Minimizing post-operative soft-tissue sagging in facial bone contouring: Adjunctive techniques

INTRODUCTION

Facial bone contouring surgeries are widely performed for esthetic refinement, particularly in East Asian populations, where smaller, more defined facial contours are culturally associated with beauty. However, these procedures can inadvertently result in soft-tissue sagging due to loss of bony support, leading to jowls and midface drooping.^[1-3] While facelift or soft-tissue lifting procedures are available to address such issues, they are often performed separately and involve additional recovery. This technical note introduces three intraoperative adjunctive techniques that can be used during facial bone contouring to prevent soft-tissue descent without requiring separate lifting surgery. These methods aim to bridge the gap between skeletal refinement and soft-tissue stability in a preventive manner.

METHODS

Technique overview

Chin muscle suspension in narrowing genioplasty

T-osteotomy-based narrowing genioplasty involves disinsertion of the geniohyoid and anterior digastric muscles. After repositioning and fixation of the genial bone segments with titanium plates, 2-0 polydioxanone (PDS) non-absorbable suspension sutures are used to anchor the detached musculature to the fixation hardware [Figure 1]. This prevents inferior displacement of the chin soft tissues and maintains lower facial definition.

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Figure 1:

(a) This technique reduces the risk of postoperative jowl formation and enhancing the definition of the lower face. (b) A schematic illustration showing the placement of non-absorbable sutures (Blue line) during the genioplasty procedure to secure the detached musculature to the metal fixtures. Illustration created with Adobe Illustrator (Adobe Inc., San Jose, CA, USA).

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Buccal fat management in malar reduction

Reduction malarplasty, by decreasing midface bony projection, can destabilize the overlying soft tissue.^[4] Through the existing intraoral approach, a conservative portion of the buccal fat pad is removed to reduce bulk and prevent ptotic displacement [Figure 2]. Care is taken to avoid over-resection to preserve midface volume.

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Figure 2:

(a) Reduction of buccal fat helps minimize the risk of prominent cheek drooping. (b) In reduction malarplasty, the decrease in midface skeletal support often leads to midface sagging; this intervention prevents visible soft tissue descent. Illustration created with Adobe Illustrator (Adobe Inc., San Jose, CA, USA).

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Fascial tension sutures in mandibular reduction

In mandibular angle reduction, intraoral dissection traverses the buccopharyngeal fascia and buccinator muscle.^[5] During closure, 3-0 or 4-0 absorbable sutures are used to reapproximate the fascia with tension [Figure 3], thereby suspending the soft-tissue envelope and minimizing lower cheek drooping. This step is often overlooked when only muscle re-approximation is performed.

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Figure 3:

(a) After completing bone contouring, wound closure must include the repair of the incised buccopharyngeal fascia. (b) These sutures provide sufficient tension to suspend the overlying soft tissues, reducing lower cheek drooping and enhancing jawline definition. Illustration created with Adobe Illustrator (Adobe Inc., San Jose, CA, USA).

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RESULTS

As this is a brief technical note, systematic data collection was beyond the scope of the manuscript. However, these adjuncts have been incorporated into our routine practice for over 3 years with consistently favorable esthetic outcomes and no technique-related complications. Anecdotally, we observed reduced incidence of jowl formation, improved midface contour preservation, and increased patient satisfaction. Quantitative studies are underway.

DISCUSSION

These adjunctive techniques are simple, reproducible, and add minimal complexity to facial bone contouring procedures. They function preventively, targeting the soft-tissue shifts that often follow skeletal reduction. While not designed to address severe soft-tissue laxity, these steps may delay or reduce the need for future lifting surgeries. Compared to standalone lifting procedures, these techniques offer the advantage of being incorporated during the primary surgery, without requiring additional incisions or recovery time. However, their effectiveness in patients with advanced aging or significant soft-tissue laxity remains limited. The absence of quantitative outcome data is a limitation, and future prospective studies, including randomized controlled trials, are necessary to validate their efficacy. Pre- and postoperative three-dimensional imaging, objective measures of facial sagging, and patient-reported outcomes should be incorporated in future evaluations.

CONCLUSION

Chin muscle suspension, buccal fat modulation, and fascial tension suturing are three simple and effective intraoperative techniques that help maintain soft-tissue support during facial bone contouring. Their ease of integration into standard procedures makes them a valuable addition to the esthetic surgeon’s toolkit.