When osteotomies should be considered

Osteotomy at various levels of the facial skeleton is entirely justified in selected aesthetic surgical patients. By the very nature of aesthetic surgery, the morbidity potential associated with such osteotomies must be extremely low. Accordingly, osteotomy at the symphyseal level and the LeFort I level are the most commonly performed procedures in the aesthetic surgical patient. Aesthetic changes required in the vertical plane of space will require osteotomy, because these cannot be reliably and consistently achieved through changes in skeletal surface contour. Lastly, when the extent of change required is greater than what can be naturally achieved with surface augmentation, osteotomy must be considered. This last indication is frequently found in the aesthetic surgical patient presenting with a facial skeletal imbalance that has been previously treated with orthodontics to correct a skeletally based malocclusion. Recent technical advances have markedly reduced the associated morbidity of facial osteotomies and, therefore, have made this treatment option more acceptable to aesthetic surgical patients. Ceramic orthodontic brackets and surgical hooks and lingual orthodontic appliances have made presurgical orthodontic preparation more aesthetic and socially acceptable for LeFort I osteotomy patients. The use of rigid fixation, obviating the need for any postoperative intermaxillary fixation, has also made this treatment approach more appealing to aesthetic patients. Lastly, the efficacy of nonresorbable bone substitutes--in particular, porous, block hydroxyapatite--has, to a significant extent, obviated the need for harvesting autogenous bone grafts, further reducing surgical morbidity.