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    Asian trend to surgically reshape jaw redefines notion of 'less is more'

    While many pleasing outcomes can be achieved with a high-tech device or well-placed series of injections, there are still a host of instances in which surgery may be the better option. Case in point: the jawline.

    When a large masseter makes the jaw appear wider, botulinum toxin can be used to reduce the size of the masseter muscles; sometimes, part of the masseter may need to be removed. If it's a bone issue, however, the only option is to actually remove part of the jawbone itself to achieve reduction, says Jeffrey Spiegel, M.D., a board-certified plastic surgeon in Boston.

    The jaw, Dr. Spiegel says, may be the most significant facial element we assess to determine gender and attractiveness, and therefore, altering structural components of the face may be necessary to help to create attractive faces.

    "There's a growing percentage of Asian women who have the (surgical facial reshaping) procedure because they're aware of it," says Dr. Spiegel, who performs at least two of these procedures per week. "In Asian culture it ranks up there, right under blepharoplasty."

    But there's a feminization trend in pockets of Asia for men, too. While a square jawline is considered a hallmark characteristic of the male face, in China and Korea, men with square faces and blunt jawlines are opting to undergo facial reshaping surgery for a more elliptical face, which is considered more complementary to their finer features.

    ASIAN STUDY According to a paper by Xiaoping Chen, M.D., et al, International Plastic and Cosmetic Center, Nanjing Medical University, Jiangsu, China, "The procedure in men versus women usually requires extra care to achieve the subtle contours necessary to produce an elliptical-shaped face."

    In a recent issue of Archives of Facial Plastic Surgery, Chen et al reported their results of facial reshaping by ostectomy in 19 men with square faces (Chen X, et al. Arch Facial Plast Surg. 2011;13(4):244-246).

    Ostectomy was performed under general anesthesia and included resecting the mandibular angle, splitting the lateral cortex and reducing the chin width via intraoral approach. The amount of resection necessary was determined preoperatively and varied depending on the width of the chin and the shape selected by the patient.

    "The mandibular angle in men is usually more prominent than that in women, which may be why simple osteotomy is sometimes not sufficient in men," Chen et al reported.

    When the osteotomy was completed, the muscular attachments were stripped and the central segment was removed. The two separate segments were then centered and fixed with titanium plates and screws, and the bony edge of the mandible was trimmed with an oscillating saw. In some cases, it was necessary to resect part of a hypertrophic masseter.

    Results were evaluated at three and six months postprocedure. Patients had natural-looking, narrow and stable mandible contours and were generally satisfied with their appearance. Complications included edema in the lower face (treated with 10 mg/d corticosteroids for three days) and some difficulty in opening the mouth for one to two weeks.

    BEAUTY AND BALANCE Although there's a higher demand for surgical facial reshaping in Asia, Dr. Spiegel says one can expect certain variables to influence how surgeons approach the face in the United States.

    "I have patients who come to me and say, 'I don't think I look attractive.' They don't need a rhinoplasty, a facelift, a blepharoplasty. Instead, they have gender cues, such as facial shape, cheekbones, the jawline, the Adam's apple, that need to be addressed," he says.

    Men may look too harsh or aggressive; transgendered women look very masculine. And if surgeons are looking to create a more feminine or attractive face, you look at these areas, Dr. Spiegel says.

    As for his approach to facial reshaping surgery, "The technique itself isn't really novel. (My approach) is similar to their approach. But I also add contouring with soft tissue fillers — an important part of refining the results."

    In the end, creating a more balanced appearance in some faces requires less — not less in terms of invasiveness, but less in terms of physical bone structures — and may demonstrate a shift in how we think about achieving beauty and balance and allowing those to drive the cosmetic choices made by surgeon and patient.

    "It's an exciting time in the field of research. Interest in the relationship between facial attractiveness and evolutionary biology is giving us a greater understanding into how to evaluate faces as well as a cadre of new procedures with accurate and specific solutions for patients," Dr. Spiegel says.