Background The application of a surgery-first approach in patients with hemimandibular elongation (HE) remains poorly defined. In this pilot study, we introduce a modified surgery-first segmental orthognathic surgery (OGS) technique that integrates novel osteotomy design and structural precision to address HE. Methods Nine patients with HE underwent segmental Le Fort I osteotomy, bilateral sagittal split ramus osteotomy (BSSRO), and unilateral mandibular body osteotomy, using both virtual surgical planning (VSP) and individualized cutting guides. Surgical accuracy was evaluated by comparing three-dimensional (3D) models obtained at 1 week postoperatively (T1) with VSP. Mid-term skeletal stability was assessed by comparing 3D models at T1 with those at 6–12 months postoperatively (T2). Symmetry-related parameters (chin deviation, chin rotation, bilateral mandibular body length discrepancy, and asymmetry index) were measured and compared. Results All patients healed u
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