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Postauricular Approach for Mandibular Angle Ostectomy: An Alternative for Shortening the Recovery Time
Abstract
Many surgical procedures to improve mandibular contour have been introduced in East Asia. Despite consensus regarding mandible contouring surgery, surgery which includes angle ostectomy and lateral cortex excision, some patients require only mandibular angle ostectomy. The intraoral approach is a widely used method, but has disadvantages with regard to the need for endotracheal intubation and patients are limited in their food intake for a considerable length of time. The authors wanted to shorten the recovery period and so the postauricular approach is introduced in this study and assessed.One hundred seventy-five Asian patients underwent mandibular angle ostectomy via a postauricular approach. All operations were performed under intravenous sedation without endotracheal intubation. Superficial subcutaneous dissection and vertical dissection were performed, with special care taken to avoid injuring the facial nerve. Patients responded to a simple questionnaire during the postoperative period. Questions solicited the patient's reason for their choice of this approach and their satisfaction with it.No visible scar and no palpable bony step were observed without ear pulling. Some patients experienced temporary sensory changes in the postauricular area. None of the patients complained of perioral numbness or facial paralysis. Six patients had significant bleeding in the operative field and 1 patient experienced salivary leakage for 2 weeks which was managed well without event. Of the 175 patients, 133 responded to the questionnaire. Satisfaction was expressed by 94.7% of patients and 88.7% of patients would recommend this surgery to their friends; 69.2% of patients experienced inconvenience for 1 week or less.The postauricular approach for mandibular angle ostectomy is a very convenient method for surgeons to use for patients who want to undergo mandibular angle ostectomy with a short recovery time.
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.
We monitored by means of UV-visible spectroscopy the formation and consumption of triiodide ion (I3-), generated when iodide ion (I-) is used as redox mediator in lithium-oxygen batteries. Results evidence the initial formation of I3- during oxidation, and its decomposition during reduction. Correlation of absorbance with capacity is consistent with the mediation of peroxide oxidation above 3 V. Decrease of I3- absorbance and the appearance of a peak at a wavelength of 410 nm after 14 hours at open circuit voltage revealed side-reactions associated to electrolyte degradation leading to the formation of HOI. This work shows that UV-visible spectroscopy is a valuable tool for following reactions involved in the operation of lithium-oxygen batteries based in the absorbance of the species formed or consumed.
Rechargeable Li–O2 batteries with high theoretical energy density urgently require efficient cathode catalysts to improve their electrochemical performance. Here we first demonstrated the application of Ni-based-organic frameworks of Ni(4,4’-bipy)(H3BTC) (4,4’-bipy = 4,4’-bipyridine; H3BTC = 1,3,5-benzenetricarboxylic acid) (Ni-MOFs) as high-performance cathode catalyst of rechargeable Li–O2 batteries. It is found that Ni-MOFs with three-dimensional (3D) micro-nano structure, open catalytic sites and large specific surface area have guaranteed the free transfer of O2 and effective contact between the electrolyte and the catalytic sites. A preliminary test of Ni-MOFs showed an extremely high capacity of 9000 mAh g–1, a high round-trip efficiency of 80%, and a respectable cycling of 170 cycles without obvious voltage drop. Furthermore, plastic rechargeable Li–O2 batteries with Ni-MOFs as the cathode catalyst have been assembled, displaying an energy density of 478 Wh kg–1. This study leads to both fundamental and technological advances of Ni-MOFs as the cathode of rechargeable Li–O2 batteries.
Smile is one of the most natural and important expressions of human emotion. Man uses his lips mainly to register his emotions. Thus, the slightest asymmetry or weakness around the lips and mouth may transform this pleasant expression into embarrassment and distortion. The circumoral musculature, the major part of which is supplied by the marginal mandibular branch of the facial nerve, is the main factor in this expression. Therefore, an injury to this nerve during a surgical procedure can distort the expression of the smile as well as other facial expressions. This nerve often gets injured by surgeons in operative procedures in the submandibular region, like excision of the submandibular gland due to lack of accurate knowledge of variations in the course, branches and relations. In the present study, 50 facial halves were dissected to study the origin, entire course, termination, branches, muscles supplied by it, its anastomoses with other branches of facial nerve on the same as well as on the opposite side and its relations with the surrounding structures. The marginal mandibular branch of the facial nerve was found superficial to the facial artery and (anterior) facial vein in all the cases (100%). Thus the facial artery can be used as an important landmark in locating the marginal mandibular nerve during surgical procedures. Such a study can help in planning precise and accurate incisions and in preventing the unrecognized severance of this nerve during surgical procedures.
In order to avoid injury to the marginal mandibular branch of the facial nerve during surgery in the face and neck, a simple method for locating this branch was devised. The anatomical relations between the marginal mandibular nerve and both the facial artery and vein were analyzed in 19 dissection preparations. The following distances were considered: (1) the angle of the mandible to the intersection point nerve-vein; (2) mandibular angle to the facial artery; (3) inferior mandibular margin to the intersection point nerve-vein; (4) facial artery to the intersection point projection nerve-vein; (5) facial artery to the intersection point projection nerve-vein on the inferior mandibular margin; and (6) facial vein to the facial artery. These data are useful for an easier localization of the marginal mandibular nerve in the submandibular region. All reference points employed are easily detected in a living subject.
A square mandible is considered unattractive in Asia; as a result, mandibular reduction is the most common type of operation performed. The authors review the importance of mandibular tubercles in the lower margin of the parasymphysis area and introduce their resection techniques and results.
From April of 2005 to September of 2009, 178 patients underwent tubercle resection in the parasymphyseal area. The procedures used were as follows: mandibular angle reduction in 139, genioplasty in 39, and mandibular angle reduction with simultaneous malar reduction in 58 patients. In the chin area, horizontal osteotomy was performed in 35 patients to reduce chin length. Other patients underwent mandibular tubercle resection and burring.
With the exception of one patient who developed hyperesthesia in the left lower lip 2 years after the procedure, all patients achieved satisfactory aesthetic results after mandibular tubercle resection and concurrent mandibular reduction.
The authors consider mandibular tubercle resection, either as a single procedure or combined with mandible reduction, essential for patients who require a slimmer, more feminine lower face.
The aim of this study was to elucidate the anatomical structures that are vulnerable to injury during sagittal split ramus osteotomy (SSRO). Twenty-nine hemifaces of 19 Korean adult cadavers (11 men and 8 women; age range, 50-91 years) were dissected, and the locations of the facial nerve, retromandibular vein (RMV), and external carotid artery (ECA) were measured on the base of the mandibular posterior border and occlusal plane. Sagittal split ramus osteotomy was performed on the cadaver heads at intervals of 10 mm, and the proximity of the facial nerve was observed. The buccal branch and mandibular branch crossed the posterior border of the mandible (PBM). Most buccal branches (86%) crossed between 7/10 and 10/10 of the distance from gonion to mandibular notch (MN). Most mandibular branches (86%) were between 6/10 and 1/10 of the distance from gonion to MN. Most facial nerve trunks (FNTs) (82%) were within a circle of 9 mm in radius. Its center was located 34 mm posterior and 7 mm inferior to the MN. The FNT was located in the range of 11 to 14 mm medial to the PBM. The FNT emerged out of the stylomastoid foramen and ran anteroinferiorly in a direction of 45 degrees. In 10-mm ramus setback osteotomy, FNT was very close to the PBM, running almost vertically. Retromandibular vein was 5.5 to 8.6 mm posterior and 4.2 to 9.1 mm medial to the PBM. The ECA was located at 5.7 to 6.5 mm posterior and 10.5 to 12.9 mm medial to PBM. Facial nerve could be averted from injury by doing less setback. Bleeding after SSRO is likely to be due to the injury of RMV which is closer to the PBM (4-9 mm) than ECA (12-13 mm).
Giving a square and muscular appearance, a prominent mandibular angle is considered to be unattractive in the Orient. Because of the different aesthetic sensitivities, the problem is reported more frequently in the Orient than that in the West. In most reports, the final choice of surgical procedure, including the approach, position of ostectomy, and volume of bone to be cut, depended subjectively on the experience of the surgeon and the desire of the patient. This article provides a study to make the surgical procedure accurately and objectively, involving 46 female patients asking for reduction of prominent mandibular angle for cosmetic reasons. Measurement and analysis of cephalometric radiographs were performed preoperatively. According to the different characteristics of the prominent mandibular angle in front and lateral views of the radiographs, the patients were classified into 4 types. In each type, ostectomy of different extent via different approaches or masseter botulinum toxin A injection only was given. Postoperative cephalometric analysis was also made to evaluate the result objectively. The results have been generally satisfactory.
The mandible's contour determines the shape of the lower part of the face and thus influences the appearance of the face and neck. There are two types of operative procedures that can be used on mandibular contour and they do not require orthodontic treatment: mandible angle reduction and genioplasty. We divided the mandible angle reduction group into Types A, B, and C according to the grade of angle protrusion. Type A needs just an angle resection, Type B needs an angle resection and resection of part of the body, and Type C needs resection of the angle, the body, and part of the symphysis. We have performed 258 mandibular contouring procedures. In genioplasty, shaving, advancement, shortening, and lengthening generally can be employed. Furthermore, when vertical lengthening is used, ostectomized mandible angle bone is carved and then grafted between the horizontal osteotomy site. Of the mandible angle reduction cases, 21 were Type A, 186 were Type B, and 28 were Type C. The curved ostectomy is most important in mandible angle reduction cases in order to achieve a more natural curve of the mandible's lower border. A total of 71 patients were very pleased with the results of the combined procedures of genioplasty and angle reduction.
A prominent mandibular angle is considered to be unattractive in the Orient because it gives the face a square and muscular appearance. While described infrequently in the United States, this entity is commonly encountered in the Orient owing to different facial characteristics and different aesthetic sensibilities. We present a retrospective study of 42 female patients who presented requesting the reduction of a prominent mandibular angle for cosmetic reasons. We describe our approach, which utilizes formal planimetry, cephalometric tracings, and Panorex mandibular radiographs. We utilize the intraoral approach and use an oscillating saw to resect the predetermined segment of bone. In 18 of the 42 patients, we resected muscle as well. We also describe using the preauricular incision in a patient undergoing a concomitant rhytidectomy. Our cosmetic results have been generally satisfactory, with only one inaccurate osteotomy. We had three infections which resolved without sequelae.
A patient with a large, squarish, or broad face who desires a small, round, or slender face can undergo mandibular contouring surgery to reduce the width of the lower face. The successful correction of a prominent mandibular angle by conventional angle ostectomy has been reported. However, in the majority of patients with a widened facial appearance, both the mandibular angle and part of the mandibular body anterior to it are protuberant laterally, so both must be resected. At our clinic, operations to reduce the width of the lower face have been performed on 76 patients (9 males and 67 females) during the last 5 years. Initially, we employed a combination of shaving of the lateral cortex and multistaged curved cuts of the mandibular angle. This operative technique, however, required a high level of skill and was time-consuming. A retrospective study of the results revealed the following additional drawbacks. The objective of this procedure is, in a sense, to create morphologically analogous mandibles in all patients, but on the one hand, the resulting relief of the mandibular angle tended to lack individuality, and on the other hand, the primary purpose of reducing the width of the lower face was not fully accomplished in some patients. With angle-splitting ostectomy, which we performed at a later date, however, the width of the lower face was efficiently reduced, producing a natural relief of the mandibular angle. If the surgeon in charge has precise anatomic knowledge and performs this on the basis of an accurate preoperative diagnosis and an operative plan, he or she will encounter no particular difficulties during the operation. There were no complications, such as hematoma, infection, or asymmetry, and aesthetic benefits were achieved even in patients with facial asymmetry.
A square mandible is often indicated for operative correction in Orientals, whereas it is seldom regarded as requiring treatment in other races. A prominent mandibular angle is often corrected by resecting the angle. However, subjects with a prominent mandibular angle often have a disproportional chin, and mandibular contouring surgery from the ramus to the symphysis is conducted effectively by resection of the angle and genioplasty. Advancement, recession, shortening, and/or elongation by horizontal or sagittal osteotomy of the chin were performed in our series of 16 Japanese patients. The resected width of the angle ranged from 10 to 15 mm, and the resected length ranged from 42 to 62 mm. Masseter muscle resection was combined with the treatment in 13 patients who requested it. In the concomitant genioplasty, advancement was performed in six, reduction in one, and simultaneous advancement and elongation in nine cases. Operative results were satisfactory, and the patients' facial contours were improved substantially by mandibular contouring from the ramus to the symphysis in all cases. The author concludes that the entire mandibular contour should be considered in mandibular angle plasty, and concomitant genioplasty based on racial anthropometric measurements is very effective.
Many surgical techniques have been applied toward correcting the prominent mandibular angle. One of the most popular methods is mandibular angle ostectomy. However, gross asymmetry, mandibular condylar fracture, and unnatural contouring of the mandibular angle are frequent consequences. Therefore, we perform ostectomy of the lateral cortex around the mandibular angle in patients with wide and squared lower faces. Seventeen female patients with ages ranging from 23 to 35 years underwent surgery. Ostectomy of the lateral cortex of the mandible and mandible angle ostectomy were performed in five patients (group I). Ostectomy of the lateral cortex only was performed in the remaining 12 patients (group II). The follow-up period ranged from 1 to 5 years. Postoperatively, the bigonial distance was effectively reduced in both groups (group I, mean 13 mm; group II, mean 12 mm). Compared with group I, the gonial angle and mandibular plane-sella-nasion angle were within normal ranges in group II. We therefore conclude that the ostectomy of the lateral cortex alone allows the reduction to be achieved without changing the angle of the mandible itself. Moreover, although the resection of the mandibular angle was not performed, the contour of mandibular angle became soft, giving a more natural appearance.
A prominent mandibular angle is considered to be unattractive in Asian countries because it gives the face a square and muscular appearance. Successful correction by angle ostectomy has been reported, but one of the serious complications of angle reduction ostectomy is fracture of the mandibular condyle. If the ostectomy line is misdirected vertically, the condyle may be fractured. The authors experienced two cases of condylar fracture during angle reduction. Case 1 was a pulled-out condylar fracture, where an L-shaped miniplate was then attached by external approach, and intermaxillary fixation (IMF) with arch bar was used on postoperative day 14. With release of the IMF, a systematic approach for a jaw-opening exercise was begun. On postoperative day 21, the elastics were placed to assist in guiding protrusion of the mandible anteriorly 24 hours a day. After postoperative day 28, it was possible to completely abandon daytime elastic fixation. The exercise was modified to lateral movement. Case 2 was green-stick condylar fracture, with the IMF with arch bar applied on postoperative day 10. After releasing the IMF, the exercise involved the daily use of several tongue blades, and range of motion increased by wedging additional blades until postoperative day 21. More aggressive stretching was continued with 22 blades on postoperative day 28. On the removal of the arch bar, the occlusion was stable and followed by more aggressive stretching and physical therapy. Both cases were successfully restored and had good results. The authors believe the exercise protocols and algorithms they used may serve as a standard procedure of treatment in condylar fracture caused by angle ostectomy.
The terms "mandibular angle reduction" and "reduction angleplasty" refer to operations to reduce the width of the lower face and change a square face to an oval one. Because the terms emphasize the word angle, however, they imply that the operations apply to the mandibular angle. The most frequent complaint after these operations is that the change in the lateral appearance is clear but that the change in the frontal appearance is not noticeable. Such a result is related to the fact that bone resection is performed mainly in the mandibular angle area and is focused particularly on resection of the posterior projection through curved ostectomy. That is, because operations limited to the mandibular angle area cannot properly satisfy patients' requirements, the operation must be applied to a larger area. Therefore, it seems reasonable to change the terms "mandibular angle reduction" and "reduction angleplasty" to "mandible reduction" and "reduction mandibuloplasty." In addition, the most important technique in the operation is the resection of the outer cortex of the mandible. In particular, the corticectomy technique using a reciprocating saw is quite safe and effective for the maximum resection of lateral flaring within a very short time.
Injuries to the buccal region of the face can carry multiple complications due to the complex anatomy that lies within. The facial nerve and the parotid duct can be easily injured by sharp or penetrating trauma to the cheek. The purpose of this paper is to present the full spectrum of current treatment modalities available to manage these injuries. The anatomy of the parotid gland and duct are described, and surgical techniques and therapeutic alternatives for the immediate and delayed treatment of the parotid duct injuries are reviewed. Clinical cases are presented to illustrate the treatment options outlined.
A prominent mandibular angle is considered to be unattractive in Asians because it gives the face a square, coarse, and muscular appearance. Asian women desire to have an ovoid, reduced, and slender face by aesthetic mandibular angle resection. Mandibular angle ostectomy has been known to be effective and to satisfy both surgeons and patients. Especially in Korea, it has become as popular as facial bone contouring surgery, which reduces lower facial width. However, a narrow surgical field hinders direct view of the site, making a procedure that is rather difficult to perform. Despite thorough presurgical planning and attention, there can be many complications and unfavorable results. The purpose of this study is to find out the cause of these complications of mandibular angle ostectomy and to develop methods that could prevent these complications from occurring. A questionnaire consisting of 30 questions regarding mandibular angle ostectomy was sent to 40 Korean plastic surgeons. Data from 33 surgeons were analyzed. The total number of operations was 1251, and among them complications appeared in 124 operations, a complication rate of 9.9%. In regards to severe complications, there were 8 cases of subcondyle fracture of the mandible and 6 cases of severe bleeding. Transient facial nerve injury, infection, trismus, asymmetry, undercorrection, overcorrection, secondary angle formation, and entrapped bony segment were also noted as complications. We will report the cause and the prevention methods for each complication.
The sagittal split ramus osteotomy is a well-established procedure, and many authors have attempted various modifications of the surgical technique. Nowadays, it is widely acknowledged that people in Korea, Japan, and China prefer an oval face, the lower part of which is slender. Therefore, among facial contouring procedures, the mandible reduction procedure is the most popular procedure in these countries. It is quite difficult for patients to undergo two different procedures on almost the same region separately.
For patients who underwent sagittal split ramus osteotomy on their mandible for various reasons, the authors performed mandible reduction at the same time if necessary. In the event that two procedures are performed simultaneously, the risk would be higher regarding postoperative stability, but there was no significant problem in achieving stable occlusion after surgery through a rigid fixation technique and 2 weeks of rigid intermaxillary fixation.
The authors attained satisfactory aesthetic results and good postoperative stability by performing sagittal split ramus osteotomy and mandible reduction at the same time.
This procedure is thought to be useful for patients who are to undergo sagittal split ramus osteotomy for various reasons and want to have a slender lower face.
A prominent mandible and squared contour are typical facial features considered unattractive in Korea and in other Asian countries; thus, mandible reduction is widely practiced. While reviewing the unsatisfactory surgical cases of mandible reduction, the authors discovered that failure was largely because the patients' chins were left intact. The authors have reached the conclusion that paying attention to the shape of the chin is crucial and therefore correction in the procedure of lower facial contouring surgery is required.
From March of 2003 to April of 2005, 254 women underwent mandible reduction. Of these patients, 39 required correction of chin shape in addition to mandible reduction.
Narrowing the chin and modification of chin shape can be accomplished by narrowing genioplasty with central strip resection. This mid-symphyseal sectioning procedure produces safe and very satisfactory results. This procedure not only augments the narrowing effect by leaving soft tissues attached but also enables modification of chin shape by altering the shape of resection. By applying this procedure, additional modifications of the chin to correct asymmetry or microgenia are possible.
Narrowing genioplasty, either as a single procedure or in combination with mandible reduction, makes the lower face appear slender and produces a more feminine contour.
The prominent mandibular angle: preoperative management, operative technique, and results in 42 patients.
- Baek
Refinement in aesthetic contouring of the prominent mandibular angle.
- Baek