Ann Chir Plast Esthét 2001 ; 46 : 336-40  2001 Éditions scientifiques et médicales Elsevier SAS. Tous droits réservés S0294-1260(01)00035-8/SCO

Case report

Mandibular angle augmentation with the use of distraction and homologous lyophilized cartilage in a case of morphing to Michael Jackson surgery M.Y. Mommaerts 1∗ , J.S.V. Abeloos 1 , H. Gropp 2 1 Service de chirurgie maxillofaciale, hôpital général Saint-Jean, Ruddershove 10, 8000 Bruges, Belgique ; 2 Service de chirurgie maxillofaciale, Diakoniehospital, Groepelinger Heerstrasse 406, 28239 Bremen,

Allemagne (Received 13 January 2001; accepted 9 March 2001)

Summary Correction of an ill-defined mandibular angle is not an easy task, whether it is requested by the “congenital, orthognathic or cosmetic” patient. Deliberate over-correction has not been reported to our knowledge. This article presents a combination of distraction osteogenesis and lyophilized cartilage used to three-dimensionally over-augment the mandibular angle of a long-face prognathic patient who had the wish to be morphed to Michael Jackson or at least as far as current techniques and his endogenic features allowed.  2001 Éditions scientifiques et médicales Elsevier SAS distraction osteogenesis / lyophilised cartilage / mandible / maxillofacial surgery

Résumé – Augmentation de l’angle mandibulaire par distraction et homogreffe de cartilage lyophilisé dans un cas de « Jacksonisation » du visage. La correction d’un angle mandibulaire mal défini n’est pas une tâche facile, que la demande du patient soit secondaire à une anomalie congénitale, orthognathique ou esthétique. Les auteurs présentent un cas clinique de face longue qui souhaitait ressembler à Michael Jackson. Pour surdimensionner les angles mandibulaires, le procédé chirurgical a associé distraction et utilisation d’une homogreffe de cartilage costal lyophilisé. Le résultat clinique et radiologique est présenté avec un recul de deux ans.  2001 Éditions scientifiques et médicales Elsevier SAS cartilage lyophilisé / chirurgie maxillofaciale / distraction ostéogénique / mandibule

A well-defined gonial angle stands for youth and an assertive personality. The contour of this angle is missing in patients with a vertical facial growth pattern, in certain congenital malformations (e.g. facial microsomia) and in the ageing patient. Accentuation of the angle has been done with alloplastic implants [1 – 5], homologous transplants [6], orthognathic procedures [7-9], rhytidectomy and liposculpturing techniques [10], bone splitting and bone grafting techniques [11], and distraction osteogenesis [12 – 17]. Normally, patients strive for

∗ Correspondence and reprints.

an ideal, beautiful, normal contour. We were confronted with a patient who requested a three-dimensional overcorrection. His quest was to obtain the facial features of Michael Jackson, his idol that he imitated professionally. This goal was achieved by stretching the pterygomasseteric sling and augmenting the angle in a dorsal and caudal direction by the use of segmental distraction osteogenesis and by lateral augmentation with lyophilized rib cartilage transplants during a second surgical session.

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Figure 2. Fragment of lateral head film showing the preoperative condition of retromaxillism and macromandibulism.

Figure 1. Preoperative three-quarter facial view at the age of 19 years. Note the high-angle mandible with loss of posterior definition.

CASE REPORT The patient presented first in 1992 at the age of 19 years with complaints about his prognathic profile and his high chin (figure 1). Radiological examination confirmed that the Angle class III malocclusion was based on retromaxillism and macromandibulism (figure 2). Technetium bone scans taken in 1993 and 1994 demonstrated ongoing growth in both condyles. The operation was postponed until 1995 despite the nearly finished presurgical orthodontic treatment. A Le Fort I – type osteotomy with midline split for advancement and posterior widening of the maxilla, a mandibular set-back, a chin reduction-plasty and bilateral ‘sandwich’ zygomatic osteotomies [20] were performed. The postoperative course was uneventful and the result was objectively satisfying (figures 3 and 4). In 1997 he uttered the wish that his face could be morphed towards that of Michael Jackson, his idol that he imitated professionally. Patient’s own analysis of the characteristic features concentrated on the chin, the nose, the gonial angles and the malar prominence. After thorough discussion and psychiatric analysis, we agreed to

morph him in a way that all changes could be undone and that the tissues were not at risk for considerable permanent damage. We had solutions for the chin (midline split with widening and setback, vertical midline excision of skin and subcutaneous tissues), for the malar prominences (a second ‘sandwich’ zygomatic osteotomy), but none for the posterior mandibular augmentation. Finally, a combination of segmental distraction osteogenesis with the 20 mm vertical distraction device (Medicon®, Tuttlingen, Germany) together with lateral augmentation with lyophilized homologous rib cartilage [6] was chosen. The latter was obtained form the Tissue bank of the AZ St. Jan. It was decided to postpone the rhinoplasty (open approach, lateral osteotomies, silicone L-shaped prosthesis, trimming of the lateral and medial crurae, Weir-excisions and suspension sutures) till the second stage surgery, when the distraction devices had to be removed and the cartilage had to be applied. The first surgical session was in september 1998, the second in january 1999. A stereolithographic model (figure 5) helped to discuss the distractor type with Prof. Wangerin and Dr. Gropp in Stuttgart. Radiological and stereolithographical examination showed that there was limited bone stock available at the mandibular angle. The osteotomies were done in an oblique fashion from an intra-oral approach. The distractors were fixed upside-down via a transbuccal approach.

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Figure 4. Fragment of lateral head film showing harmonious maxillo-facial proportions. Figure 3. Two years postoperative three-quarter facial view. Normal features except for a deficient gonial angle.

At the end of the distraction period, the transported segments were at the level that was judged appropriate by the patient (figure 6). Dorsal and caudal augmentation was achieved. An infection at the left side was cured with antibiotics. The distractors could be removed without undue difficulties. Two pieces of L-shaped rib cartilage were sculptured into the desired shape to laterally augment distracted segment and callus. They were trans-orally applied and transbuccaly fixed with osteosynthesis screws (figure 7). Healing was uneventful and the result is stable after two years of clinical (figure 8) and cephalometric (figure 7) follow-up.

DISCUSSION With alloplastic implants, infection, displacement and extrusion are feared for [18]. With bone grafting, resorption and asymmetry are common complications [2]. Orthognathic procedures are prone to relapse [19]. Distraction osteogenesis still has to prove its superiority. Vertical ramus distraction is usually performed in patients affected by hemifacial microsomia [12 – 17]. Here, a high level

Figure 5. Stereolithographic model of the horizontal ramus with the mandibular angle. The darker areas represent the osteosynthesis material form the previous osteotomy procedures. Note the hypoplastic features of the gonial region.

of osteotomy is indicated because of the desired occlusal plane rotation. The osteotomy is done in the retromolar area [12, 15] or above the lingula [12 – 14, 17], resulting in a stretch of the hypoplastic masseter and internal

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Figure 6. Fragment of lateral head film taken at the end of the distraction period. The transported segments are superimposed with the hyoïd bone.

Figure 8. Three-quarter facial view two years after the augmentation procedure.

Figure 7. Fragment of a lateral head film taken 2 years after the distraction and cartilage transplantation. The augmented area is more radiolucent than the mandibular body.

pterygoid muscles and in the latter also of the stylomandibular ligament. There is more long-term experience with external [12, 13, 15, 17] than with internal devices. After 1 ½ and 2 years follow-up, cephalometric analysis showed considerable to nearly complete relapse of the height of the vertical ramus [13, 17]. There is one report on mandibular border distraction that is inconclusive, because hardware deficiency resulted in relapse during the distraction phase [16]. In our case, we decided for distraction osteogenesis primarily not to attain a stable bony augmentation, but mainly to gradually expand the tissue envelope, specially the pterygo-mandibular sling. The muscular insertions were not stripped from the transported segment for that purpose. The lyophilized cartilage implants could than be placed in a stable pocket and in a position previously determined by the patient. Lyophilized cartilage is known for decenia to have a low infection rate and to calcify or ossify gradually over the years [6, 21, 22]. The lateral head film taken two years after the augmentation procedure (figure 7) does not allow to conclude that the distracted callus is very thin and radiolucent or that the cartilage is slowly ossifying. The patient refused a control CT scan.

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CONCLUSION Three-dimensional over-augmentation of the mandibular angle was successful in one patient using a combination of internal distraction osteogenesis and transplantation of homologous cartilage. Clinical and radiological follow-up of two years showed stable results.

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