Remove everything below the nerve!

Facial contouring surgery involves trimming facial bones to alter the shape of the face. For the face shape to change from trimming facial bones, surrounding soft tissue (skin, fat, muscle, etc.) must respond favorably. Putting this another way, as soft tissue needs to respond to alter the face, the maximum effect of facial contouring possible is essentially the maximum amount of responsive soft tissue.  

In passing thought, you would think removing maximal bones would maximally change the face shape but this isn’t so in reality. Removing bone mass in excess of responsive soft tissue will not be reflected in the shape of trimmed bone, resulting in excess soft tissue which will in turn create a sagging shape.

When consulting outpatients, I’m often asked, “Is my nerve line high? Is it low?” Inside the lower jawbone, there is what’s called the inferior alveolar nerve (IAN) which controls feeling in your teeth and lower lip. If you look at an x-ray of facial bones, this nerve goes through the jawbone slightly below the center, and the placement of this nerve differs by individual. There is a tendency to think that if this nerve is high, a lot of bone mass can be removed to enable a slimmer face while if this nerve is low, not a lot can be removed, making it less slim.  

I’m often requested to “remove everything below the nerve line because I want my face to be really slim!” This is because they think removing all the bone mass under this nerve line will make them really slim.

But, if you remove all the bone mass under the IAN, the space formed from lost soft tissue cannot be reflected completely. It responds least favorably midway on your jawline (between the mandibular angle to the chin). Removing a lot below the IAN will push the IAN up a lot, and relatively responsive areas will result in a dog jaw (coined for resembling the jaw shape of dogs with no angle) and getting pushed up less mid-jawline will result in sagging, similar in shape to the sagging jawline of the elderly.  

Removing a lot of bone mass isn’t what’s important but removal within the limits of responsive soft tissue can create an attractive jawline. Moreover, the amount cut and direction & placement of the cut made must be adjusted delicately, removing a little in areas that respond well and removing more in less responsive areas.

I once watched a drama called ‘Hair Show,’ which is about the world of hair designers. Quoting one of the lines, “When getting a haircut, I don’t think about how much hair I’m going to cut off, I think about how much I want left in the end.” Likewise, I also perform surgery considering the bone shape remaining in the end, rather than the size of bone mass removed.   

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