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Revision Surgery for Overdone Mandible Angle Reduction

[ Author:Fushun Ma | Time:2011-10-20 10:13:04 |  Font Size: [Large Medium Small]
Tags: revision surgery, mandible angle reduction, over reducted mandible bone

In order to achieve a dramatic surgical result the mandible bone often be over resected in a mandible angle reduction surgery. Many years ago mandible reduction surgery was not very popular and the surgeons didn't have chance to observe the facial contour changes in long term post operation patients. So they focused on the short time reduction result by cut off bigger piece of the mandible bone. Even more some clinics charge their patients by the weight of the removed mandible bone. In that circumstances a overdone reduction surgery can easily happens. Now, many surgeon have already know the possible long term side effect of mandible over reduction and the progress in surgical technique provides more selections of surgical approach to make the face narrower than just cut off a bigger piece of the mandible bone. The rate of overdone mandible angle reduction is lower. However still many patients with over reduced mandible angle need to do a revision surgery to mandate their more and more obvious deformity such as "horse face deformity". And still some reduction surgeries have been overdone by some inexperienced surgeons. So once a while a over reduced mandible bone revision surgery can be encountered by Dr. Fushun Ma.

 revision surgery of over resected mandible bone
The photo on the left shows an unsatisfactory result after over reduction of the mandible bone. Photo on the right shows the facial contour has been improved after a revision surgery.

profile photos of over reducted manidlbe revision surgery
Before the revision surgery the mandible bone line is indented. After revision the natural mandible line reappears.

comparison pictures of over reducted mandible bone revision surgery
Before revision the mandible line from the ear lobe to the chin is straight. After revision surgery this line is back to the normal curved formation.

 CT image of over reduced mandible bone CT image of normal mandible bone
On the left is the CT image of this girl's mandible. Comparing to the normal mandible CT image on the right
 side the lower edge of the mandible bone of this girl is too straight and the angle of mandible (  larger,  greater than 130 degree.

Previously the girl in these pictures did zygoma and zygomatic arch reduction surgery and mandible reduction surgery in order to make her face slimmer. She ended up with an unsatisfactory surgery result because her mandible bone was over resected and only the front end of her zygomatic arch was pushed inward using Frontal End Zygoma and Zygomatic Arch Reduction approach. The lower part of the face is too narrow and the rear end of the zygomatic arch remains wide giving a "diamond shape" face. The over reduction of the mandible bone made her face too narrow on the lateral view giving a "horse face" look. As time goes by this girl's facial contour changes and she get more and more unsatisfied about her look. Finally she made her mind to do the revision surgery more than ten years later after her first operation. The revision surgery couldn't give her "original" face back as she wished. However her face does look more natural and more balanced. Most of all she is satisfied with the revised facial contour.

Finding the right approach for the revision surgery

Theoretically the over resected mandible bone should be restored by bone graft to make the shape and size back to normal and to mandate any possible indentations left on the mandible bone by the reduction srugery. In fact many years ago the revision surgery was done like that. Some bone tissue harvested from the patients own body was grafted into the mandible to fill the bone defect. As autologous bone graft needs to cut patients own bone there will be another surgical wound and also the bone tissue is difficult to carve. So many surgeons turned to synthetic materials such as steel plate, artificial bone and solid silicon.  For this kind of materials the big challenge to the plastic surgeons is fixing the implant to the receipt mandible bone because the lower edge and the corner of the mandible bone are not connected to any other part of the facial bones. It is difficult to fix the foreign materials into the bone. Often the mandible movement will make the fixing screw loose. On the other hand the implanted foreign materials prolonged pressing on the receipt tissue will cause local tissue atrophy and discomfort.

In order to find a minimal invasive, none foreign body related approach of mandible bone restoration Dr. Fushun Ma tried autologous fat graft to improve the unsatisfactory facial outline caused by mandible bone over resection during the mandible and mandible angle reduction surgery. This approach turned out to be very effective.  This girl's revision surgery was done by fat graft. Two years follow up pictures show the survival rate of the fat is good and post revision mandible lower line and mandible corner looks good. This is not a isolated case. Dr. Ma has applied fat graft for several dozens of mandible over resection patients for restoring their facial outline. All of them improved.

Fat graft can only fix the facial outline not the mandible bone itself. As a matter of fact no approach can perfectly restore the original shape and size of the mandible bone once it has been over trimmed. What we can only do is to mandate the shape of the face to make it looks smoother and normal. After fat graft the whole facial appearance could be improved. However if you feel the mandible bone and CT scan the mandible bone its size and shape remains as before the revision. Further more as the survival rate of the grafted fat varies from patient to patient and from surgeon to surgeon more than one sessions of surgery may be needed to achieved a good result. However like this girl most of Dr. Fushun Ma's patient of mandible revision surgery using fat graft are satisfied by just one operation.

Background story

Dr. Fushun Ma knew this girl since more than ten years ago. In order to avoid confusion we name this girl "Lily". At that time Lily and her friend came to see Dr. Ma for a consultation of mandible reduction surgery. Lily let her friend to do the surgery first and she waited and observed her friend for a month. Lily concluded that her friends face changed not as much she thought it would be. So Lily went to another plastic surgeon and did her mandible reduction surgery there. One more month passed Lily's friend came back to see Dr. Fushun Ma and asked Dr. Ma to do the reduction surgery again because she thought the post operation change was too subtle to satisfy. It is at that time that Dr. Fushun Ma knew that Lily already did her surgery by another surgeon and Lily's facial reduction effect of one month post operation is dramatic. Seeing this Lily's friend started to worry the effectiveness of her surgery and wanted to redo the surgery.

Back then Dr. Ma didn't have much experience on mandible reduction surgery. Without seeing Lily Dr. Ma couldn't predict the long tern result of Lily's surgery. As Lily's friend had just had her surgery in less 3 months the scaring in the surgery site was most severe at that post operation time period. It was too early to redo the mandible reduction surgery. So Dr. Ma asked Lily's friend to come back 6 months later to do another reduction surgery for free.

Lily and her friend did their surgeries in 1994. Mandible reduction surgery was not very popular then and not many people wanted to trim their face by dong mandible reduction surgery. So these two girls story impressed Dr. Ma very much and Dr. Ma always beared in mind that one day Lily's friend would come back to redo the surgery. 6 months later Lily's friend didn't come. Another one year past Lily's friend still didn't show up. Dr. Ma didn't have any contact information of these two girls at that time. Two years went away since Dr. Ma last saw Lily's friend when Dr. Ma felt disappointed for lost the post surgery follow up of Lily's friend Lily showed up, not for her friend but for hersulf. Lily told Dr. Ma that her friend's face looked more and more beautiful as the swelling went away after she last saw Dr. Ma while Lily's face looked more and more unnatural with timing. Lily's friend turned to be very satisfied with her surgery result. It is Lily's turn to see Dr. Ma. Lily wanted Dr. Ma to take a look at her face to see what had happened.

After some visual assessment and local physical check up Dr. Ma felt that the mandible reduction of Lily was overdone making her face looked unnatural. However her facial contour didn't looked as bad as in the photos of more than ten years later (showing on this page). So Dr. Ma persuaded Lily to give up any thought of doing a revision surgery.

Soon after that Dr. Ma went abroad studying and working for 6 years. When Dr. Ma came back to work in Beijing again his contact information already changed Lily still managed to find Dr. Ma insisting on doing a revision surgery by Dr. Ma. Dr. Ma toke some pictures of Lily again. Comparing to the pictures token 6 years ago her facial contour really changed a lot. She made her mind to do anything to restore her "original" face even a slightly improvement toward it would meet her goal. Lily didn't want to use any synthetic materials for the revision surgery because she previously had some unhappy experience with the artificial implants in her body and she also didn't want to cut her own bone from some other place in her own body. This made her surgery more complicated.  As Dr. Ma wasn't sure how to meet her requirement he postponed her surgery for another couple of years until Lily agreed to try fat graft and the revision surgery was finally carried out.

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