Aesthetic facial skeletal surgery—evolution of thought and technique

Introduction

Aesthetic facial skeletal surgery has become one of the most popular and demanding fields of surgery today. With the technologic advancements and the development of surgical techniques, it is possible to not only make an abnormal face more normal but also modify the normal face to create a supranormal or aesthetically enhanced face. A key concept, however, makes this field quite challenging. The human face is composed of different components and building blocks; therefore any attempt to alter facial features must consider establishing or reestablishing harmony among the components, rather than making isolated alterations. In other words, aesthetic enhancement often involves form, whereas certain alterations must consider the functional elements as well. Orthognathic surgery, for instance, although used to create the ultimate aesthetic face, requires the consideration of functional elements to create osteotomies and stable fixations in addition to the critical soft tissue projections determining the aesthetic outcome. Moreover, the facial form is recognized as a summation, contributed to by both the skeletal foundation and the overlying soft tissue. Due to the challenges mentioned, facial aesthetic surgery necessitates not only a deep and profound knowledge of normal aesthetic relations and physical anthropologic values but also an understanding of patient values and expectations often influenced by gender, cultural, societal, and psychologic factors.

Webster’s unabridged dictionary defines beauty as “the quality which makes an object seem pleasing or satisfying in a certain way.” For instance, the golden ratio, first described by Euclid, is said to be an important feature, found in many classically appealing and harmonious architectural structures, objects, and many natural phenomena. The aesthetics of the human face also falls within the principles mentioned before. Simply put, attractive faces, across different cultures, whether in drawings or in reality, feature certain proportions that create a full and harmonious appearance, which is appealing to the eye. Leonardo da Vinci, for instance, confirmed the presence of the golden ratio in the human face in the sketch shown in Fig. 1.1 . Since ancient times, many artists, scientists, and surgeons have attempted to quantify beauty to propose guidelines for facial alterations. ^, However, there is no one universal formula that defines beauty. On the other end of the spectrum, certain facial features, such as asymmetry, tissue excess, or deficiencies, to mention a few, are considered unattractive by many.

Evolution of thought and technique

Due to the central positioning, the plane of projection, and the rather soft cartilaginous foundation, the nose is considered the key element in defining beauty to oneself and others. As a result, nasal injuries or deformities are readily detectable in the face and could result in serious self-image issues and social limitations besides functional limitations. Since ancient times, the nose has been viewed as the “organ of reputation,” and rhinokopia, or nasal amputation, was previously used as a punishment to humiliate individuals for the crimes they committed. Due to their high prevalence and the highly noticeable features, nasal injuries and deformities, therefore, received extensive attention with regard to reconstruction throughout the ages. The Edwin Smith Surgical papyrus, dated circa 3000 BC, is an ancient document describing 48 surgical case reports. Among the procedures described, there is what seems to be the first detailed description of the treatment of nasal fractures by manipulation of the nasal bones and cartilage. Total nasal reconstruction can be traced back to the Sanskrit texts of ancient India. During the sixth century BC, Indian potters developed techniques to harvest skin from the forehead and cheeks to reconstruct the nose. Although the exact timeline is not known, pedicled tissue transfer took the place of skin grafts to correct larger defects involving the soft tissue surrounding the nose as well. By the nineteenth century, techniques in rhinoplasty had improved dramatically. In his famous work Rhinoplastik, which was published in 1818, Carl Ferdinand Von Graefe described three different surgeries in nasal reconstruction: the Indian technique with the forehead flap used to correct nasal defects; the delayed Italian flap, a technique formulated by Tagliacozzi; and the German method, which entailed a graft harvested from the arm to reconstruct the nose. The first nasal reconstruction in the United States was performed by Dr. J. M. Warren in Boston in the late 1830s. The discovery of local anesthetics, the vasoconstrictive properties of cocaine, and the antiseptic qualities of phenol further facilitated performance of such procedures as more and more patients were undergoing such corrective surgeries. In fact, it was in 1887 that Dr. John Orlando Roe published an article describing the first purely aesthetic rhinoplasty using an internal approach to correct a “pug nose,” which is described as a deformity caused by large lower lateral cartilages with or without a dorsum concavity. Therefore nasal reconstruction served as a gateway to understanding the challenges and interplay of soft and hard tissues in aesthetic facial skeletal surgery.

The late nineteenth century is considered a revolutionary period in the history of American facial plastic and reconstructive surgery. As techniques in rhinoplasty improved, attention was directed to other components of the face. In 1881, while a staff member of the Manhattan Eye, Ear, and Throat Hospital in New York, Robert Talbott Ely performed an otoplasty on a 12-year-old boy with protruding ears. After such landmark interventions, such as Ely’s otoplasty, more and more surgeons felt comfortable modifying facial structures with cartilaginous foundations and rather thin overlying skin. Furthermore, injuries that resulted during World War I challenged many surgeons to push the limits and develop new techniques in an attempt to correct facial deformities caused by injuries. In addition to soft tissue modification and transfer techniques, many injuries required restoration of bony structure with bone grafts from other sites of the body.

Parallel to the development of techniques in restoration, alteration, or enhancement of the soft tissue structures of the face, five major concepts were developed, allowing restoration and modification of the facial components:

• 1.

  Autogenous bone grafting for augmentation or enhancing existing structures

• 2.

  Osteotomies to move the positions of bone in three-dimensional space

• 3.

  Alloplastic implants and injectable fillers

• 4.

  Skeletal contour reduction procedures

• 5.

  Understanding of the soft and hard tissue relationships

Autogenous bone grafts and allogeneic bone substitutes

During this era, Dr. Paul Tessier, among other surgeons, developed and described techniques and instruments for the purpose of harvesting of (1) iliac, (2) costal, (3) tibial, and (4) calvarial autogenous bone grafts. Tessier further characterized craniofacial defects and the approaches required for restoration. He correctly identified that the borders of craniofacial defects associated with agenesis are not normal bone due to the lack of periosteum and, thus, required freshening of the edges to reach bleeding bone that had better healing potential. Furthermore, as techniques in alterations of the midface and the upper face developed, he soon recognized that autogenous bone grafts can be used not only to alter facial contour but also to restore defects in terms of volume, provide resistance to masticatory forces, and reestablish the buttress system in the face. Later on, such techniques were further developed for purely aesthetic purposes to enhance the bony prominences of the face, notably the supraorbital temporal ridge, malar–midface, and mandible–chin. However, early bone substitutes, although successful in reestablishing or modifying facial contour, failed to reestablish the structural integrity needed to resist the functional forces in the face. Autogenous bone grafting techniques, although effective, could not, however, be used to correct larger defects because revascularization and blood supply limited the healing potential of such defects.