EXPLORE
Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Archive for the ‘chin reduction’ Category

Case Study – Female Submental Chin Reduction

Sunday, February 11th, 2018

 

Background: Chin reduction remains an infrequently performed and challenging procedure. It is a far ‘simpler’ aesthetic prospect to stretch out the soft tissues of a bony prominence through implants or osteotomies (chin expansion) than it is to do a bony chin reduction. While often believed that simple burring of the bone from an intraoral approach will work, and it does for horizontal bony reduction, it often creates secondary soft tissue issues.

When soft tissues are detached from the bone and the bone support simultaneously reduced, there is a high risk of a subsequent soft tissue sag. This is well chronicled in both chin and cheek reductions. While it would be great if the facial soft tissues always contracted and shrunk down around areas of reduced bone support…this is not always so.

Appreciation of soft tissue sags and redundancies serves as the basis for a submental chin reduction approach. And it also is how soft tissue problems after other chin reduction approaches are managed.

Case Study: This female was bothered by her overprojecting chin. This was present both at rest and when smiling. It was too vertically long and had slightly too much horizontal projection. Its width and current shape was acceptable.

Under general anesthesia and through a submental incision, a 5mm vertical bony chin reduction was initially done. Then a 3mm horizontal bony chin was done. A full-thickness segment of skin, fat and muscle was removed and the soft tissues tightened around the reduced chin bone.

The submental chin reduction technique provides direct visual access for the best 3D bony chin reduction result. It allows the opportunity to do so while staying well below the exit of the mental nerve from the sides of the bone, making the risk of lip numbness negligible. It also allows for the opportunity, and almost always a necessity, to reduce excessive soft tissue and tighten it around the chin bone.

But the submental chin reduction does place a scar under the chin and this is always an aesthetic concern. These scars typically heal well and the incisional appearance is almost never a concern. There may be a need for a secondary submental soft tissue revision as the desire to limit the length of the scar must be balanced against how much soft tissue to remove. during the tuck part of the procedure. This means that occasionally there may be some soft tissue redundancies (dog ears) that appear at the end of the incision only seen after complete healing.

Highlights:

1)  A 3D chin reduction is often done best by a submental approach.

2) With bone reduction often comes the need for soft tissue reduction as well to prevent soft tissue pad sagging or excess.

3) The submental chin reduction incision heals well but soft tissue redundancies at their ends may need to be revised secondarily.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Chin Asymmetry Correction

Saturday, January 6th, 2018

 

Background: The chin is the most projecting part of the lower face. As the most anterior projecting point of the mandible, the chin puts the overlying soft tissue under the most tension of any area of the face other than the nose. As a result the shape of the symphyseal chin bone is readily seen. Whether the chin bone is round or more square or whether a cleft occurs in the bone, its shape is reflected on the overlying soft tissue pad between the mouth and the neck.

While having a clear idea of the shape of the chin bone can be aesthetically advantageous in some people, it is not so when chin bone asymmetry exists. It is striking that even small amounts of differences in the shape of the chin between the two sides can be so readily seen. Such asymmetry, like that of the nose, draws the eye right to it.

The origin of such bony chin asymmetry impacts the treatment needed to correct it. Many such asymmetries come from a developmental issue of the lower jaw and the chin part of the asymmetry is really just a symptom of the overall problem. Other chin asymmetries are more discrete and are isolated just to the chin bone itself. They often occur from trauma to the chin, usually at a younger age, and is the result of a subperiosteal bleed and ossification of this subperiosteal collection of fluid over time.

Case Study: This young male had chin asymmetry that occurred from a fall as a child. He otherwise had a symmetric face and a normal occlusion.The left side of his chin stuck out more than the right and appeared like a bump projecting outward and downward.

Under general anesthesia a 3 cm submental incision was made. After wide superiosteal undermining that exposed both sides of the chin, a reciprocating saw was used to remove the excessive horizontal and vertical components of the longer asymmetric side of the chin. A handpiece and burr was then used to smooth out any sharp edges.

In chin asymmetry the first consideration is which is the preferred side, which is what looks best to the patient. If the smaller shorter side is preferred then reduction must be done to the larger side. Such reductions rarely are one-dimensional. Think of the asymmetric bone as a three-dimensional problem. (horizontal projection, vertical lengthening and excessive width) With that in mind the next consideration is the surgical approach. (intraoral vs submental) While avoiding a scar, when possible, is always preferred it should not supersede the ability to do a complete 3D reshaping. This is why I prefer the submental incision in many chin asymmetry cases.

Highlights:

1) Most chin asymmetries are bony in origin with the overlying soft tissue mirroring the shape of the underlying bone.

2)  A chin asymmetry often has a 3D component to it and this must be considered in the treatment planning.

3)  Discrete bony chin asymmetries are optimally treated through a submental incision with a shaving technique to the bone reshaping.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Aesthetic Correction of the High Angle Jaw Deformity

Saturday, December 23rd, 2017

 

Background: The shape of the jawline consists of various anatomic zones that has numerous dimensions. While the most common aesthetic concerns are a chin that does not have enough horizontal projection or jaw angles that are not wide enough, there are many other types of aesthetic deformities of the jawline.

One such undesired jawline shape is that of the ‘high angle jaw deformity’. This is a jawline shape that has high vertically short jaw angles at the back end and a vertically long chin on the front end. The resultant slope of the jawline creates a high mandibular plane angle. The mandibular plane angle is traditionally described by cephalometrics as the angle formed by the intersection of the Frankfort horizontal line with a line drawn through the mandibular plane. (Frankfurt Mandibular Plane Angle or  FMPA) The normal range for the mandibular plane angle is around 22 degrees +/- 5 degrees.

Short of doing an x-ray analysis, the alternative way is to measure the interaction of the mandibular plane line with that of horizontal line drawn for the lowest chin point back. This will roughly create a similar angle number as that of the FMPA.

The high angle jaw deformity creates a hyperdivergent face where the chin can look and actually be long, the back of the jaw looks deficient/missing and the face can seem long and narrow. Creating an improved lower facial shape requires elongating the jaw angles and shortening the chin.

Case Study: This young female was bothered by the shape of her jaw, feeling that her chin was long and her jaw angles too high. This gave her a steep mandibular plane angle and a long thin face.

The concept for her aesthetic jaw surgery was to elongate the jaw angles with implants and vertically reduce the chin bone.

Under general anesthesia an intraoral approach was used to perform a wedge reduction bony genioplasty. A 5mm wedge of bone was removed and the downfractured chin segment put back together with small plates and screws. Through intraoral posterior vestibular incisions custom jaw angle implants were placed that lowered the jaw angles by 10mms (5mm width) and had long anterior wings that came forward to the back of the bony genioplasty cut.

Short of orthognathic surgery correction of a high angle jaw deformity requires alteration of the front and back ends of the bony jaw. While bone removal can vertically shorten the chin, custom designed implants are needed to drop the jaw angles down.

Highlights:

1) A high jaw angle can be associated with a vertically long chin.

2) Reshaping the high mandibular plane angle jaw consists of vertically lengthening the jaw angles and vertically shortening the chin.

3) Custom jaw angle implants are needed to create the smoothest jawline that joins with the reduced chin.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Submental Chin Reduction and the Geniohyoid Muscle

Friday, December 15th, 2017

 

Chin reduction is the least commonly performed chin reshaping procedure. This is because how to reduce a large chin is not well known or practiced by most plastic surgeons. While a reverse sliding genioplasty is commonly believed to be an effective chin reduction procedure, it is not. Pushing the bone back with its attached tissues ends up creating increased submental fullness as well a bony bulge along the inferior border of the jawline. Similarly simple burring of the bone from an intraoral approach only reduces its horizontal projection and risks creating soft tissue chin pad ptosis as a result.

The submental approach to chin reduction is a far more effective procedure. The bone can be reduced in any dimension and any excess soft tissue can be reduced at the same time. This is best exemplified when vertical bone height is being reduced along with excess horizontal projection and width. In removing a horizontal wedge of the inferior border of the chin to reduce its height, the cut inferior wedge of bone will have the genioglossus muscle attached. This muscle attachment should not just be cut and released as the bone segment is removed.The retracted muscle can pull downward toward the hyoid and can create increased submental fullness.

To prevent this muscle contraction possibility, the genioglossus muscle attachment is removed from the wedge of bone and grasped with suture. This suture allows the muscle to be reattached to the inferior cortex of the now shortened chin through a hole placed in the bone. This restores the muscle and its length to where it originally belongs. As the chin is vertically shortened any increased fullness of the submental region below it would be aesthetically disadvantageous. Keeping tension across the geniohyoid muscle will help prevent that from occurring.

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 – The Submental Chin Reduction Technique for Horizontal Macrogenia

Tuesday, December 5th, 2017

 

Background: While chin augmentation is a very common aesthetic facial reshaping procedure, reduction of a prominent chin is not. Not only are the patient requests for macrogenia reduction far fewer, but the techniques to do so have completely different considerations. In chin implant augmentation the issue is whether there is enough soft tissue to accomodate the amount of augmentation needed. In chin reduction surgery the questions are whether enough bone can be reduced and what happens to the overlying soft tissue in doing so.

Historically, and to some degree today, chin reduction is viewed as the reverse of a sliding genioplasty. If the bone can be cut and moved forward for increased projection it should similarly be cut and moved back for lessening chin projection. But in reducing a chin prominence there is always the issue of managing the ‘extra’ soft tissue which is a non-consideration in the expansile effects of chin augmentation. In reality a sliding genioplasty is a poor method for horizontal chin reduction in most cases as it results in a bulge of soft tissue below the chin as that is where the excess soft tissue ends up pushed back by the bone..

Similarly in an intraorral chin reduction burring technique, there is always the risk of the soft tissue redundancy (and the loosen soft tissue attachments) falling off the end f the bone, creating chin ptosis.

Case Study: This 60 year-old female had been bothered by her prominence chin for many years. She felt it stuck out too far horizontally and she sought a maximal chin reduction effect.

Under general anesthesia and through a submental incision, the soft tissue was degloved from the bony chin. A high speed handpick and burr was used to reduce the projection of the chin by 8mms from side to side and cross the central chin projection. This required removing the outer cortex of bone and exposed the marrow space. Bone wax was used to stop the bleeding from the marrow space and provide a permanent seal.

The soft tissue chin pad was brought back over the flattened bony prominence, excess full-thickness tissue removed as per the preoperative markings and the mentalis muscle sewn to the periosteum on the underside of the inferior border of the chin to tighten down the chin pad. The posterior neck skin edges were then closed to it. (she also had upper and lower lip advancements done)

The combination of bone and soft tissue reduction creates the greatest amount of chin reduction that is possible. Only the submental chin reduction technique treats all components of significant horizontal macrogenia.

Highlights:

1) Macrogenia or chin hyperplasia always affects both bone and soft varying degrees.

2) The submental chin reduction technique is best for when significant chin reduction is needed.

3) Burring reduction of the bony chin from below allows for a lot more bone reduction than can be achieved from any intraoral approach.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Submental Chin Reduction

Saturday, November 25th, 2017

 

Unlike chin augmentation, chin reduction surgery is performed far less commonly. As a result, it is not a well understood procedure in terms of proper diagnosis and technique. While chin reduction is often perceived as an intraoral bony burring procedure, this is a very limited procedure that is rarely effective and often leads to postoperative ptosis problems. There are very indications for it.

Many chin excess problems are a combination of both bone and soft tissue. It is hard to separate the two as bone reduction alone causes a potential lack of overlying soft tissue support creating a tissue sag. While an intraoral osteotomy approach does maintain the attachments of the lower soft tissue chin pad (and this helps in preventing ptosis), the chin osteotomy technique limits what bony dimensional changes are possible and can still not get rid of a large soft tissue pad.

The submental chin reduction technique offers the greatest possibilities for total chin change of both bone and soft tissue. While there is the disadvantage of a scar to do so this is often not as big of a concern to patients (who are mainly female) as many surgeons may think.

Coming from below the bone can be reduced in any dimension one desires by shaving and with virtually no risk of any mental nerve injury. Whether this be in a vertical or horizontal shortening, or often in a combination of both, the end of the chin bone can be reshaped as needed.

As valuable as the versatility of the bony changes are, the submental approach is the only method for adequately dealing with the soft tissue. The soft tissue chin pad can be reduced by a full-thickness crescentic excision or, at the least, a submental tuck of tissues can be done.

One important feature of coming from below in chin reduction is the possibility of resuspending the neck tissues that are often need to be detached when performing a vertical bone reduction. By doing so this prevents a secondary submental fullness which is what occurs when a sliding genioplasty is done in reverse.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Submental Approach to Chin Reduction

Friday, November 10th, 2017

 

The chin is the projecting feature of the lower face and consists of combined bone and soft tissue. While the chin may be more commonly recognized for treatment of deficiencies in its size and projection, it is also prone to the opposite issues of excess and sagging. Chin bony overgrowths (hyperplasia), chin pad sagging (ptosis) and hyperdynamic chin pad protrusions are all a collection of aesthetic chin prominences.

Unlike augmenting the chin with an implant or moving the bone which can be done in an intraoral scarless manner, decreasing the size of the chin can rarely be so done. By definition most chin excesses are a combination of bone and soft tissue which must be both addressed for an effective aesthetic change. This eliminates the use of an intraoral approach in many cases as this access provides no method for soft tissue removal or tightening. The intraoral approach can be used to try and lift up the sagging chin pad in some cases of ptosis but this has very variable amounts of success.

When using a submental approach for chin reduction, the key is the location and length of the scar. The incision and resultant scar must be placed far enough back under the chin so it does one end up on the visible anterior edge of the chin. But the length of the scar is also of critical importance to limit its potential visibility. When removing redundant soft tissues (submental excision and tuck), it is easy to end up chasing redundancies at the end of the incisional closure and have a longer scar that one may have initially anticipated. If the scar becomes too long or curves up at the ends it may become visible from the side.

The method that I use to eliminate the risk of a long submental scar that may become visible is to keep it within the width of the sides of the mouth above. Dropping a vertical line down from the mouth corners and angling it inward as it crosses the jawline into the neck provides the limit of how far the submental scar line can extend out laterally. These marked lines provide a guideline during a submental chin reduction of how aggressive one can be.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Submental Technique for Bony Chin and Jawline Asymmetry Correction

Wednesday, October 25th, 2017

 

Background: Lower facial asymmetry is most commonly associated with the shape of the jawline. While patients often present with chin asymmetry, closer inspection often reveals that it extends back along the jawline as well. With the chin asymmetry the jawline on the longer chin side is lower and conversely it is higher on the shorter chin side. A debate can be had about which is the normal side and whether the condition is hypoplasia or hyperplasia which has great relevance when it comes to treatment planning.

True lower facial bony asymmetry has soft tissue asymmetries as well which would be consistent with that of a developmental origin. The lips will be tilted with different horizontal positions of the mouth corners. The base of the nostrils will be tilted and even the eyes may have subtle differences in the horizontal lines between the inner and outer canthi. Most of these soft tissue asymmetries are far less correctable than that of the underlying bone

Correction of chin and jawline asymmetry must take into consideration numerous anatomic factors. In the chin area the short length of the tooth roots do not pose any restrictions for the amount of bone that can be removed. But in the jawline behind the chin the location of the inferior nerve as it courses through the bone is, however, a potential surgical restriction. When vertical bone reduction is indicated (facial hyperplasia) preoperative x-rays are needed to determine the limits of these bony changes.

Case Study: This young female presented with chin asymmetry with a longer right side and a visible tilt of the chin to the left. Physical and radiographic examinations  showed that a right facial hyperplasia was the cause with vertical elongation of the entire jawline which drove the position of the chin to the opposite side. This was evident at facial rest but more apparent when smiling. A panorex x-rays showed the amount of bony differences between the two sides with the jaw angles and intrabony nerves highlighted.

Under general anesthesia a submental approach to the chin and right jawline resha[ing was used. Initially the chin asymmetry was addressed by an inferior border shave across the bone, horizontal deprojection and a left corner angled reduction. The right jawline ws reduced by an inferior border shave of 7mms back to the anterior attachment of the master muscle. Redundant soft tissue was removed over the chin area and the muscles reattached along the chin with sutures suspended to bone holes.

The immediate intraoperative view of the chin showed he improved symmetry as well as an overall rounding effect to ‘desquare’ the chin as well. The cant of the smile line and occlusion above the chin will remain the same as before surgery as would be expected.

The aesthetic management of the chin and jawline asymmetry from hyperplasia that does not include occlusal adjustments is based on removing bone along the inferior and/or inferolateral border. The submental approach offers a direct line of sight method doing so with the greatest accuracy and safety to the inferior alveolar nerve. The fine line scar under the chin is a reasonable aesthetic tradeoff for these more predictable any changes. Radiographic surgical planning is essential and, while 3D CT scans have the most visual appeal, a traditional panorex x-ray offers a vert measurable method to determine a safe amount of vertical bony reduction along the inferior borders.

Highlights:

  1. 1) Chin asymmetry is often associated with jaw asymmetry as well.
  2. 2) The submittal approach offers the most effective reshaping of the chin and jawline due to line of sight visual access.
  3. 3) The location of the metal nerve and tooth roots can limited the extent of bony symmetry that is possible to achieve.

Dr. Barry Eppley

Indianapolis, Indiana

Hyperdynamic Chin Ptosis Correction

Tuesday, October 24th, 2017

 

The chin has many potential deformities that occur to it as the most projecting structure of the lower face. It is most common to think of chin deformities as bony in origin and that augmentation or reduction of its projection is the aesthetic objective. But the overlying soft tissues of the chin are also prone to deformities that affect the mentalis muscle or the position/bulk of the soft tissue chin pad.

One type of soft tissue chin deformity is that of hyperdynamic chin ptosis. This is an aesthetic chin issue that only appears when one animates or smiles. At rest the chin profile looks normal or only has a slight amount of an excessive chin pad. But with smiling the soft tissue chin pad elongates and pulls down. In some cases oblique lines or indentations extend upward onto the face lateral to the chin as an extension of the downwardly displaced chin pad. Besides vertical chin lengthening the linear line of the jaw is disrupted in profile.

While Botox injections can be tried as an initial treatment, as it would be for any excessive facial expression, this is not a lifelong approach even if it is completely effective. Surgery is the only effective treatment and consists of subtotal excision of the redundant chin pad. The key to this excision is its location and extent. It should be placed more posterior than the actual animated overhang and its width should also stay inside a vertical line dropped down from the corner of the mouth.

When the lower portion of the chin pad is excised the mentalis muscle will be a part of its excision. Closure consists  muscle reapportion and a tucking of the chin pad back under the anterior projection of the chin bone. In some cases it may be beneficial to remove some bone to allow for a better submental tuck

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.

Read More


Free Plastic Surgery Consultation

*required fields


Military Discount

We offer discounts on plastic surgery to our United States Armed Forces.

Find Out Your Benefits


Categories