Assessing Clinical Judgment in Orthognathic Surgery and Genioplasty Patients Using the FACE-Q Appearance Appraisal Scales

Goals/Purpose:  Patients undergoing orthognathic surgery usually have a dentofacial deformity secondary to congenital anomalies or trauma that cannot be corrected with orthodontic therapy alone. Typically, the goal in orthognathic surgery is not only to establish ideal dental occlusion, but also to optimize facial aesthetics.  Thus, many patients undergo combined orthognathic surgery with genioplasty in an attempt to create an aesthetic facial shape, as the chin not only contributes to facial proportion in frontal and lateral views but also supports overlying soft tissues. The decision to pursue combined orthognathic surgery with genioplasty is based on both the clinical judgment and expertise of the physician and the desires of the patient.  The objective of this study is to measure and compare patient satisfaction with facial appearance pre- and postoperatively as a way of assessing clinical judgment, specifically the decision to pursue combined orthognathic surgery with genioplasty or orthognathic surgery alone. To achieve this goal, the study utilized the FACE-Q, a new patient-reported outcome (PRO) instrument composed of numerous independently functioning scales, including facial appearance appearance and quality of life, which measure outcomes in patients undergoing aesthetic facial surgery.

Methods/Technique:  As part of the FACE-Q validation project, 51 patients from a single center in the USA presenting for orthognathic surgery with or without genioplasty were asked to complete the following FACE-Q scales: Satisfaction with Facial Appearance overall, Satisfaction with Lower Face and Jawline, and  Satisfaction with Chin. Each scale consists of multiple individual item questions. Patients completed the scales either at the time of their pre-operative consultation and/or at postoperative visits. The physician was blinded to FACE-Q scores when deciding whether to pursue combined orthognathic surgery with genioplasty or orthognathic surgery alone.  Pre and post-treatment scores were compared using paired t-tests, calculating Kazis’ effect size, and the standardized response mean.

Results/Complications:  Of the 51 patients who completed the FACE-Q scales, 29 (56.9%) underwent combined orthognathic surgery with osseous genioplasty, while 22 (43.1%) underwent orthognathic surgery alone. 29 patients (56.9%) completed the scales preoperatively, while 22 (43.1%) completed them postoperatively. The postoperative follow-up period ranged from 1 to 14 months (mean 4.9, SD 4.3). Participants ranged in age from 15 – 66 years (mean 29.1, SD 15.0). Twenty-nine patients (56.9%) were male, and twenty-one (41.2%) were female.  Thirty-one (60.8%) identified as White non-Hispanic, six (11.8%) as Black non-Hispanic, and five (9.8%) as Asian or Pacific Islander. Thirty-four (66.7%) were single or never married, eleven (21.6%) married or living with a significant other, and three (5.9%) divorced.

Postoperative FACE-Q scores were significantly higher among both groups of patients indicating that both patients who underwent combined orthognathic surgery with genioplasty and those that underwent orthognathic surgery alone experienced increased satisfaction with facial appearance, lower face/jawline, and chin.  For example, both groups experienced increased FACE-Q scores in facial symmetry (mean difference +0.87, p<0.002), profile (+1.37, p<0.001), lower face appearance (+0.94, p<0.011), jawline shape (+1.03, p<0.006), chin appearance (+0.91, p<0.001), chin shape (p<0.011), and chin size (+0.75, p<0.006).

However, while both groups demonstrated increased FACE-Q scores post-op compared to pre-op, scores were higher among those patients undergoing orthognathic surgery alone compared to the combined group both pre- and post-op. For example, those undergoing orthognathic surgery alone were less concerned preoperatively about the appearance of the area under their chin (+0.83, p<0.045), the size of their chin (+0.77, p<0.11), or the shape of their chin (+0.34, p<0.391). Similarly, those patients undergoing orthognathic surgery alone had higher postoperative FACE-Q scores compared to the combined group, indicating that those undergoing orthognathic surgery alone were happier with the appearance of their chin. For example, they were more satisfied postoperatively with their profile (+0.54, p<0.044), chin style (+0.52, p<0.040), and chin appearance overall (+0.80, p<0.009).

Conclusion: The primary goal of orthognathic surgery is to correct dentofacial deformities. However, another desired outcome is improved aesthetic appearance. Therefore, many surgeons opt to perform combined orthognathic surgery with genioplasty to enhance aesthetic outcomes, particularly given the relative ease of performing genioplasty. However, not all orthognathic patients should undergo genioplasty; only those who are most likely to benefit from it, based on a combination of clinical judgment and patient preference. The results from the study above indicate that patients who undergo orthognathic surgery alone based on clinical judgment and patient preference, are in fact just as happy, if not happier, with their results, than those who undergo combined orthognathic surgery with genioplasty, though both groups of patients were satisfied with their results as demonstrated by the increase in FACE-Q scores among all patients.  Furthermore, the FACE-Q may be an important tool in assisting physicians in making the decision to perform genioplasty, as it can successfully confirm and/or compliment clinical judgment. In the study above, FACE-Q scores confirmed the physician’s decision to only pursue genioplasty in select patients as demonstrated by the higher pre- and postoperative FACE-Q scores in both groups of patients.