Facial Contouring Revision

Facial Contouring Revision: How Tools, Software, and Techniques Evolved

Facial contouring revision (“안면윤곽 재수술”) is one of the most demanding areas in craniofacial and aesthetic surgery. It asks surgeons to restore symmetry, function, and aesthetics after previous bone work on the jawline, chin, or cheek. Success requires far more than “redoing” the first operation. It calls for precise imaging, digital planning, device selection, and staged decision-making that respects nerves, bite stability, and soft-tissue behavior. To understand why modern revisions look more natural and remain more stable, it helps to see how the field got here decade by decade.

1990s: Foundational Osteotomies and Analog Planning

In the 1990s, surgeons relied on plain radiographs, plaster models, and manual measurements. Contouring focused on mandibular angle reduction, burr contouring, and conventional genioplasty using rotary instruments. Titanium plates and screws provided fixation, but plate profiles were bulkier than today’s. Surgeons corrected width and projection reasonably well, yet predicting three-dimensional soft-tissue response was limited. When outcomes disappointed, revisions addressed obvious irregularities or asymmetry with hand-shaping and secondary contouring. Lacking digital templates, over-resection and edge steps were more common complications.

Early–Mid 2000s: CT, Cone-Beam, and the Rise of Ultrasonic Cutting

With CT and later CBCT becoming routine, surgeons mapped bone thickness, nerve canals, and asymmetry with far better confidence. At the same time, ultrasonic (piezoelectric) osteotomy gained popularity. Unlike rotary burs, piezo tools preferentially cut mineralized tissue while sparing soft tissue—a major safety upgrade near the inferior alveolar nerve and sinus walls. Revision surgery benefited immediately: surgeons could shave less, control heat, and preserve cortical integrity. Still, planning was mostly mental; while images were digital, the operative plan was not yet fully simulated.

Late 2000s–2010s: Virtual Surgical Planning (VSP) and CAD/CAM

The 2010s changed everything. Virtual surgical planning (VSP) let teams import CBCT data into 3-D software, mark landmarks, and simulate osteotomies and repositioning in silico. Surgeons could mirror the healthy side, test chin movements in millimeters, and preview how mandibular angle changes would look in front view and profile. Meanwhile, CAD/CAM enabled patient-specific cutting guides and fixation plates. In primary cases this meant precise one-and-done moves; in facial contouring revision it meant the chance to correct over-resection, fill defects, and restore symmetry with far fewer intraoperative surprises. Low-profile plates reduced palpability, and resorbable options appeared for selected indications.

Late 2010s–2020s: 3-D Printing, Navigation, and Patient-Specific Implants

As 3-D printing matured, surgeons printed anatomical models to rehearse complex revisions. Intraoperative navigation allowed real-time confirmation of drill and saw positions against the plan, crucial when scar tissue obscured planes. At the same time, patient-specific implants (PSIs)—in titanium, porous polyethylene, or PEEK—opened a new frontier: angle reconstruction after over-shaving, chin contour restoration after unstable genioplasty, and selective cheek augmentation to balance width. In revision, PSIs help rebuild structure without excessive bone harvesting, while titanium mesh plus bone graft remains an option for larger deficits.

2020s–Now: AI-Assisted Analysis, Photogrammetry, and Workflow Integration

Today, planning combines CBCT + facial photography + surface scans into a single 3-D ecosystem. Some platforms apply AI-assisted cephalometric analysis and automatic symmetry mirroring to flag hidden asymmetries. Photogrammetry (multi-camera 3-D face capture) adds soft-tissue detail to the bony map, improving the match between skeletal moves and skin behavior. Surgeons export cutting guides, splints, and patient-specific plates in one workflow. The result is a repeatable, auditable pathway that shortens operating time, protects nerves, and makes revision outcomes more predictable.

What Actually Changed in the Operating Room

1) Cutting Devices and Thermal Control

• Then: Rotary burrs and oscillating saws dominated; heat and chatter threatened bone edges.
• Now: Ultrasonic (piezo) saws provide cleaner cuts and gentler handling near neurovascular structures, ideal for revision planes with scar tissue.

2) Fixation and Biomaterials

• Then: Standard titanium plates with taller profiles and limited bending fidelity.
• Now: Low-profile titanium and CAD-bent plates reduce palpability; resorbables serve selective roles. In revision, patient-specific plates match the plan and reduce trial-and-error.

3) Implants for Reconstruction

• Then: Onlay bone grafts were the mainstay; shaping matched the surgeon’s hand skill.
• Now: Patient-specific implants in PEEK, titanium, or porous polyethylene rebuild angles, borders, or chins with millimetric fit. Surgeons can combine PSIs with particulate bone or BMP-free grafting where biology needs help.

4) Intraoperative Guidance

• Then: Surgeon experience and fluoroscopy.
• Now: Navigation and custom guides verify resections and placements in real time, a big advantage when anatomy was altered in a prior surgery.

Why Revisions Fail—and How Modern Planning Fixes It

1. Over-resection of the mandibular angle
   Problem: “Hollowed” lower third, soft tissue sagging over thin bone, and visible step deformities.
   Modern fix: Angle reconstruction with patient-specific titanium or PEEK; border smoothing with piezo; optional soft-tissue suspension to re-support the envelope.
2. Unstable or misdirected genioplasty
   Problem: Pointy or asymmetric chin; mental nerve paresthesia; poor neck definition.
   Modern fix: VSP-guided sliding genioplasty with accurate millimeter control and custom plates; if bone stock is insufficient, PSI chin with screw trajectories planned away from the nerve.
3. Cheek over-reduction or flare mismatch
   Problem: Midface looks flat or outer arch still flares.
   Modern fix: Zygomatic arch setback with guides or onlay PSI to rebuild volume strategically; mirror the contralateral side for symmetry.
4. Asymmetry that survived the first surgery
   Problem: One side wider, lower, or sharper in shadow.
   Modern fix: Mirroring workflow: plan from the preferred side, generate cut guides for the other, and confirm with navigation. Soft-tissue debulking or fat grafting finishes the balance.
5. Soft-tissue ptosis after aggressive bone cuts
   Problem: Jowling or neck laxity despite slimmer bone.
   Modern fix: Pair skeletal restoration with soft-tissue suspension, submental contouring, or energy-based tightening in later stages. Staging reduces risk.

Today’s Standard Revision Workflow (Step by Step)

1. Data capture: CBCT for bone and nerve; standardized front, oblique, profile photos; optional 3-D surface scan or photogrammetry.
2. Diagnosis map: Identify the driver—width, projection, length, or asymmetry—and separate bony from soft-tissue problems.
3. Virtual surgical planning: Mirror the better side, simulate osteotomies, and choose between bone reconstruction vs PSI onlay.
4. Guide and plate design: Export cutting guides and patient-specific plates/implants; pre-bend any standard plates as a backup.
5. Intraoperative execution: Use piezo near nerves, verify with navigation, and secure fixation along planned screw vectors.
6. Staged soft-tissue plan: Delay adjuncts like fat grafting, energy devices, or thread suspension until swelling settles; revise only what remains.
7. Follow-up and imaging: Low-dose scans at set intervals confirm union, plate position, and symmetry maintenance.

What Patients Can Realistically Expect Now

• Better symmetry—faster: Mirroring and guides translate directly into front-view balance and profile coherence.
• Fewer surprises in recovery: With controlled cuts and stable fixation, swelling follows a predictable arc; most definition is readable by four to six weeks, with fine refinement up to six months.
• Natural soft-tissue drape: Rebuilding structure—rather than just shaving more—lets skin and fat settle where they belong, which is the secret to the “born-with-it” look.
• Targeted solutions for nerve safety: Navigation and piezo help the team work around the inferior alveolar nerve and mental foramen more confidently.

Safety Priorities That Never Change

• Bite and TMJ first: If occlusion is unstable, address it before cosmetic bone moves.
• Nerve mapping: Plan osteotomies and screw vectors to respect the inferior alveolar nerve and mental nerve.
• Over-reduction avoidance: Natural results come from ratio restoration, not maximum slimming.
• Staged improvements: Do the highest-leverage skeletal correction first, then refine soft tissue.
• Transparent revision policy: Allow tissues to settle before deciding on touch-ups; patience produces safer outcomes.