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Archive for the ‘chin ptosis correction’ Category

Technical Strategies – Shortening Vestibuloplasty

Saturday, July 1st, 2017

 

Soft tissue malposition of the anterior lower face is manifest in several presentations. Chin ptosis or sagging refers to the hanging of the soft tissue chin pad off the end of the bone. It most commonly occurs from some type of chin surgery that has stretched out the soft tissue attachments. Chin implant removal is a classic example of its cause although not the only one. It can also occur from a sliding genioplasty setback, multiple intraoral chin surgeries and aging associated with alveolar bone loss.

Chin ptosis may also be associated with lower lip incompetence. As the chin pad tissue slides off of the bone it may pull down on the lower lip, creating lack of lip closure at rest and lower teeth show. This creates a dual negative perioral effect.

The most well known treatment for chin ptosis and/or lower lip incompetence is mentalis muscle resuspension. This well chronicled procedure reattaches the bony origin of the muscle higher up on the bone often at a position between the incisor tooth roots. The muscle drags up with it the overlying soft tissues of the chin pad correcting chin pad ptosis and pushing up the lower lip. While these effects of muscle manipulation often look good during surgery, they unfortunately are often not maintained as well as one would like particularly that of the lower lip.

As a result other adjunctive procedures are commonly done with mentalis muscle resuspension to help improve its long-term success rate. One of these procedures is a vestibuloplasty, specifically a shortening vestibuloplasty. The anterior mandibular vestibule is the lined space between the teeth and the lower lip. The depth of the vestibule is usually a reflection of the superior position of the mentalis muscle on the bone. With a deep vestibule the superior muscle attachment is located lower and often so is that of the lower lip.

In a shortening vestibuloplasty the mucosal lining of the depth of the vestibule is removed and a layered closure is done. This raises the height of the vestibule (shortens its depth) and helps provides support to the elevated lip.

Dr. Barry Eppley

Indianapolis, Indiana

Vertical Excision Technique for Chin Ptosis Correction

Monday, March 2nd, 2015

 

The number of different procedures available for correction of chin ptosis (chin pad ptosis) indicates that there is no one single procedure that works the best. While chin ptosis correction techniques vary, it is important to appreciate that there are different anatomic variants of chin ptosis. There are contributions of bone, skin and fat, mentalis muscle and lower lip positioning. Together these create different types of chin ptosis problems.

vertical wedge excision for chin ptosis correction 1vertical wedge excision for chin ptosis correction 2In Volume 3 Number 2 2012 issue of Plastic Surgery Pulse News, an article appeared entitled ‘A Novel Correction of Chin Ptosis By Vertical Wedge Excision of Subcutaneous Soft Tissue’. Using a single patient example, the authors describe a vertical midline wedge excision of soft tissue. In this technique the vertical laxity of the ptotic chin pad is tightening along the inferior border of the chin mental border while correcting the horizontal tissue laxity as well. The technique also improves anterior chin projection and softens the labiomental crease as well. This vertical wedge of mentalis and soft tissue when brought together creates a clothesline effect that helps reposition and suspend the ptotic tissues up over the lower anterior border of the mandibular symphysis. In the process, the soft tissues of the chin pad are rotated upward, augmenting the anterior chin and re-creating the labiomental fold. Any excess skin and subcutaneous fat is then trimmed in a horizontal fashion in the submental region.

Muscle Resuspension in Submental Chin Ptosis Correction Dr Barry Eppley IndianapolisThis vertical wedge excision technique for chin ptosis correction is based on tissue excision rather than tissue resuspension. That is a fundamental difference and requires an appreciation of whether the patient’s chin ptosis has a component of excessive chin tissues or not. By using a vertical excision of chin pad tissues, a vertical triangular excision creates a clothesline effect that allows the remaining chin pad to be positioned superiorly and anteriorly. It is easy to see why this technique could cause an abnormal bunching of chin tissues if the chin ptosis was caused by laxity and not excessive tissue as well. The authors acknowledge that this technique is not useful for every chin ptosis problem, particularly when there is already too much chin projection present.

Chin ptosis is a multifactoral problem that has different anatomic variants. The first important classification is whether the chin ptosis is associated with a lower lip sag or not. If there is no lower lip sag there is no benefit to mentalis muscle resuspension or trying to move the chin tissues back upon the one. The next important chin ptosis classification is whether there is excessive chin tissues or whether there is a normal amount of tissue volume. If the overhanging chin tissues are normal in volume, and their resection may be associated with causing a lower lip sag, then resuspension should be done. When the ptosis is caused by excessive chin tissues then resection would be the appropriate approach.

When it comes to resection of the chin pad, it can be done horizontally (under the chin), vertically (as shown in the article) or through a combined vertical and horizontal technique. (inverted T) There is no question that adding a vertical direction to the chin pad excision provides an additional element of chin pad reduction that is helpful.

Dr. Barry Eppley

Indianapolis, Indiana

 

Plastic Surgery Correction of Chin Ptosis

Saturday, April 4th, 2009

A chin that sags over the line of the jaw (chin bone) is called chin ptosis. (ptosis is medically defined as a sagging of a body part) While some people have this naturally, most of the time it is due to the soft tissues of the chin sliding downward for a reason. This can occur from simple aging, loss of one’s lower front teeth, and due to different surgical procedures of the chin. A few people actually have pseudo- or perceived chin ptosis which occurs as a result of a natural deep crease below the lower lip (submental crease) which makes the chin look ptotic (particularly when smiling) even though it is not.

Successful correction of chin ptosis can usually be done for those problems caused by prior surgeries. Chin surgeries that are well known to cause soft tissue sagging include the intraoral placement of implants, removal of an overly large implant and bony reductions. Other less common causes include intraoral access for repair of mandibular symphysis and parasymphyseal fractures and vestibular lowering procedures (preprosthetic surgery) in preparation for improved lower denture fit.

Treatment is  based primarily on resuspension or tightening of the mentalis muscles  with or without hard tissue chin expansion. For sagging caused by intraoral access to the chin, the mentalis muscles must be brought back up into their original anatomic position. The intraoral route of access to the chin always divides the upper attachments of the mentalis muscles. (some surgeons put them back well while others do not) This is why the submental (under the chin) skin approach for chin implants is always better with a very acceptable scar and why I use it in my Indianapolis plastic surgery prasctice.  It is not always easy to find good muscle to sew to and this is why a bone-anchoring technique with titanium screws or Mitek suture anchors is my preferred method for a ‘high’ reattachment.

If chin implant removal is the cause of sagging, replacement with a new implant alone may be satisfactory. Or if the patient no longer wants an implant but still desires an augmentation, moving the chin bone forward as a natural ‘implant’ may create enough expansion to fill out and elevate the sagging chin tissues. A chin osteotomy is an excellent opportunity to elevate the muscles as well as the plates and screws used to hold it in its new place are good anchoring points for the muscle.

Chin reduction procedures are especially prone to chin sagging problems after. The lower attachments of the mentalis muscle must be divided to access the chin bone. Once the bone is reduced by burring, the muscle and sometimes skin must be shortened and reattached. Usually tightening the muscle across the reduced bone and reattaching it to the muscle on the underside of the chin is adequate. If not, bone holes can be made on the inferior ledge of the chin bone onto which the muscle can be reattached.

 he chin is unique in that the mentalis muscle is attached and suspended across it  both above and below the chin prominence. The skin and fat are attached to the underlying muscle and follow its position on the bone. If the muscle sags, so does the appearance of the chin. The key to correction of chin ptosis is management of the mentalis muscle attachments in most cases.

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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