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Archive for the ‘bony genioplasty’ Category

The Step-Off Deformity in a Sliding Genioplasty

Monday, December 1st, 2014

 

The sliding genioplasty is a well known chin reshaping procedure. Unlike its cousin, the chin implant, it has a much greater versatility than simply increasing horizontal projection alone. It can be done to create a multidimensional effect from increasing or shortening vertical height, increasing or dereasing chin width and in some cases even moving the chin backwards for horizontal shortening.

The sliding genioplasty is a pedicled bone flap that maintains muscular attachments from the tongue and neck muscles which keeps the bone alive. While some perceive that it is a free bone graft,. it is not nor would it work if it was. Any bone gap created by the cut bone movement heals because the bone is alive and can make new bone to heal the gap without the need for bone grafting.

Sliding Genioplasty step off front view Dr Barry Eppley IndianapolisThe basis premise of the sliding genioplasty is that it is created by a horizontal full-thickness bone cut through both cortices. The angle of the horizontal bone cut historically controlled how the bone could move since it was wired together and had to maintain some degree of bone contact. But with today’s titanium plate and screw fixation techniques, the angle of the bone cut is less important.

Sliding Genioplasty step off Dr Barry Eppley IndianapolisBut no matter how the bone is cut, the back end of the bone cut goes through the inferior border of the mandible. This usually occurs somewhere behind the level of the mental foramen in the mid body of the mandible. Since the cut chin bone is usually moved forward to some degree, this creates a step-off or inferior edge deformity. The more the chin moves forward, the more than an inverted V step off deformity may be felt. Depending on the patient’s soft tissue thickness, such a step off may even been seen along the edge of the bone.

While step-offs in sliding genioplasties are common, the question is whether they should be managed at the time of the initial surgery. In most cases it is not necessary as the bone remodels over time and their prominence will become less or even completely become non-existent with enough healing time. There is also the issue that their management may potentially cause as many problems as it is intended to solve. Trying to fill the defect at the time of the initial genioplasty with some type of filler (e.g., hydroxyapatite granules) could result in a lump or clump of material that would be just as bothersome as a bone indent may be.

Dr. Barry Eppley

Indianapolis, Indiana

Profileplasty by Rhinoplasty and Sliding Genioplasty

Saturday, July 13th, 2013

 

While one does not see their face in a profile view naturally (only in pictures), the world sees your face in three-quarter view or in profile. Thus the perception of one’s own facial profile is important and it is stressed in many plastic surgery procedures. The two most important hard structures that make up the profile is the nose and the chin. As such the combination of a rhinoplasty and genioplasty is often done together. When done simultaneously, this combination has even been called a profileplasty.

These two profile structures influence each other even if only one is surgically changed. It is well acknowledged that reducing a large nose makes the chin look bigger and chin augmentation can make the nose look smaller. Certainly it can be a very powerful profile changer when a larger nose and a smaller chin are simultaneously corrected.

While a reduction rhinoplasty can be done by various methods based on the actual deformity, these represent relatively minor technical differences in the manipulation of the bone and cartilages. In contrast, a genioplasty can be done by fundamentally different techniques…an implant or an osteotomy. (sliding genioplasty) There are advantages and disadvantages to either type of genioplasty but most patients undergo the ‘simpler’ implant augmentation. Only a minority of chin augmentations are done by a sliding genioplasty although this is often the common chin augmentation technique for oral and maxillofacial surgeons.

Long-term outcomes of combined rhinoplasty and genioplasty patients are rarely reported probably because most plastic surgeons correctly assume that patients are very happy and there is little to gain by looking at the long-term results. But no studies to my knowledge have ever been reported looking at combined rhinoplasty and sliding genioplasty augmentation.

In the July 2013 issue of the Archives of Facial Plastic Surgery, a study was published entitled ‘Combined Rhinoplasty and Genioplasty: Long-term Follow-up’. In this paper, a total of 90 cases of combined open rhinoplasty and augmentation/reduction genioplasty over a three year period were reviewed to assess the stability of the aesthetic results. Specifically the chin was studied by anthropometric measurements. Soft tissue pogonion projection to the true vertical line and mandibular height (incisor to menton) were measured. The average horizontal augmentation genioplasty had 7mms advancement and the average vertical lengthening genioplasty had 5mms increased height. The measurements shows a 100% stability after three years. In reduction genioplasty, half of the patients had 100% stability after three years. The results of this study showed that there is minimal change (less than 1mm) in the chin position as part of a profileplasty.

While rhinoplasty and genioplasty is common, doing the genioplasty portion by a sliding osteotomy rather than an implant is very uncommon. The only advantage that a bony genioplasty has over an implant in most typical aesthetic patients is when a vertical chin change is needed. Given the average amount of horizontal advancement in this study that movement alone is well within the range of what an implant can do. The stability of the bony movements of a sliding genioplasty has been extensively studied before without being done at the same time as a rhinoplasty. This study corroborates what many studies have shown before, bony chin changes are fairly stable and any relapse or bone resorption is not clinically observable or significant.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Sliding Genioplasty with Implant Overlay for Chin Implant Replacement

Saturday, July 6th, 2013

 

Background:  Chin augmentation is the most common implant enhancement procedure of the face. It is usually highly successful as long as the chin is not horizontally too short. Once horizontal chin deficiences approach 10mms or more, it will also have other dimensional issues as well being also vertically short.Trying to make a chin implant correct an overall short chin will leave the patient with a suboptimal result.

Once a chin implant augmentation procedure is deemed inadequate, one has to consider whether a new implant or a sliding genioplasty would be better. With greater than a 10mm horizontal deficiency, only a custom computer-designed implant will suffice. Besides that no existing commercially-made chin implants do not exceed 11mms, none provide any vertical lengthening at all. The other option is a sliding genioplasty. The downfractured chin segment can be moved as far forward as the thickness of the chin bone which almost always is more than 10mms. The other benefit that a sliding genioplasty provides is that the chin can be vertically lengthened by opening up the chin segment as it is brought forward.

While a sliding genioplasty can provide significant horizontal and vertical chin changes, it is not always a perfect chin augmentation procedure either. The amount of horizontal projection increase can not exceed the thickness of the chin bone so very short chins may still be left aesthetically deficient. In addition as the u-shaped chin segment is brought forward, the chin shape will actually become more narrow as the projection is increased. This may be an aesthetic disadvantage for some men who prefer or desire a more square or wider chin appearance in the frontal view.

Case Study: This 50 year-old male wanted to make one final effort at improving his chin shape. He had a prior history of two chin augmentation procedures using implants. He originally had an original 7mm anatomic silicone chin implant that was subsequently replaced by a 9mm Medpor two-piece chin implant that had been separated in the middle to give more of a square chin look. While he was improved with each procedure, he felt his chin was still too short. In addition, his chin felt tight and mildly uncomfortable even years after the second procedure.

Under general anesthesia, an intraoral anterior mandibular incision was made. The indwelling Medpor implant was exposed, unscrewed and removed. Contrary to popular perception the Medpor material did not have any bone ingrowth and, although the surrounding tissues were adherent, was not unduly difficult to remove. A horizontal chin osteotomy (sliding genioplasty) was done with the back end just beyond where the tails of the removed implant were. The downfractured chin segment was brought forward 12mms and secured into placed with a titanium step plate and two screws above and below the osteotomy line. To make the chin have more width, a small square silicone chin implant was placed in front of the chin segment and secured to it with screws. The mentalis muscle was then resuspended over the implant and advanced bone in layers.

His recovery showed the typical swelling and bruising down into the neck that commonly occurs with sliding genioplasties. It took almost three weeks until all swelling and bruising had resolved.

Significant chin deficiencies that do not achieve good results with implants may achieve better results with a sliding genioplasty, particularly when a vertical chin deficiency exists. Contrary to common perception, an implant can be used in front of a sliding genioplasty if more horizontal projection or greater width is needed.

Case Highlights:

1) Once a horizontal chin deficiency exceeds 10mms, standard chin implants will not produce an ideal result.

2) A sliding genioplasty can almost always extend the chin further forward than an implant.

3) To overcome the round chin shape that will occur from a sliding genioplasty, a square chin implant can be overlaid in front of the advanced chin segment.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Extreme Chin Augmentation with Combined Osteotomy and Implant

Monday, December 3rd, 2012

 

Background: Chin augmentation is a very common plastic surgery procedure that helps bring into balance the lower face with more projecting upper facial features. It is by far most commonly done with synthetic implants that provide varying amounts of increased horizontal projection as well as some width changes. Less frequently, sliding genioplasties (chin osteotomies) are done for chin augmentation when more horizontal projection is needed than implants can provide and/or vertical lengthening is aesthetically beneficial as well.

In more extreme cases of chin deficiencies, neither implants or an osteotomy is really adequate. When the chin is really short, this indicates that the entire lower jaw is underdeveloped and an overlying malocclusion (bite deformity) exists as well. While this type of patient should ideally have orthodontics and subsequent orthognathic surgery for jaw correction, this may not be an option for many so afflicted patients. While one could argue that an implant or an osteotomy is better than nothing, and that is most certainly true, they will fall far short of the needed amount of augmentation.

Extreme cases of chin deficiences require a novel approach to get visible and satisfactory results that often must approach 20mms of increased horizontal projection. Combining an osteotomy with an implant is relatively unprecedented although there is no reason why they can not be done together. The implant can merely be placed on the front edge of the osteotomy which is naturally denuded of soft tissue for the execution of the bony cut. Because there is no defined soft tissue pocket, it would be critical to secure the implant to the bone to avert displacement later.

Case Study: This 35 year-old male presented for chin augmentation. He had seen other plastic surgeons who told him his chin was too small for an implant. He did not want at this point in his life to undergo the orthognathic surgery process. In addition, he did not have the quality of dentition that would support in good health a prolonged course of orthodontics. By measurement in photographs using the Frankfort horizontal plane, his soft tissue chin point was deficient by 29mms from an ideal horizontal position. At this amount of horizontal deficiency, he also had a vertical chin deficiency as well.

Through an intraoral approach, an obliquely-oriented horizontal chin osteotomy was done staying 5mms below the mental foramen. The chin was downfractured and then advanced and held into a maximally advanced position with a step plate secured with screws above and below the osteotomy line. A maximal advanced position is one in which there still remains a small amount of bony contact between the front edge of the upper chin bone and the back edge of the advanced chin segment. The step plate was bent downward to create some vertical lengthening as well.

To get more chin projection than just that of the bone, a 7mm extended synthetic implant was placed on the front edge of the advanced chin bone. It was secured to the chin bone with a screw on each side of the midline. The wings of the implant extended back along the advanced chin bone to ensure that they covered the end of the osteotomy site where a bony notch typically occurs. The mentalis muscle was then reattached and closed in two layers with a single mucosal layer closure.

His postoperative course was typical for any sliding genioplasty patient. There was swelling and bruising along they jawline and neck that persisted for about three weeks after surgery. When seen at three months after surgery, all swelling had resolved and he had no residual mental nerve numbness. He had dramatic improvement in the appearance and shape of his chin, even if it still was mildly deficient. At ten years after his surgery, he has not had any implant or bone healing problems.

Case Highlights:

1)      Severe chin deficiencies are not optimally treated by synthetic implants or osteotomies alone. Neither are capable of increasing the horizontal chin projection more than approximately 15mms.

2)      Combining a sliding genioplasty with an implant in front of it can achieve horizontal projection increases of up to 20mms.

3)      Combining implants with a chin osteotomy requires screw fixation of the implant to the advanced chin segment and long enough wings of the implant to cover the notch at the end of the osteotomy cut.

Dr. Barry Eppley

Indianapolis, Indiana

The Aesthetics of the Chin and Its Relationship to the Face

Tuesday, July 3rd, 2012

The chin creates the dominant effect on the appearance of the lower face. Thus, it has a major effect on facial balance and appearance. When out of proportion to the rest of the face, it can create a perception that other facial features are the culprit when it is really at fault. Understanding the proper relationship of chin shape and projection helps one plan for the right procedure when attempting to improve one’s facial appearance.

The most aesthetically pleasing chin is almost always simplistically perceived as falling on a vertical line that drops down from the nasion or junction of the nose and forehead. While this measure of chin position does have considerable value, today’s understanding of chin aesthetics is far more complex and truly three-dimensional. The ideal chin should have an oval shape in women and a more square shape in men. The upper part of the chin has a concave form that curves outward into a convexity (representing the thicker soft tissues of the chin pad) before it turns inward again at its lower edge.

The horizontal position of the chin should lie directly under where the lower lip pouts outward. With adequate projection, it can make the nose look smaller which is why it is frequently augmented in a reductive rhinoplasty. When a chin is weak or horizontally short, it can make other facial features look bigger, often creating a wider or more square facial shape. When the chin is too big or horizontally forward, the rest of the face can look recessed or more flat.

The frontal shape of the chin is very gender-specific. Women should have a more angular or narrow chin but not too pointy. (or too narrow) The greatest width of the chin should lie well within vertical lines drawn down from the canines or eye teeth. Men should have a wider or more square chin whose width can be out to vertical lines dropped down from the corners of the mouth. In the frontal view, the length of the chin is another important aesthetic element. To be in proper facial balance, the height of the lower face is always stated as being no greater than 1/3 of the total height of the face. But the lower 1//3 of the face is comprised of by more than the chin proper. By this standard, the height of the chin proper should constitute no more than ½ of the lower third facial height.

The appearance of the chin is also affected by the rest of the jawline and neck. Jowls or too much fat and hanging skin along the jawline makes the face look more square which is not the fault of the bony chin. It also makes the jawline heavy and can even create the illusion that one is overweight. This is particularly true when there is submental or neck fullness as well. The back part of the jawline or jaw angles impacts how the chin looks from the frontal view. Wide flaring jaw angles can make the chin look too narrow whereas diminuitive or non-flared jaw angles can make the chin look wide.

When considering any facial surgery, it is important to consider the aesthetics of the chin and how it impacts or is affected itself  by the rest of the facial features. Chin surgery can have a major impact on improving facial balance.   

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Correction of Bony Chin Asymmetry

Thursday, June 14th, 2012

Background:The lower 1/3 of the face or the jawline plays a major influence on the shape and appearance of the face. The position and shape of the chin is the dominant feature of the jawline, sticking out like the nose does in the central third of the face. When the chin is too weak or too strong, it creates a strong impression and can lead to the desire for the very common chin augmentation procedure or the less commonly performed chin reduction.

But the chin really is a four-dimensional facial structure that can have balance and proportion problems that are more than just being too short or too long or too short or too tall. The chin can also be asymmetric or crooked, as seen by being deviated from a line drawn down from the nose, upper lip and midline of the upper teeth. When the chin is off to the side the face looks twisted and shorter on the deviated side.

While there can be soft tissue deformities that are the cause of chin asymmetry (e.g., involuted hemangioma, lymphangioma or just plain soft tissue differences), most are caused by a bony deficiency. This is commonly a developmental deformity of the entire lower jaw as the chin position is an indicator of overall jaw development in most cases. In some cases orthognathic surgery is needed to realign the entire lower jaw and with that movement the bony chin becomes more aligned as well.

But bony chin asymmetries can be associated with near a normal bite relationship or orthodontically corrected bites. This eliminates the possibility of moving the entire jaw for chin realignment and the focus must change to moving just the chin bone itself. This uses a variation of the well known sliding genioplasty or chin osteotomy. Rather than sliding the chin tip forward, the bone is slide towards the longer side of the face back to the midline. Often one side of the repositioned chin must be vertically lengthened or tilted to equal out the sides of the jawline to the sides of the chin.

Case Study: This 25 year-old female had long-standing chin asymmetry. She had orthodontics as a teenager with a corrected Class II occlusion. With frontal chin asymmetry, she also had a horizontal chin deficiency as well. By measurements, the chin was deficient by 9mms in horizontal shortness and 7mm deviated to the left side. A modified and asymmetrically placed chin implant was considered but the chin deformity was deemed too great to provide a good result with this approach.

Under general anesthesia she underwent a sliding genioplasty through an intraoral approach. The downfractured chin segment was moved forward the desired 9mms asymmetrically (rotated as it came forward with the short facial side moving further than the longer opposite side. This allowed the midline of the chin to move a full 7mms to fall into the facial midline. The chin was stabilized with a step chin plate and screws.

Her postoperative course had the typical chin swelling of which 50% was gone by three weeks and 90% by six weeks after surgery. At three months after surgery, her horizontal chin was dramatically enhanced and achieved the desired goal. Her chin point was in the midline but asymmetries existed on each side of the chin with a notch on they jawline from where the chin was moved and a soft tissue deficiency over the tail of the chin osteotomy on the original longer facial side. She went on to have revisional surgery to improve these residual chin asymmetries.

While moving the tip of the chin to the midline by an osteotomy is the correct treatment in significant chin asymmetries, there are often residual deficiencies at the lateral ends of the chin osteotomy and jawline that will exist no matter how well aligned the midline of the chin is. These can be addressed by either augmentation or fill-in with hydroxyapatite granules at the time of the osteotomy (which are often not seen then) or treated secondarily in a revisional procedure. It is best to wait a full three or six months after the procedure to fully appreciate the chin shape and give the patient time to adjust to their new facial look.

Case Highlights:

1) Asymmetry of the chin is most commonly caused by a deviation or deformity of the lower jaw. Rarely is it an isolated soft tissue problem.

2) Correction of chin asymmetry is best done with a shifting or rotational osteotomy, aligning the midline of the chin to superior facial midlines.

3) While an osteotomy technique centers the midline of the chin and corrects any horizontal deficiency, the sides of the chin may still have some asymmetry due tomore posterior jawline differences between the two sides.

Dr. Barry Eppley

Indianapolis, Indiana

Chin Narrowing by Lateral Tubercle Reduction

Sunday, November 13th, 2011

A square chin and jawline is considered desireable in a male but not so in a female. It is also deemed unattractive in certain ethnicities such as in the Asian face as well as in the male to female transgender face. Reduction of a square jawline is often perceived as that of the jaw angles. While jaw angle reduction surgery has a role to play in facial contouring, it only provides some narrowing in the posterior mandible or back part of the jaw. It has no slimming effect in the front part of the jawline in the chin area.

 

Narrowing of the chin or front part of the lower face can be done by several methods, all of which require bone reduction. If a chin osteotomy (osteoplastic genioplasty) is being done, the width of the chin will naturally narrow when the chin bone is brought forward and/or vertically lengthened. But not everyone needs horizontal or vertical chin lengthening so an osteotomy can be ineffective. The other approach is direct burring reduction of the chin or mandibular tubercles. By reducing the bony sides of the chin it can be narrowed in the frontal view.

 

When doing an osteotomy to create a chin narrowing effect, it is important to realize that the bone will not narrow behind the osteotomy cut. This also is where a step-off can be created at this junction which is most evident when horizontal advancements are done. As the bone edge of the downfractured chin segment moves forward, this step-off can be created. It can be a difficult area to reach for smoothing out this step-off and there is risk to the mental nerve which is very close by. This is why it is helpful to make that osteotomy cut back as far as possible to extend the natural narrowing effect of the advancing osteotomy and avoid a prominent step-off.

 

Reducing the sides of the chin can be done by either burring or saw reduction. Using a saw always removes more bone quickly with less risk of injury to the mental nerve. The more relevant question is whether it is done through an incision inside the mouth or from an external submental incision from below. Most of the time an intraoral approach is used if only the sides of the chin need to be reduced. But when an overall chin reduction is being done reducing height and/or projection, a submental approach is used so that the extra soft tissues can be managed by excision and redraping to prevent postoperative sagging or ptosis.

 

To achieve a more slim feminine lower face, reduction of the jawline must be considered as a whole. Changing the width of the chin from a more square to a tapered shape creates an essential change in the frontal view. Barring the need for horizontal or vertical lengthening of the chin, burring or saw reduction of the sides of the chin can be done from either an intraoral or submental approach.

 

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Vertical Lengthening of the Short Chin by Bony Genioplasty

Sunday, August 28th, 2011

Background:The shape and projection of the chin is an important facial feature. As the chin sits as a prominence on the lower edge of the face, it has multiple dimensions associated with its shape. While commonly perceived as having only a horizontal component to it, and treated most commonly with an implant if it is too short, this overlooks its vertical and width dimensions. Chins can also be too vertically short or long as well as too wide or too narrow.

The lower face, of which the chin is a significant component, should ideally make up 1/3 of total facial height. When the lower face is vertically short, it is almost always because the bony height of the chin is too small. There are some uncommon exceptions, such as a small maxilla where the lower jaw over rotates with a resultant malocclusion, but this is easy to spot. The vertically short chin can occur regardless of its horizontal dimension presenting with either microgenia, normal chin projection or macrogenia.

The chin that is too vertically short is commonly seen in combination with some degree of horizontal deficiency. The amount of vertical and horizontal shortness determines whether an implant or an osteotomy is the better treatment. With just a few millimeters of deficiency in either dimension, an implant can readily treat both with good positioning on the lower end of the chin bone and proper implant style selection. Anything more than a minor deficiency is best treated by a lengthening osteotomy.

Case Study: This 35 year-old male wanted to improve his ‘weak’ chin. On examination he had both a vertical (8 to 10mms) and horizontal (5mms) chin deficiency. This made his lower face look short and gave his chin a short squat appearance. Computer imaging confirmed that a vertical chin lengthening procedure would improve his facial aesthetics.

Under general anesthesia, a horizontal chin osteotomy was done through an intraoral approach. The downfractured chin segment was vertically lengthened by 8mms and brought forward 5mms. It was held into position with a modified step titanium chin plate to create these dimensional changes. A hydroxyapatite block was shaped with a burr to create a wedge fit between the upper and lower chin segments. It was put in place after the chin segment had been stabilized by the plate. The mentalis muscle was reapproximated over the plate-bone-block chin construct and the mucosa closed.

After a chin osteotomy, considerable swelling ensued which took close to three weeks to return to a more normal appearance. The lower lip had some temporary numbness which was expected and the chin felt very stiff and unnatural for about a month after surgery. It took a good six weeks until the chin felt more normal and a natural part of his face again.

While the improvement in the chin’s appearance was immediate, critical analysis at 3 months after surgery showed the final result. He had complete return of all feeling and lower lip and mentalis muscle movement at that point. In seeing him at two years after surgery, the improvement was maintained as expected.

Case Highlights:

1) The second most common chin deficiency is in the vertical dimension. It can be seen in both the frontal and profile views and will likely have a horizontal problem as well.

2) The only method for significant vertical lengthening of the chin is an osteotomy with or without an interpositional synthetic graft.

3) Vertical chin lengthening can be combined with other dimensional movements including horizontal advancement and width narrowing or expansion.

Dr. Barry Eppley

Indianapolis, Indiana

Jawline Surgery and Facial Derounding

Saturday, June 11th, 2011

One recent high profile facial change reported in the media is that of Bristol Palin. At a dinner in Washington in late April, she was reported to be unrecognizeable. Something was very different about her face. She had a distinctly more angled jaw and sharpened chin. It was speculated that she had a facelift, fillers or even implants in her cheeks.

What did she have done? According to the 20 year-old reality star, she had corrective jaw surgery. While she acknowledged that it changed her look, the surgery was done for medical necessary reasons. She underwent the procedure so her lower jaw and teeth could align properly. In essence she had a pre-existing malocclusion (underbite) that was treated by a mandibular (jaw) advancement. (sagittal split ramus osteotomy, SSRO) It is impossible to know how big of a jaw advancement she had done, but judging by her preoperative profile pictures, probably in the range of 4 or 5mms at best. But this procedure alone would not account for her new profile and jawline.

She likely may have had the additional cosmetic procedures of neck/submental liposuction and a chin or genioplasty procedure. What type of chin reshaping she had can only be speculated, but it likely was a chin osteotomy as opposed to a chin implant. It is very common to do a chin osteotomy as a complementary procedure to a jaw advancement osteotomy. This is because the same equipment is used for both procedures and if you are asleep for one bone cutting procedure, it makes sense to cut and move the chin bone as well. This is also a good opportunity to perform a natural bone moving procedure that will heal and never pose any problems in the future in a very young patient, unlike the risks (albeit very low) of having a synthetic chin implant.

The other giveaway that it might be a chin osteotomy is the shape of the new chin. The chin is more narrowed, almost a bit pointy, and there is a slight inward indentation as the chin moves around into the side of the jaw. This is a look that a chin osteotomy (osteoplastic genioplasty) can create as the end of the chin bone moves forward. It frequently will create a more narrow chin as the u-shape of the chin bone moves ahead of the rest of the arc of the lower jaw. A chin implant usually does not create as much chin narrowing and makes the sides of the chin wider not more narrow, unless a central chin button style implant is used.

Because she had jaw surgery, she may well have lost some significant weight in the 6 week recovery phase. As one can not eat or chew normally for this period of time, all patients will lose some weight. A 10 or 15 weight loss could account for her overall thinner face, regardless of whether neck liposuction was done.

This conversion of her round face to one that is more oval occurs because of the triple effect of three changes; a more prominent chin, a trimmer neck profile and a more narrow submalar (below the cheeks) area. While Bristol Palin achieved this result by jaw and chin bony advancement and neck liposuction and/or surgically-induced weight loss, the more common ‘facial derounding’ surgery uses a slightly different approach. The more traditional approach uses chin implant augmentation, neck liposuction and buccal lipectomies.

Dr. Barry Eppley

Indianapolis, Indiana

Narrowing The Width Of The Chin By Osteotomy

Tuesday, May 31st, 2011

Changes in the chin are traditionally perceived as the need for a horizontal increase or improved anterior projection. While many chin deficient patients need horizontal augmentation, there are other dimensions in which the chin may need to be changed. Vertical lengthening or shortening is the other most recognized alteration that can be done to the chin.

The least recognized and often overlooked chin change is in its width or transverse dimension. Increasing the width of the chin is done in male chin augmentation, usually using an implant to get a more square or wider masculine appearance. Narrowing the chin, however, can obviously not be done with an implant. Like vertical chin shortening, only a chin osteotomy can reliably make that change.

Burring of the sides of the chin from an intraoral approach can make for a more narrow or pointed chin but it has limits as to what can be achieved. This is best thought of some mild chin contouring. There is also the issue of extensive soft tissue release with a burring technique and there is no guarantee of good soft tissue readaptation afterwards. This is why a chin osteotomy may be preferred when a significant narrowing effect is aesthetically desired.

The chin osteotomy is done with a traditional intraoral vestibular incision. Once downfractured with an osteotomy cut below the mental foramen, the mobilized chin segment is brought forward for exposure. The amount of chin narrowing is then marked in the midline and bilateral sagittal osteotomies are made. A central bone segment is then removed based on the desired amount of chin narrowing. General 5mm to 7mms needs to be removed to make a visible external difference. The chin segments are then brought together and plated on their superior surface to hold them together. Plating superiorly is important so that the anterior surface is still available for plate fixation for an advancement or vertical lengthening which may still be done.

With a narrowing chin osteotomy, it is important to look for any palpable edges above or out laterally which may need to be burred to prevent any notching that can be felt through the skin. Good mentalis muscle resuspension/tightening is needed once the chin bone is stabilized even though the soft tissue has not been released from the inferior border of the mandible and chin.

While a chin osteotomy is needed when a significant narrowing effect is needed, there are other considerations for its use as well. Certain chin shapes when advanced by osteotomy may be still too wide in the frontal view. This can be seen with certain women’s chins. Changing the chin to one with less width can be aesthetically advantageous as it comes forward, resulting in more of a u-shape and creating the perception of some flare to the jaw angles as well.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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