RealSurgerymax
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Order of Operations to Aesthetics
Orbital form & position is essential for an aesthetic face and as it turns out may even dictate primary landmarks in the Aesthetic Order of Operations. That is, the surgical correction of other facial features cannot be planned around an existing orbital position/Inter-pupillary Distance (IPD) that is far from optimal. Ideal nasal, cheekbone, lip and jaw aesthetics are probably secondary to orbital position. Similar to the basic mathematic order of operations if you attempt to solve the problem out of order it will never be right.
Take for instance the case where faces are made narrower through zygomatic reductions and gonial angle amputations to “correct” the ES ration of narrow IPD individuals. Even if it results in some perceived improvement the approach can almost never result in ideal facial form because it’s usually using unideal anatomy as the point of reference. It’s really no different than performing a mandibular setback to achieve a “correct” bite relationship with a retruded maxilla. Seldom is a chin or jaw in actual need of a setback. Likewise a zygomatic bones rarely require reduction. The rest of the face needs to either come forward or be moved laterally. Although the more expensive and time consuming undertaking, this is about ideal aesthetics
While the blackpilled/lookism aesthetics community is well aware of the principle of Forward Growth there is a lot of ignorance about Lateral Growth. Lateral Growth may be dismissed because there is a false assumption that nothing can be done about aside from surface-level augmentation like zygomatic implants and ZSO which will inevitably make ratios appear worse in the narrow face+IPD individual (Similar to placing chin implants on extremely biretruded jaws.)
Augmentation vs. Expansion
Unlike augmentation which is stuck-on, expansion comes from a deeper place and moves the related structures with it producing natural yet powerful results.
It’s well known that the biretruded jaws can be expanded or moved forward as an “augmentation from behind” that also moves the related structures (the mouth and its contents) through double jaw surgery (Bimax.) What isn’t well known is that the midface can also be expanded from within moving the related structures (the orbit and its contents) through a few means including various orbital osteotomies.
Orbital Osteotomies
The most well known osteotomy for translocation (movement) of the orbit is the Orbital Box Osteotomy. This is because virtually all orbital osteotomies are performed for severe facial deformities which require maximal capture of the eyeballs and related soft tissue (with a deep 360° osteotomy of the effective orbit). However aesthetic cases do not require large movements of the orbital rims or orbital contents so don’t necessarily require a deep 360° osteotomy of the entire orbit.
This should come as good news since the most of the major complications from a standard orbital box osteotomy are neurosurgical. Remember most reconstructive Craniofacial surgery is performed on children who do not have a pneumatized frontal sinus, so access to the orbital roof requires a frontal craniotomy which exposes the brain.
In adult males with a pneumatized frontal sinus osteotomization of the orbital roof may be possible of sufficient depth without ever entering the cranial vault. Surgery within the frontal sinus is extremely low risk as compared to transcranial access to the orbital roof. There are two published cases of box osteotomies through the frontal sinus in adult males that I know of.
Even without the possibility of trans-sinus access, a 360° osteotomy isn’t necessary for orbital widening less than 10mm. 180° orbital osteotomies have and can also be performed:
A Maxillary 180° Orbital U-Shaped Osteotomy originally described by Tessier for translocation of the orbit & its contents by smaller distances.
A rare reference to this forgotten osteotomy
Comparative diagram of the modifications for orbital shift osteotomies by yours truly.
Orbital form & position is essential for an aesthetic face and as it turns out may even dictate primary landmarks in the Aesthetic Order of Operations. That is, the surgical correction of other facial features cannot be planned around an existing orbital position/Inter-pupillary Distance (IPD) that is far from optimal. Ideal nasal, cheekbone, lip and jaw aesthetics are probably secondary to orbital position. Similar to the basic mathematic order of operations if you attempt to solve the problem out of order it will never be right.
Take for instance the case where faces are made narrower through zygomatic reductions and gonial angle amputations to “correct” the ES ration of narrow IPD individuals. Even if it results in some perceived improvement the approach can almost never result in ideal facial form because it’s usually using unideal anatomy as the point of reference. It’s really no different than performing a mandibular setback to achieve a “correct” bite relationship with a retruded maxilla. Seldom is a chin or jaw in actual need of a setback. Likewise a zygomatic bones rarely require reduction. The rest of the face needs to either come forward or be moved laterally. Although the more expensive and time consuming undertaking, this is about ideal aesthetics
While the blackpilled/lookism aesthetics community is well aware of the principle of Forward Growth there is a lot of ignorance about Lateral Growth. Lateral Growth may be dismissed because there is a false assumption that nothing can be done about aside from surface-level augmentation like zygomatic implants and ZSO which will inevitably make ratios appear worse in the narrow face+IPD individual (Similar to placing chin implants on extremely biretruded jaws.)
Augmentation vs. Expansion
Unlike augmentation which is stuck-on, expansion comes from a deeper place and moves the related structures with it producing natural yet powerful results.
It’s well known that the biretruded jaws can be expanded or moved forward as an “augmentation from behind” that also moves the related structures (the mouth and its contents) through double jaw surgery (Bimax.) What isn’t well known is that the midface can also be expanded from within moving the related structures (the orbit and its contents) through a few means including various orbital osteotomies.
Orbital Osteotomies
The most well known osteotomy for translocation (movement) of the orbit is the Orbital Box Osteotomy. This is because virtually all orbital osteotomies are performed for severe facial deformities which require maximal capture of the eyeballs and related soft tissue (with a deep 360° osteotomy of the effective orbit). However aesthetic cases do not require large movements of the orbital rims or orbital contents so don’t necessarily require a deep 360° osteotomy of the entire orbit.
This should come as good news since the most of the major complications from a standard orbital box osteotomy are neurosurgical. Remember most reconstructive Craniofacial surgery is performed on children who do not have a pneumatized frontal sinus, so access to the orbital roof requires a frontal craniotomy which exposes the brain.
In adult males with a pneumatized frontal sinus osteotomization of the orbital roof may be possible of sufficient depth without ever entering the cranial vault. Surgery within the frontal sinus is extremely low risk as compared to transcranial access to the orbital roof. There are two published cases of box osteotomies through the frontal sinus in adult males that I know of.
Even without the possibility of trans-sinus access, a 360° osteotomy isn’t necessary for orbital widening less than 10mm. 180° orbital osteotomies have and can also be performed:
A Maxillary 180° Orbital U-Shaped Osteotomy originally described by Tessier for translocation of the orbit & its contents by smaller distances.
A rare reference to this forgotten osteotomy
Comparative diagram of the modifications for orbital shift osteotomies by yours truly.
