Comprehensive Consideration and Design for Treatment of Square Face

Middle and lower-facial feminization surgery in East Asian transgender and cisgender women: Surgical techniques and outcomes

PURPOSE

Facial feminization surgery (FFS) is a group of surgical procedures for transgender or cisgender women with masculine facial characteristics. This study aimed to investigate the cosmetic outcomes of middle and lower FFS including reduction malarplasty and mandibular angle ostectomy in East Asian transgender and cisgender women.

METHODS

A retrospective study was conducted using the clinical notes and records of transgender women (Group I) and cisgender women (Group II) who underwent FFS, incorporating reduction malarplasty and mandibular angle ostectomy at the West China Hospital of Stomatology, Sichuan University. Outcomes were assessed using computed tomography (CT) images, which were supplemented by medical records and photographs. Data were collected preoperatively and at intervals of at least 1 year postoperatively, focusing on mid- and lower-facial width, mandibular angle, and patient-reported complications. FACE-Q reports of facial appearance and psychosocial parameters were also compared between the 2 groups.

RESULTS

Thirty-four transgender women and 39 cisgender women were enrolled in the study. Significant reductions in mid- and lower-facial width, and mandibular angle, were observed in all patients (P <.001). Transient nerve weaknesses were the primary complications noted. Group I exhibited a more pronounced improvement in FACE-Q scores pre- and postsurgery compared to Group II (P <.001).

CONCLUSION

FFS using reduction malarplasty and mandibular contouring procedures is an effective technique for feminizing the facial skeleton. Remarkably, transgender women experienced a more significant enhancement in facial appearance and psychosocial well-being following FFS when compared to cisgender women.

Hard and Soft Tissue Facial Landmarks for Mandibular Angle Reduction: A Clinical Study

BACKGROUND

Square faces, which are influenced by genetic factors and structural features, are considered undesirable among the Asian population. Surgical interventions, such as mandibular angle reduction, aim to alter these characteristics, though complications may arise. We aimed to investigate the morphology of the mandibular angle and masseter muscle thickness using computed tomography (CT) and to analyze hard and soft tissue correlations to enhance surgical outcomes for patients with square faces.

METHODS

This retrospective clinical study included 100 Taiwanese patients aged 18-50 years. CT was used to analyze key clinical parameters, including bilateral mandibular width, mandibular divergence angle, ramus height, distance from the mandibular angle to the inferior alveolar nerve (IAN), and the thickness of the masseter muscle.

RESULTS

Significant correlations were noted between the patients' physical height and weight, mandibular width, ramus height, masseter thickness, and distance from the angle to the IAN. Males exhibited a significantly longer and thicker ramus height (66.48 ± 4.28 mm), greater masseter thickness (15.46 ± 2.35 mm), and greater safety range for mandibular angle reduction surgery (18.35 ± 3.19 mm) (p < 0.00008). Significant correlations were observed among all parameters, except between mandibular width and gonial angle and the distance from the angle to the IAN and between mandibular divergence and masseter muscle thickness (p > 0.1).

CONCLUSIONS

Our study highlighted the complex interplay among factors that contribute to square facial morphology. Careful preoperative assessments and customized surgical planning are essential for addressing this multifaceted clinical challenge.

Morphological Changes of the Mandibular Angle After Orthognathic Surgery with Class III Deformity in East Asia

The aims of this study were to analyze the morphological changes of the mandibular angle after orthognathic surgery for mandibular setback and investigate related factors. This retrospective study included patients from January 2017 to December 2021 diagnosed with skeletal class III deformity who underwent BSSRO (Group I) or bimaxillary surgery (Group II). Preoperative (T0), within 1 month postoperatively (T1), and 6 months postoperatively (T2) CT scans were collected from 61 patients to three-dimensionally analyze the proximal segment displacement, the linear and angular changes of the mandibular angle. The gonion points moved posteriorly and laterally (P < 0.001), while the inferior movement was not significant (P = 1.000, P = 0.274). The intergonial width increased by 3.32 ± 1.87 mm and 2.34 ± 1.77 mm as revealed by T2 CTs, respectively, in Group I and Group II. Mandibular angle decreased in both groups and by 1.41 ± 2.95° in Group I and 1.37 ± 3.41° in Group II. The increase in intergonial width between T1 and T0 was negatively correlated with the preoperative mandibular angle (P = 0.003) and positively correlated with the transverse outward movement of the proximal segment (P < 0.001). After surgery, the intergonial width increased and the inferior and posterior border of the proximal segment flared outward. The changes in intergonial width and mandibular angle were mainly related to the rotation of the proximal segment, which has a certain impact on the aesthetics of the lower face. Therefore, controlling the position of the proximal segment is of vital importance to lessen the changes in the mandibular angle area.Level of Evidence III. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Neurectomy of the Masseteric Nerve Using an Extra-Oral Approach to Treat Masseter Hypertrophy: Case Report and Literature Review

Masticatory muscle hypertrophy is a benign clinical anomaly which leads to facial asymmetry or a squared face appearance. We report a case of masticatory muscle hypertrophy, particularly on the right side, that was successfully treated by neurectomy of the right masseteric nerve through an extra-oral approach. Clinical examination showed significant aesthetic improvement of the facial symmetry with complete paralysis and atrophy of the right masseter muscle. The impaired postoperative function of the frontal branch of the right facial nerve was fully restored 10 weeks postoperatively. The patient no longer experiences headaches or discomfort with eating or sleeping on her right side.

Comparing the esthetic impact of virtual mandibular advancement, bichectomy, jawline, and their combination

INTRODUCTION

The purpose of this study was to compare the effects of mandibular advancement (MA), bichectomy, jawline, and their combination on facial attractiveness. The 3-dimensional (3D) visual sculpting is a method to perform the task.

METHODS

FaceBuilder software, a Blender 2.93 LTS add-on, was used to generate a 3D head and face model of a female patient with Class II Division I malocclusion. MA, bichectomy, jawline, and combination modifications were performed on the model using a 3D virtual sculpting tab, and 4 new head models were created. Five hundred thirteen participants scored lateral and frontal views of the modified and reference models. The Mann-Whitney U, Kruskal-Wallis, and Wilcoxon tests were used for statistical analysis.

RESULTS

MA modification received the highest frontal and lateral image scores. The raters found the jawline frontal photograph to be the least attractive. Significant differences were observed between the lateral and frontal attractiveness scores in all modifications except bichectomy. The combination of 3 modifications in both frontal and lateral images received the second-lowest score.

CONCLUSIONS

Facial esthetic modifications receive different attractiveness scores in lateral or frontal evaluations. MA outperforms bichectomy and jawline augmentation in terms of improving facial attractiveness.

Comprehensive correction of maxillofacial bone deformity-consideration and combined application of orthognathic surgery and facial contouring surgery

The maxillofacial skeleton is the basis of the contour of the face. Orthognathic surgery and facial contouring surgery change jaw tissue and affect facial appearance in different manners. Orthognathic surgery is the main method to correct dental and maxillofacial deformities. It changes the shape of the jaw and improves the occlusal relationship by changing the three-dimensional position of the jaw. Facial contouring surgery mainly adopts the method of "bone reduction", which changes the "amount"of the jawbone by cutting a part of the bone tissue to improve the facial appearance, generally without changing oral function. The combined use of orthognathic surgery and facial contouring surgery is becoming increasingly common in clinical practice. This also requires oral and maxillofacial surgeons to have a holistic consideration of the comprehensive correction of maxillofacial bone deformity, and to perform comprehensive analysis of jaw deformities and jaw plastic surgery to achieve the most ideal results. The author's team has been engaged in the clinical work of orthognathic surgery and facial contouring surgery and accumulated rich clinical experience in the comprehensive correction of maxillofacial bone deformity. In this article, the indications, treatment goals, treatment modes, treatment methods, and key points in the surgical operations of comprehensive maxillofacial bone surgery were summarized.

Autogenous Fat Transplantation and Botulinum Toxin Injection Into the Masseter Muscle to Create an Ideal Oval Face

BACKGROUND

East Asian faces vary in shape but only oval faces seem to be considered attractive. Many patients with wide faces seek removal of part of the mandibular angle and/or zygoma to achieve an ideal facial contour, but the procedure is high risk and the recovery period is relatively protracted.

OBJECTIVES

We sought to achieve ideal facial contours through the use of autologous fat grafting (AFG) combined with masseter botulinum toxin (BTX) injection for patients with wide faces and masseter hypertrophy.

METHODS

Fourteen patients with wide faces underwent AFG of the forehead, temporal region, cheeks, zygomatic body, nose, nasolabial fold, tear trough, and chin; and BTX injection into the masseter muscles. Each patient was photographed more than 6 months after the operation. The pre- and postoperative ratios pertaining to the facial aesthetics of the face were calculated. The Hollowness Severity Rating Scale (HSRS) and Ricketts's E-line were used to evaluate the photographs. Patient satisfaction was also investigated.

RESULTS

All patients received AFG and 1 to 3 BTX injections. The face length:bizygomatic breadth, bigonial breadth:bizygomatic breadth, and lower-face height:middle-face height ratios improved greatly after treatment. The mean HSRS score decreased from 2.214 preoperatively to 1.071 postoperatively. The chin and nose became more prominent than before. Facial swelling persisted for an average of 11.929 days. All patients were satisfied with the treatment outcome.

CONCLUSIONS

A combination of AFG and BTX injection was able to achieve an ideal oval face in East Asian patients with wide faces and masseter hypertrophy, with very few complications. Recovery was rapid and patient satisfaction was high.

LEVEL OF EVIDENCE: 4

A digital photograph study evaluating facial taperness and square face perception of Taiwanese females

BACKGROUND

This study assessed the perception of facial taperness in Taiwanese females among people with dental knowledge and laypersons. Additionally, this study also specified the criteria by which "square face" was defined regarding Taiwanese females' facial taperness.

METHODS

A series of digitally modified photos with different levels of facial taperness (Gonion to Gonion/Zygoma point to Zygoma point-Go-Go/Zy-Zy ratio ranges from 65% to 90%) were randomly arranged and presented to the raters. Visual analog scale (VAS) lines were used for scoring the photos on a scale of 0-100. The true or false question about "defining square face" was incorporated in the same questionnaire. The reliability of the true/false square face question and the esthetic evaluation by VAS were assayed. The receiver operating characteristic curve was used to define the cutoff point on "square face." The effects on the raters' genders, orthodontic treatment experience, and their professional background on the perception of a square face were assayed.

RESULTS

The overall reliability of the raters was within the acceptable range. The VAS score evaluation revealed that the average expectation for best facial taperness was 75%, whereas the facial taperness of over 83% was considered as the square face. The facial taperness reaching to 90% was regarded as the most unattractive. Gender, therapy, and professional experience have no impact on the standard of square facial form evaluation.

CONCLUSION

A face with a taperness greater than 83% was evaluated as a square face, and a face with a taperness around 75% was considered as the most attractive.

Three-Dimensional Analysis of Mandibular Angle Classification and Aesthetic Evaluation of the Lower Face in Chinese Female Adults

BACKGROUND

Reduction gonioplasty is very popular in East Asia. However, there has been little quantitative criteria for mandibular angle classification or aesthetics. The aim of this study was to investigate the quantitative differences of mandibular angle types and determine the morphologic features of mandibular angle in attractive women.

METHODS

We created a database of skull computed tomography and standardized frontal and lateral photographs of 96 Chinese female adults. Mandibular angle was classified into 3 groups, namely, extraversion, introversion, and healthy group, based on the position of gonion. We used a 5-point Likert scale to quantify attractiveness based on photographs. Those who scored 4 or higher were defined as attractive women. Three types of computed tomography measurements of the mandible were taken, including 4 distances, 4 angles, and 3 proportions. Discriminant analysis was applied to establish a mathematic model for mandibular angle aesthetics evaluation.

RESULTS

Significant differences were observed between the different types of mandibular angle in lower facial width (Gol-Gor), mandibular angle (Co-Go-Me), and gonion divergence angle (Gol-Me-Gor) (P < 0.01). Chinese attractive women had a mandibular angle of 123.913 ± 2.989 degrees, a FH-MP of 27.033 ± 2.695 degrees, and a Go-Me/Co-Go index of 2.0. The "healthy" women had a mandibular angle of 116.402 ± 5.373 degrees, a FH-MP of 19.556 ± 5.999 degrees, and a Go-Me/Co-Go index of 1.6. The estimated Fisher linear discriminant function for the identification of attractive women was as follows: Y = -0.1516X1(Co-Go) + 0.128X2(Go-Me) + 0.04936X3(Co-Go-Me) +0.0218X4(FH-MP).

CONCLUSIONS

Our study quantified the differences of mandibular angle types and identified the morphological features of mandibular angle in attractive Chinese female adults. Our results could assist plastic surgeons in presurgical designing of new aesthetic gonion and help to evaluate lower face aesthetics.

Validation of a Photonumeric Assessment Scale for Grading the Slope of the Asian Forehead

BACKGROUND

As the number of aesthetic treatments has grown, so have the number of photonumeric assessment scales used to compare the effectiveness of these aesthetic treatments in specific anatomical areas; however, these are primarily based on Caucasian features.

OBJECTIVE

To assess the validity of the first aesthetic scale for assessing the slope of the Asian forehead. A secondary objective was to correlate this scale with subject demographics and baseline characteristics.

METHODS

During 2 validation sessions, 13 raters assessed full frontal and lateral facial images of female (n = 28; 56.0%) and male (n = 22; 44%) subjects. For each subject, the severity of forehead sloping was graded from 0 (convex forehead, optimal forehead volume) to 4 (concave forehead, very severe sloping). Raters also assessed the age of each subject and the estimated aesthetic treatment effort required to treat each subject.

RESULTS

Inter-rater reliability was "substantial" with scores of 0.67 and 0.68 for the first and second validation sessions, indicating high reliability. BMI showed the highest correlation with the scale and was a significant predictor in the final regression model.

CONCLUSION

This photonumeric assessment scale will be useful for assessing the slope of the Asian forehead in both clinical and research settings.

Occlusion-Fit V-Line Guide and Gooseneck Saw for Safe and Accurate Mandibuloplasty in Asians

BACKGROUND

A slender or slim face with narrow facial features is considered esthetically appealing in Asian people. Plastic surgery to obtain an oval face, called a 'V-line,' is popular among young people.

MATERIALS AND METHODS

A total of 20 Korean patients were included in this study. The patients underwent mandibular anguloplasty with three-dimensional computer-aided design and manufacturing surgical guides that were accurately fitted to the upper and lower teeth, allowing for precise replication of a virtual surgery during a real surgical procedure.

RESULTS

There were no significant complications, including severe bleeding, facial nerve injury, or airway obstruction. All patients were satisfied with the esthetic and functional results, except for one who was neutral toward the result. The mean satisfaction score was 4.75, which was between 'satisfied' and 'very satisfied.'

CONCLUSION

The V-line guide and gooseneck saw allowed for safe and fast resection of bone in the mandibular angle area. This technique provides consistent results during surgery as well as minimizing surgical complications.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Cosmetic bone contouring

PURPOSE OF REVIEW

In recent years, cosmetic bone contouring surgery has become increasingly popular, especially in East Asian countries. These procedures are also being requested by patients in the United States at an increasing rate. The purpose of this study is to provide an overview of what is involved with these procedures and their potential complications.

RECENT FINDINGS

In some cultures, a wide jaw and a square face are aesthetically unpleasing, whereas an ovoid or 'melon seed face' is thought to be feminine, delicate and beautiful. Mandibular angloplasty, mandibular lateral cortex excision, reduction malarplasty, as well as genioplasty may be performed to alter the facial contour and bring about dramatic results.

SUMMARY

Whether a surgeon choses to incorporate these procedures into practice or not, the craniofacial surgeons should be familiar with the procedures as well as the potential complications.