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Archive for the ‘chin reduction’ Category

Case Study: Female Chin Reduction

Monday, March 5th, 2012

Background:The chin is the dominant feature of the lower third of the face. When in good balance with the rest of the face it is an asset and a pleasing feature. When it is short or weak, it makes the face profile too convex and suggests a weak nature to the person. When it is too prominent, the facial profile becomes concave and makes the midface look retruded. Eitherway the chin plays a major role in facial appearance

Macrogenia, or overgrowth of the chin, creates a lower face that is out of balance with the upper and middle facial thirds. Most cases of macrogenia are a combination of excessive horizontal and vertical bone development. While macrogenia can be a reflection of an overall lower jaw overgrowth as evidenced by a Class III malocclusion, most larger chins occur in isolation. In women, the position of the chin should be slightly convex in profile and not too vertically long. Too much chin projection creates too strong of a lower face and a more masculine look.

Correction of a large chin is more complex and difficult than correction of an underdeveloped or small chin. While the bone reduction is fairly straightforward, whether by osteotomy or burring reduction, management of the excess soft tissues is another matter.In small chin reductions, the soft tissue will shrink and adapt to the new bone shape. But in large chin reductions, the soft tissues will not shrink enough and will sag if not removed or tightened. This can create the classic ‘witch’s chin deformity’.

Case Study: This 33 year-old female felt her chin was too big and wanted it reduced. She had a slightly concave facial profile, a vertically long chin, and a normal occlusion. In doing an imaging analysis based on photographs, the amount of chin reduction needed was a minimum of 8mm horizontal reduction and a 6mm vertical reduction. This amount of bony movement was felt to be too much for an intraoral osteotomy in which the soft tissues would only bunch up with the backward or reverse sliding genioplasty.

Under general anesthesia, a submental approach to her chin reduction was done. Through a curved 4 cm skin incision, the chin bone was widely exposed. A fine burr was initially used to make a deep vertical bone cut in the midline down through the outer cortex of 8mms in depth. A burr was then used to remove the side portions of the remaining chin bone down to the same level and tapering it into the prejowl area. From the inferior edge, the chin bone was burred down 6mms. A wedge of skin, muscle and fat was removed from the front edge of the incision and the muscle layer was then put back together and tightened over the lower edge of the reshaped chin bone. The skin was then closed and a tape dressing and ice pack applied.

She had a fair amount of chin swelling after surgery that took three weeks before any amount of chin reduction could be appreciated. After three months, a very evident reduction in the size of the chin would be appreciated.

Of the two methods for chin reduction, the submental approach is the most versatile. It allows not only for better bony chin reshaping but permits soft tissue reduction and tightening as well. Failure of the soft tissues to adhere tightly to the new reduced bony chin shape will result in an unsightly soft tissue sag.

Case Highlights:

1) A large and prominent chin consist of both excess bone and soft tissue. Both must be managed for a successful chin reduction procedure.

2) Most chin reductions are best done from a submental approach where the bone can be reduced in all dimensions and the soft tissues tightened.

3) Chin reduction surgery involves a temporary period of swelling and several months to see the final result.

Dr. Barry Eppley

Indianapolis, Indiana

Chin Narrowing by Lateral Tubercle Reduction

Sunday, November 13th, 2011

A square chin and jawline is considered desireable in a male but not so in a female. It is also deemed unattractive in certain ethnicities such as in the Asian face as well as in the male to female transgender face. Reduction of a square jawline is often perceived as that of the jaw angles. While jaw angle reduction surgery has a role to play in facial contouring, it only provides some narrowing in the posterior mandible or back part of the jaw. It has no slimming effect in the front part of the jawline in the chin area.

 

Narrowing of the chin or front part of the lower face can be done by several methods, all of which require bone reduction. If a chin osteotomy (osteoplastic genioplasty) is being done, the width of the chin will naturally narrow when the chin bone is brought forward and/or vertically lengthened. But not everyone needs horizontal or vertical chin lengthening so an osteotomy can be ineffective. The other approach is direct burring reduction of the chin or mandibular tubercles. By reducing the bony sides of the chin it can be narrowed in the frontal view.

 

When doing an osteotomy to create a chin narrowing effect, it is important to realize that the bone will not narrow behind the osteotomy cut. This also is where a step-off can be created at this junction which is most evident when horizontal advancements are done. As the bone edge of the downfractured chin segment moves forward, this step-off can be created. It can be a difficult area to reach for smoothing out this step-off and there is risk to the mental nerve which is very close by. This is why it is helpful to make that osteotomy cut back as far as possible to extend the natural narrowing effect of the advancing osteotomy and avoid a prominent step-off.

 

Reducing the sides of the chin can be done by either burring or saw reduction. Using a saw always removes more bone quickly with less risk of injury to the mental nerve. The more relevant question is whether it is done through an incision inside the mouth or from an external submental incision from below. Most of the time an intraoral approach is used if only the sides of the chin need to be reduced. But when an overall chin reduction is being done reducing height and/or projection, a submental approach is used so that the extra soft tissues can be managed by excision and redraping to prevent postoperative sagging or ptosis.

 

To achieve a more slim feminine lower face, reduction of the jawline must be considered as a whole. Changing the width of the chin from a more square to a tapered shape creates an essential change in the frontal view. Barring the need for horizontal or vertical lengthening of the chin, burring or saw reduction of the sides of the chin can be done from either an intraoral or submental approach.

 

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Horizontal Chin Reduction in a Female

Friday, July 9th, 2010

Background:The prominent position of the chin makes it have a significant impact on one’s facial appearance. While most chin surgery involves implants for a small or horizontally short chin, a larger or more prominent chin is equally disturbing although less common. Because chin reductions are infrequently done, there is less information available on techniques and outcomes for it.

Compared to chin augmentation which is more common in men, chin reduction is more frequently requested in women. Even a slightly too prominent chin is less aesthetically tolerated in women as opposed to men. Long chins, pointy chins, and those that stick out too far are common chin complaints from women. A chin can be too long vertically, too far forward horizontally, have a too wide or too pointy shape, or some combination of several of these features. Diagnosing the exact dimensional problems with the chin is critical is determining the best way to shape it.

Case Study: This is a case of a 35 year-old female who has been bothered by her chin shape since she was a teenager. She felt that is was too long and pointy, particularly in a profile view. She despised her appearance in a picture from the side. She stated that the pointy nature of the chin became worse when she smiled.

In looking at her chin, its shape problems can be identified as largely horizontal (too far forward in profile), slightly long vertically (emphasis on slight), and with a mildly pointy shape. The pointy shape becomes more obvious when she smiles as the soft tissues around the mouth and face are pulled backwards against the hard outline of the chin bone.

Chin reductions always involve bone removal and reshaping. There are only two basic approaches, burring down the bone or cutting off the end of the chin bone and repositioning it. (chin osteotomy) Both of these chin reduction methods must always take into consideration how the surrounding soft tissue will adapt. One must remember that less enveloping soft tissue is needed afterwards. For this reason, horizontal chin reductions are best done by burring and excising and tightening the soft tissue envelope through an incision under the chin. Vertical chin reductions are best done by osteotomies which removes a wedge of bone. The soft tissues of the chin have less risk of excess and redundancy when reduced in vertical height.

Planning for this patient’s chin reshaping showed the desired movements of 7mm horizontal reduction, 2mms vertical reduction and flattening of the lower border to round out its shape. (get rid of the point) The chin reduction was done through a 3 cm long submental incision using a burr to do the reduction. Excess muscle was excised and plicated over the freshly burred lower border. Skin excess was then removed and the incision closed. A chin pressure dressing was used for just 24 hours.

Chin reductions do result in some discomfort, very similar to a chin augmentation with an implant. There are no restrictions after surgery and one can eat and drink unaffected. It takes several weeks for the major swelling to subside and the final result can be appreciated in 6 to 8 weeks. The chin will usually appear tight and look stiff for the first few weeks after surgery.

She was very pleased with her outcome and felt it made a very noticeable change in her chin appearance. She no longer felt that her chin was pointy. With her original chin problem (horizontal), the result is most noticeable in profile views.

Case Highlights:

1) Chin reductions is largely a female request with the desire to get rid of a prominent chin that is either too long, strong, or both.

2) Horizontal chin reductions are best done by burring and muscle and skin tightening to avoid soft tissue sag. A submental incision is used which results in a well-placed scar.

3) Reducing a prominent chin has about the same recovery time as a chin augmentation. However, it takes longer to see the final result as small amounts of swelling takes months to completely go away.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Bone Reduction Surgery

Monday, February 1st, 2010

Changing one’s bony prominences is the primary method for altering the shape of the face. The face is composed of a variety of bones which have convex and concave contours. The external appearance of the face is highly influenced by the convex bone contours. From the brow bone down to the long curvilinear shape of the mandible, there are numerous key bony projection points. (e.g., cheeks, chin, jaw angles)

Most commonly, a variety of plastic surgery operations exist to enhance or increase their projections. Chin, nose, cheek and jaw angle implants are prime examples. It is almost always easier to increase facial bone projection by adding to the bone rather than actually moving the bone.  There are also, however, operations that work in reverse…to reduce or deproject these very same prominences.

Facial bone reductions are not as well known and are less commonly done. Unlike augmentations, facial reduction procedures require modification or shortening of the bony prominences. While some can be shaved down, others require actual cutting off or out of bone sections to change the amount of bony projection.

Brow bone reduction is requested when the brows have a very prominent or ‘Neanderthal’ appearance. Mainly this procedure is done in men and in male to female conversions. (facial feminization surgery) This must almost always be done through a frontal hairline or scalp incision. In some cases, the brow bone may be simply burred down but this is unusual. The underlying frontal sinus occupies much of the width of the brow bone so the overlying bone is quite thin. Only if one is modifying the tail of the brow can it be just burred down. The outer table of the frontal sinus must be removed, reshaped, and then put back with tiny plates and screws. The scar from the incisional approach is the key decision in deciding to undergo this operation.

Cheek reduction is about modifiying the front edge of the cheek bone and its arched form back to where it attaches to the temporal bone. Most patients that want cheek reduction are often Asians in an effort to improve their wider face appearances. A vertical bone cut is made through the body of the malar bone and a wedge of bone is removed. The reduced cheek bone is then attached to the maxilla with a four-hole plate and screws. To get the more posterior part of the arch to move inward, the thin attachment of the posterior part of the zygomatic arch is cut with an osteotome and allowed to move inward (by muscle pull) without the need to secure it.

Nasal reduction is achieved by conventional rhinoplasty techniques. A significant part of a nasal hump is actually cartilage and not bone. The key in reductive rhinoplasty is not to overdo it, creating a saddle nose or pinched upper and middle vault appearance. This can result in nasal airway breathing difficulties. When it comes to helping a face look less wide and more sculpted, the nasal dorsum often is better elevated and not reduced.

Chin reduction is done by burring down the genial prominence. While this bone area is simple to get to through a submental incision, chin reductions are notoriously prone to cause soft tissue problems if not done correctly. This is the only facial bony prominence where the soft tissue does not just ‘snap back’ over the bone. If the excess skin and muscle is not removed and readapted back to the reshaped bone, it will sag resulting in the classic ‘witch’s chin deformity. Also, unlike chin bone advancements which can be brought forward 10 to 12 mms or more, retropositioning of the chinbone can not be done as dramatic and is more in the range of 4 to 6mms at best. Going back further than that can have adverse effects on the neck causing undesired fullness.

Jaw angle reduction is most commonly done in Asians like cheek reduction. Through an incision inside the mouth, the angle of the jaw is blunted by an oblique bone cut removing the prominent tip. How much of the tip or angle area is removed is a matter of intraoperative judgment. There is a fine balance between removing too little and completely having no angle at all. A nearly straight line from below the ear to the chin is not desireable either. This is the most uncomfortable of all the facial bony prominences to reduce because the large master muscle must be raised, causing considerable swelling after also.     

Barry L. Eppley, M.D., D.M.D.

Indianapolis, Indiana

Vertical Reduction of the Long Chin

Thursday, August 20th, 2009

The chin is the predominant feature of the lower face. Whether it is too short or too long affects the overall look of one’s face. While short chin deformities make up the vast majority of corrections, long chin problems also exist. The overly prominent chin can exist in two dimensions, too far forward (horizontal excess) or too long. (vertical excess)

 Chins that are too long vertically are the result of excess bone development. Unlike chins that are too long horizontally, this is usually not an overgrowth problem of the entire lower jaw where a bite deformity (underbite or malocclusion) may also be present. The bone height of the chin (mandibular symphysis) is simply too long from below the tooth roots  downward.

Vertical chin reductions are all about having to remove bone. It would be less common to consider removing bone by simply shaving down the bottom part of the chin because of the submental scar. But in the right patient who desires an overall three-dimensional chin shape alteration, the ‘inferior’ approach can be quite successful. The historic and most common method of vertical chin reduction is done by removing a wedge of bone between the upper and lower portions of the chin. This does not disturb the soft tissue attachments and the approach is through the mouth so there would be no external scar. The chin bone is put back together in a shortened position with very tiny titanium plates and screws.

Any chin reduction procedure must consider the potential effects of the soft tissue envelope. Much like changing a breast implant to a smaller one, what happens to the expanded or stretched out soft tissue afterwards? In my Indianapolis plastic surgery experience, this is a more significant issue with horizontal reduction but it still must be considered with vertical reductions as well. In either case, the mentalis muscle must be shortened and resuspended tightly. Vertical chin reduction by interpositional wedge removal genioplasty does not require skin shortening by excision unlike most horizontal chin reductions. The finesse part of any bony chin procedure is the management of its soft tissue attachments. Failure to do so will likely result in secondary chin problems. 

Dr. Barry Eppley

Indianapolis, Indiana 

Lateral Chin Ostectomies – Narrowing the Broad or Wide Chin

Wednesday, April 29th, 2009

The chin is the most dominant feature of the lower face. It has significant influence on the perception of facial balance and how the neck looks as well. While the chin may only be thought of as being too small or too big, there are other dimensions to the chin that also play a role in how it looks. Its horizontal position relative to the rest of the face can be an overly simplistic view of its aesthetics. The width of the chin is also important. Men often want a wider chin, women usually desire a chin that is more narrow.

 

When it comes to building out a chin, whether it be for horizontal length or width, the use of an implant is a simple and very effective method. Reducing chins, however, require manipulation of the bone…specifically removing parts of the chin to change its shape. Subtraction is a slightly more complex maneuver than addition for all facial areas.

 

Broad chins can be reduced through a technique known as an oblique chin ostectomy. This is a method where bone from the side of the chin along its undersurface is removed. This can be done by burring it down, or more effectively, by sawing away the widest part of the chin and making it blend into the jawline. It can be done from either inside the mouth or from a small incision under the chin. As the bone is removed in a front to back direction, how much bone to remove and how it affects the narrowing of the chin can be seen quite easily. This procedure can be done alone or with any other chin operation, including implants. For a wide and short chin, for example, a central chin implant style can be placed with lateral narrowing to make for a slender narrower chin. This operation does cause some significant swelling, as bone manipulations will do, and some temporary numbness of the chin and lower lip as well.

 

Narrowing of the chin adds another method of cosmetic jaw enhancement including chin implants, chin, osteotomies, mandibular angle implants, and mandibular angle reduction. Chin narrowing can be done alone or in combination of any other chin/jaw method to create an overall lower jaw shape change. These changes are particularly visible through computer prediction imaging and, in my Indianapolis plastic surgery practice, I make sure that all such patients go through such imaging before surgery.

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

Options for Chin Reduction Surgery

Sunday, March 1st, 2009

Chin reduction is a form of chin reshaping surgery that involves changing the size and possibly the shape of the chin in order to make it appear smaller. This surgery may be beneficial to those who have a large chin that looks disproportionate when compared to the rest of the face. A chin may look too large in two dimensions, either being too long vertically or projecting too far forward horizontally. In rare cases, both dimensions of chin enlargement may be enlarged but usually it is one or the other.

Vertical chin enlargement is corrected by a wedge ostectomy of the chin. Through an intraoral approach, the chin bone is exposed and a reciprocating saw is used to remove a horizontal wedge of bone of the desired thickness. Usually it takes at least 5 to 6mms of bone removal if not more to make a real noticeable difference. Small plates and screws are used to hold the shortened chin bone together so that it can heal. The edges of the upper bone cut must be smoothed so it is not able to be felt through the skin. An alternative approach is an inferior border ostectomy done through a submental incision. This can also narrow the chin by lateral ostectomies as well. Good muscle resuspenions and soft tissue excision is the key to a successfulm outcome with this ‘down under’ technique. This is a good approach if there is alreasy an excess of soft tissue tissue over the chin prominence of on the underside of the chin.

Excessive horizontal chin excess is done through a burring down and tissue resuspension technique. Through an incision underneath the chin, the bone is exposed and the desired amount of excess bone removed. Because the attached soft tissues have had to be stripped off of the bone, they must be reattached or sagging (witches chin deformity) will occur afterward. Excess muscle and skin are removed and sutures are used to reattach them tightly to the bone.

All chin reduction methods require careful attention to how the bone is taken down and whether the soft tissues remained attached to the bone. Simple ‘sanding down’ a prominent chin, as has been done by many in the past, will only lead to secondary chin problems.

Frontal and profile photographic analysis should be done before surgery to determine how much bone reduction is needed. Since there is a pretty good linear relationship between bone changes in the chin and changes seen externally, photographic analysis is useful in all types of chin surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Chin Reduction Surgery for Horizontal Excess

Monday, December 22nd, 2008

The chin represents one of the five main prominences of the face, also including the nose, brow ridges/forehead, cheeks, and jaw angle.  It is the defining feature of the lower face. Augmentation or enhancement of a recessed or weak chin is a common plastic surgery procedure that is made fairly simple through the placement of a synthetic implant. Correction of a large or too prominent of a chin, however, is not only less commonly done but is more difficult to do successfully.

A prominent chin has both excess hard and soft tissue. This means that the bone not only has to be reduced but the muscle and skin must be shortened and tightened as well.  If the soft tissue of the chin is not properly addressed in a reduction, it will sag off of the reduced bone after surgery resulting in what is known as a ‘witch’s chin’ deformity.

Chin implant surgery is traditionally done through an incision under the chin in the submental crease. But in a chin reduction procedure, this incision should be moved back a bit accounting for the removal of some submental skin at the end of the procedure. Once the chin bone is exposed, the excess chin is burred down the amount estimated beforehand. Usually it takes at least 6 to 8mms to make a significant difference. It is important to make sure that the bone removed extends far enough to the sides and is tapered to keep the chin from being too square. Once the bone is removed, excess mentalis muscle is removed and this muscle flap is sutured to the underside of the chin to the platysma muscle. Making this a tight muscle closure is important. Redundant overlying submental skin is then removed and closed as well. The soft tissue closure is just as important as the bone removal.

This approach works well for a horizontal chin excess. A vertical chin excess or a long chin, however, requires an intraoral approach with an interpositional wedge osteotomy for its correction. This is a completely different operation with removal and repositioning of bone rather than a simple burring down technique.

Dr. Barry Eppley

Indianapolis, Indiana

Aesthetic Orthopedic Surgery of the Chin

Saturday, October 4th, 2008

Moving the chin bone is the simplest of all the cosmetic facial bone procedures. Because the chin is easy to get to through the mouth and there is little in the way to get there, cutting and moving the chin bone (the tip of the front of the lower jaw) is relatively easy do and commonly done. Besides cutting and moving the bone forward to create more chin prominence, bone manipulations of the chin can be much more than just traditional horizontal augmentation.

 

When the chin bone is cut and dropped down, there are many different shaping procedures that can be done to it. By making a horizontal bone cut below the front teeth, the chin can be changed in length. A wedge of bone can be cut out and the chin brought back up to shorten it in height. Conversely, the chin can be lengthened by placing a bone graft or a piece of synthetic bone in between the two cut ends to make the chin vertically longer. If the chin lengthening is relatively small (a few millimeters), nothing may need to be put in the gap between the bone pieces.

 

Aside from height changes, alterations can also be done in chin width. The chin bone once cut and brought down from the rest of the jaw, can be widened or narrowed as well. By removing a piece of bone down the middle of the chin bone, it can be brought together in a more narrowed fashion, Similarly, a bone cut can be made down the middle of the chin and it can be split apart and widened. (similar to what it done for lengthening the height of the chin)

 

With all of these chin changes, small plates and screws are needed to hold the bone segments into the desired positions. This metal hardware is very small and can never be felt from the outside. Over time and with healing, bone overgrows much of these plates and screws. I have never had to remove plates and screws from the chin due to problems with them. They are made of titanium, which is a non-magnetic metal, so there is no concern about ‘setting off the detector at the airport’.

 

Orthopedic surgery of the chin offers some advantages over more simple chin implants, particularly in changing the dimensions of chin shortening, chin narrowing, and chin lengthening. These are chin changes that implants can not do as their effects are additive, not reductive.

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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