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Dr. Barry Eppley

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Archive for the ‘chin osteotomy’ Category

Case Study: Sliding Geniopasty with Indwelling Chin Implant

Sunday, May 3rd, 2015


Background: Horizontal chin augmentation can be done using either a synthetic chin implant or a sliding genioplasty. There are advantages and disadvantages with either approach and they must be considered in an individual patient basis. The decision in any patient ultimately depends on their perception of an alloplastic vs. an autogenous approach, the risks of the procedure and its recovery and what other dimensional changes of the chin that are needed beyond just that of the horizontal change.

But the use of a chin implant does not always produce the desired amount of chin augmentation change that every patient desires. This may be due to inadequate implant selection, the chin implant settling into the bone thus losing some horizontal projection, chin implant malposition or an accommodation to the initial chin augmentation result.

When further improvement is desired after an initial chin implant augmentation, the options are either a larger implant or to convert it to a sliding genioplasty method. A larger implant is usually done as this is the simplest revisional approach provided that a new implant can create the desired horizontal change. When a larger chin implant offers but a modest additional augmentation (e.g., 5mms or less) the the sliding genioplasty option becomes a consideration. It would be either that or have a custom chin/jaw implant made.

Chin Implant Settling (Erosion) Dr Barry Eppley IndianapolisCase Study: This 26 year-old male wanted additional chin augmentation after having a prior chin implant placed several years previously. He always felt that is lower jaw was smaller. His original chin implant provided 7mms of horizontal projection but it could be seen that it had settled into the bone a few millimeters. He opted for a sliding genioplasty as he felt that would more reliably give him long-term augmentation.

Sliding Genioplasty with Chin Implant intraop Dr Barry Eppley IndianapolisUnder general anesthesia, an intraoral approach was used to access the chin. The chin implant was easily identified and it was nestled nicely into the bone. A horizontal osteotomy cut was made above it from side to side and the bone downfractured. The chin segment was then advanced 12mms and stabilized with a step plate and screws. The chin implant was never moved from its original position during the procedure.

Sliding Genioplasty with Chin Implant result Dr Barry Eppley IndianapolisSliding Genioplasty with Chin Implant 3D CT scan Dr Barry Eppley IndianapolisA sliding genioplasty can be successfully done with an indwelling chin implant. It can be argued that this is a good technique to take advantage of some of the prior procedure (and investment) and gain additional horizontal augmentation. Whatever implant settling has occurred into the bone has already reached its peak and no further inward change would be anticipated.

Case Highlights:

1) An unsuccessful chin implant result can be improved by a sliding genioplasty.

2) It is not always necessary to remove an existing chin implant when doing a sliding genioplasty.

3) A sliding genioplasty can be performed by making the osteotomy cut above the chin implant and moving both forward simultaneously.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Sliding Genioplasty for Lower Facial Elongation

Tuesday, April 14th, 2015


Background: A sliding genioplasty is a well known and historic procedure for changing the shape of the chin. It was originally described in the 1940s but has evolved considerably due to the use of rigid fixation using plates and screws. While once clever osteotomy designs and wire fixation methods were used for stabilization of the bone segments, which limits how much the chin position could be changed, plate and screw fixation now makes virtually any bony chin change possible.

Sliding Genioplasty Indianapolis Dr EppleyFor chin augmentation, the chin implant is often compared to the sliding genioplasty as creating similar effects. But the reality is that this is only partially true and they are only comparable when it comes to pure horizontal movements as seen in the profile view. Vertical and width (narrowing) changes can not be done with an implant. (although newer vertical lengthening chin implants have recently become available)

The real benefits for a sliding genioplasty are when vertical elongation of the chin is needed and when the amount of chin advancement desired exceeds that of which standard implants can achieve. This would be particularly useful in women who can aesthetically tolerate a more narrow chin as it comes both forward and down. The other benefit for a sliding genioplasty in these more substantial chin changes is that it ‘carries’ the soft tissue of the chin pad with it and does not create a devascularizing effect due to maintaining most of the soft tissue attachments (and resultant perfusion) to the bone.

Case Study: This 26 year-old female had a short chin in both horizontal and vertical dimensions. Her lower facial height was disproportionate to the rest of her face. As a result, she appeared to have a full neck/double chin.  She knew she wanted her chin augmented but was just not sure how it should be done.

Sliding Genioplasty result side viewSliding Geniop[lasty result oblique viewUnder general anesthesia, she underwent an intraoral sliding genioplasty. A low horizontal bone cut was done and the chin was advanced 16mm forward and 8mms downward. This was the maximum amount of chin bone movement that could be done while still maintaining some bone contact between the segments. Rigid fixation was achieved by a titanium step plate and screws. The bone gap (step between the upper and lower bone segments was filled with demineralized bone particles. The mentalis muscle was resuspended at closure.

Sliding Genioplasty result front viewThe vertically opening sliding genioplasty can help make the lower face more proportionate by making bringing it forward and down. This will make the jawline have more of a V-shape and will also help get rid of a double chin problem due to lack of bony projection.

Case Highlights:

1) A sliding genioplasty is historically the only chin procedure that can provide both horizontal and vertical elongation of the chin. (custom made implants can now do that also)

2) A vertically opening sliding genioplasty with horizontal advancement will make the chin more narrow as a result of these bony movements.

3) Unless the bony chin movements are extreme, bone grafting of the interpositional gap between the chin segments is not necessary. Even when needed demineralized bone substitutes can be successfully used.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female V-Line Jaw Narrowing Surgery

Tuesday, March 24th, 2015


Background: Jaw or jawline reduction surgery is directed towards narrowing the lower third of the face. Very square or wide lower faces is either considered too masculine or aesthetically undesired in women in particular and in some men. While widely considered an Asian (particularly Korean) type surgery, it is becoming more commonly requested amongst Caucasians as well to help slenderize their face.

There are non-surgical and surgical methods for jaw reduction (so called V-line jaw surgery) based on the anatomy of the mandible and its soft tissue attachments. A wide lower face can be caused by masseter muscle enlargement due to congenital development or bruxism and is treated non-surgically by Botox injections. Masseter muscle reduction is often a necessary part of jawline narrowing but mandibular bone changes are usually the cornerstone of V-line jaw narrowing.

Inferior Alveolar nerve in Jaw line Narrowing Dr Barry Eppley IndianapolisIn narrowing the jawline it is necessary to create the visual effect of a less wide mandible from angle to chin. While it is commonly perceived that the bone is cut from the sides of the jawline from back to front, this is not how it is actually done. The location of the inferior alveolar nerve in the mandible as it courses through the bone and its exit from the mental foramen anteriorly make such a bone reduction approach surgically very difficult with a high risk of nerve injury. Thus most commonly chin and jaw angle bony procedures are done to create the v-line jaw narrowing effect,

Case Study: This 21 year-old female wanted multiple facial reshaping procedures done. One of her main areas of focus was her wide lower face and shorter chin. V-line jaw narrowing surgery was planned.

Jawline Narrowing Surgery result front view Dr Barry Eppley IndianapolisUnder general anesthesia, she initially underwent bilateral jaw angle reduction by outer cortical osteotomies combined with electrocautery of the inner surface of the masseter muscle. A horizontal chin osteotomy was then done with a 5mm midline ostectomy with a horizontal advancement of 7mms.

Jawline Reshaping result oblique viewJawline Reshaping result side view Dr Barry Eppley IndianapolisThree months after her V-line jaw narrowing, she showed a more narrow jawline in the front view and a longer jawline in the side view. Additional Botox injections will be done in the masseter muscle for further thinning in the jaw angle area.

In most V-line jaw narrowing surgeries, the body of the mandible does not need to be reduced to create the effect. Chin and jaw angle changes are enough in most cases to create an adequate jawline narrowing result.

Case Highlights:

1) Jawline reshaping typically strives to make the jawline more narrow and longer in the front view.

2) Most jawline narrowing techniques involve an anterior bony genioplasty and a posterior angle/ramus reduction.

3) As the chin becomes less wide (and sometimes vertically longer) and angles become less wide, the jawline becomes perceptibly more narrow and v-shaped.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Case Study – The Reversal Sliding Genioplasty

Monday, February 16th, 2015


Sliding Geniop[asty intraop technique Dr Barry Eppley IndianapolisBackground: Chin augmentation can be done by using either an implant or actually moving the chin bone.  A chin implant is by far the most common genioplasty method because it is simpler, less invasive and easily reversible. While the sliding genioplasty method can be done alone, it is almost always used when other facial bone surgery is being done. (i.e., orthognathic surgery) Its use is also highly influenced by the training and specialty of the treating surgeon.

Sliding Genioplasty result side view Dr Barry Eppley IndianapolisWhile a sliding genioplasty can provide a variety of dimensional changes to the chin, such changes do not always produce a pleasing outcome. Just like chin implants, the new chin can be unsettling because of an unfamiliarity of the ‘new’ face. Preoperative computer imaging can help reduce this risk significantly but it can rarely still occur. A sliding genioplasty can also cause a cascade of symptoms from numbness and tightness of chin tissues that did not exist before surgery. While such symptoms usually resolve within months of the surgery, for some they may not go completely away and their persistence may eventually become intolerable.

Reverting the chin back to its original preoperative position, or to just make it less advanced or lengthened, can be done through a reversal sliding genioplasty procedure. This is merely repositioning the chin bone by making a new osteotomy cut. But in considering to do so, it is important to look at the type of indwelling fixation hardware used (by x-ray) and what soft tissue impact may ensue. These factors along with how likely the aesthetic outcome may be achieved will determine whether a reversal sliding genioplasty is worth it.

Case Study: This 52 year-old male had a sliding genioplasty done seven years ago as part of a mandibular osteotomy to fix a malocclusion. He never really liked how it changed his chin and he had numerous persistent soft tissue symptoms from it including a tight chin and a lower lip sag from it. In addition, he could feel the notch in the jawline at the back end of the original osteotomy lines were the cuts went through the inferior border. After much thought he finally decided to have it reversed.

Sliding Genioplasty Reversal result oblique view Dr Barry Eppley Indianapolis IndianaUnder general anesthesia, an intraoral approach was done using his original vestibular mucosal incision. The chin bone was exposed and the lower end of a metal fixation plate and screws were removed. (the upper end of the plate was grown over with bone) An osteotomy cut was made with a saw at the obvious stair step shape in the chin bone.  Once the bone was downfractured it was able to be pushed back until the outer shape of the chin was flush across the osteotomy. After securing with 1.5mm plate and screws, a mentalis muscle resuspension was performed as well as V-Y mucosal lower lip advancement/closure.

A reversal sliding genioplasty is performed similarly to the original advancement. Preoperative attention needs to be paid to what type of original bone fixation hardware was used to ensure it will not be problematic to remove or is in the way of the new osteotomy cut. Since the chin tissues are stretched forward what happens to the attached soft tissues along the jawline and in the central neck needs to be considered.

Case Highlights:

1) A sliding genioplasty is one method of chin augmentation that creates a natural effect by moving the chin bone below the level of the front teeth.

2) While a bony genioplasty usually leads to a significant chin augmentation effect and a satisfied patient, some can find the effect too much and may yearn for a return to their former self.

3) A sliding genioplasty can be reversed months to years later by recutting the original osteotomy line and setting/sliding the bone back.

Dr. Barry Eppley

Indianapolis, Indiana

Sliding Genioplasty Modification for Jawline/Lower Facial Reshaping

Sunday, November 9th, 2014


In facial reshaping surgery, it is important to appreciate the differences between a Western vs an Asian type face. While a strong jawline is attractive by Western standards, a more narrow lower face that makes an oval or a v-line look is preferred. To achieve this Asian form of mandibular contouring surgery, various forms of sliding genioplasties and lower border mandibular ostectomies have been developed.

The greatest variance amongst the various forms of mandibular contouring has been that of the chin. And the chin also makes the greatest contribution for most patients to the lower facial shape. Reducing the horizontal width of the chin through a central segment bone resection is the most common technique used with a horizontal sliding genioplasty. However this method does not specifically reduce the height of the chin unless a horizontal wedge resection of bone is done at the same time.

In the October 2014 issue of Plastic and Reconstructive Surgery Global Open issue, the article entitled ‘Inverted V-shape Osteotomy with Central Strip Resection: A Simultaneous Narrowing and Vertical Reduction Genioplasty’ was published. In this paper, the authors introduce a simple but very effective method to reduce the chin width and length simultaneously with an inverted V-shaped osteotomy and central segment resection instead of a horizontal osteotomy and central segment resection. Over a three year period, nearly 550 patients (75% female) underwent mandibular contouring surgery of which over 300 were treated with this narrowing and vertical reduction genioplasty technique. No significant complications occurred other than about 1/3 of the patients experienced transient mental nerve numbness which went on to full recovery.

While there are different ways to change the bony shape of the chin, this ingenious method is a clever geometric modification of a traditional linear approach to a sliding genioplasty.The square and long face can be effectively changed into a more slender oval shape as the chin is similarly changed. It also requires a minimal amount of plate and screw fixation and appears very stable for optimal healing.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Case Study: Maxillomandibular Advancement for Sleep Apnea and Improved Facial Profile

Sunday, November 2nd, 2014


Background: Sleep apnea, specifically called OSA or obstructive sleep apnea, can be a limiting condition that adverses affects one’s daytime life. This is evident by excessive daytime drowsiness and problems in concentrating and memory loss. The causes of sleep apnea have been well documented and can involve multiple sites along the nasopharyngeal airway passages for which various types of surgeries can be done.

Obstructive Sleep Apnea Indianapolis Dr Barry EppleyIn severe cases of OSA, the posterior airway can only be improved by moving the base of the tongue  and soft palate forward. This is done by moving the jaws forward, known as maxillomandibular advancement. By moving the upper jaw (maxilla) and lower jaw (mandible) forward, the entire airway is enlarged. This procedure serves as the most effective surgical treatment for obstructive sleep apnea. It is usually performed in a hospital under general anesthesia and takes about four hours to complete. Patients usually remain in the hospital for several days after the surgery and can return to work weeks later when much of the facial swelling has gone down.

Unlike traditional orthognathic surgery, the integrity of one’s bite (occlusal relationship) is not changed. As both jaws come forward the same bite relationship is maintained through the use of small titanium plates and screws. As a result of these plates and screws, the jaws do not need to be wired after surgery.

Maxillomandibular Advancement Surgery Dr Barry Eppley IndianapolisIt is generally recommended that the forward jaw movements be at least 10mms. This creates the maximal change that can be achieved by opening the entire airway space. Its success rate has been documented in numerous studies has being fairly high with a greater than 80% to 90% chance of success for patients with an AHI (apnea hypopnea index) less than 15.

However, moving the jaws forward does have aesthetic consequences. The lower face can  become disproportionate to the lower face as the jaw bones come forward leaving the orbital and forehead skeletal structures behind. This can create an undesireable facial protrusive appearance. Proper presurgical selection and patient education with imaging is important to make patients aware of these potential changes.

Case Study: This 26 year-old female suffered from severe obstructive sleep apnea. Sleep studies showed that her ANI was 8 and she did not want to wear a CPAP device. She had significant daytime tiredness with chronic red eyes. She chronically looked very tired.

Orthognathic Surgery for Obstructive Sleep Apnea Computer Planning Dr Barry Eppley IndianapolisA 3D CT scan was obtained from which virtual surgical planning was done. It was elected to move the maxilla and mandible forward 7mms and combine that with a sliding genioplasty movement of 9mms forward with a slight vertical opening. Cephalometric, model and photographic analysis was also done to see how these changes would look. Her existing bite was already orthodontically corrected into a Class I relationship.

During surgery, a one-piece maxillary advancement was done of 7mms using an interpositional occlusal splint. (computer made from the stone models) Bilateral sagittal split mandibular osteotomies were then done of 7mms placing it into occlusal relationship with the already advanced maxilla using a final occlusal splint. Finally a sliding genioplasty was performed bringing it forward 10mms with 3mms of vertical opening. Al bone segments were secured by titanium plates and screws and no jaw wiring was used after the surgery.

Orthognathic Surgery for Obstructive Sleep Apnea Dr Barry Eppley Indianapolis side viewOrthognathic Surgerry for Obstructive Sleep Apnea Dr Barry Eppley Indianapolis front viewHer after surgery results (a one month) showed a dramatic positive change in her facial appearance with a better facial profile and facial length. This is not surprising given her significant short mandible, chin and neck. Her sleep apnea had also improved with complete resolution of her daytime sleepiness. The tired red eye look was replaced by a more awake white-eyed appearance.

Orthognathic Surgery for Obstructive Sleep Apnea Dr Barry Eppley IndianapolisUndesireable facial changes can occur in some patients after maxillomandibular advancement for sleep apnea. Upper lip protrusion, an open nasolabial angle and bimaxillary protrusion can result from this surgery for certain facial types. Those patients who have a preoperative dolichofacial (long)) or brachyfacial (short) facial types will usually have improved aesthetic outcomes from maxillomandibular advancement for OSA.

Case Highlights:

1) Bimaxillary advancement (upper and lower jaws) can be a very effective treatment for severe obstructive sleep apnea.

2) While moving the jaws forward as much as possible gets the best chance for sleep apnea improvement, it can also cause a facial disproportion and an undesireable change in one’s appearance.

3) Moderating the amount of jaw movement to what aesthetically improves the face as well is an important consideration in treatment planning.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies in Plastic Surgery – Combining Chin Implant and Sliding Genioplasty for Large Chin Augmentations

Friday, October 10th, 2014


Chin augmentation can be done by a variety of surgical methods including a chin implant and a sliding genioplasty. Each of these aesthetic chin techniques has a role to play and they have their own advantages and disadvantages. But both have the same limitation…a limit to how much the chin can be horizontally projected. Chin implants are not made with standard thicknesses that are greater than 10 to 12mms. A sliding genioplasty can only be moved as far as the thickness of the bone will allow which can vary between 10mm to 16mms.

The horizontal movements provided by standard chin implants and sliding genioplasties are sufficient for the vast majority of patients with chin/jaw deficiencies. But they can be inadequate for the few patients that have horizontal chin projection deficiencies that exceed 15mm and may be as significant as 25mms.

Sliding Genioplasty and Chin Implant Dr Barry Eppley IndianapolisChin Implant and Sliding Geniplasty in Large Chin Augmentations Dr Barry Eppley IndianapolisCombining a sliding genioplasty with an implant is a novel method to achieve larger amounts of chin projection that I have done for years. Through an intraoral approach, which is needed for a sliding genioplasty, the implant is placed on the chin bone just one would normally do. It does need to be secured into placed by screw fixation otherwise it would easily become displaced. A chin implant with long wings also has the advantage of covering over the bony step-off that often occurs at  the back end of the osteotomy.

Very large chin deficiences can be managed by the creation of a custom implant but combining an implant and a sliding geniplasty may be sufficient in some of these cases. In my experience there has been no higher infection risk when placing an implant on top of a sliding genioplasty than when using a chin implant alone.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Sliding Genioplasty for Obstructive Sleep Apnea Improvement

Sunday, September 7th, 2014


Background: Chin augmentation with a sliding genioplasty is a well known aesthetic technique. It is not done as commonly as a chin implant but in the right patient has its own advantages. One of its benefits is that it brings the chin forward with its attached tongue-side musculature as well as lengthening the jawline. By so doing it can help smooth out the neck better than an implant which just pushes out the soft tissue chin pad and has no direct effect on the neck muscles behind it

genioglossus and geniohyoid muscles attached to the chinThe main muscles that a sliding genioplasty pulls forward is the genioglossus and geniohyoid. The genioglossus is a fan-shaped tongue muscle which comprises most of the tongue. Its origin is the spine on the back side of the chin bone and inserts into the hyoid bone and the bottom of the tongue. Its contraction enables one to stick their tongue out as well as enlarges the upper airway behind the base of the tongue. The geniohyoid muscle lies below the genioglossus but above the mylohyoid muscle. It runs from the back of the chin down to the hyoid bone and its contraction dilates the upper airway as it pulls the hyoid bone upward and forward.

Because of the attached muscles that accompany a sliding genioplasty, it could have an effect very similar to a direct muscle procedure used to treat obstructive sleep apnea. A genioglossus muscle advancement is an intrachin procedure where the genioglossus muscle is brought forward by using a window of bone in the chin. It is usually part of other obstructive sleep apnea procedures and is rarely done alone since obstructive sleep apnea almost always involves various structures at different areas of the airway. It is limited to a forward muscle movement that is no further than the thickness of the chin bone.

Case Study: This 46 year-old male presented with symptoms of obstructive sleep apnea and a short lower jaw.  He wore CPAP at night. He had a class II malocclusion and an overall heavy face appearance. He was overweight but certainly not obese. He had significant daytime sleepiness. A sleep study showed multiple apneic episodes greater than 10 seconds and a drop in oxygen saturations to 84%. His apnea-hypopnea index (AHI) was 25. He did not want a maxillomandibular advancement.

Sliding Genioplasty Technique for Obstructive Sleep Apnea Dr Barry Eppley IndianapolisUnder general anesthesia, an intraoral approach was used to deglove the chin. A mid-level near horizontal osteotomy bone cut was made through the chin keeping the muscles attached to the lingual side of the chin. The chin was brought forward 16mms and stabilized with central step plate as well as two side plates due to the magnitude of the movement.

Obstructive Sleep Apnea Sliding Genioplasty result sidew view Dr Barry Eppley IndianapolisAfter surgery he had a significant increase in chin horizontal position and an improved facial profile. Despite the very large chin movement, his chin projection was not excessive. He had improvement in his sleep apnea symptoms but not a complete cure of it as was expected before surgery. His sleep study numbers improved to an AHI of 15.

Obstructive Sleep Apnea Sliding Genioplasty result front view Dr Barry Eppley IndianapolisFor a genioglossus movement to be effective, its forward movement must be considerable. (greater than 15mms) This is not usually possible with the traditional technique of moving the genial tubercle alone. This sliding genioplasty was beneficial for this patient’s sleep apnea symptoms because of the magnitude of its movement. His initial lower jaw retrusion permitted a large sliding genoplasty movement.

Case Highlights:

1) One type of occipital skull deformity is that of the prominent nuchal ridge which forms a raised horizontal ridge across the back of the head.

2) The prominent nuchal ridge should not be confused with the occipital knob which is a raised button of bone at the center of the nuchal ridge.

3) Nuchal ridge reduction is done through a small horizontal incision over the central part of it.

4) Some patients with a prominent nuchal ridge have intermittent occipital headaches due to tight neck muscle attachments.

Dr. Barry Eppley

Indianapolis, Indiana

Management of the Step-Off in a Sliding Genioplasty

Sunday, March 30th, 2014


A sliding genioplasty is a well known method of chin augmentation. It is often compared to a chin implant when considering aesthetic changes to the chin as a more natural alternative. But the reality is that its indications for use are somewhat different than an onlay bony augmentation. It is often only used when the amount of chin augmentation is considerable, certain dimensional chin changes are needed (vertical lengthening, width narrowing) or some functional improvement is desired. (e.g.,  lower lip incompetence, mentalis muscle hyperactivity, sleep apnea)

Sliding Genioplasty Dr Barry Eppley IndianapolisWhen a sliding genioplasty is performed, unlike a chin implant augmentation, it creates a sharp step-off between the upper fixed and lower repositioned bony edges. Essentially it is a stair-step effect whose degree and angulation depend on what type of bony movement is done. The bigger the horizontal advancement or the amount of vertical lengthening that is done, the more significant this step-off is.

The step-off in a sliding genioplasty can be more than an anatomic observation. This bony area provides support to the overlying upper soft tissue chin pad and part of the labiomental fold or labiomental sulcus. While it does not provide exclusive support to the labiomental fold, a significant bony step-off from a sliding genioplasty can make it deeper or more indented.

Filling in the sliding genioplasty step-off can be a useful aesthetic maneuver to help make for a more natural chin shape. Numerous alloplastic materials have been advocated for this induced bony contour defect from silicone and Medpor implants to even bone grafts. But getting a good adaptation and adequate fill can be challenging not to mention the alloplastic nature of some of these graft choices.

Hydroxyapatite Granules in Sliding Genioplasty Dr Barry Eppley IndianapolisOne of the best and most historic bony replacement/augmentation methods is hydroxyapatite (HA) granules. Composed of either resorbable or non-resorbable calcium phosphate materials, their granular form allows for a complete fill of a bony defect. Packing granules into a bony defect creates a porous graft that allows for extensive vascular ingrowth and some degree of bony ingrowth or even bone replacement. This is an ideal material for the step-off of a sliding genioplasty which can either be used as a simple fill in or can be packed into an overfilled shape for more of a soft tissue augmentation effect.

While not every bony genioplasty step-off needs to be filled in or augmented, large chin movements can prevent adverse overlying soft tissue effects.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Sliding Genioplasty for Obstructive Sleep Apnea

Sunday, November 10th, 2013


Background: Sleep apnea is a well known nocturnal disorder in which one’s breathing is either very shallow or actually pauses during sleep. It is the length of these breathing pauses that are significant as they result in a drop of one’s oxygen levels due to decreased air intake. This creates a variety of medical problems not the least of which is daytime drowsiness. Definitive diagnosis of sleep apnea requires a sleep study or polysomnogram.

There are different causes of sleep apnea but by far the most common is located in the nasal or oral airway, known as obstructive sleep apnea. (OSA) This is where one’s breathing is interrupted by an actual blockage to the airway which is evident by snoring due to the turbulent flow of air around the obstruction. There are many risk factors associated with OSA including being overweight, smoking, age, male gender, large tonsils adenoids and diabetes.

OSA has been treated by a wide variety of surgical procedures as secondary treatment options when either CPAP fails or is not desired. These all address obstructive elements along the nasal and oral airway and can include septoplasty and turbinate surgery, tonsillectomy and adenoidectomy, uvulopalatopharyngoplasty, soft palate pillarplasty, radiofrequency base of tongue treatments, genioglossus base of tongue advancements, hyoid bone myotomy and suspension and maxillomandibular advancement surgery. Moving the upper and lower jawbones forward can be the most effective OSA surgery because it increases the posterior airway space although it is the most invasive.

In OSA patients that have a short jaw (and an obvious short chin), it is easy to see how moving the jaw forward will carry the base of the tongue with it. This opens up the airspace behind the tongue or at least adding support for the tongue to not fall back as much when one lays down. But in the patient with a short lower jaw who does not want to move the whole jaw forward, will just a sliding genioplasty help?

Case Study: This 48 year-old male had documented OSA but was not particularly compliant with CPAP. He had a moderately short lower jaw that measured an 8mm  horizontal distance between his upper and lower incisor teeth. (8mms overjet) In profile his chin was short and he had a thicker bullish neck. He was moderately overweight.

Under general anesthesia, an intraoral approach was used to access the bony chin. A sliding genioplasty was performed and the chin bone was brought forward 16mms and vertically lengthened by 4mms. It was secured by a 2.0mm titanium step plate with two screws above and below the osteotomy cut. Due to the large chin advancement, additional plates and screws were placed on the sides of the chin for additional stability. The mentalis muscle was resuspended and the intraoral incision closed.

After surgery, he had an immediate improvement in his OSA symptoms by polysomnogram testing. His apneic episodes dropped by over 70% and his oxygen saturations did not drop below 93%.at any time during the test period. His chin profile showed a substantial change although the amount of chin projection did not look a great as the amount that the bone was moved.

A sliding genioplasty is the most extreme form of a genioglossus advancement. The genioglossus muscle remains attached to the lingual cortex of the downfractured chin segment and is carried forward as the bone is moved. While there is no exact known measurement that the genioglossus needs to be moved forward to create posterior airway space improvement, one would suspect that it would need to be at least 10mms. It is no surprise then that a 16mm chin advancement offers some improvement in OSA symptoms.

Case Highlights:

1) A sliding genioplasty moves the chin bone forward and with it comes the attachment of the geniglossus muscle which pulls on the tongue.

2) Forward tongue positioning may be beneficial  in some select cases of sleep apnea associated with a posterior airway obstruction due to tongue collapse.

3) In patients with a short chin who have sleep apnea, a sliding genioplasty may provide sustained reduction in airway obstructive symptoms.

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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