wiley

CONTENTS

Cover

List of Contributors

Foreword I

Foreword II

Foreword III

Foreword IV

Foreword V

Preface

Acknowledgements

About the Companion Website

1 Introduction to Aesthetic Orthognathic Surgery and Rhinoplasty

1.1 Introduction
1.2 Patient Education
1.3 Overview of Orthodontic Considerations
1.4 Growth Evaluation
1.5 Timing
1.6 Nasal and Adjunctive Procedures
1.7 Summary of Goals: Guiding Principles for Aesthetic Orthognathic Surgery
References

2 Assessment and Evaluation in the Aesthetic Orthognathic Patient

2.1 Evaluation (Clinical Exam)
2.2 Evaluation (Records Obtained and Analyzed)
2.3 Overview of Spatial Analysis: Six Planes and Determinants
2.4 Cephalometrics (Radiographs) and Anthropometrics (for Soft Tissue)
2.5 Conclusions – Assessment and Evaluation
References

3 Orthodontic Considerations in Orthognathic Surgery

3.1 Introduction
3.2 Treatment Planning in Orthognathic Surgery
3.3 Anteroposterior Dimension Considerations
3.4 Transverse Dimension Considerations
3.5 Vertical Dimension Considerations
3.6 Asymmetries
3.7 Condylectomies in Orthognathic Surgery
3.8 Postsurgical Orthodontics
3.9 Conclusions
Acknowledgments
References

4 3D Analysis, Planning, and Model Surgery

4.1 Conventional Planning
4.2 3D Planning
4.3 Components and Advantages of 3D Planning
4.4 Steps and Logistics of 3D Planning for Orthognathic Surgery
4.5 3D Planning Steps
4.6 3D Planning, Planes of Space, and Aesthetics (Figure 4.23)
4.7 Types of Splints
4.8 Considerations for Specific Case Types
4.9 Conclusions
References

5 Convex Facial Profiles, Class II Skeletal Problems

5.1 Introduction
5.2 Convex (Class II) Versus Concave (Class III) Profiles
5.3 Convex Profiles and Class II Skeletal Problems
5.4 Goals of Treatment (Convex, Class II Skeletal Patterns)
5.5 Summary
References

6 Concave Facial Profiles, Class III Skeletal Problems

6.1 Introduction
6.2 Etiopathogenesis
6.3 Presentation
6.4 Class III with Vertical Deficiency: Deep Bite
6.5 Class III with Vertical Excess: Open Bite
6.6 Goals of Treatment (Concave, Class III Skeletal Patterns)
6.7 Summary
Case 1 18-yo F with Concave Profile, Poor Upper Lip Support, Lip Incompetence, Class III Malocclusion, Anterior Open Bite
Case 2 20-yo M with Concave Profile, Maxillary Hypoplasia, Mandibular Prognathism, Long Prominent Chin, Class III, Anterior Open Bite
Case 3 28-yo M with Concave Profile, Class III Malocclusion, Prominent Chin
Case 4 17-yo M with Concave Profile, Gummy Smile, Prominent Chin, Long Lower Third, Class III Malocclusion
Case 5 20-yo F with Progressive Change in Occlusion, Chin and Mandible Becomes More Prominent; Right Condylar Hyperplasia (Rotational Type), Macrogenia, Prognathism
References

7 Anterior Open Bite

7.1 Introduction
7.2 Dental Open Bite
7.3 Skeletal Open Bite
7.4 Diagnosis and Etiology
7.5 Short Ramus Condyle Length
7.6 Condylar Resorption
7.7 Other Open Bite Examples – Posterior Open Bite
7.8 Orthodontic Management
7.9 Surgical Management
7.10 Complications/Relapse
7.11 Controversy
7.12 Conclusions
Case 1 24-yo F with Anterior Open Bite, Gummy Smile, Difficulty Closing Lips, no TMJ Symptoms
Case 2 25-yo F with Anterior Open Bite, Gummy Smile; History of TMJ Symptoms; Difficulty Closing Lips
Case 3 24-yo F with Anterior Open Bite, Convex Profile, Mentalis Strain, Prior TMJ Symptoms (Stable)
Case 4 18-yo F with Anterior Open Bite, Lip Incompetence, Mandibular Asymmetry
References

8 Width and Transverse Problems

8.1 Introduction
8.2 Etiopathogenesis
8.3 Evaluation
8.4 Surgical Correction of Transverse Maxillary Hypoplasia
8.5 Surgically Assisted Maxillary Expansion (SAME)
8.6 Segmental Le Fort Osteotomy
8.7 Mandibular Transverse Problems
8.8 Mandibular Arch Width Hyperplasia
8.9 Mandibular Arch Width Hypoplasia
8.10 Mandibular Angle Excess (Bigonial Hyperplasia)
8.11 Mandibular Angle Deficiency
8.12 Conclusions
Case 1 18-yo F with VME, Convex Profile, Transverse Maxillary Discrepancy, Retrognathia, Lip Incompetence
Case 2 18-yo F with VME, Anterior Open Bite, Transverse Narrowing; Convex Profile, Retrognathia
Case 3 26-yo F with VME, Anterior Open Bite, Convex Profile, Narrow Maxillary Arch, Deficient Mandibular Angles; Class II Malocclusion
Case 4 20-yo F with Concave Profile, Over-Widened Maxilla; Midline Discrepancies, Class III Malocclusion
References

9 Facial Asymmetry

9.1 Introduction
9.2 Assessment and Determinants of Facial Asymmetry
9.3 Evaluation and Workup
9.4 Treatment
9.5 Conclusions
Progressive – Growing Patient
Case 1 Condylar Hyperplasia Growing Boy, 6–9 yo M with Progressively Worsening Mandibular and Chin Deviation
Congenital Asymmetry – Manage While Growing Versus Post-Growth Cessation
Case 2 HFM Post-Growth Cessation. 18-yo M with L-Sided HFM
Asymmetric Mandibular Growth History of Condylar Hyperplasia and/or Short RCU
Case 3 16-yo M with Right Mandibular Hyperplasia, Left Mandibular Hypoplasia, (Condylar Change) Class II Presentation, Compensation of Maxilla (Maxillary Cant)
Condylar Hyperplasia – Active (Progressive)
Case 4 54-yo F with History of Prior Orthognathic Surgery, and Recent Mandibular Deviation and Open Bite on Right; Right Condylar Hyperplasia (Vertical Type), Maxillary Hypoplasia, Vertical Deficiency (Hx of Prior Orthognathic Surgery)
Case 5 26-yo F with Worsening Projection and Deviation of Chin (Toward the Left), Right Condylar Hyperplasia (Rotational Type), Class III Malocclusion
Global Facial Asymmetry – Bone/Soft-Tissue
Case 6 18-yo F with History of Progressive Wasting Left Face, with Worsening Asymmetry; Global Left Facial Hypoplasia, Asymmetry, Bony and Soft Tissue (Discoid Lupus)
References

10 Midface and Orbitozygomatic Aesthetics

10.1 Introduction
10.2 Etiology of Midface Deficiency
10.3 Anatomy
10.4 Clinical Evaluation and Assessment
10.5 Management and Techniques
10.6 Global Modification
10.7 Considerations for Orthognathic Planning and Execution for Midface and Malar Deficiencies
10.8 Conclusions
Case 1 26-yo F with History of Left Zygomatico-Orbital Fracture; Leading to a Deformity with Increased Poor Rim Support, and Exopthalmos
Case 2 22-yo F with History of Right Facial GSW (gunshot wound) as Young Girl, Loss of Structure and Physiologic Growth Stimulation Lead to Poor Malar and Orbital Size and Support, Down-Slanting Palpebral Fissure; Malar and Facial Hypoplasia on the Right
Case 3 26-yo F with Concave Profile, Malar and Infraorbital Flattening, Lack of Midfacial Support; Class III Malocclusion (Anterior Crossbite and Open Bite)
Case 4 16-yo F with History of Right Complete Cleft Lip and Palate; Concave Profile, Malar and Infraorbital Flattening, Lack of Midfacial Support; Class III Malocclusion (Anterior Crossbite), Nasal and Lip Deformities
Case 5 18-yo F with Concave Profile, Malar and Infraorbital Flattening, Lack of Midfacial Support; Class III Malocclusion (Anterior Crossbite), Nasal Deformity
Case 6 26-yo F with Concave Profile, Malar and Infraorbital Flattening, Lack of Midfacial Support; Class III Malocclusion (Anterior Crossbite), Mandibular Asymmetry; Nasal Deformity
References

11 Smile Aesthetics

11.1 Introduction
11.2 The Smile in Action
11.3 Smile Classifications
11.4 Components of the Ideal Smile
11.5 Facial and Smile Symmetry
11.6 Ideal Proportions of the Lower Facial Third
11.7 Lip Line
11.8 The Smile Arc
11.9 The Profile Smile
11.10 Lateral Negative Space
11.11 Dental Components
11.12 Gingival Components
11.13 Conclusions
Case 1 Buried/Vertically Deficient and/or Thin Lip Smile Examples
Case 2 Vertical Maxillary Excess – “Gummy” Smile Examples
Case 3 Asymmetric Smile Examples
Case 4 Narrow Smile, Possible Buccal Corridors, and/or Thin Upper Lip
Case 5 Nonconsonant Smile Examples
Case 6 Strained or Incompetent Lip Smiles
References

12 Chin and Submental Aesthetics

12.1 Introduction
12.2 Systematic Evaluation
12.3 Genioplasty: Osseous or Alloplastic Augmentation?
12.4 Conclusion
Case 1 Microgenia, Excess Submental Fat, Nasal Deformity
Case 2 Facial Aging, Excess Submental Skin, Platysmal Banding
Case 3 Convex Profile, with Bimaxillary Labioalveolar Protrusion, Microgenia, Thick Lips
Case 4 Convex Profile, Retrognathia, Microgenia, Excess Submental Tissue, Nasal Deformity
Case 5 Convex Profile, Retrognathia, Microgenia, Excess Submental Tissue
Case 6 Convex Profile, Retrognathia, Microgenia, Jowls, Excess Submental Tissue
References

13 Rhinoplasty: Evaluation and Workup

13.1 Introduction
13.2 Goals of Rhinoplasty
13.3 Nasal Anatomy
13.4 Preoperative Evaluation
13.5 Conclusions
References

14 Rhinoplasty: The Nasal Dorsum, Midvault, Septum, and Osteotomies

14.1 Introduction
14.2 Dorsal Reduction
14.3 Dorsal Augmentation
14.4 Nasal Dorsum
14.5 Radix Grafting
14.6 Midvault
14.7 Nasal Septum
14.8 Osteotomies
14.9 Correction of the Deviated Nose
14.10 Conclusions
Case 1 18-yo M, Complains of Prominent Hump, Asymmetric, Down-Turning Nasal Tip
Case 2 24-yo F, Complains of Prominent Hump, Broad Nasal Tip
Case 3 22-yo F, Complains of Prominent Hump, Infralobular Fullness, Broad Nasal Tip
Case 4 28-yo F, Complains of Prominent Nose, Hump and Tip
Case 5 19-yo F, Complains of Deviated Nose, Prominent Hump, Asymmetric Nasal Tip
References

15 Rhinoplasty: Control of Tip, Ala, and Tripod Complex

15.1 Introduction
15.2 Nasal Tip
15.3 Normal Tip Morphology: Relationship of the Tip and Alar Lobules
15.4 Tip Definition: Management of the Bifid, Bulbous, and Boxy Tip
15.5 Increasing and Decreasing Tip Projection
15.6 Rotating and Derotating the Nasal Tip
15.7 Alar–Columellar Discrepancies
15.8 Conclusions
References

16 Nasal Considerations and Orthognathic Surgery

16.1 Introduction
16.2 Anatomy and Aesthetics
16.3 Nasal Function and Dentofacial Abnormalities
16.4 Goals of Treatment: Orthognathic and Nasal Surgery
16.5 Nasal Changes Depending on Type of Le Fort Movement
16.6 Adjunctive Procedures During Le Fort I to Alter Nasal Function and Aesthetics
16.7 Examples Where Le Fort Improves the Nasal Appearance
16.8 Conclusions
References

17 Rhinoplasty and Orthognathic Surgery

17.1 Introduction
17.2 Nasal Deformities in the Orthognathic/Dentofacial Setting
17.3 Rhinoplasty Techniques to Address Specific Nasal Deformities Created from Orthognathic Surgery
17.4 Decision on Rhinoplasty Timing: Simultaneous Versus Staged
17.5 Conclusions
References

18 Rhinoplasty Technique

18.1 Introduction
18.2 Anesthesia and Preparation
18.3 Incision and Exposures
18.4 Cephalic Trim and Access to the Septum
18.5 Dorsal Reduction (if Indicated)
18.6 Septoplasty
18.7 Spreader Graft Placement
18.8 Osteotomies
18.9 Turbinates
18.10 Tip and Base (Posterior Septal Angle) Modification
18.11 Medial/Intermediate Crural Tripod Leg
18.12 Domal Suturing
18.13 Creation of Tip Projection (Deprojection) and Rotation (Derotation)
18.14 Tip Grafting
18.15 Alar or Lateral Crural Grafting
18.16 Closure
18.17 External Base and/or Sill Modification
18.18 Splints and Dressing
18.19 Postoperative Care
18.20 Conclusions
References

19 Orthognathic Technique: Le Fort I and Bilateral Sagittal Split Osteotomy (BSSO)

19.1 Introduction
19.2 Operative Sequence
19.3 Maxillary Orthognathic Surgery: Le Fort I Osteotomy
19.4 Mandibular Orthognathic Surgery: Bilateral Sagittal Split Osteotomy
References

20 Osseous Genioplasty

20.1 Introduction
20.2 Evaluation and Workup
20.3 Diagnosis
20.4 Planning
20.5 Relevant Anatomy
20.6 Preoperative Discussion
20.7 Operative Technique
20.8 Outcomes
20.9 Complications
20.10 Conclusions
References

21 Submental Liposuction

21.1 Introduction
21.2 History
21.3 Relevant Anatomy
21.4 Technique
21.5 Considerations for Submental Liposuction in Orthognathic Surgery
21.6 Conclusions
References

22 Fat Grafting

22.1 Introduction and Clinical Usage
22.2 Underlying Biology
22.3 Practical Considerations
22.4 Technique
22.5 Processing
22.6 Injection
22.7 Conclusions
References

23 Alloplastic Facial Augmentation

23.1 Introduction
23.2 Indications
23.3 Materials
23.4 Malar
23.5 Mandibular Angle
23.6 Chin
23.7 Conclusions
References

24 Anesthesia for Orthognathic Surgery and Rhinoplasty

24.1 Introduction
24.2 Airway Assessment
24.3 Airway Management
24.4 Intraoperative Concerns
24.5 Local Anesthetics
24.6 Nausea and Vomiting
24.7 End of Case Care
24.8 Conclusions
References

25 Operative Preparation and Setup for Aesthetic Orthognathic Surgery and Rhinoplasty

25.1 Preoperative Workup
25.2 Laboratory Studies
25.3 Preparing the Operating Room
25.4 Positioning
25.5 Medications
25.6 Intraoperative Precautions
25.7 Instruments
25.8 Immediate Postoperative Care
25.9 Conclusions
References

26 Postoperative Care and Considerations

26.1 Introduction
26.2 Procedure Length and Hospital Course
26.3 Splints and Dressings
26.4 Edema, Bruising, Swelling, and Leakage
26.5 Bleeding
26.6 Nausea and Vomiting
26.7 Diet
26.8 Medications
26.9 Wound Care
26.10 Activity
26.11 Follow-Up
26.12 Conclusions
References

Index

End User License Agreement

List of Tables

Chapter 5

Table 5.1
Table 5.2
Table 5.3
Table 5.4
Table 5.5

Chapter 6

Table 6.1
Table 6.2
Table 6.3
Table 6.4

Chapter 7

Table 7.1

Chapter 8

Table 8.1
Table 8.2

Chapter 9

Table 9.1
Table 9.2
Table 9.3
Table 9.4
Table 9.5
Table 9.6
Table 9.7
Table 9.8
Table 9.9
Table 9.10
Table 9.11
Table 9.12
Table 9.13
Table 9.14
Table 9.15
Table 9.16
Table 9.17
Table 9.18
Table 9.19
Table 9.20

Chapter 10

Table 10.1
Table 10.2
Table 10.3
Table 10.4
Table 10.5

Chapter 11

Table 11.1
Table 11.2
Table 11.3

Chapter 12

Table 12.1
Table 12.2
Table 12.3
Table 12.4

Chapter 16

Table 16.1
Table 16.2
Table 16.3
Table 16.4
Table 16.5
Table 16.6
Table 16.7
Table 16.8
Table 16.9

Chapter 17

Table 17.1
Table 17.2
Table 17.3
Table 17.4
Table 17.5
Table 17.6

Chapter 20

Table 20.1

Chapter 21

Table 21.1
Table 21.2

Chapter 22

Table 22.1
Table 22.2

Chapter 23

Table 23.1
Table 23.2
Table 23.3
Table 23.4

Chapter 24

Table 24.1
Table 24.2
Table 24.3
Table 24.4
Table 24.5
Table 24.6
Table 24.7
Table 24.8
Table 24.9

Chapter 25

Table 25.1
Table 25.2
Table 25.3

Chapter 26

Table 26.1
Table 26.2
Table 26.3
Table 26.4
Table 26.5