Fig 1.
(Left, upper and lower) Preoperative frontal cephalogram and face. White and gray arrows mark protruded zygoma and mandibular angle, respectively. The lower facial midline is deviated to the affected side. The dotted red line shows the mirror image of the jaw line. (Middle, upper and lower) Postoperative frontal cephalogram and face, status after 1st stage of correction. White and gray arrows show reduction of zygoma and mandibular angle, respectively. The bone gap between the mandibular segments is maintained to augment the jaw line of the left affected side. Red arrows indicate the movement of each segment. The asymmetric deformity along the affected jawline can be accentuated after OGS (black arrows). (Right) The final result after the 2nd stage of treatment. Fat injection could address the deficient area after OGS to obtain symmetry. Abbreviations: BFPR, buccal fat pad removal; MAR, mandibular angle resection; MR, masseter muscle reduction; Type, Pruzansky-Kaban classification; OGS, orthognathic surgery; ZR, zygoma reduction.
Fig 2.
Evaluation of facial surface area discrepancy index (FDI).
FDI = affected side area / non-affected side area. Digitized facial landmarks: n, nasion; sn, subnasale; ls, labiale superius; me, menton.
Fig 3.
Performing the visual analogue scale (VAS) on one of the patient photographs.
The scale is from 0 (complete symmetry) to 10 (complete asymmetry). The rater move the red arrow on the gridline.
Fig 4.
Pre- and postoperative visual analogue scale (VAS).
*: Mann-Whitney U test.
Table 1.
Patient demography.
Fig 5.
The 24-year-old female patient (case 4) was diagnosed with HFM (type I).
Her natural head position was inclined to the right to compensate for her chin deviation. She was treated using Le Fort I, bilateral sagittal split osteotomy, genioplasty, and mandibular angle reduction, without a second stage of fat injection. Her natural head position adjusted spontaneously after surgery.
Fig 6.
The patient (Case 9, type IIA) was an 18-year-old female who underwent OGS consisting of LeFort I, bilateral sagittal split osteotomy and genioplasty, combined with right zygoma reduction.
6 months postoperatively, soft-tissue augmentation for the deficient cheek using microautologous fat transplantation technique was performed with 47 ml of autologous fat. (Upper, before surgery; middle, after OGS; lower, after fat injection).
Fig 7.
3-dimensional cone-beam computed tomogram of the patient case 9 in Fig 6.
Preoperative image (left) showed facial bone deformity and asymmetry. The patient received two-jaw surgery, genioplasty, and right zygoma reduction (right).
Fig 8.
A female patient with Type IIB hemifacial microsomia involving the left side of face (case 13).
She was followed up at 5 years of age (above left and middle). The panorex X-ray showed hypoplastic and inferiorly displaced condyle without adequate glenoid fossa. She was 7 years 9 months of age during the distraction osteogenesis (above right). Facial appearance was improved at 8 years 6 months of age (below left). Significant facial asymmetry was noted at 21 years 1 month of age (below middle). She received two stages of surgical correction. The facial appearance was improved at 22 years 2 months of age (below right).
Fig 9.
Three-dimensional surgical simulation for the case 13.
Preoperative views were shown in the upper row. There was prominent asymmetry in the maxilla and mandible with occlusal canting. Part of the left zygomatic arch was missing. The ramus was short, but was thick after the previous distraction osteogenesis. The left condyle was hypoplastic and displaced inferiorly, medially and anteriorly. There was no proper glenoid fossa. The articulation was judged acceptable for orthognathic surgery. The surgical simulation and planning was shown in the lower row.