Orthofacial surgery — Moving the skeleton with an aesthetic goal, not only an occlusal one
The shift from orthognathic to orthofacial surgery, the three levels of intervention on skeleton and soft tissue, fully digital planning, and the procedures combined in the same operation: rhinoplasty, mandibular contouring, lipofilling and rejuvenation.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- Orthognathic surgery was born to correct the occlusion, with the face changing as a by-product. Orthofacial surgery reverses the premise: the facial result is designed and the occlusion is resolved within it.
- The change is not one of technique but of goal and sequence: the skeletal movements the occlusion permits are many, and among them one chooses the one that also improves the face.
- The logical consequence is doing in one operation what used to be three: bimaxillary surgery, rhinoplasty and contouring, because the skeleton being moved is the one supporting the nose and the contour.
- Fully digital planning is what makes that approach viable: without three-dimensional simulation of skeleton and soft tissue, combining procedures in one operation is a gamble.
- And the honest limit: this does not turn functional surgery into aesthetic surgery at will. When the occlusion does not permit the movement the face would ask for, the occlusion rules.
From orthognathic to orthofacial
For decades orthognathic surgery was planned from the occlusion: it was decided where the teeth had to end up and the skeleton was moved to take them there; the facial result was a consequence one accepted, not a goal one designed. The shift in perspective that has been consolidating starts from a simple observation: for the same final occlusion there are several combinations of skeletal movements, and not all give the same face. If that is so, the choice among them can and should be made on aesthetic grounds. That is what the term orthofacial surgery designates: the same toolbox, planned the other way round. First one defines how the middle and lower thirds of the face should end up — malar projection, incisor show, lower-third length, cervicomental angle, nasolabial angle — and then one seeks the combination of osteotomies producing that face with a stable occlusion. The practical difference shows above all in borderline cases: the patient whose occlusion could be corrected in one arch but whose face clearly improves by moving both.
The levels of intervention
| Level | What moves | What changes in the face |
|---|---|---|
| Major skeletal | Maxillary and mandibular osteotomies: advancements, setbacks, impactions, downgrafts and occlusal plane rotations | The proportions: lower-third length, midfacial projection, tooth show, cervicomental angle and the whole profile |
| Contour skeletal | Genioplasty, angle and mandibular border contouring, malarplasty, reduction or augmentation of the malar eminence | The shape within those proportions: lower-third width, angle definition, jawline, and malar width and height |
| Soft tissue | Lipofilling, buccal fat removal, resuspension and, in older patients, the manoeuvres of cervicofacial lifting | The finish: what the skeleton cannot provide, and correction of the excess or deficit of coverage that the bony movement exposes |
| Nasolabial unit | Rhinoplasty, with or without dorsal preservation, in the same operation as the maxillary surgery | The transition between nose and lip, where it shows most that surgery was planned in parts rather than as a whole |
Why the nose and the maxilla are operated on together
For a long time performing rhinoplasty and maxillary surgery in one operation was considered reckless, and the practice was to wait six months. The argument for doing them together is anatomical and hard to refute: the Le Fort I osteotomy alters the base on which the nose rests. Advancing or impacting the maxilla changes the position of the anterior nasal spine, alar base width, the nasolabial angle and tip projection, and all of that happens before the nasal surgeon has touched anything. Operating on the nose afterwards means correcting a result that is already conditioned; operating simultaneously means designing the whole nasolabial unit in a single plan. The drawbacks are real and belong on the table: longer operating time, additive oedema that hampers intraoperative judgement, and a learning curve that is not the sum of the two separately. The organisational consequence is the usual one in this field: it demands a team that masters both operations or two teams planning together from the outset, not passing the patient along.
Digital planning, and what it really solves
- The full workflow starts from fusing cone-beam CT, intraoral scan and three-dimensional facial photography or scanning into a single model. Without that fusion, skeleton and face are planned in separate worlds.
- Printed splints and cutting guides transfer the plan to theatre with a precision the conventional intermediate splint cannot match, and above all allow planning of asymmetric movements, the ones the eye does not reproduce well.
- In severe facial asymmetry the digital workflow allows planning in one stage what used to be two: the skeletal correction and the mandibular contouring, with dedicated guides for each manoeuvre.
- The caution worth keeping: soft-tissue simulation is indicative, not predictive. It serves to compare alternatives and to show the patient where the face is heading, not to promise them an image.
- And a consent consequence sometimes overlooked: showing a simulation creates an expectation, and it is worth recording in writing that it is a planning tool and not the guaranteed result.
The adult patient: skeleton and ageing at once
Classic orthognathic surgery was conceived for young patients, growth just complete and skin intact. Increasingly the patient in clinic is an adult in their forties or fifties, and there an interaction appears that must be anticipated: moving the skeleton redistributes a skin envelope that no longer has the elasticity of twenty. A mandibular setback or maxillary impaction leaves an excess of soft tissue that in a young patient readapts and in an older one droops; conversely, a large advancement tightens skin that perhaps welcomed the tension. The consequence is that in adults the plan must include from the outset what will be done with the soft tissues, and that combining skeletal surgery with rejuvenating manoeuvres — lipofilling, resuspension, neck treatment — is not a cosmetic addition but the way the skeletal result becomes visible. The specific choice depends on facial type: a long thin face does not respond like a short broad one, neither to the same bony movement nor to the same envelope management.
The limits, stated plainly
An aesthetic approach to the facial skeleton has a boundary worth stating before a poor result states it. The occlusion is not negotiable: when the movement the face would ask for leaves an unstable or traumatic occlusion, the occlusion rules, and the rest is solved with contouring. The temporomandibular joint sets another limit: large movements, particularly counterclockwise rotations of the occlusal plane, load the condyle, and in a joint with pre-existing pathology relapse is not a remote possibility but the expected course. The airway is a third limit and it cuts both ways: some movements improve it substantially and others compromise it, and in a patient with sleep-disordered breathing that vector outweighs the profile. And one final consideration that is not technical: when the indication shifts from functional to aesthetic, assessing the patient’s expectations stops being a formality.
How the plan is ordered
Does the desired face require moving the skeleton or only contouring it?
Which movement combinations does the occlusion allow?
What else does the planned movement change?
References
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- 2.Raffaini M, Arcuri F. Fully digitalized workflow for one-stage mandibular contouring and orthognathic surgery to correct severe facial asymmetry. Aesthetic Plast Surg. 2022;46(6):2905-2911.
- 3.Raffaini M, Magri A, Conti M, Arcuri F. Advanced facial rejuvenation after bimaxillary surgery in three different facial types. Aesthetic Plast Surg. 2022;46(1):183-193.
- 4.Raffaini M, Arcuri F. Simultaneous bimaxillary surgery and rhinoplasty: evolving concepts in orthofacial surgery. In: Orthofacial Surgery. Cham: Springer; 2024:115-125.
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- 6.Raffaini M, Bianchi B, Arcuri F. Operative protocol for re-do orthognathic surgery. Int J Oral Maxillofac Surg. 2026.
- 7.Roy T, Steinbacher DM. Ancillary procedures in orthofacial surgery: malarplasty, lipofilling, bichectomy, and jaw angles. In: Orthofacial Surgery. Cham: Springer; 2024:127-137.
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