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Archive for the ‘chin reduction’ Category

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

OR Snapshots – Submental Chin Reduction Incision

Wednesday, June 7th, 2017

 

Chin reduction is a far more challenging operation in many ways than chin augmentation. Unlike chin augmentation, which rarely has to consider the overlying soft tissue because it stretches it out, this is a major consideration when making the chin smaller.  While the chin bone can be reduced in all of its dimensions (height, width and projection), the overlying chin soft tissue pad and the tissues on the underside of the chin do not magically shrink down when its bone support is lessened.

In cases of minor chin bone reshaping an intraoral approach may be effective and not cause adverse soft tissue effects. But the risk of creating a witch’s chin and submental soft tissue redundancies becomes very real as the chin bone reduction becomes greater and more of its soft tissue attachments are released.

The soft tissue issues are not ameliorated by an intraoral sliding genioplasty technique for horizontal chin excess. While cutting and sliding the chin bone back does keep inferior border soft tissues attached and reduces the risk of a witch’s chin deformity, it causes submental fullness as the attached soft tissues get pushed back.

The role of the submental chin reduction technique is that it manages both bone reduction/reshaping and removes/tightens the overlying soft tissues. It accomplishes both tissue reductions by an external skin incision in the anterior submental region. While the resultant scar is always a nervous trade-off, good placement and limited lengths make for a favorable scar outcome.

The key to the submental scar is its initial placement on the back edge of the inferior border and in a curved fashion. Its length should never exceed vertical lines drawn down from the mouth corners even during closure if working out dog ears are necessary. The incision should stay within the confines of the mouth width. The other key is when removing soft tissue excess, int is actually worked out of the neck not the soft tissue chin pad. This prevents the resultant scar from ending up on the front edge of the soft tissue chin pad where it could become more visible.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – T-Shaped Chin Reduction Osteotomy

Wednesday, August 24th, 2016

 

The traditional chin bone procedure for aesthetic enhancement is that of a sliding genioplasty. Cutting the chin bone and moving it forward has been a facial bone reshaping procedure that has been done for over half a century. It is mainly used as a bony alternative to a synthetic chin implant for chin augmentation. It is less frequently done for reductive chin procedures not only because there is less need but there is generalized less public and even surgeon awareness.

Reducing the bony chin works best for reducing its height and/or width. Moving the bone back for horizontal chin reduction is fraught with causing other soft tissue problems. Such bony chin manipulations have achieved greater awareness more recently due to the popularity of the so called ‘V-line’ Jaw surgery. While frequently used in Asians to reduce their wide and prominent jawlines, it is becoming more common to use it in females with a large lower jaw of any ethnicity.

T-Shaped Chin Reduction intraop 1 Dr Barry Eppley IndianapolisT-Shaped Chin Reduction intraop 2 Dr Barry Eppley IndianapolisA fundamental component of V-line jaw surgery is in how the front part of the jaw, the chin, is reduced. To shorten and narrow it the type of osteotomy pattern (bone cuts) must be different than the traditional sliding genioplasty. While a horizontal bone cut is still used, a double horizontal bone is used to reduce the vertical chin height. The space between the bone cut depends on how much vertical height needs to be shortened. The down fractured chin segment is then cut vertically in two parallel cuts whose space between them is the amount of chin width that has been predetermined to be reduced.

T-Shaped Chin reduction intraop 3 Dr Barry Eppley IndianapolisThis leaves the chin in three pieces; a stable fixed upper segment and two smaller mobile lower segments. The three bone segments are brought together with midline alignment of the two lower segments and fixed together by a single plate and screws. The bone cut patterns and how the chin is put back together creates the T-shape.

Since the chin width is narrowed by sliding the bone segments to the middle, there is often a step off along the lower edge of the jawline at the back end of the horizontal osteotomy line. Care must be taken to look for it and reduce it if needed.

Chin Reduction Reshaping Osteotomies result front view Dr Barry Eppley IndianapolisChin Narrowing Osteotomies result Dr Barry Eppley IndianapolisThe success of this type of chin reduction depends on how much bone is removed and how well the overlying soft tissue adapts to a smaller underlying bone support.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Submental Chin Reduction

Sunday, May 1st, 2016

 

Background:  Chin augmentation is one of the most common facial reshaping procedures both historically and to the present day. While augmenting the chin is a straightforward procedure using a variety of implant shapes, management of the large chin (macrotia) is a completely different story. Not only is it less commonly needed  but the procedure to do it are not well understood.

The traditional and often chosen procedures for macrogenia are intraoral approaches either shaving or cutting the bone and moving it back. Shaving the chin bone intraorally is a simple procedure and seems like it would work…but it doesn’t. It consistently leads to soft tissue chin ptosis as the degloving of the soft tissues and the soft tissue excess creates a soft tissue sag off of the bone. A bony genioplasty has a role in vertical and width reduction of the chin. (V line jaw surgery) But doing a sliding genioplasty and moving it backwards for too much horizontal projection create sa relative soft tissue excess. This  results in the excessive soft tissue being relocated to a bulge under the chin.

The submental chin reduction is a technique that addresses both the bone and soft tissue aspects of a large chin. Using an incision below the chin, the bony chin can be reduced by  shaving or burring the chin in all three dimensions. Once the bone is reduced, the excess soft tissue created can be managed by a submental tuck which redrapes the soft tissue over the remodeled chin bone.

Case Study: This 25 year-old female had a prior history of a vertical reduction boy genioplasty done to reshape a large chin. It failed to achieve its desired aesthetic goals and actually made the chin wider as it vertically shortened it, exaggerating the patient’s original aesthetic chin concerns.

Submental Chin Reduction incision Dr Barry Eppley IndianapolisUnder general anesthesia, a submental incisional approach was used to expose the bony chin. The incisional length was  4 cms and stayed well within vertical lines dropped down from the corners of the mouth. The bony was burred down horizontally and in width. The sides of the chin was taken down back behind the mental nerves removing the stepoffs from the prior chin osteotomy.

Submental Chin Reduction Reshaping result front view Dr Barry Eppley IndianapolisSubmental Chin Reduction Reshaping result oblique view Dr Barry Eppley IndianapolisSubmental Chin Reduction Reshaping result side view Dr Barry Eppley IndianapolisHer submental chin reduction results after three months showed improvement in the shape of the chin being smaller in horizontal projection and in its width.

Highlights:

1) Chin reduction is a challenging procedure because of the need to manage the excess soft tissue as well as that of the bone.

2) A submental chin reduction allows for reduction of both the bone and the soft tissue chin pad.

3)  A submental chin reduction allows for 3D reshaping of the chin bone including length, projection and width.

Dr. Barry Eppley

Indianapolis, Indiana

X-Ray Planning in Submental Chin Reduction

Monday, April 11th, 2016

 

Chin reduction surgery is sought for those patinets afflicted with a chin that is too strong or protrusive. A large chin can exist in numerous dimensions, albeit being vertically too long, too horizontally forward or too wide. In many cases the chin protrusion is caused by at least two and sometimes all three dimensional excesses.

Intraoral chin reduction is reserved for  a minority of large chin patients. A chin that is too vertically long can be reduced by a wedge reduction bony genioplasty. But chins that are too far forward should not be reduced by shaving or setback genioplasties. This will lead to soft tissue chin problems of redundancies and/or chin ptosis. (sagging)

A submental chin reduction is the most effective technique  for a chin that needs multiple dimensional changes. It is preferred because it can deal with the resultant soft tissue excess that results from loss of bone support. It also provides direct access for reducing the jawline behind the chin along the inferior border.

Submental Chin Reduction PlanningThe best and simplest method for estimating and planning the bone removal in a submental chin reduction is a panorex x-ray. This x-rays provides visualization of the important mental nerve as it courses through the bone.

Submental Vertical Chin Reduction Dr Barry EppleyWith x-ray planning as a precise guide, the measurements can be transferred to the bone during the chin reduction surgery. This will allow the maximum amount of bone removal while protecting the integrity of the mental nerve as it courses through the jawbone.

Submental Chin Reduction before and after radiographic resultsSubmental Chin Reduction radiographic result predictgion planning vs actual resultAn after surgery x-ray shows the execution of the exact bone removal plan and how close the path of the nerve is to the underlying bone cut. Comparison of the preoperative planning panorex to the result seen in the after surgery panoex shows how well the surgical bone removal was done.

The use of a panorex x-ray in submental chin reduction is a valuable presurgical tool which is of  greatest importance when bone needs to be removed along the jawline behind the chin.

Dr. Barry Eppley

Indianapolis, Indiana

The Submental Chin Reduction Technique

Friday, December 25th, 2015

 

The treatment of macrogenia (large chin) is much different than that of microgenia (small chin) and is also more challenging. Expanding the chin (chin augmentation) can done very reliably and in a straightforward manner through an implant or sliding genioplasty as it pushes out the overlying skin and soft tissue. While a prominent chin bone can be reduced, the success of any chin reduction procedure usually depends on what happens to the resultant excess soft tissue that will result from loss of bone support.

While a few limited chin reductions can be done from an intraoral approach, significant chin reductions require a different approach for two reasons. First, significant chin reduction requires a multi-dimensional approach to the bone reduction. This often includes horizontal, vertical and width bone removals. If the surgeon is skilled in bony genioplasty techniques and the patient is young, an intraoral vertical and midline wedge bone removals can reshape a large chin. But the best access to doing every dimension of bony chin change is from a submental approach from below. Secondly, any successful management of excess chin soft tissue involves excision which can only be done from below. Resuspension or ‘tightening’ of chin tissues done intraorally is not really an effective method making the chin soft tissues less in volume.

A submental chin reduction has several key technical steps to be successful. These include the location and extent of the incision, the method of bone removal and tye closure method which includes a submental tuck-up procedure,

Incision for Submental Chin Reduction Dr Barry Eppley IndianapolisThe submental incision needs to precisely placed and put back a few millimeters further that the standard submental skin crease (many young people do not have such a crease) The curve of the inferior border of the jawline is marked out and the submental incision placed 5 to 10mms behind it. Its length is no greater than 3.5 cms and is curved to follow the curve of the jawline.

Submental Chiun Reduction bone removal Dr Barry Eppley IndianapolisThe submental skin incision allows direct access to the entire bottom of the chin which is done through wide subperiosteal undermining. A reciprocating saw is the most reliable way to make horizontal, vertical and width bone reduction with little risk of damaging the skin edges of the relatively small access incision. Burring can be done to smooth out all reduced bone edges. The bone should only be reduced until the marrow spaces are encountered where some bleeding will occur. That can easily be controlled by bone wax.

Submental Chin Reduction immediate result Dr Barry Eppley IndianapolisAfter chin reduction and reshaping the soft tissue chin pad is pulled over the reduced bone and its mentalis muscle edges sewn to either the bone edges (through drilled bone holes or to the muscle and periosteam on the underside of the bone edge. This fixes the anterior edge of the submental incision. The excess submental tissues behind the incision are advanced forward and the ‘excess tissues’ are trimmed and the incision closed. Rather than removing the redundant chin soft tissue pad, they are redraped over the reduced chin bone. This ensures that the submental incision is moved behind the new inferior border of the chin and the now ‘fuller’ neck tissues are removed and brought forward.

The technique for submental chin reduction is not well described or frequently performed. But careful attention to detail can create a submental scar that is both very aesthetically acceptable and not overly long.

Dr. Barry Eppley

Indianapolis, Indiana

Surgical Techniques – Submental Jawline Shave for Inferior Border Irregularities after Chin Reduction

Monday, February 9th, 2015

 

Shaping of the jawline is done for many different reasons. The most common reason worldwide is tapering a wide jawline through a combination of a chin reduction osteotomies and jaw angle shaves or ostectomies. In other patients with just a large or long chin, a chin reduction osteotomy is used.

chin reduction osteotomy x-ray with shave line dr barry eppley indianapolisWhen the chin is vertically reduced the osteotomy line usually extends to the inferior border of the jawline below the mental foramen or even more posterior.  Depending on the amount of vertical chin bone reduction and the angle of the bone cut, the line of the jawline from the jaw angle (back) to the chin.(front) can become non-linear. A bump along the lower edge of the jawline behind the chin can occur because of the location of the vertical reduction. (anterior) This makes the chin vertically shorter in the front but boxy in shape and a fullness (bump) behind the chin on the jawline.

Jawline Shave Technique Dr Barry Eppley IndianapolisJawline Shave Reciprocating Saw Dr Barry Eppley IndianapolisReduction of this bump or hump on the jawline is best done through a submental approach. This provides the most direct access which is important is re-establishing a straight line along he lower edge of the jawline. This also places the bone work sufficiently below the mental nerve foramen to avoid injury to it. Removing the irregular jawline section is best done with a reciprocating saw to provide a smooth cut.

The submental approach to straightening a ‘crooked’ jawline by an inferior border irregularity or reducing its vertical length is the one most effective approach. Its limitations is that it can not reach all the way back to the ramus or jaw angle area.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies in Plastic Surgery – Muscle Resuspension in Vertical Chin Reduction

Wednesday, November 19th, 2014

 

While a short chin is both common and easily treated by an implant or bony in most cases, the long or big chin is a much more challenging aesthetic issue. The tissue excess over the front end of the lower jaw makes its reduction fraught with problems of redundancy and potential tissue sag. Where does all the soft tissue go if the bone that is supporting it is reduced or removed?

It is these soft tissue considerations that make an intraoral approach for chin reduction usually problematic. While a pure vertical reduction can be done by a wedge removal bony genioplasty from an intraoral approach, burring reduction or reverse sliding genioplasties ‘create’ soft tissue excesses or tissue sagging. These ‘new’ soft tissue problems will mar any aesthetic change that the bone reduction has accomplished.

A submental approach to chin reduction offers dual management of bone and soft tissue excesses. Through an incision under the chin, the soft tissues are initially freed off of the bone. The chin bone can then be reduced in any dimension whether it is vertical, width or horizontal projection. Once the bone is reduced, the amount of soft tissue excess becomes apparent.

Submental Vertical Chin Reduction Dr Barry EppleyThere are two types of soft tissues excesses created by a submental chin reduction. The first is the amount of skin, muscle and fat over the chin prominence that is removed by a submental excision and tuck. The second, which is most manifest in a vertical chin reduction, is the loss of the mandibular attachments to the infrahyoid musculature. If not resuspended there will be a resultant submental fullness due to muscle retraction.

Muscle Resuspension in Submental Chin Reduction Dr Barry Eppley IndianapolisResuspension of the released anterior strap muscles is done through bone holes placed through the new lower edge of the chin bone. Reattaching this muscle helps tighten the submental area so that its contour fits better to the reduced chin without an abnormal bulge in the submental soft tissue triangle.

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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