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Archive for the ‘chin clefts’ Category

Technical Strategies – Vertical Chin Cleft Creation with Chin Implant Augmentation

Sunday, December 3rd, 2017

 

The chin has few topographic features on an otherwise round convex shape as it covers the projecting chin bone. Chins can have either a dimple or cleft. A chin dimple is a circular central indentation of the soft tissue chin pad. A chin cleft is a vertical indentation through the lower half of the chin pad that extends to the inferior border. While many perceive that these chin indentations are caused by the bone underneath them (particularly a vertical cleft), they are actually anomalies in the soft tissue and not the bone.

The vertical chin cleft is the easiest to understand since the lower jaw is formed by the paired brachial arches that meet in the middle in the embryo. Failure to have a complete meeting in the middle can result in a ‘cleft’ of the overlying soft tissues. Or more likely the union of the tissues developed a very slight separation that resulted in a very minor soft tissue cleft.

When surgically trying to make a chin cleft, making a vertical defect in the bone alone will not work. Or in the case of placing a chin implant, a ‘cleft’ chin implant will also not create the desired effect. It requires soft tissue manipulation, preferably from a submental incision, to make an effective external cleft appearance.

When doing a combined chin implant and vertical cleft creation, the bigger the chin implant the more likely it will be effective. Whether the chin implant is round or square does not matter, it can be done equally well in either one. The key technical points are two-fold. First a wedge of cleft must be made through the center of the implant to create a channel for the soft tissue anchoring. In so doing the implant will need to be secured with screws on each side so it remains positionally stable. Secondly a vertical wedge of soft tissue (muscle and fat)is removed from its underside up to the dermis of the skin. Sutures can then be placed to pul the skin down into the implant cleft. This will create a resultant vertical indentation of the overlying external chin.

A vertical chin cleft can also be created in patients who are not undergoing chin implant augmentation. The technique is the same with the exception that a vertical groove is made into the lower edge of the bone as opposed to that of an implant.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Chin Cleft Creation Surgery

Monday, November 2nd, 2015

 

Background: One of the very unique aesthetic features of the chin are dimples and clefts. While often perceived as being similar, they are not. Chin dimples are central circular indentations in the central mound of the chin pad. A chin cleft is a vertical groove located more along the inferior chin pad and crosses along the edge of the bone. Both can have variable depths and degrees of prominence. Both involve soft tissue defects that go through the mentalis muscle beneath it.

male chin cleftfemale chin cleftChin clefts are well recognized and famous men and women are known to have them. Chin clefts are far more common in men although they can occur in women as well. Often perceived as being a masculine trait, the vertical chin cleft creates a very recognizeable feature of the lower face.

These variously shaped indentations in the chin are both revered and despised. Some people like them who do not have them while others who have them do not like them. There are surgeries of variable effectiveness that can both create and reduce their appearance. Chin cleft creation surgery does exist and the most well known celebrity who is known to have it done in recent times is the singer and entertainer Michael Jackson.

Case Study: This 45 year old male desired a vertical chin cleft to be placed down the central lower end of his chin. He was aware that there would be a trade-off of a vertical scar in the center of it.

Chin Cleft Creation Surgery intraop Dr Barry Eppley IndianapolisUnder local anesthesia  a chin cleft creation surgery was done. A near full thickness wedge of soft tissue (skin, fat, muscle) was removed along the length of the desired chin cleft. Deep sutures were placed to sew down the skin edges to the periosteum of the bone. This created an initial skin edge puckering effect which will go away as it heals.

Chin Cleft Creation Surgery result front view Dr Barry Eppley IndianapolisHis 6 month results show a visible vertical chin cleft of medium depth. The skin scar was virtually undetectable in the center of the chin cleft

Chin cleft creation surgery (chin cleftoplasty) is a simple procedure that can be done under local anesthesia in the office as an isolated operation. It can also be safely combined with all other forms of chin reshaping surgeries.

Highlights:

1) A chin cleft is a vertical midline indentation in the lower chin that has variable depths and lengths.

2) The best method for chin cleft creation surgery is an external approach removing a full thickness wedge of tissue.

3) External chin cleft creation surgery usually results in an acceptable scar that can be hard to detect in the depth of the cleft.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Square Chin Implant and Vertical Cleft Creation

Friday, February 27th, 2015

square chin implant dr barry eppley indianapolisChin augmentation is most commonly done by placement of a synthetic silicone implant. Chin implants today come in a wide variety of dimensions, historically providing only horizontal projection, but now available in vertical lengthening styles as well. For men chin implants are even available to provide an increase in width, also known as a square chin look, to provide a more masculine chin/jawline appearance.

One other chin feature that is often desired in men is that of a chin cleft. Certain chin implants have a central cleft in them in an effort to create a midline cleft with the chin augmentation. While it looks good on the implant, it does not translate to creating that effect on the outside after implant placement. It simply is not that easy to create a vertical chin as it does not come exclusively from a defect or notch in the bone, contributions also come from a muscular diastasis as well.

square chin split implant technique dr barry eppley indianapolisvertical chin cleft creation technique dr barry eppley indianapolisTo effectively create a vertical chin cleft at the same time as placing a chin implant, it requires a concerted effort to make it appear. The chin implant is first split down the midline and separated. A 5 to 7mm gap is made between the implant. Because the implant is now in two pieces it is necessary to secure each implant half by screw fixation. Then a bone hole is made through the bottom of the chin in the midline. This allows a permament suture to be placed that is used to pul the mentalis muscle down into the implant gap. A stronger effect can be created by removing some soft tissue under the skin as well before passing the suture. How tight the suture is tied down will impact the degree of cleft creation. The shape of the cleft (its width) is also influenced by the size of the midline implant gap.

Square Chin Implant with Cleft result Dr Barry Eppley IndianapoliisA vertical chin cleft can be done at the same time as a square chin implant augmentation in men. Breaking up the wider square chin with a cleft helps add a visual feature of interest and disrupts a completely flat horizontal line across the bottom of the chin.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Correction of Chin Clefts

Wednesday, July 8th, 2009

Midline clefts of the chin are both a desired as well as a disliked facial feature. For some patients who have these chin clefts naturally, they would like the depth of the cleft softened or even completely removed.  Such a procedure, chin cleft reduction, is possible.

 

Contrary to popular perception, clefts of the chin are not primarily caused by an underlying cleft or defect in the chin (mandibular symphysis) bone. While some chin clefts do have a notch or indentation in the underlying bone, most do not. The cleft in the skin is caused by a separation or dehiscence of the paired mentalis muscle as it comes together over the chin. Technically, it is not a true separation but a failure of the muscle to come together during development as occurs in non-cleft patients.

 

The depth of the chin cleft is a reflection of the magnitude of the muscular split. In complete muscle separations, the chin cleft can be quite deep or indented with the edges of the skin completely turned in with little subcutaneous tissue between the cleft and the underlying bone. This understanding has relevance to how it may need to be corrected. Less deep chin clefts do not have such severe skin indents or inturning as the muscle is split less completely and more tissue exists between the cleft and the underlying bone.

 

Correction (reduction) of chin clefts is done through an incision inside the mouth just above where the lower lip starts from the depth of the vestibule. The muscle is elevated off of the bone down to the underside of the chin bone. One can see the actual separation of the mentalis muscle. Muscle is freed up on both sides of the cleft and is sewn together across the muscle separatikon with dissolveable sutures. It is important to overcorrect or give it a little pucker as there will be some relaxation after surgery. This maneuver will certainly soften and reduce the depth of a chin cleft but may not completely get rid of it.

 

I have found that the best chin cleft corrections come from simultaneous chin bone manipulations as well. Whether it is a chin implant placement or a chin osteotomy, changing the shape of the underlying bone (advancements or vertical lengthening) has a positive effect on the outcome of chin cleft correction.

 

When the chin cleft quite deep, some consideration may need to be given to doing external skin incisions as well. Incising along the edges of the chin cleft, with or without a dermal-fat graft placed underneath, and bringing the external skin edges together gives the best correction. But at a price of an external scar…which may or may not be worth it. Some patients would argue that a fine line scar that is less indented is not as problematic as a very deep chin groove.

 

Conceptually, it is best to think about chin cleft surgery as a reduction of it, not a complete elimination. In my Indianapolis plastic surgery practice, this is a concept that I emphasize about this surgery. Some chin clefts will nearly disappear, the deepest ones are merely reduced. (unless one is willing to accept an external skin scar.  

 

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

 

 

Chin Cleft Surgery – Making Them or Removing Them

Wednesday, May 27th, 2009

A cleft or dimple of the chin is  a visible indentation in the midline of the chin prominence. It can be small or quite deep and its presence is genetically determined. (dominant gene) It has appeared on many well known faces and most people can quickly name at least one famous person who has one. It has been said to be present because there is a V or Y-shaped fissure on the bony chin button. It has been reported that this fissure in the chin is the result of incomplete fusion of the left and right halves of the jaw during fetal development. Having done a lot of chin surgery, I don’t think this is exactly accurate. I have yet to see a cleft chin where the bone looks incompletely fused. It is a mere notch in an otherwise very well formed and well united manidbular symphysis.

Some patients desire to have a cleft chin made. This can be done using two different chin surgery approaches. . If one’s chin projection (horizontal position) is satisfactory, a midline groove is made in the bone either through an incision inside the mouth or from under the chin. The mentalis muscle is then sutured down to the bone through a bone hole with a permanent suture. If one’s chin projection is short, an implant can be used in which a groove has been fashioned in it. In a similar fashion to the bone, the mentalis muscle can be sutured down to it. I prefer to pass the suture through the implant and down through the bone as well. As sutures to the implant alone can often pull through a softer material such as silastic rubber. Both techniques will create a cleft or chin dimple at the lower edge of the chin. It will be moderate in size and soemwhat rounded. One can make a deeper indentation in whcih the dimple is much more inverted but this would involve an external skin scar whcih I do not advise.

Other patients  who have a cleft in their chin would like it removed. This is a bit trickier but can still be done. ( I should say improved) From inside the mouth, the muscular attachments to the chin fissure are released. The space formed between the released muscle and the bone must be filled to prevent reattachment and ongoing external chin indentation. The best interpositional graft is a dermal-fat graft which is a natural filler. This does require a harvest site and a scar somewhere with graft dimensions being at least 1 x 2 cms. The buccal fat pad can also be used. Another option is cadaveric or animal-derived dermis but the infection risk is a little higher as it revascularizes much slower. Chin dimples that are released in this way will not always make the chin perfectly smooth. In those chin clefts which are really deep and inverted, one has to use an external skin approach to level out the skin. In this case, the scar may be worth it given the depth of the groove which was originally present.

Cleft or dimples of the chin can be surgically created or removed. Using an intraoral or submental approach, the chin bone and mentalis muscle can be molded or released. The use of an external skin incision has been advocated by some but this leaves the potential risk of a poor scar in a very visible location. Its use should be reserved only for the most severe cases of cleft chin release.

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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