Residency · Residency · Oral Maxillofacial Surgery
Facial Cosmetic Surgery Fundamentals for OMFS
Introduction
Facial cosmetic surgery is an integral component of OMFS training and practice. The OMFS surgeon's expertise in facial skeletal anatomy, soft tissue management, and surgical access positions the specialty uniquely for cosmetic procedures of the face. This lecture covers the foundational principles of facial cosmetic surgery including patient assessment, aesthetic analysis, core procedures, and ethical considerations.
Patient Assessment
Consultation
The surgeon must understand patient motivations and distinguish between realistic goals and unrealistic expectations. Psychological readiness is assessed, screening for body dysmorphic disorder (BDD), depression, and external motivators such as pressure from others. Specific aesthetic concerns and desired outcomes are documented using the patient's own words. The medical history addresses bleeding disorders, keloid tendency, tobacco and nicotine use, previous surgeries, and medications (anticoagulants, isotretinoin). Standardized preoperative photographs (frontal, lateral, oblique, worm's eye, bird's eye) are obtained with consistent lighting, background, and positioning.
Facial Aesthetic Analysis
Facial proportions are assessed by horizontal thirds (trichion-glabella, glabella-subnasale, subnasale-menton), which should be approximately equal, and facial fifths, dividing the face into five equal segments by the intercanthal distance. Profile analysis uses the Ricketts E-line (upper lip 4 mm behind, lower lip 2 mm behind) and the nasolabial angle (90-110 degrees). Chin assessment evaluates the mentocervical angle (80-95 degrees) and cervicomental angle (105-120 degrees). Skin quality is assessed by Fitzpatrick skin type, elasticity, texture, sun damage, and acne scarring. No face is perfectly symmetrical, and pre-existing asymmetries should be pointed out during consultation.
Core Procedures
Rhytidectomy (Facelift)
Rhytidectomy addresses jowling, midface descent, and cervical skin laxity. The SMAS (superficial musculoaponeurotic system) is the key surgical plane. SMAS plication involves folding and suturing the SMAS without dissection beneath it. SMASectomy excises a strip of SMAS with redraping. The deep plane facelift involves sub-SMAS dissection to the nasolabial fold, producing more durable results but carrying higher nerve risk. The incision is pre-auricular, extending post-auricular into the hairline. Complications include hematoma (most common, 3-5%), facial nerve injury (marginal mandibular and temporal branches), skin flap necrosis (increased with smoking), infection, and alopecia. Smoking cessation is mandatory for at least 4 weeks before and after surgery due to the risk of skin flap necrosis.
Blepharoplasty
Upper blepharoplasty involves excision of redundant eyelid skin (dermatochalasis) and orbital fat for functional or cosmetic purposes. Lower blepharoplasty addresses under-eye bags (pseudoherniation of orbital fat) and skin laxity. The transconjunctival approach leaves no visible scar and is ideal for fat removal or repositioning without skin excess. The subciliary approach allows skin excision but carries higher risk of lid malposition (ectropion). The snap test assesses lower lid laxity preoperatively, with poor snap-back indicating lid tightening is needed. Complications include ectropion, dry eye, diplopia, and retrobulbar hemorrhage (an emergency requiring lateral canthotomy).
Rhinoplasty
The open approach uses a transcolumellar incision connecting bilateral marginal incisions for superior visualization. The closed (endonasal) approach places all incisions internally with less edema but is more technically demanding. Key maneuvers include dorsal hump reduction, tip refinement (cephalic trim, suture techniques), osteotomies (lateral, medial), spreader grafts, and alar base reduction. Septoplasty may be combined for functional improvement. OMFS surgeons may perform rhinoplasty in conjunction with orthognathic surgery. Complications include asymmetry, over-resection (pollybeak, saddle nose), nasal obstruction, and infection.
Mentoplasty (Chin Surgery)
Osseous genioplasty is an OMFS core procedure involving a horizontal osteotomy of the mandibular symphysis with advancement, setback, or vertical change. Alloplastic chin augmentation uses silicone, porous polyethylene (Medpor), or ePTFE implants placed through a submental or intraoral incision. Osseous genioplasty provides more precise and stable results with lower infection and erosion rates. It is often combined with rhinoplasty or orthognathic surgery for optimal facial balance.
Otoplasty
Otoplasty corrects prominent ears (protruding pinna). Mustarde sutures recreate the antihelical fold. Conchal reduction involves excision of conchal cartilage to reduce ear projection. It is typically performed after age 5 to 6 when ear growth is near complete. Complications include hematoma, overcorrection (telephone ear deformity), and suture extrusion.
Summary of Core Cosmetic Procedures
| Procedure | Key Anatomic Layer | Incision | Most Common Complication | Critical Contraindication |
|---|---|---|---|---|
| Rhytidectomy (facelift) | SMAS | Pre-auricular extending post-auricular | Hematoma (3-5%) | Active smoking (flap necrosis) |
| Upper blepharoplasty | Orbital septum/orbicularis | Supratarsal crease | Lagophthalmos | Dry eye syndrome (relative) |
| Lower blepharoplasty | Orbital septum/fat pads | Transconjunctival or subciliary | Ectropion; lid malposition | Poor snap test without lid tightening |
| Rhinoplasty | Nasal cartilage/bone | Open (transcolumellar) or closed | Asymmetry; over-resection | BDD; unrealistic expectations |
| Osseous genioplasty | Mandibular symphysis | Intraoral vestibular | Mental nerve paresthesia | Active infection; inadequate bone |
| Otoplasty | Auricular cartilage | Post-auricular | Hematoma; overcorrection | Age <5-6 years (incomplete growth) |
Adjunctive Procedures
Neck Liposuction and Platysmaplasty
Submental liposuction uses a tumescent technique to address the submental fat pad. Platysmaplasty involves midline plication of platysmal bands to improve the cervicomental angle. These procedures are often combined with a facelift for comprehensive rejuvenation.
Fat Grafting (Lipofilling)
Autologous fat is harvested (from the abdomen or flanks), processed, and injected into the face. It addresses volume loss in the midface, nasolabial folds, temporal hollowing, and lips. The Coleman technique uses gentle harvest with low-pressure liposuction, centrifugation, and small aliquot injection. The survival rate is 40 to 60%, so overcorrection by 20 to 30% is recommended. The risk profile is low, though repeat sessions may be required.
Chemical Peels and Laser Resurfacing
Chemical peels range from superficial (glycolic acid) to medium (TCA 25-35%) to deep (phenol-croton oil) and treat fine lines, pigmentation, and scarring. Laser resurfacing with CO2 or erbium:YAG may be ablative or non-ablative and addresses wrinkles, texture, and photodamage. Deeper treatments carry risk of dyspigmentation, scarring, and prolonged healing, with higher risk in darker skin types.
Principles of Wound Healing in Cosmetic Surgery
Tension-free closure is paramount for minimal scarring. Incisions should follow relaxed skin tension lines (RSTLs) and natural creases. Layered closure with deep sutures reduces tension on skin edges. Scar management includes silicone sheeting, sun protection, and steroid injection for hypertrophic scars. The healing timeline is 3 to 6 months for scar maturation, with the final result at 12 months.
Ethical Considerations
Informed consent should clearly discuss risks, alternatives, expected outcomes, and limitations. Surgery should be declined for patients with unrealistic expectations or signs of BDD. Honest before-and-after photography without digital manipulation must be maintained. Pressure to perform unnecessary procedures should be avoided. Continuing education is essential, and fellowship training or mentorship should be pursued for advanced procedures. Scope of practice for OMFS cosmetic surgery varies by state and institutional credentialing.
Clinical Pearls
Patient selection is the most important factor in cosmetic surgery success, and screening for BDD and unrealistic expectations is essential. Smoking is an absolute contraindication for facelift due to the risk of skin flap necrosis, and cessation for at least 4 weeks is required. The SMAS is the key anatomic layer in rhytidectomy, and deeper dissection yields more durable results but carries higher nerve risk. Osseous genioplasty is preferred over alloplastic implants for chin augmentation due to superior long-term stability. Standardized preoperative photographs should always be documented, and pre-existing asymmetries should be discussed with the patient.
References
- Niamtu J. Cosmetic Facial Surgery. 3rd ed. Elsevier; 2023.
- Neligan PC, Rodriguez ED. Plastic Surgery: Volume 2 -- Aesthetic Surgery. 4th ed. Elsevier; 2018.
- Sykes JM, et al. "Cosmetic Surgery of the Face." In: Miloro M, et al., eds. Peterson's Principles of Oral and Maxillofacial Surgery. 4th ed. Springer; 2022.
- American Academy of Cosmetic Surgery. "Guidelines for Liposuction Surgery." American Journal of Cosmetic Surgery. 2020;37(1):S1-S24.