Modification of Square Face in Men

ORIGINAL ARTICLE Modification of Square Face in Men

Xiaoping Chen, MD; Jinde Lin, MD; Jie Lin, MD; Jian Shen, MD; Yudan Zhou, MD; Xuan Wu, MD; Yanwu Xu, MD

Background: Women with elliptical faces are consid- Results: The results of the ostectomy were satisfactory ered to be aesthetically appealing in Asia. Some men 3 to 6 months postoperatively. The bigonial distance was prefer this shape for themselves and choose to have effectively reduced and stable chin contours were their square-shaped face altered to an elliptical shape. achieved. The overall shape of the face was elliptical. There To accomplish this, we perform an ostectomy that was no microgenia, facial asymmetry, hematoma, infec- includes resection of the mandibular angle, splitting of tion, or permanent mental nerve injury. the lateral cortex, and reduction in the width of the chin. Conclusion: Ostectomy that includes resection of the mandibular angle, splitting of the lateral cortex, and re- Methods: Nineteen men with a square face (aged 22-30 duction in the width of the chin is a safe and effective years) underwent ostectomy, including resection of the method to modify a man’s square-shaped face into a more mandibular angle, splitting of the lateral cortex around elliptical appearance. the mandibular angle, and reduction of the width of the chin by an intraoral approach. Arch Facial Plast Surg. 2011;13(4):244-246

N ASIA, A WOMAN WITH AN ELLIP- bone along the external mandible oblique line tical face is thought to be beau- was made with a round burr. These small holes tiful and a man with a square face were connected with a fissure burr, and the lat- is thought to appear masculine. eral cortex of the mandible was carefully split However, some men prefer the el- (Figure 1). A horizontal T-shaped osteotomy and 2 ver- liptical shape for themselves and choose I tical osteotomies for the reduction of the chin to have their square face altered. We de- were planned, as shown in Figure 2. The hori- scribe the use of ostectomy to achieve this zontal osteotomy line was approximately 5 mm goal, including resection of the mandibu- below the root of the incisor and approxi- lar angle, splitting of the lateral cortex, and mately 3 to 4 mm below the mental foramen. reduction of the width of the chin. The amount of resection that was necessary in the central segment was determined preopera- tively and varied depending on the width of the METHODS chin and the shape chosen by the patient. When the osteotomy was completed, the muscular at- Nineteen men with square-shaped faces were tachments were stripped and the central seg- selected; their ages ranged from 22 to 30 years. ment was removed. The soft-tissue attach- Their desired outcome was an elliptical- ment was left intact to maintain blood flow to shaped face. We performed an ostectomy on the lateral bony segments. Two segments were all of these patients, including resection of the approximated centrally and fixed with tita- mandibular angle, splitting of the lateral cor- nium plates and screws. Finally, to obtain a tex around the mandibular angle, and reduc- more natural contour of the lower border of tion in the width of the chin, using an intra- the mandible, the bony edge of the mandible oral approach. was trimmed to the desired size, using an os- All patients underwent general anesthesia cillating saw. Contouring of the bony edge was through nasotracheal intubation. The ap- extended to the mandible angle because nar- proach to the symphyseal area was accom- rowing genioplasty was usually performed in plished with a conventional intraoral vestibu- combination with the mandible reduction pro- Author Affiliations: lar incision and subperiosteal dissection. A cedure. If the patient had chosen to increase Department of Plastic Surgery, straight-line ostectomy on the mandibular angle the length of his chin, we inserted the bone seg- International Plastic and and the mandibular body was made with an ment obtained through osteotomy into the Cosmetic Center, Nanjing electric reciprocating saw, and this portion of space that had been prepared. It sometimes was Medical University, the mandibular angle was removed. A row of necessary to resect part of a hypertrophic mas- Nanjing, China. small holes that descended to the cancellous seter muscle. In addition, partial buccal fat pad

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Lateral cortex splitting

Mandibular angle resection

Figure 1. Resection of mandibular angle, splitting of the lateral cortex, and Figure 3. Preoperative (A) and postoperative (B) appearance. reduction of the width of the chin (T-shaped osteotomy).

A B

A C

Figure 4. Preoperative (A) and postoperative (B) appearance. Figure 2. The process for reducing the width of the chin. A, Split lateral cortex. B, The 2 lateral segments of chin bone are moved inward. C, Rigid fixation with titanium plate and titanium screws. D, Resected bone of the mandible angle. thought to be masculine. The majority of patients who request alteration of a square-shaped face are women. However, with the increasingly tolerant attitude toward removal was performed in patients with prominent cheeks. freedom of sexual orientation and development of the When the operation was completed, the wound was irrigated; transsexual operation,3,4 the number of men seeking to a suction tube to allow drainage was then placed and main- 5 tained for 48 to 72 hours. The patient’s lower face was lightly modify their faces into an elliptical shape is increasing. compressed with a dressing. Antibiotics were administered for It has long been thought that the square-shaped face 3 to 5 days, and the sutures were removed 7 days postopera- is the result of hypertrophy of the masseter muscle. The tively. operation commonly performed to alter this shape is osteotomy of the mandibular angle and partial excision of 6 RESULTS the masseter muscle by an intraoral approach. Al- though there is no appreciable difference between methods used to modify a male vs female square face,7 there The postoperative results in all patients were satisfac- are some variations. The mandibular angle in men is usu- tory at 3 and 6 months. The final facial shape was ellip- ally more prominent than that in women, which may be tical; the bigonial distance was effectively reduced and why simple osteotomy is sometimes not sufficient in men. the chin contours were stable. The patients’ lower face Therefore, a combination of a mandibular angle resec- was narrowed, and the remolded mandible shapes were tion with splitting of the lateral cortex around the man- stable and appeared to be natural (Figure 3 and dibular angle was routinely used in our study to im- Figure 4). There were no complications, such as mi- prove postoperative outcomes.8 The mandibular bone in crogenia, facial asymmetry, hematoma, infection, or per- men is more thick and solid than in women, which in- manent mental nerve injury. In addition, there was no creases the risk of insufficient osteotomy as well as ac- insufficient or excessive osteotomy, fracture of the man- cidental fractures and injury of nerves and vessels. Be- dible, or facial nerve injury. All patients developed edema cause of these risks, resection of the mandibular bone in in their lower face, which was alleviated with cortico- men requires special attention. The outcome of man- steroid therapy, 10 mg/d for 3 days. Patients had vari- dibular angle osteotomy and splitting the lateral cortex able difficulties in opening their mouth for 1 to 2 weeks. around the mandibular angle is most often satisfactory in women. Partial excision of the masseter muscle is usu- COMMENT ally not necessary, which significantly decreases the risk of injury to the marginal mandibular nerve and deep Facial contour preferences have a strong relationship with middle masseteric artery, thus avoiding a massive hem- gender in Asia.1 Culturally, Asian people believe the ideal orrhage.9 In addition, trauma to the temporomandibu- female facial contour to be elliptical,2 which is thought lar joint is greatly decreased. However, in most of our to be feminine and gentle, and the square-shaped face is male patients, we found that the masseter was quite hy-

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©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 pertrophic and the inner layer of that muscle usually achieved via reduction of the lateral and central man- needed to be resected. Men with square-shaped faces usu- dible as well as the chin. The procedure in men vs women ally have square-shaped chins, which are wide and promi- usually requires extra care to achieve the subtle con- nent. When only resection of the mandibular angle and tours necessary to produce an elliptical-shaped face. splitting of the lateral cortex is performed, most men are not satisfied with the results because their chin is still square.10 The wide chin affects the outcome of the lower facial contouring; reducing the width of the chin could Accepted for Publication: June 22, 2009. improve the contour of the lower face. Therefore, it is Correspondence: Xiaoping Chen, MD, International Plas- necessary to reduce both the mandibular space and the tic and Cosmetic Center, Nanjing Medical University, 146 width of the chin in men with a square face to achieve Hanzhong Rd, Nanjing, 210029 China (cxp585@hotmail an elliptical shape. .com). Men with a square face usually have a prominent and Author Contributions: Study concept and design: Chen. hypertrophic mandibular angle as well as a strong man- Acquisition of data: Chen and Xu. Analysis and interpre- dibular body. They may also have mandibular ramus and tation of data: Chen, Jinde Lin, Jie Lin, Shen, Zhou, and mentum defects. The anatomic elements affecting the post- Wu. Drafting of the manuscript: Chen, Jinde Lin, Jie Lin, operative result include the mandibular ramus, man- Shen, Zhou, Wu, and Xu. Critical revision of the manu- dibular angle, mandibular body, and chin. In addition to script for important intellectual content: Chen. Adminis- the hypertrophic degree of the mandibular angle and the trative, technical, and material support: Chen. shape of the mandible ramus and body, the square for- Financial Disclosure: None reported. mation of the face is affected by the chin shape. There- fore, osteotomy for modification of a man’s square face REFERENCES should not be limited to the mandibular angle area; alteration of the entire mandible should be considered.11 1. Xiaoping C, Jianliang S. Tan Xiaoyan correction of square face [in Chinese]. Chi- nese J Plast Surg. 1998;14:169-172. The range of osteotomy has been expanded to modifi- 2. Wong FT, Soo G. Ng WP, van Hasselt CA, Tong MC. Implications of Chinese face cation of the mandibular ramus, mandibular angle, and reading on the aesthetic sense. Arch Facial Plast Surg. 2010;12:218-221. mandibular body, as well as narrowing of the square chin.5 3. Spiegel JH. Challenges in care of the transgender patient seeking facial femini- For the square face with a short chin, we usually insert zation surgery. Facial Plast Surg Clin North Am. 2008;16(2):233-238, viii. suitably thick bone segments obtained through oste- 4. Becking AG, Tuinzing DB, Hage JJ, Gooren LJ. Transgender feminization of the facial skeleton. Clin Plast Surg. 2007;34(3):557-564. otomy into the space prepared with horizontal oste- 5. Lam SM. Aesthetic facial surgery for the Asian male. Facial Plast Surg. 2005;21 otomy. This procedure increases the chin height and im- (4):317-323. proves the effect of the chin reduction. 6. Mu X. Experience in East Asian facial recontouring: reduction malarplasty and Men requesting alteration of a square face are seek- mandibular reshaping. Arch Facial Plast Surg. 2010;12(4):222-229. 7. Becking AG, Tuinzing DB, Hage JJ, Gooren LJ. Facial corrections in male to fe- ing a more feminine appearance and have high expecta- male transsexuals: a preliminary report on 16 patients. J Oral Maxillofac Surg. tions of the operation. The results of typical mandibular 1996;54(4):413-419. osteotomies do not meet these expectations, because the 8. Hwang K, Lee DK, Lee WJ, Chung IH, Lee SI. A split ostectomy of mandibular patients prefer a much smaller lower face than this tech- body and angle reduction. J Craniofac Surg. 2004;15(2):341-346. nique can provide. Therefore, before the operation, the 9. Hwang K, Kim YJ, Chung IH, Lee SI. Deep middle masseteric artery (dMMA) at- tributed to hemorrhage in resection of masseter muscle and mandibular angle. patients should be well informed of probable postopera- J Craniofac Surg. 2001;12(4):381-386. tive effects to avoid possible disputes. If men are consid- 10. Park S, Noh JH. Importance of the chin in lower facial contour: narrowing ge- ered to have poor motives or a body dysmorphic disor- nioplasty to achieve a feminine and slim lower face. Plast Reconstr Surg. 2008; der,12 no operation should be performed. 122(1):261-268. 11. Jin H, Kim BG. Mandibular angle reduction versus mandible reduction. Plast Re- In conclusion, ostectomy is a safe and effective pro- constr Surg. 2004;114(5):1263-1269. cedure to modify a square-shaped face into a more ellip- 12. Xiaoping C, Jianliang S, Xiaohua Z. Problem patients and body dysmorphic dis- tical one. The successful results in these patients were order [in Chinese]. Chinese J Plast Surg. 2005;21:306-308.

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