Facial Bone Contouring: Complications and How to Manage
Many patients who seek facial bone contouring surgeries desire a slim jaw, but such procedure is not merely a procedure that slims down the face by resecting mandibular angles but a procedure for shaping an aesthetically pleasing lower face that blends well with the upper and midfacial area. To achieve this, the overall shape of the mandible must be taken into account, and genioplasty must also be considered to create an aesthetically pleasing lower face.
Currently, there is a consensus regarding facial bone-contouring surgery that includes angle ostectomy and lateral cortex excision or shaving. In addition, the importance of lower chin contour has been emphasized, and several techniques such as tubercle excision and narrowing genioplasty.
Nerve Injuries
One of the most common complications in facial bone contouring procedures noted by many publications is nerve injury. Studies have shown that the frequency of neurosensory deficit occurrence may range from 8% to 32%. However, such complication is usually temporary, and patients would generally recover 6 to 12 months post surgery. In some cases, patients have reported sensory deficit after the surgery in 3 different regions - namely chin, lower lip, and intraoral.
In the same study, it is also reported that there were some patients who reportedly experienced sensory deficit for more than a year following the surgery. Occurrence of paresthesia may also decrease the patient’s overall satisfaction with the surgical outcome. Neurosensory deficit is perceived by the patients as paresthesia or as reduced sensitivity over the anatomical region innervated by the inferior alveolar nerve. It is important to note that alveolar nerve lesions are usually caused by direct or indirect mechanical traumatic events. Furthermore, additional damage might occur from inflammatory phenomena, bleeding, and/or hematomas surrounding the mandibular canal.
Lastly, facial nerve palsy can result from traction or direct trauma to the facial nerve, especially by accidental penetration of an instrument behind the ascending ramus. Treatment for facial nerve palsy should be conservative, waiting for spontaneous recovery.
To minimize nerve injury occurrence, a performing surgeon should keep the panoramic view of the nerve canal in mind and perform a careful dissection of the periosteum and cutting of the bone. Some articles have indicated that occurrence of numbness is also related to the patient’s age at the time of surgery and patients who have underwent a foreign body injection in or around the chin area may experience painful sensations and/or uneven skin surface because of incomplete removal.
Infection
Infection is another common complication with its rate and possibility being dependent on various factors such as the surgical environment, antibiotic injections (prophylactic antibiotics and duration), personal oral hygiene, age, and the duration as well as the extent of the surgery. These have been identified as possible factors affecting the prevalence of postoperative infection.
It is also interesting to note that infection rates may also differ due to age, gender, and other factors not related to the surgical procedure. In addition, infected patients usually showed the following signs and symptoms: localized pain, swelling, surface erythema, pus formation, limited motion, fever, lymphadenopathy, malaise, a toxic appearance, and an elevated white blood cell count.
When infection and drainage within the oral wound are detected, a compressive dressing with elastic tape and antibiotic injection should be administered, applied and kept for 7 days. If an infection is not promptly resolved, it may be treated with daily injections of antibiotics until healing is complete and no other complications are present.
Asymmetry
Improperly performed facial bone contouring surgeries can lead to many complications, most of which can cause asymmetry. Cheek asymmetry can result from inaccurate preoperative planning. Furthermore, inadequate fixation of the anterior aspect of osteotomized zygoma can result in displacement.
Special care should be given to perform a clean and straight cut at the upper portion of the malar complex as this will allow good bony contact, easier rigid fixation, and better healing.
Another cause of asymmetry is drooping cheeks when the procedure is performed intraorally. Therefore, it is important during intraoral dissection to preserve the masseter muscle attachments on the zygomatic arch.
Condylar Fracture
Blind angle ostectomu or the use of an osteotome instead of a saw to complete an ostectomy may cause condylar fracture. An uncontrolled fracture can then extend to the condylar neck causing adverse effects. Linear condylar fractures may be treated with intermaxillary fixation for 4 weeks, while a displaced condylar fracture may require additional open reduction before intermaxillary fixation.
To avoid complications of malar reduction or mandibular angle reduction, preoperative planning for exact bone resection is mandatory. In addition, the operative technique should be selected based on the patient’s facial contour and shape and age. Blind ostectomy or osteotomy should be avoided where possible, and direct visualization with adequate protection of the soft tissue is recommended.
Tearing of Facial Artery
Other complications of facial bone contouring surgery includes the possibility facial artery tearing during dissection or osteotomy of the mandibular margin; however, this can be avoided by limiting the placement of the instrument to the lower margin of the periosteum.
After periosteal dissection, gauze packing may be applied to protect the soft tissue around the mandible. Management of intraoperative hemorrhage requires visualization of the problem area; and may involve rapid completion of an osteotomy to allow application of direct pressure with gauze packing, vascular clips, or electrocautery.
Facial Bone Contouring: Finesse in Art
In practicing the art of facial bone contouring, it requires a practitioner to bring more than basic knowledge of the procedure and anatomy to the table - it requires one to possess finesse in skills and techniques as the risks of complications is significantly higher than most other procedures due to the fact that procedures may be performed under blind angle ostectomu.
Additionally, the anatomy of the face suggests that there are many nerves and arteries which are susceptible to damage if a practitioner does not employ right techniques.
Lastly, while complications should be prevented and avoided if possible, where not possible, a skilled practitioner must always be prepared to manage and address any possible complications that may occur.
Therefore, it is imperative for a physician to not only understand the anatomy of the area of procedure, but also be equipped with the latest and most advanced techniques.
References:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2884897/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4174213/
https://academic.oup.com/asj/article/31/6/634/209878
Learn How to Manage Facial Bone Contouring Complications at our upcoming Advanced Rhinoplasty & Bone Contouring Mini-Fellowship!
IFAAS Mini-Fellowship (Observation)
Korean Advanced Facial Aesthetic Surgeries -
Advanced Asian Rhinoplasty & Bone Contouring
March 23-25, 2020 | Seoul, South Korea
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