The chin has a prominent role in defining facial shape and its aesthetic look. Whereas a strong prominent chin has been associated with strength and increased masculinity, a short chin portrays the opposite appearance of weakness. As a result, cosmetic chin augmentation with an implant has been done in plastic surgery for more than four decades. It is as common to be done by itself as often as it is combined with other facial procedures to improve one’s profile.

While having been done for a long time, chin augmentation surgery has undergone a surge in the numbers of procedures performed. In 2011, a 70% increase in chin augmentations was reported compared to the previous year according to statistics published by the American Society of Plastic Surgeons. News outlets have picked on this increase in chin augmentation surgery and have credited it to such recent electronic device interactions such as Skype on the internet and Facetime on the iphone. It is theorized that seeing one’s face on web cameras and smartphone pictures has increased awareness of chin deficiencies.

While this explanation is intriguing and a bit trendy, it likely has little to do with why more chin augmentations are being done. There are better explanations that make more sense and are reflective of a variety of different factors. First, there are more chin implant options today than ever before. Most of them are made of silicone which makes it easy to create new styles and sizes. Go to any facial implant manufacturer and you will see that there are more chin implant options than almost all other facial implants combined. One of the more popular facial implant manufacturer has 14 different styles not to mention different sizes within each style. One may argue how really different many of these implant styles are but they give surgeons a lot of options. When more options are available, more procedures end up being done.

Another major driving force is the rise in two other specific facial procedures, rhinoplasty and facelifts. Both are being done by an increasing number of surgeons but facelifting treats a problem that eventually affects all of the population. The rise of numerous types of limited or less invasive facelifts has spurned a lot of attention in the younger patient with earlier signs of aging. This has drawn a lot more attention to how one’s face looks as it ages. Since facelifts focus on the shape of the jawline and the neck, any chin deficiency will be quickly recognized. Chin augmentation adds length to the jawline which helps in improving the smoothness of the jawline and the sharpness of the neck angle.

There may also be some influence, as had been suggested, that more people are seeing themselves than ever before. Whether by digital camera, smartphone or on Facebook, people are having to see more of themselves particularly in profile. When combined with an ever increasing desire to remain competitive in the workplace, change in social circumstances such as divorce and an ever increasing emphasis in society on looking and feeling younger, all types of facial rejuvenation procedures are increasing.

Put together, there are many reasons chin augmentation is increasing. But the main reason it continues to grow is because it is works. It is one of the most significant structural changes of the face, whether it is a small increase to complement a facelift or a major change to improve a naturally short jaw.  

Dr. Barry Eppley

Indianapolis, Indiana   

The fastest growing cosmetic plastic surgery operation in 2011 was…chin augmentation. Done primarily with an implant, enhancing one’s profile by improving the projection of the chin increased over 70% last year. The rise in chin augmentation has been linked to the increasing use of Skype and FaceTime, applications where you are forced to look at yourself while talking to others. The distortion of webcams rarely improves one’s appearance and often makes the face look fatter. More likely the increase is due to new chin implant sizes and styles and the growing number of different types of facelifts which are often combined with chin implants to create a more defined and smoother jawline and neck angle.

The wearing of facial hair at one time in history represented a matter of convenience, the man didn’t want to bother with the nuisance of shaving. Men wearing facial hair today, however, is done much more often for style reasons and to create a specific facial look. This is evidenced by the observation that many facial hair styles require daily work to keep them in good shape. This is most evident in the manicuring required of a goatee.

A weak chin can throw off the symmetry of an otherwise attractive face, making the nose seem larger, the neck look fuller and even creating the appearance of jowls. It is well known that wearing facial hair can help camouflage a weak chin without resorting to surgery. A weak chin can use a fuller beard to hide and balance that area with the other areas of the face. If you have a diamond-shaped face, a full beard will add girth to the jawline and chin. A goatee is the most common facial hair pattern that I see in men who come in for chin augmentation. The goatee not only adds horizontal projection to the chin but also makes it look wider as well, giving the chin a more square and dominant look.

But for those men who want to lose the facial hair and the daily grooming, chin augmentation can save one hundreds of hours over years. One of the more simpler and less complicated of all the facial implant procedures, it requires just one hour or less of surgery to get the chin you always wanted. Through a small incision of just one inch or inch and a half  under the chin (the incision is often less than 25% of the total chin implant length), an implant can be slide in and along both sides of the  jawline and centered over the midportion of the weaker chin bone. The subsequent scar under the chin heals in an inconspicous manner.

Chin implant styles for men can easily mimic what a goatee can do. This is because they can provide more than just a one-dimensional effect of horizontal projection. Chin implants come in more square-shaped designs than can make for a wider chin as well as one that just juts out further. Square designs exist that even have a central groove for those that desire an enhancement feature of a central groove or cleft. If properly positioned on the lower end of the chin bone, an implant can add some vertical length as well.

To improve the shape and strength of the male chin, external facial hair or an internal implant can be used. Each approach has its own advantages but the chin implant eliminates the need for any daily care and maintenance.  

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Increasing the prominence or projection of a chin is a common aesthetic facial procedure. It can be of great benefit alone or in combination with such procedures as rhinoplasty, neck liposuction and facelifts. As the predominant and leading feature of the lower third of the face, the chin is one of the most important structural elements of one’s profile. A weak or strong chin casts an impression of one’s personal characteristics even though it may not be an accurate one.

In doing chin assessment and in considering before and after surgery results, the profile view is almost always exclusively shown. While the side view can demonstrate some dramatic changes, the amount of horizontal projection of the chin is but just one dimension. Even though it is the view that most people see us as (actually the oblique or three-quarter view is), we see and know ourselves more from a frontal view. This is how we see ourselves everyday in the mirror.

The forgotten view of the chin, so to speak, is the frontal view. What is relevant about the frontal view in chin augmentation is the width and shape of the chin. It is important to realize that there are chin shape differences between man and women just like there are differences in the amount of horizontal projection. While there are more chin augmentations that are done in men, I have observed there are higher rates of dissatisfaction in women. Many of these dissatisfactions are related to overprojection and the creation of too much chin width.

In the frontal view, the male chin is wider and more square shaped. This of course has to do with a bigger overall jaw but it is also aesthetically desired. The squareness of the male chin can easily extend out to a vertical line drawn down from the canines, if not more is some cases. Conversely, the female chin should not only be more narrow but it often has an appealing aesthetic taper to the midline, stopping short of being a strong point. It is not square at all but converges from the sides toward the midline can is more of a v-shape.

Understanding these gender chin differences is important for chin implant augmentation. Most of the chin implant designs are more male-oriented. The evolution of chin implants has most of them having extended or long lateral wing designs. While this is critical in male chin augmentation to create a wide and prominent extension of the chin back into the jawline, it is not always beneficial for females. Many women would be aesthetically better if the implant was more centrally tapered and had shorter lateral extensions, particularly the younger woman who has no aging jowl concerns.

In chin augmentation, many off-the-shelf implant designs exist. All of the materials can easily be modified by simple intraoperative shaping. Gender differences should be taken into account, not excluding the frontal view and how the implant may affect that important patient view.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Background:  Chin augmentation is the original and the most common area of facial skeletal enhancement. As a projecting edge of bone that is fairly easy to access, placing a chin implant is understandably perceived as a very simple and near error-free facial implant procedure. Despite this commonly-held belief, however, chin implants do have problems and need to be revised, replaced, or even removed.  

There are two common chin implant problems, malpositioning and implant selection. Malpositioning of a chin implant can occur in two different ways. Superior or upward migration of the implant usually occurs if it is placed from inside the mouth. While the intraoral approach avoids an external incision, its path of dissection provides an avenue for the implant to slide up along the bone afterwards. Lateral or wing malpositioning is actually the most common problem and is a result of the newer styles having thin and more floppy wing extensions which can easily fold onto themselves. Chin implants can also have size (undersized, oversized) and style (too wide, too narrow) problems which is a preoperative diagnosis and selection issue.

Case Study: This 40 year-old male was unhappy with the result of his chin augmentation. He had two prior chin implant procedures. They were done from an intraoral incisional approach. He felt that his chin was still not defined and prominent enough. He wanted a more masculine chin appearance. He had a record of his indwelling chin implant which was silicone in composition,7mms in projection, with limited lateral wings.

To improve his chin result, two different approaches were discussed for a revisional surgery. First, use a submental skin incision to remove the existing implant and replace a new one at the lowest position on the bone. Secondly, a different implant style would be used that had greater lateral extensions to add more lateral chin fullness and width.

During surgery, the submental incision was done but no implant was found at the inferior border of the chin. Located 14mms above the chin border, an implant was found and removed. There was 2 to 3mms of bone resorption underneath the implant when it was removed. Pockets  were dissected out along the  lower border of the jaw from the midline about 4.5 cms per side. A new chin implant style, a chin-prejowl design, was then inserted. Pulled down to the lower edge of the bone, the implant was secured with a single 12mm long titanium screw.

The immediate results of this chin implant exchange and repositioning can be seen just one hour after surgery. The chin had more lateral fullness and better horizontal projection, particularly at the low edge of the chin bone which is the most important point of increasing its projection.  

Case Highlights:

1)      Chin augmentation requires proper placement of the implant on the bone. Intraoral chin augmentation is prone to superior implant migration and malpositioning.

2)      Replacement of a highly positioned chin implant is best done from a submental approach with screw fixation.

3)      In the male chin augmentation, consideration needs to be given to an implant design that provides more lateral fullness and extends back further towards the body of the mandible.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis

An important part of any rhinoplasty evaluation is that of the chin. Patients who pursue rhinoplasty to make their nose smaller should not be surprised that they may have a comparatively smaller chin by facial proportion assessment. This is because a ‘weak’ chin can make a nose appear more prominent. In patients that come in because they feel that their nose is too big, I ask them close to the end of the consult to take a close look at your chin. It is simply a question of facial balance. A small or receding chin can make the nose appear bigger than what it really is. This is similar to the influence of the forehead on the appearance of the nose. A sloping or recessed forehead can make nasal projection seem bigger than what it really is.

The balance of the chin to the nose is almost always done in a profile view. A vertical line is mentally (or physically done on a picture) drawn down from the edge of the lower lip and the horizontal chin position is assessed by where it is in reference to this line. If the tip of the chin falls behind this line, chin augmentation will usually be aesthetically helpful. Conversely, if the tip of the chin is beyond this vertical line, chin reduction may be needed. Classic cephalometric analysis and tracings use the glabella, or lower portion of the forehead between the eyebrows, as the place to drop this vertical line to determine proper chin position. But the lower lip is easier and a more accurate reference.

But chin assessment in rhinoplasty should not be limited to just the profile view. This is an overly simplistic approach. Like the nose, chin assessment must be evaluated in the frontal view as well. The width and shape of the chin is also important. A more narrowed nose with a wide chin is not aesthetically ideal, particularly in a female. Conversely, too narrow a chin in a male even if brought ideally forward is similarly mismatched to many results of a male rhinoplasty.

The width of the chin is not as established an ideal as that of horizontal chin projection. But there are some guidelines to go by. The width of the chin should not usually be wider than a vertical line drawn down from the inner aspect of the iris in females or from the center of the pupils in males. There is a central pad of the chin that is discernible in most patients and it is usually close to the same width as that of the outside edge of the nostrils, known as alar width. The central pad chin width is not really changeable but the outside or lateral width of the chin is. A chin implant, based on the style chosen, can help widen or narrow the chin’s width. A chin osteotomy can do the same. Most chin osteotomy advancements will actually narrow the chin as it comes forward, unless midline expansion via a separate bone cut is made.

Rhinoplasty and chin augmentation are close cousins that impact each other’s appearance. Like the nose, the chin must also be assessed in three dimensions as well.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis Indiana

Background: The chin is one of the facial prominences and the most noticeable part of the lower jaw. Horizontal chin shortness has been recognized for many decades and has largely been improved through the use of synthetic implants. Placing an implant on the front edge of the bone is a simple and relatively uncomplicated method of horizontal increase.

Great results can be seen in many profile examples of chin implant augmentation but the chin and the face is more than just a side view. Patients see themselves more commonly in the front view and this perspective is becoming appreciated in chin surgery. The other dimensions of vertical length and transverse width have greater impact in the frontal view and also have an impact on chin appearance. Since a strong chin is a well recognized male facial characteristic, the chin should be enhanced from three-dimensional changes.

Case: This is a 28 year-old male who previously had an implant placed for a short chin. While there was an improvement, he was still not happy with the final appearance. He had an implant that provided 8mms of horizontal advancement. In assessing his chin with computer imaging, his chin was slightly short horizontally by 3mm to 4mms but was also vertically deficient by 5mm to 6mms. He also thought his chin was wide as well.

Given the needed changes to achieve a more pleasing three-dimensional change, it was decided that it could not be predictably done by a bigger implant. An implant could not provide enough vertical length improvement. An osteotomy was planned to not only make these desired changes but to replace what the existing implant has already created.

An intraoral approach was used to both remove the existing implant as well as perform the osteotomy. The existing pocket of the implant had already made most of the dissection needed for the osteotomy cuts. The capsule of the implant pocket was removed, exposing the raw bone surfaces. With a reciprocating saw an angled horizontal cut was made below the mental nerves. The chin segment was downfractured and then moved forward 11mms and opened up vertically 5mms. The backledge of the chin segment was put to the bone of the upper chin bone as a point of rotation for the vertical opening. It was secured using a custom-bent chin osteotomy plate. The chin implant was cut down in size and used as a fill for the step of the chin osteotomy. This was done to prevent further deepening of the labiomental crease.

Chin osteotomies create more swelling after surgery than implants. It usually takes about ten days after surgery until the chin returns to a more normal appearance and three weeks for most of the swelling to go away. While many patients can expect some temporary lower lip numbness, he experienced very little. The improvement in the side view shows the desired moderate horizontal advancement.

In the front view, however, the increase in vertical length is more apparent and gives the chin better facial balance. While it is often stated that the lower face should be 1/3 of vertical facial height, in men the lower facial height should be slightly greater than 1/3 of total facial height.

Case Highlights:

1) Changing the shape of the chin is more than just about horizontal advancement. Vertical length and width of the chin must also be considered for the best aesthetic result.

2) Mild vertical lengthening of the chin can be done with an implant that is secured on the inferior edge of the bony chin.

3) When more than a few millimeters of chin lengthening is needed, an opening osteotomy is best. It can be done to only lengthen the chin or bring it forward as well as with a vertical increase.

4) When a chin implant has failed to achieve the desired aesthetic outcome, a chin osteotomy can be considered which offers greater options for some chin changes.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis Indiana

The chin and neck angle relationship is one of the most significant facial markers that has a significant influence on the age of one’s appearance. A well defined chin point and a contoured neck angle are what most of us had in the first three to four decades of life. Aging changes the neck angle and, combined with even a slightly weaker chin, creates that loss of youth look.

The combination of neck liposuction and chin augmentation is one the most effective and relatively simple facial procedures. The best patients are generally under the age of 55 (average range 35 to 50 years old) who do not significant neck skin looseness or laxity. The neck skin may have some wrinkling and sun damage but one should not be able to pinch more than an inch of loose skin. (not bunching up fat, just loose skin) The key is patient selection for a good result. If significant loose skin exists, some form of a necklift (facelift) is needed.

Candidates for this combination often seek out or have already had non-surgical treatments like Thermage or SkinTyte. These minimally invasive neck and jowl treatments do not have the capability to really change facial contour. While they do create a minor amount of skin tightening and wrinkle reduction, they often leave patients disappointed. They are not capable of removing a double chin or a jowl sag.

For patients with a good chin profile, neck liposuction alone is all that is needed. I prefer the use of Smartlipo as it can be comfortably and effectively be done under local or sedation anesthesia. With Smartlipo, a 1mm fiber is threaded through a small stainless cannula for insertion under the neck skin. The cannula keeps the fiber from bending and breaking. The tip of the fiber sticks out beyond the cannula just a bit to deliver the heat energy to the fat. The fiber has an aiming beam so one can always see the laser point under the skin and know exactly where the laser is. The key to laser lipolysis is that it is performed with temperature monitoring so the neck tissues do not get too hot. The wavelengths of the laser has three beneficial effects. Its effect on hemoglobin seals off blood vessels which results in less bruising. The heat is very effective for breaking down and melting fat. Additionally, by heating the underside of the skin significant tissue tightening will result. While there is debate about how much skin tightening occurs after laser liposuction, it is fair to say that it is greater than that which is achieved by liposuction alone.

The recovery after Smartlipo of the neck is a maximum of ten days. Often it is within just a week. In some cases, the addition of simultaneous skin resurfacing can be done if there is any pre-existing wrinkles. This will not increase the recovery time at all as less than 50 micron depths are used.

The potential benefit of a chin implant with neck liposuction must be looked at carefully. Many neck contour changes can be enhanced by some more chin projection. Rarely does one need an implant of any significant size, 3 to 5mms of increased horizontal projection can be enough. With flexible silicone implants, they can be placed through the same under the chin incision used for neck liposuction, just slightly larger. Incision lengths less than 15mms are all that is needed.

For the right patient, Smartlipo of the neck with or without chin augmentation provides a very visible neck change, is cost effective, and does not have a long recovery.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

Chin augmentation using an implant is a very common and highly successful procedure.With easy access to the front of the lower jaw (mandible) and few anatomic structures in which to be concerned about injuring, changes in the chin are quick and predictable. As a stand alone procedure or in combination with numerous other facial changes, chin implants provide a great tool for structural facial enhancement.

But like all implants used anywhere on the body, they are not complication-free. Mishaps and untoward outcomes do occur and secondary surgery is occasionally needed. Most of these problems are eminently improveable by implant adjustment or replacement and/or soft tissue modification.

Unhappiness with chin projection or shape after augmentation is a function of implant selection. There are now over seven styles of chin implants that offer more than a set amount of horizontal advancement. How far the implant goes back along the jawline and how much fullness to the side of the chin that is created can be altered by chin implant options that are now currently available. By comparison to the original operation, replacement with a new chin implant is a relatively easy operation since a pocket already exists. In some cases, a chin implant may have been asked to do too much. If the amount of forward chin movement needed is greater than 10mms, one may consider an osteotomy instead for such large chin changes. It will be prone to less potential complications.

Chin implants can shift as they are placed along a curved bone surface. Such shifting can occur horizontally or vertically. Most commonly, an implant that has shifted to the right or left is easy to spot as the central chin point is off-center. The center of the chin and its underlying implant should be along a vertical line drawn down from the center of the lower lip and through the midline between the mandibular central incisors. To prevent shifting during initial placement, a centrally-placed screw through the implant to the bone can be used. Similarly, correcting a deviated implant uses the same approach.

Vertical malposition (up too high) is usually the result of the implant being placed through an intraoral (inside the mouth) approach. With an open path from which it was inserted, it can easily slide up from the inferior border of the chin. It is more important to use a screw with the intraoral approach than from an incision under the chin where upward migration is limited by the  superior extent of the pocket dissection during placement.

One of the newer complications of contemporary chin implants (anatomic designs) is lateral wing malposition. While it is usually a benefit to have the implant extend back further along the jawline, it is necessary to have these wings tapered to blend into the bone as the implant ends. This makes the wings very thin and extremely flexible. It is quite easy for them to fold or bend at the back end of the pocket during placement. This can be felt as a bend or fold along the jawline at the implant-bone transition. The implant must be removed, the pocket extended and the implant re-inserted.

One of the well known chin augmentation problems does not involve an implant at all. When a chin implant is removed for whatever reason, the expanded soft tissues may not shrink back down. If they do not, and the larger the original implant the less likely they will, the chin soft tissues fall creating the classic witch’s chin deformity. This can be corrected by refilling the collapsed space with a new implant or an advancement osteotomy.  Another option is to remove the lax tissues and tighten them from underneath the chin. (a submental tuck-up)

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

A full or fat neck is most commonly treated by liposuction, particularly if one is fairly young. The results from neck liposuction are significantly influenced by the quality of the overlying skin. Good taut or thick skin will respond by shrinking and adapting upward to a less obtuse neck-jaw angle. Loose or inelastic skin may shrink somewhat but it will be irregular with band and cords apparent to the eye. When neck skin is loose, the liposuction procedure must be combined with some type of facelifting procedure. Whether it is more of a limited or full facelift will depend on how much loose skin exists.

One often overlooked consideration in neck liposuction is that of the chin. Should the chin be brought forward or is its projection adequate where it is currently? In the spirit of what one is trying to achieve by removing fat from the neck…a more evident jaw and neck line…the chin should not be forgotten. In some cases, it can be a good complement to the look that liposuction creates.

One effect that neck liposuction does create is the illusion that the chin is a little more prominent. As the neck-jaw angle, technically known as the cervicomental angle, become less obtuse and positioned back somewhat, it can look like the chin is a little more prominent. That is easy to understand as the chin may look more forward because the neck has moved back. In some cases, changing the shape of the neck may be all that is needed to improve what one thinks is a short chin.

In other cases, neck liposuction should really be combined with a chin implant. The problem is not just too much fat in the neck but the chin is really short as well. This is a much more prevalent issue in men than it is in women. Men can aesthetically tolerate a more prominent chin anyway, women must be more careful about de-feminizing their appearance. A combined neck liposuction-chin implant procedure is a classic ‘ying-yang’ facial procedure where movements in opposite direction create a better overall effect than either one alone.

Whether a chin augmentation is an additive benefit to neck liposuction can be determined easily prior to any surgery with computer imaging. Imaging profile structures, where the skin is in contract to the background, is very accurate and predictive of what surgery can really achieve. One can have themselves imaged with neck liposuction alone, combined with a small chin implant, and then combined with a larger chin implant as well. Looking at all three changes can really help one decide what is best for themselves.

The shape and appearance of the neck is partially influenced by the forward position of the chin. In many ways, the chin is an extension of the horizontal vector of the neck. As with any neck reshaping procedure, the chin should not be forgotten in surgical consideration and planning

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis