Corrective Jaw Surgery - cosmetic or functional?

In the course of my orthognathic practice, I realise that we are all conditioned by societal norms to a certain extent. Some of us more than others. And one of these norms that is implicitly accepted is that it is okay for girls to be vain, or at least less vain than boys. I am using vanity as a neutral word here, without the sometimes negative concotation that it comes with. So, when I first started practice, I expected to see more female orthognathic patients than male. The reality turn out otherwise. The ratio is about even. However, the primary reason given by the patient for seeking orthognathic surgery differs between male and female.

Most of the patients seeking corrective jaw surgery are young, ranging from  mid-teens to mid-twenties. A smaller number of patient are older, up to about middle age, who present with different reasons why they are considering surgery. 

Let's look at the younger group. This group of patients are typically still schooling. Some are in secondary school, some are in university and many of the local boys are serving national service. They are still considered minors and dependent on their parents for legal consent. Even those who are above the legal age for consent will usually still need parental approval for both moral and financial support. Indeed, I always encourage younger patients to bring along family members during the consultation process. 

The first thing that I ask a new orthognathic patient is what brought him or her to my clinic. I need the patient to tell me what his concerns are and what are the outcomes that he is looking for. This is probably the most important part of the consultation process as it determines the final treatment plan.

The most common reasons offered by male patients are inability to chew food properly, difficulty in pronouncing certain words, discomfort in the jaw joints. Aesthetic improvement is usually mentioned in a "by the way" manner, as if it is of lesser importance. Female patients are more forthright in identifying the aesthetic flaws that they see in themselves and what they are seeking to change through surgery. 

Is corrective jaw surgery a functional procedure or is it a cosmetic one? Well, it is both cosmetic and functional. Those whose primary reason was to correct an functional deficit certainly wants to achieve a good aesthetic outcome as well. Those seeking cosmetic improvement would certainly not want the function of the masticatory system compromised for the sake of the aesthetic enhancement. However, the treatment plan does differ slightly depending on what the primary motivation of the patient is. For example, a patient with a protruding lower jaw (Class III) who seeks surgery to improve chewing efficiency may opt to have a single jaw surgery to set back his protruding lower rather than a double jaw surgery. However, if this same patient were to say that his  main objective for seeking surgery is for cosmetic enhancement, then the treatment plan would probably entail moving the upper jaw forward, the lower jaw backwards, plus a chin reduction.This will address the patient's aesthetic goals and at the same time improve function. While a one-jaw surgery can achieve the objective of getting the teeth to meet in an ideal (Class I) bite, it may not achieve the full aesthetic improvement that a two-jaw surgery can. This is because most jaw deformities often present with other concurrent aesthetic challenges such as a flat midface or a big chin or facial asymmetry. Correct both jaws produce better results in general but the downside is that surgery and recovery is longer and more expensive. 

When presented with choices of a primarily functional or an aesthetic treatment plan, most patients opt for the aesthetic plan, regardless of male or female. Even those who initally said that they are primarily looking to improve function will prefer the aesthetic plan. This is because the increased morbidity of a two-jaw operation is not double that of a one-jaw procedure. Likewise, cost is also not doubled. In Singapore, orthognathic surgery is not classified as a cosmetic surgery which means that it is a Medisave claimable procedure, and is also eligible for subsidy when done in a Government hospital. 

Orthognathic surgery is in a unique position whereby it is not a cosmetic procedure but yet the cosmetic benefit of such surgery is more signficantly felt by the patient than the functional improvement. Few other surgeries can produce as dramatic a change in facial appearance. A less known positive effect of such surgery is the improvement in self-esteem. In my twenty years of doing orthognathic surgery, I have witness in some patients, a dramatic change in personality after the surgery. These are patients who are very self conscious and shy about their appearance. When I first saw them, they are quiet and reserved. At the end of treatment, when they are fully recovered from the surgery, they became more confident, outspoken and jovial. I am pretty sure such personality change is not the result of them eating better after surgery. 

Having said all this, I have to add that undergoing orthognathic surgery is not a walk-in-the-park. It is fairly invasive and like all surgeries, comes with its risks and complications. It is important that you establish a good rapport with your surgeon, understand the pros and cons of each option, including the option of not doing any surgery, before making a decision.