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Archive for the ‘chin osteotomy’ Category

Technical Strategies – Interpositional Grafting in Vertical Chin Lengthening Osteotomies

Thursday, February 8th, 2018


While much thought goes into the horizontal projection of the chin, and numerous chin augmentation procedures exist to change it, much less interest is in its other dimensions. One often overlooked deficiency of the chin is its vertical length. A short vertical chin is usually associated with a flatter mandibular plane angle where the horizontal position of the chin and jaw angle points are almost on the same line.

While some vertical chin deficiencies are part of  an overall underdeveloped chin (both vertical and horizontal shortness) some chins may have an isolated vertical deficiency. The chin may have enough forward projection but just looks short. This is usually very apparent when the classic vertical thirds of the face are considered.

Vertical lengthening of the chin as an isolated change can be done by an opening wedge bony genioplasty. Just like the osteotomy used in the classic sliding genioplasty the same intraoral bone cut is made. But instead of moving the bone forward, the front edge of the bone is dropped downward. With the back wings of the inferior bone segment staying in contact with the bony jawline, the front part of the chin is vertically lengthened by the size of the opening wedge. (bony gap) This gap and the vertical chin lengthening it creates is maintained by plate and screw fixation.

This opening wedge of the chin creates a bony gap. If this bone defect is not too big, bone will naturally fill it in over a period of up to six months after surgery. The exact size of a horizontal bone gap in the chin that can heal on its own is not precisely known. But the general rule that I use is that I don’t graft this gap when it is less than 5 or 6mms. But when the gap is closer to 8 to 10mm it is of benefit to do so.

Interpositional grafting of an opening wedge genioplasty can be one by a variety of materials. The use of allogeneic or cadaveric blocks or granules is an effective. A large solid block placed in the center grafts the biggest part of the defect and the sides can be left alone to heal in on their own.

Vertical chin lengthening helps to put the face in better balance and fixes an uncommon chin deficiency that is best appreciated in the frontal view.

Dr. Barry Eppley

Indianapolis, Indiana

The Geniohyoid Muscle in Vertical Chin Reduction

Saturday, December 9th, 2017


There are many types of dimensional changes that can be done to the bony chin. From an osteotomy standpoint, the most common bony movement is horizontal of the down fractured segment with the well known sliding genioplasty procedure. This is effective at not only moving the bone but also has the benefit of moving the submental tissue beside and beneath it as well due to their bony attachments.

One of these tissue attachments is the geniohyoid muscle. This paired suprahyoid muscle originates from the bony spine on the backside of the chin bone and inserts back and down onto the hyoid bone below. When the bone is cut and downfractured for a sliding genioplasty, its attachment remains and the muscle is pulled forward as the chin is moved forward. This serves as the anatomic basis for an improved submental contour in the forward advancing sliding genioplasty.

But in vertical chin reductions done by the intraoral removal of a horizontal wedge of bone (wedge reduction genioplasty), the geniohyoid muscle is at risk. In removing the wedge of bone part or all of the genioglossus attachment may be lost. The retracted muscle can pull downward toward the hyoid and can create increased submental fullness.

To prevent this muscle contraction possibility, the geniohyoid muscle attachment is removed from the wedge of bone and grasped with suture. This suture is kept in the midline and the downfractured bone segment is brought back up to close the space from the removed bone wedge. The bone is secured in its vertically shortened position with 1.5mm plates and screws. The muscle suture is then tied down to a single screw placed in the midline, creating a bone-anchored soft tissue attachment.

In vertical chin reduction any increased fullness of the submental region below it would be aesthetically disadvantageous. Keeping tensions across the geniohyoid muscle will help prevent that from occurring.

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.


  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

Technical Strategies – The Vertical Opening Wedge Genioplasty

Friday, August 4th, 2017


Chin asymmetry is easily seen as the most projecting part of the lower face is shifted off of the facial midline. The central chin point is shifted to one side or the other and can occur for variety of reasons. The most common reason is developmental or traumatic where the sides of the jaw have different lengths, most commonly because there is a shorter side due to developmental deformities or from traumatic injuries/fractures.

In cases of chin asymmetry due to shortening of one side, realignment of the chin can be done by a unilateral lengthening of the shorter side. This is called an opening wedge genioplasty which is performed through an intraoral approach. Just like a traditional sliding genioplasty a horizontal bone cut is done well below the mental foramens and at a low anteroposterior angle as possible. Once the bone is down fractured (mobilized) the the longer or normal side is fixed with a single small two-hole plate and screws with bone to bone contact. This becomes the hinge point at which the opposite shorter side is opened.

The opening wedge distance on the shorter chin side that it is vertically lengthened is determined by the distance the central chin point is off the facial midline. In theory this is a 1:1 ratio, although like an obtuse or scalene triangle, the opening wedge usually has to be slightly greater than the amount of midline asymmetry.

The opening wedge is then stabilized with a much longer plate than was used on the opposite hinge point. Cadaveric corticocancellous bone pieces are used to fill in the empty intrabony wedge space to ensure healing. It is important to fill out the wedge defect all the way out to the inferior border to avoid a step-off deformity.

The vertical opening wedge bony genioplasty is a useful technique for those chin asymmetries which are caused by a shorter sided jaw segment.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Vertical Lengthening Genioplasty

Wednesday, October 19th, 2016


Chin augmentation is traditionally thought as a choice between a chin implant and a sliding genioplasty. While seen as the two procedure choices for chin reshaping they are not really interchangeable. Besides the difference between synthetically augmenting the bone vs actually cutting and moving the bone, they can achieve different dimensional chin changes.

The one movement that a sliding or bony genioplasty can do much better than an implant is changing the vertical dimension of the chin.  While it is obvious that an implant can not shorten the chin, it historically could not lengthen it very well either. That has changed more recently with vertical lengthening chin implant styles. But the intraoral genioplasty remains an historic mainstay for increasing the vertical length of the lower face. (chin)

vertical-lengthening-genioplasty-intraop-dr-barry-eppley-indianapolisDone through an intraoral mucosal incision, the chin bone is cut well below the level of the lower tooth roots. An opening wedge is performed by dropping down the chin bone to the desired vertical distance that is needed to create the aesthetic result. In most cases the vertical gap that needs to be created is at least 7mms. Much less does not produce a very obvious vertical lengthening. The amount the vertical gap can be opened is only limited by the length of the fixation plate used and what other chin dimensions need to be changed if any.

A debatable issue with vertical chin lengthening is whether the bone ago created between the two chin segments needs to be filled in. In small gaps in the range of 5mms or less grafting of the defect is probably not needed. The body will fill it in on its own. But larger bone gaps should be grafted. I prefer to use allogeneic cadaveric bone grafts which conveniently come in wedge forms that can fit nicely as an interpositional bone graft.

Interpositional Gtafting in Vertical Lengthening Genioplasty

Saturday, September 10th, 2016


The sliding genioplasty is a well known chin augmentation procedure that is commonly used for horionzontal advancement. But cutting and moving the chin bone can be done for other dimensional changes of which vertical lengthening is also a good indication. Historically vertical lengthening of the chin could only be done with an opening bony genioplasty.

When the chin bone is fractured and moved downward it is held into its new position by a plate and screws. Such fixation devices can increase the vertical length of the chin up to 1 cm or more. This leaves a large bone gap between the two cut bone edges. The question has always been at what amount of opening should the gap be filled and with what material?

There is no exact science that tells us what size bone gap in a vertical lengthening genioplasty can heal in on its own and what size bone gap can not. The chin does have a remarkable capacity to create bone from its two cut bone edges. As a general rule I do not  place any interpositional material for bone gaps less than 6mms. But larger amounts of vertical chin expansion merit some graft material to aid bone healing

While a bone graft would be the ideal material to place into a vertical lengthening genioplasty, harvesting a bone graft for an elective aesthetic procedure is not appealing. A wide variety of alloplastic materials have been used instead of which hydroxyapatite granules and blocks are the most common.

vertical-lengthening-genioplasty-with-interpositional-bone-graft-dr-barry-eppley-indianapolisvertical-lengthening-genipplasty-with-interpositional-bone-graft-oblique-view-dr-barry-eppley-indianapolisAn other graft option is that of tissue bank or cadaveric bone. Available from a variety of tissue banks in the U.S., processed solid wedges of corticocancellous bone are available for human implantation. These are excellent interpositional graft choices for a vertical lengthening genioplasty. Placed behind the fixation plate in the central opening of the bone, they not only add to structural stability but provide a scaffold for bone ingrowth. The entire opening wedge of the genioplasty does not need to be grafted, only the largest gap in the center. The wedge shape of the corticocancellous bone makes it an ideal fit for this type of bony opening.

The options for filling the  bone gap of a vertical lengthening genioplasty are either hydroxyapatite blocks or tissue back bone. Both can be very effective and their cost differences are not significant.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Four-Piece Total Jawline Augmentation

Sunday, December 20th, 2015


Background: The desire for a more pronounced and visible lower jawline exists in both men and women. The surgical methods to do so are more commonly requested by men particularly when it comes to a substantially larger jawline change. Making a jawline more evident focuses on increasing the size and shape at its ‘corners’, that of the projecting chin and the back ends at the bilateral angles.

When creating a total jawline augmentation effect, there are two basic approaches.  The historic and still most commonly used method is a three implant approach of independently placed chin and jaw angle implants. In some cases the chin implant may be substituted with a siding genioplasty. The newer method of jawline augmentation is the fabrication and placement of a one-piece custom made jaw implant that wrap around the chin from angle to angle. It is the preferred method of total jawline augmentation given the preoperative designing of the implant and its smooth one-piece construct. But cost considerations may lead some patients to still undergo the classic three implant method.

Chin and jaw angle implants exist in standard styles and sizes. While for some patients these historic standard chin and jaw angle implant styles will effectively work, newer implants styles offer improved total jawline augmentation results for many patients. Newer vertical lengthening jaw angle implants have allowed for increased visible angularity of the back part of the jaw. When vertical elongation of the chin is needed either newer vertical lengthening chin implants can be used or the historic approach of an opening sliding genioplasty. When significant vertical and horizontal chin augmentation is needed, chin implants and a sliding genioplasty can be combined.

Case Study: This 25 year male wanted a total jawline change. Not only was his lower jaw horizontally short but it was vertically deficient as well. This was evident in the short chin and large overbite which are directly related. When he opened his mouth slightly the improvement in his chin and jaw height could be seen confirming the needed vertical dimension of his chin and jawline.

Chin and Jaw Angle Jawline Augmentation result side viewChin and Jaw Angle Jawline Augmentation result oblique viewUnder general anesthesia, he had an opening sliding genioplasty (7ms done and 7mms forward) with a chin implant overly (5mm horizontal augmentation) done through an intraoral approach. Through posterior intraoral incisions jaw angle implants that added 7mm vertical length and 5mm width were placed.

At one year after surgery the improvement in his jawline could be appreciated. Ideally longer vertical lengthening jaw angle implants would have improved his result and are being considered. The sliding genioplasty and chin implant overlay produced a satisfactory improvement to the front part of his jawline

Total jawline augmentation can be effectively done using a non-custom implant approach. It can require the thoughtful application of newer chin and jaw angle implant styles and the selective use of sliding genioplasty techniques.


  1. Total jawline enhancement consists of front (chin) and back (jaw angle) augmentation.
  2. Preformed chin and jaw angle implants is the historic and standard approach to total jawline enhancement.

3. Vertical chin augmentation in total jawline enhancement can be done by a combined sliding genioplasty with a chin implant overlay.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Sliding Genioplasty and Chin Implants

Tuesday, November 24th, 2015


A sliding genioplasty is a very versatile chin reshaping procedure that has been used for decades. In elective chin augmentations it is the alternative option to the use of a chin implant. Although chin implants are by far more commonly done in a ratio of at least 20:1 if not greater. While chin implants are a simpler procedure they are not appealing to everyone nor are they always the best choice for every type of chin deficiency.

A sliding genioplasty is usually best done for younger patients who have significant chin deficiencies. There also is a much higher tendency to  them at the time of orthognathic surgery when other facial bones are being manipulated as well. In larger chin deficiences moving of the bone has less potential for any long-term problems than does an implant.

The limits of how far forward a sliding genioplasty can move the chin horizontally is a function of the thickness of the chin bone. It is important to maintain some bone contact between the upper and lower chin segments, meaning the back edge of the downfractured chin segment should at least touch the front edge of the chin bone above it. (and be stabilized by plate fixation)

Sliding Genioplasty Chin Implant Combination Dr Barry Eppley IndianapolisBut in some larger chin deficiencies even maximal forward chin bone movement may still leave one with less than an ideal profile change. In these circumstances, whether recognized during the initial sliding genioplasty or afterwards, the solution can be a chin implant. A chin implant can be placed on the front edge of the sliding genioplasty to gain an additional 3 to 5mms of horizontal chin projection. An extended anatomic chin implant is used so that its wings cover the step off area on the back side of the osteotome line. It is critically important that the chin implant is secured by screw fixation to the sliding genioplasty segment.

While chin implants and sliding genioplasties are traditionally thought of as being mutually exclusive, they do not have to be. In need of extreme amounts of chin projection, the combination of a sliding genioplasty with a chin implant overlay can be a useful chin augmentation strategy.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Asian V Line Surgery

Monday, November 23rd, 2015


Background: Reshaping of the entire jawline to a more slim or narrowed shape has become known as V line surgery. It is most commonly done in Asians to change a wide and more square jaw to a more narrow and triangular one. It is a bony reshaping surgery which focuses on the chin anteriorly and the jaw angles posteriorly

The cornerstone of V line surgery is what happens in the anterior chin area. As the most projecting point of the lower jaw it must become less wide and often times vertically shorter or longer depending on the patient’s natural chin shape. This is usually done by various of osseous genioplasty concept where the chin bone is downfractured, a midline resection done and then put back together. A horizontal wedge reduction can be done to shorten it if the chin is initially vertically long or the reassembled chin can be put back together and brought forward for a horizontally deficient chin.

The secondary part of V line surgery is a change in the width of the jaw angle. In the past the jaw angle was merely amputated or cut off. While very effective this wipes out any jaw angle shape and can be prone to create soft tissue sag due to loss of ligamentous and muscular attachments. Today it is recogized that preserving the jaw angle shape is important and angle reductions can be done by either a burring reduction or an outer corticotomy.

Case Study: This 22 year Asian female was undergoing a variety of facial reshaping procedures including V line jawline reshaping surgery. She had a naturally short flatter chin and needed more horizontal projection as well as narrowing

Asian Female Jawline Narrowing result Dr Barry Eppley IndianapolisUnder general anesthesia, she had an intraoral horizontal chin osteotomy done with a midline wedge resection. The bones were put back together with 1.5mm plate and screw fixation and advanced 5mm. The bony stepoffs at the inferior border were trimmed behind the back edge of the osteotomy line.  Through different intraoral vestibular incisions the jaw angles were reduced by rotary burring, reducing the outer cortex almost to the marrow space.

Asian Chin Reshaping result side view Dr Barry Eppley IndianapolisAsian Female Jawline Reshaping result oblique view Dr Barry Eppley IndianapolisAt six months after surgery she had a much improved jawline shape. Due to the desire to have further horizontal chin projection, a secondary procedure was done to add a small curvilinear central chin implant of 5mms to create the final jawline shape now seen.

V line jaw reshaping surgery is technically challenging and requires expertise in chin osteotomies as well as mandibular ramus surgery. Secondary revisions are not rare and may need to be done to correct any residual bony asymmetries or projecion deficiencies.


  1. V line or jawline narrowing surgery is often a combination of chin and jaw angle bony changes.
  2. The most important element of v line surgery is the anterior chin which must be narrowed and often lengthened to create most of the effect
  3. Jaw angle width narrowing may also be necessary but it is important to avoid obliterating the shape of the jaw angle in doing so.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Vertical Jawline Augmentation

Saturday, October 10th, 2015


Background: Lower jaw deficiencies are most commonly perceived as being of the horizontal variety. A short chin invokes the need for horizontal chin augmentation and this certainly is the most common jaw augmentation procedure. It is also the simplest and most easily performed. But jaw deficiences can occur in other dimensions as well and their diagnosis and treatment require a greater understanding and surgical expertise to treat.

Vertical jaw deficiences usually present with a visible shortening of the lower third of the face. Other clinical findings include a very flat mandibular plane angle, some percentage of dental overbite at the incisors and downturning of the corners of the mouth. Patients usually know how to make their lower jaw look better by opening their mouth a bit vertically to create a longer jaw.

The hardest dimension to change in the lower jaw is the vertical one.  This is why vertical jawline augmentation is rarely written about or discussed. While the chin can be vertically changed by using one’s own bone through an opening wedge bony genioplasty, the ramus and body of the mandible must be vertically elongated by implants. Since there are no preformed vertical lengthenng jaw implants other than that of the chin, custom implants must be made for vertical change in the back of the jaw.

Case Study: This 23 year old male had a vertical jaw deficiency that he camouflaged by opening his mouth slightly. He felt that this made his face look better along his entire jawline as well as around his mouth. Measuring the vertical change at his incisors between when he occluded completely and when he felt he looked the best was 7mms.

Chin Implant Overlay on Sliding Genioplasty intraop Dr Barry Eppley IndianapolisUnder general anesthesia he had combined chin and jaw angle procedures for a vertical jawline augmentation effect. For the chin he had a sliding genioplasty that opened 7mms and brought the chin forward 8mms. A silicone chin implant was overlaid on front of the sliding genioplasty for greater horizontal projection. Vertical lengthening jaw angle implants were used for the back part of the jaw that dropped it down 10mms and widened it by 5mms.

Jawline Surgery result front view Dr Barry Eppley IndianapolisJawline Surgery result side view Dr Barry Eppley IndianapolisHis very early after surgery results showed a significant improvement in the lower third of his face. It was not only vertically longer but the chin and jaw angles had more definition.

Vertical lengthening of the entire lower third of the face can be done by either the three piece combined autologous/alloplastic approach as in this patient or it can be done by a complete custom implant. Each has their own advantages and disadvantages with the custom approach being more unified but also being more costly.


1) Lower jaw deficiencies can occur in the vertical dimension as well as in horizontal under development.

2) Vertical jaw deficiencies must be treated differently using vertical lengthening sliding genioplasties, vertical lengthening jaw angle implants or vertical lengthening custom total jawline implants.

3) Management of the chin determines the total overall approach to the type of vertical jawline augmentation done.

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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