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Archive for the ‘chin augmentation’ Category

The Mentalis Muscle and Chin Augmentation

Monday, September 18th, 2017

 

The mentalis is a well known muscle of the chin. Any chin surgery procedure involves manipulation of this muscle no matter what type of dimensional chin change is being done or how it is being done. (implant vs. osteotomy vs osteotomy) Since it is the only muscle that has attachments to the anterior surface of the chin bone, postoperative problems with its function can occur. While many chin procedures are done successfully with the return of normal muscle function, mentalis muscle dysfunction is not rare and is a frequent source of after surgery chin problems. Given the frequent misunderstanding of the mentalis muscle anatomy and function amongst patients and even some surgeons, its role and relevance in chin augmentation surgery merits review.

The mentalis is a paired central muscle of the chin that runs vertically over the chin bone. It actually has two halves and is separated by a fat pad that is most prominent near its bony origin underneath the labiomental fold below the lower lip. The relevance of this central fat pad in the muscle is not clear. The muscle is attached to the bone at the depth of the internal vestibule superiorly and runs down vertically to insert into the soft tissues of the lower submental chin pad. It is important to appreciate that the point of firm fixation is at its origin to the bone but its insertion is into the soft tissue inferiorly. The primary function of the muscle is contraction of the chin pad superiorly and inward (towards the lower lip) which will concurrently raise the lower lip creating a pout type facial expression. It is innervated by the marginal mandibular branch of the facial nerve which crosses over the jawline laterally to reach the muscle’s surface.

In chin augmentation surgery incisional access is either intraoral through the mucosa or submental through the skin. In sliding genioplasty the only choice is intraoral. But implant placement can be done both ways. Both incisional approaches cut through the mentalis muscle but they do so through different areas of the muscle. (origin or insertion. This is more than just an anatomic distinction, it can have a significant influence on muscle tension and function after surgery.

Cutting through the insertion of the muscle with an intraoral approach does so at the point of its maximal muscle thickness and tension. It is extremely important to leave an adequate cuff of muscle attached to the bone with this maneuver, otherwise there will be nowhere to attach the released inferior bulk of the muscle bellies. Without a reattachment the muscle will contract down, the labiomental fold will get deeper and the chin pad will pull down off of the bone. (chin ptosis)

With a retained muscle cuff onto which the released muscle can be reattached, one is essentially re-establishing muscle length at the thickest part of the muscle. But it is easy to see how the muscle length is changed when the soft tissue chin pad is stretched out by an implant or an advanced bony chin segment. The larger the chin pad displacement the tighter the muscle closure will be. This accounts for many a patient’s complaints of prolonged chin tightness and stiffness after a sliding genioplasty, particularly in large advancements. It can also occur with chin implants and is most commonly seen when the implant rides up high and pressures the resutured muscle origin.

In the submental approach for chin implants, it is the insertion of the muscle that must be cut and lifted up to reach the bone. Since this is not a firm bony attachment, muscle elevation and closure is done at the thinner lower portion of the muscle and has a much lower risk of adversely affecting muscle tension and postoperative function. This is why there are far fewer complaints of chin stiffness and tightness from submentally placed chin implants as re-establishing muscle length is much easier as opposed to pulling the muscle back up to its original bony attachment.

Mentalis muscle anatomy and its function is just one issue to consider in chin augmentation and is most relevant with implants where both incisional options are in play. When the patient prefers an intraoral approach for a standard chin implant I use the muscle splitting approach through its septum rather than cutting the muscle’s bony attachment.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Severe Double Chin Correction

Friday, August 25th, 2017

 

Background: The lower face is perceived by the shape and projection of the chin and the cervicomental angle. A fairly well defined neck angle and a discernible chin are positive facial features regardless of age, gender or ethnicity. This speaks to the popularity of such plastic surgery procedures like chin augmentation and neck liposuction which strive to achieve these individual facial improvements.

A well known lower facial aesthetic deformity is the double chin. This does not occur because one really has two chins, it just looks like one does. The real chin is usually horizontally short but creates the upper part of the double chin. The second ‘chin’ is a fat and skin roll in the upper neck that sits below the bony chin. It is more recessed than the bony chin and thus creates a double roll in profile, like a set of stairs, into the lower neck. The double chin often appears as part of an overall facial lipodystrophy in its more severe form.

Case Study: This 25 year-old female had a rounder fuller face and a double chin in profile. The chin was horizontally short due to a more recessed lower jaw and a high mandibular plane angle. She also had a hyperactive mentalis muscle due to the short chin.

Under general anesthesia, a 10mm sliding genioplasty was performed from an intraoral approach to improve her chin projection and stretch out the submental area. Submental/neck liposuction and buccal lipectomies were also done to help deround her face as well,.

Her result shows the dramatic change that can occur from the diametric movements of increased shin projection and decreasing the cervicomental angle.While both tissue movements are concurrently helpful, the biggest influence is from the sliding genioplasty.

As the chin bone is brought forward it carries with it the genioglossus and geniohyoid muscle. This creates a tissue stretch in the upper neck and helps elevate the ‘second chin’ of the double chin. This is an effect that is not created by the placement of a chin implant on the bone. Which is why in cases of severe double chin cortrection the sliding genipoplasty is the preferred approach to implants even though it is far less initially appealing to do so.

Highlights:

  1. The double chin is always associated with a short lower jaw projection and a thicker fatty neck.
  2. ]The diametric movements of stretching out the chin and pulling back on the neck creates the best double chin correction.
  3. The best chin augmentation for the severe double chin is a sliding genioplasty as the bone movement lengthen the neck muscles as well.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Mersilene Mesh Chin Implant Replacement

Saturday, May 20th, 2017

 

Background: Chin augmentation is one of the oldest facial reshaping procedures. It has been performed for over fifty years and just about every conceivable material has been used to perform it. But historically and currently silicone implants have been preferred due to the wide variety of styles and sizes that are commercially available as well as their ease of insertion and removal.

But silicone implants are not perfect as they do not permit tissue ingrowth into them or attach firmly to the surrounding tissues. (depending upon how you view it this can be an advantage as well as a disadvantage) This lack of tissue adherence has allowed the use of a few select biomaterials for chin augmentation that have tissue adherence by virtue of having surface porosity or actual intermaterial porosity

One of these porous materials is mersilene mesh. Mersilene mesh is a synthetic non-resorbable polyester fiber that looks and feels like a fine mesh screen.  This mesh structure allows for fibrovascular ingrowth. It comes in thin sheets that are easily cut and has been widely used in hernia repair. But it has been applied for many other medical applications from ptosis eyelid repair to vaginal and urethral slings. It can be folded into a multilayer shape and sutured together to create a ‘chin implant’.

Case Study: This 30 year female had a history of two prior chin implant surgeries. She originally had a small anatomic chin implant which she felt produced inadequate projection and not the desired v-shape to the chin. It was subsequently replaced by a mersilene mesh implant to improve its projection and shape. This second chin implant ended up looking more like a block on the end of the chin and was further removed form the desired chin look.

Under general anesthesia and through the existing submental incision, the mersilene mesh material was tediously removed due to ingrowth of the surrounding soft tissues. It not only was stuck to the overlying tissues but had left an imprint on the underlying bone. (passive underlying resorption) An anatomic silicone chin implant was used as a replacement and its sides was tapered into more of a v-shape with s scalpel technique. The new implant was placed more on the bottom edge of the chin bone to add some vertical projection as well.

Mersilene mesh chin implants can be successfully removed with careful technique. Patients should expect more postoperative swelling than the original placement surgery due to the increased tissue dissection needed.

Highlights:

  1. Despite tissue ingrowth mersilene mesh chin implants can be successfully removed.
  2. Mersilene mesh material leaves impressions in the bone like every other type of chin implant.
  3. The shape options in mesh style implants are limited and can be the reason for chin implant replacement.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Double Chin Correction

Tuesday, February 21st, 2017

 

Background: The shape of the chin has a major effect on facial appearance. Since the chin is a projecting facial structure, it highly influences the shape of the face and how defined the neck can look. The shorter the chin becomes the more convex the facial profile becomes and the neck looks increasingly ‘lost’.

A common aesthetic facial concern is that of the Double Chin. This is really an urban term that is a misnomer. It is not really a double chin per se, it is really a chin deficiency or lack of enough chin projection. When combined with even a small amount of excess neck fat, which occurs right under the chin (submental fat), the profile will show two humps or mounds. They may look like two projecting chins but the lower ‘chin’ ir excessive neck fat.

The treatment of the double chin is a classic diametric surgery. Each ‘chin’ change must be in opposite directions to create the best facial profile change. The upper ‘chin’ must be moved forward and requires some type of bony procedure. (implant vs sliding genioplasty) The lower ‘chin’ requires soft tissue reduction using liposuction fat removal. Together the entire lower face is improved as it becomes more ‘pulled out’ and defined.

Case Study: This 45 year-old female was bothered by the increasing size of her double chin as she aged. She has always had a shorter chin but as she had gotten older the ‘double chin’ appeared.

Under general anesthesia an initial small submental incision was made through which the neck was treated by liposuction removing about 12ccs of fat. The submental incision was extended to 1.5 cms and a 7mm thick curvilinear silicone chin implant was placed in a subperiosteal pocket on the bottom of the anterior chin bone. (the implant had no extended side wings)

Double Chin Correction result side view Dr Barry Eppley IndianapolisDouble Chin Correction result front view Dr Barry Eppley IndianapolisHer eight week postoperative result show elimination of the double chin and a much improved facial profile. Between the chin augmentation and the liposuction, it really takes at least six weeks after surgery to see the full benefits of the double chin correction procedures. Depending upon the degree of horizontal (and even vertical) chin deficiency, the chin deficiency may be better done using a sliding genioplasty for a more 3D chin augmentation effect. It also can have a more positive neck reshaping effect as it pulls the underlying neck muscles (roof of the neck) forward and up.

Highlights:

1) The double chin deformity is a combination of excess fat fullness under the chin and insufficient horizontal chin projection.

2) The combination of submental/neck liposuction and chin augmentation effectively treats the double chin deformity.

3) Whether the chin augmentation is best done by a chin implant or sliding genioplasty depends on the degree of horizontal chin deficiency.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Chin Implant Stacking

Sunday, February 5th, 2017

 

Chin implants come in a wide variety of sizes and shapes. They can be placed either from an intraoral degloving approach from inside the mouth or from an incision underneath the chin. Both can be successful chin augmentation techniques as long as the implant stays where it is placed, albeit with either suture or screw fixation.

In some cases of chin augmentation the amount of horizontal projection is better but may still be deficient from the patient’s perspective. This could be due to either an inadequately sized chin implant or that the patient’s chin deficiency exceeded what standard implants can achieve. More times than not it is the latter. In these situations it is always better to either choose a larger implant if it is available or have a custom one made.

Chin Implant Stacking in Chin Augmentation Dr Barry Eppley IndianapolisBut another technique exists for improving the chin augmentation effect without removing the indwelling implant. This is the technique of facial implant stacking. This is where a new implant is placed on top of the other one. This provides additional horizontal projection and possibly some width if the implant wings are kept. When stacking implants it is important to secure them to the underlying implant as well as to the bone. Double screw fixation is ideally needed to prevent rotation of the overlying stacked implant.

The stacking of chin implants should be reserved for the very rare situations when other more established alternatives do not exist due to either standard implant limitations or for cost reasons.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Intraoral Chin Implant Placement

Wednesday, February 1st, 2017

 

Chin augmentation through the use of an implant is an historic procedure that dates back over fifty years and is still commonly performed today. It is typically done with a silicone chin implant due to its wide variety of styles and sizes and its smooth surface which facilitates its insertion and placement.

A chin implant can be inserted from either above or below the chin, each with its own distinct advantages and disadvantages. The submental or under the chin technique uses a  skin incision to access the chin bone to make the subperiosteal pocket. It has the advantage of not disrupting the origin of the mentalis muscle attachments, has a lower risk of potential implant contamination and ensures a more desired lower implant position on the bone. Its lone disadvantage is the concern about the scar appearance which usually heals very well. It is the more commonly use chin augmentation technique.

The intraoral chin implant technique approaches the chin bone from above. Its lone advantage is that it is a scarless chin augmentation. It has to disrupt the mentalis muscle bone attachments to create the subperiosteal pocket down to the bottom of the chin bone. Without  screw fixation there is a risk of the implant sliding upward towards the direction from whence it was placed after wound closure. In theory it is the more contaminated approach although there are no studies that validate the intraoral approach is associated with a higher rate of infection than the submental route.

Intraoral Chin Implant placement Dr Barry Eppley IndianapolisOne technical strategy in using the intraoral route for implant placement is to use a vertical muscle splitting approach. Rather than disrupting the complete mentalis muscle attachments through a horizontal degloving incision, the muscle is split vertically below its attachment point and the subperiosteal pocket created in a more blind instrumented fashion. The implant can then be inserted and rotated into position and secured in the desired location.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Medpor Chin Implant Removal

Saturday, November 26th, 2016

 

The use of implants for chin augmentation is the most popular method to achieve enhanced projection of the lower face. Many materials have been used for chin implants and today it usually comes down to the use of either a silicone or Medpor material. There are surgical advocates for both types of chin implants and both can be successfully used under the right circumstances.

Where silicone and Medpor chin implants differ dramatically and unequivocally is if the patient wants the implant removed. The aggressive tissue ingrowth into the Medpor material makes its removal difficult and fairly traumatic to the surrounding tissues. I have read some surgeons who say the material can’t be removed. This is not true, it is just that it is much more difficult than the easy removal of silicone implants.

If a Medpor chin implant is removed, there is often the need to replace it. The question is what should that be. That depends on why the implant was originally placed, its size and shape, and what the patient’s aesthetic goals.

medpor-chin-implant-removal-and-sliding-genioplasty-replacement-intraop-dr-barry-eppley-indianapolisIn this example a small petite female with a very short chin and high jaw angles had a Medpor chin implant placed. The implant produced numerous adverse aesthetic sequelae including a wide and elongated chin. Through an intaoral approach the Medpor chin implant, which was secured by 6 screws, was able to be removed in many pieces. The tissue ingrowth of the wings of the implant had adhered to the mental nerves which required careful separation to avoid nerve avulsion. The chin augmentation replacement was a sliding genioplasty. This brought the chin forward, made it less wide and vertically shortened it as well.

While chin implants are made of different materials, their effectiveness is best determined by the selection of implant style and size. It is important that chin augmentation in females is seen as aesthetically different than that of men. The type of chin implant style that works well in men often does not in females.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Chin Implant after Sliding Genioplasty

Saturday, August 6th, 2016

 

Background: The sliding genioplasty is a well known chin augmentation procedure that is often viewed as a substitute for a chin implant. While this is certainly true in some patients, for other patients it is a better alternative as both an autologous operation and because it can offer some dimensional chin changes that an implant has historically not been able to do.

One dimensional limitation of this bony genioplasty operation is that the amount of horizontal augmentation obtainable is controlled by the thickness of the bone. To ensure bony healing as well as survival of the downfractured chin segment, bone contact must be maintained. This means that the maximal amount of horizontal bone movement is that the back cortex of the mobilized chin segment must stay in contact with the front cortex of the intact chin bone above it.

Because of this anatomic limitation not every sliding genioplasty can achieve ideal chin projection. This leaves the role of a chin implant to achieve an even better chin augmentation result.

Chin Deficiency after Sliding GenioplastyCase Study: This 25 year-old female had previously undergone a sagittal split mandibular advancement with a sliding genioplasty. Even with these two combined lower jaw movements, her chin projection remained aesthetically deficient.

Chin Implant after Sliding Genioplasty intraop Dr Barry Eppley IndianapolisUnder general anesthesia an intraoral approach was used to access her chin. A extended medium chin implant was placed below the existing metal plate from her prior sliding genioplasty. The implant was positioned lower on the chin bone to help create some vertical lengthening as well. (8mms forward and 3mm down) The implant was secured in its position with two 1.6mm screws at the superior aspect of the implant.

There is no reason that an implant can not be placed on top of a prior sliding genioplasty. This would be the simplest way to improve a prior bony chin augmentation procedure. With the many styles of chin implants now available many alloplastic options exist to change the shape of the prior remodeled chin bone.

Highlights:

1) A sliding genioplasty does not always create the ideal horizontal position of the chin particularly in significant lower jaw deficiences.

2) A chin implant can be a secondary addition to a prior sliding genioplasty.

3) The extended wings of a chin implant can help camouflage any bony irregularities along the jawline from the prior sliding genioplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Volume Comparison of Chin Implants and Injectable Fillers

Sunday, May 29th, 2016

 

Chin Implant Augmentation Indianapolis Dr Barry EppleyChin augmentation is a common aesthetic facial reshaping procedure that is second only to rhinoplasty. It has been traditionally performed by the placement of a preformed implant. While many different chin implant styles have been used over the years, the basic concept of an alloplastic chin augmentation is the same.

The emergence of injectable methods for facial augmentation using a variety of injectable fillers and fat has now become an accepted treatment approach for chin augmentation. While no injectable material offers an assured and permanent outcome as that of an implant for chin augmentation, it does provide an opportunity for patients to non-surgically ‘wear’ the result for awhile to determine if it suits them.

An interesting but relevant issue when using injectable fillers for chin augmentation is how do they compare volumetrically. To create an injectable chin augmentation effect, what volume of injectable filler is needed to compare to what a chin implant does? It is not a fair comparison if one is ‘testing’ an injectable filler and the volume injected does not equal what that of the effect that a chin implant does.

Volume Displacement of Facial Implants Dr Barry Eppley Indianapolisextended-anatomical-chin-implantComparing facial implants and injectable fillers is done using volumetric displacement. Based on the Archimedes principle of displacement, volume of displaced water would equal to the volume of the implant. (provided that they sink in water and all chin implants do) Using the most commonly used extended anatomic chin implants (Implantech) of small, medium, large and extra large, their weights in grams and volume displacement were as follows:

Small Chin Implant        2.1 grams     1.3cc

Medium Chin Implant   2.7 grams      1.7cc

Large Chin Implant      3.4 grams     2.2cc

X Large Chin Implant  4.0 grams     2.7cc

The volume displacement of all injectable fillers is on the syringe so the comparison to chin implants is straightforward. It shows that a 1cc syringe of any of the hyaluronic acid-based fillers (e.g., Juvederm) would be less than even a small chin implant. A small anatomic chin implant more favorably compares to 1.5cc of Radiesse. Larger chin augmentation effects requires up to 3ccs of injectable filler regardless of the type.

There are other variables that affect how any of these materials create an external facial augmentation effect. The most significant would be how well does the material push on the overlying soft tissues or push off of the bone to create their effect. This is known as G Prime Force or their elastic modulus. It is quite clear that implants are stiffer than any liquid material and would have a higher resistance to deformation. (thus creating more outward effect given a similar material volume) Therefore it is probable that comparing volume displacements alone overestimates the effect of injectable fillers compared to that of chin implants.

Dr. Barry Eppley

Indianapolis, Indiana

The Vertical Lengthening Chin Implant

Sunday, January 24th, 2016

 

Chin augmentation is the most historic but still the most commonly performed facial augmentation procedure. While many other types of facial implants have been developed, increasing projection of a deficient lower face is still the most potentially dramatic facial augmentation change of them all.

Chin implants have evolved considerably over the past few decades with numerous new styles. The fundamental concept of these style changes has been to create a more natural chin augmentation look or augment different regions of the chin area. But the one constant of all the chin implant styles is that they create a straight horizontal dimensional increase. This is so because all of the implant remains on the front edge of the chin bone.

But some chin deficient patients have more than just a horizontal bone deficiency. Certain short chins are also vertically deficient as well. Historically the only surgical method to substantially increase chin height was an opening wedge sliding genioplasty.  While effective some patients would prefer to avoid a bone cutting surgery.

While it is true that a standard chin implant can be placed very low on the  bone(on its ledge so to speak), this is not how the implant is designed or made to be used. This makes it potentially unstable to sit on the lower end of the bone and, even in doing so, produces a a very limited vertical lengthening effect.

Vertical Lengthening Chin Implant vs Standard Chin Implant Dr Barry Eppley IndianapolisTo address the combined horizontal and vertically lacking chin with an implant, the vertical lengthening chin implant (Implantech) has been developed. What is unique about this chin implant style is that the projection of the implant goes down from the chin at 45 degrees. This creates a combined horizontal and vertical increase. The implant actually sits on the ledge of the chin by design and thus it is more stable. To ensure optimal stability and positioning, a single 2.0mm screw can be placed through the implant to the bone when done from a submental incision. When done intraorally, a 1.5mm screw can be placed through the top edge of the implant to prevent any risk of upward migration. (which actually should be done with all chin implants placed intraorally)

Vertical Lengthening Chin Implant result 1 Dr Barry Eppley IndianapolisVertical Lengthening Chin Implant result 2 Dr Barry Eppley IndianapolisProper patient selection for the vertical lengthening chin implant is critical. It should only be used in patients with a significant vertical deficiency of the chin that also has a horizontal shortness as well. Most of these patients with have an almost 45 degree backward slant between the lower lip and chin. In general, the shorter the horizontal chin deficiency the more likely there will chin height shortness as well. Because it is an implant the width of the chin will also get bigger as the chin gets longer with greater horizontal projection. (a key aesthetic consideration)

Vertical Lengthening Chin Implant result 3 Dr Barry Eppley IndianapolisIn some men with slight or even no real vertical deficiencies, the addition of chin height will create a stronger or more masculine lower facial appearance. While this may be effective for some men, this is not a good strategy for women.

Vertical Lengthening Chin Implant sizes Dr Barry Eppley IndianapolisDifferent sizes (angulations) of the vertical lengthening chin implant are available which can increase the vertical up to 7ms while increasing the horizontal up to 12mms. Such chin augmentation changes may allow some patients to avoid an osteotomy of the chin.

The vertical lengthening chin implant is truly the first 3D chin implant ever made as it increases all three chin dimensions.

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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