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Archive for the ‘sliding genioplasty’ Category

Case Study – Sliding Genioplasty Combined with Chin Implant

Friday, October 6th, 2017

 

Background: Routine chin deficiencies are well managed by with an implant or a sliding genioplasty. The concept of a routine chin augmentation, in my experience, generally falls into a horizontal chin position movement of 10mms for less. Once the aesthetic need becomes greater than a centimeter there is undoubtably an overall lower jaw skeletal deficiency that should ideally managed by a combined orthodontic-orthognathic surgery approach.

But some lower jaw deficient patients will never undergo movement of the entire lower jaw and teeth positions for a variety of reasons. They may appear just for chin augmentation only as a camouflage approach to their lower facial deficiency.

While a large chin implant can be used, most standard chin implants do not provide more than 10mms of horizontal advancement. While larger custom chin implants can be made, such a load of synthetic material on the chin may exceed the soft tissue stretch to safely accommodate it. The projection off such a large chin implant may also appear unnatural with a much thinner jawline behind it.

A sliding genioplasty can usually exceed 10mms if the bone thickness will allow it. I have seen it often go to 14 to 16mms. But in such large tiny chin movements there will be pronounced stepoffs on their sides and the labiomental fold will definitely get much deeper as the bone underneath it has become deeper as the lower chin point comes forward.

Case Study: This young male has a large chin deficiency with a skeletally short lower jaw. From an ideal chin projection standpoint for a male (vertical line dropped down from the lips) he was 22mms horizontally short. Orthognathic surgery was not an option that he wanted to pursue.

Under general anesthesia, an intraoral sliding genioplasty was performed with 14mms of horizontal advancement based in the limits of maintaining bone contact. (lingual cortex of lower chin segment with buccal cortex of upper chin segment) To add a little extra to the what moving the bone achieved a 5mm extended anatomic chin implant was placed in front of the front edge of the chin bone. The wings of the implant went back along the sides of the advanced chin segment across the step off area. Due to the large step-off created an hydroxyapatite block was placed to prevent a severe deepening of the labiomental fold. (the fold is always going to get deeper in larger chin augmentations, you just want to try and lessen that effect)

The need for a combined sliding genioplasty and implant for aesthetic chin augmentation is rare and is avoided by the traditional use of orthographic surgery. The value of such a chin implant is three-fold; 1) its a small amount of additional horizontal augmentation, 2) its wings can cover up the indentation along the sides of larger sliding genioplasty movements (the concave jawline deformity) and 3) it keeps the chin from looking too thin in the frontal view.

It is not a mortal surgical sin to combine two chin augmentation methods that are often viewed as competitive procedures. Each has their own distinct aesthetic effects and in rare cases may be used synergistically to create a better aesthetic outcome than either one can achieve alone.

Highlights:

  1. Large chin deficiencies are often beyond what a sliding genioplasty or a chin implant can effectively treat alone.
  2. Combining a sliding genioplaty with a chin implant can maximize the amount of horizontal advancement and cover bony step offs on the sides. 
  3. Large sliding genioplasty movements will require fill of the step-off to avoid a severe deepening of the labiomental fold.

Dr. Barry Eppley

Indianapolis, Indiana

The Mentalis Muscle and Chin Augmentation

Monday, September 18th, 2017

 

The mentalis is a well known muscle of the chin. Any chin surgery procedure involves manipulation of this muscle no matter what type of dimensional chin change is being done or how it is being done. (implant vs. osteotomy vs osteotomy) Since it is the only muscle that has attachments to the anterior surface of the chin bone, postoperative problems with its function can occur. While many chin procedures are done successfully with the return of normal muscle function, mentalis muscle dysfunction is not rare and is a frequent source of after surgery chin problems. Given the frequent misunderstanding of the mentalis muscle anatomy and function amongst patients and even some surgeons, its role and relevance in chin augmentation surgery merits review.

The mentalis is a paired central muscle of the chin that runs vertically over the chin bone. It actually has two halves and is separated by a fat pad that is most prominent near its bony origin underneath the labiomental fold below the lower lip. The relevance of this central fat pad in the muscle is not clear. The muscle is attached to the bone at the depth of the internal vestibule superiorly and runs down vertically to insert into the soft tissues of the lower submental chin pad. It is important to appreciate that the point of firm fixation is at its origin to the bone but its insertion is into the soft tissue inferiorly. The primary function of the muscle is contraction of the chin pad superiorly and inward (towards the lower lip) which will concurrently raise the lower lip creating a pout type facial expression. It is innervated by the marginal mandibular branch of the facial nerve which crosses over the jawline laterally to reach the muscle’s surface.

In chin augmentation surgery incisional access is either intraoral through the mucosa or submental through the skin. In sliding genioplasty the only choice is intraoral. But implant placement can be done both ways. Both incisional approaches cut through the mentalis muscle but they do so through different areas of the muscle. (origin or insertion. This is more than just an anatomic distinction, it can have a significant influence on muscle tension and function after surgery.

Cutting through the insertion of the muscle with an intraoral approach does so at the point of its maximal muscle thickness and tension. It is extremely important to leave an adequate cuff of muscle attached to the bone with this maneuver, otherwise there will be nowhere to attach the released inferior bulk of the muscle bellies. Without a reattachment the muscle will contract down, the labiomental fold will get deeper and the chin pad will pull down off of the bone. (chin ptosis)

With a retained muscle cuff onto which the released muscle can be reattached, one is essentially re-establishing muscle length at the thickest part of the muscle. But it is easy to see how the muscle length is changed when the soft tissue chin pad is stretched out by an implant or an advanced bony chin segment. The larger the chin pad displacement the tighter the muscle closure will be. This accounts for many a patient’s complaints of prolonged chin tightness and stiffness after a sliding genioplasty, particularly in large advancements. It can also occur with chin implants and is most commonly seen when the implant rides up high and pressures the resutured muscle origin.

In the submental approach for chin implants, it is the insertion of the muscle that must be cut and lifted up to reach the bone. Since this is not a firm bony attachment, muscle elevation and closure is done at the thinner lower portion of the muscle and has a much lower risk of adversely affecting muscle tension and postoperative function. This is why there are far fewer complaints of chin stiffness and tightness from submentally placed chin implants as re-establishing muscle length is much easier as opposed to pulling the muscle back up to its original bony attachment.

Mentalis muscle anatomy and its function is just one issue to consider in chin augmentation and is most relevant with implants where both incisional options are in play. When the patient prefers an intraoral approach for a standard chin implant I use the muscle splitting approach through its septum rather than cutting the muscle’s bony attachment.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Facial Reshaping Surgery with Chin Augmentation and Facial Fat Removal

Friday, September 15th, 2017

 

Background: The round face is often characterized by soft tissues excesses and bony deficiencies. It takes a combination of both tissue issues to create a round or convex facial shape. Very often the lower jaw/chin is short or deficient and the lack of a bony projection is the linchpin to this type of facial shape. While such a facial shape may be adorable as an infant or young child, it is often not perceived so in adulthood.

When the chin is short, the debate is often between that of an implant or a sliding genioplasty. There are advantages and disadvantages to either chin augmentation method. But the round or fuller face usually has a fuller submental fad pad and attached neck muscles that are relatively short. Moving the chin forward in the round face has the advantage of stretching out the attached neck muscles and improving the shape of the neck even if liposuction or a submentoplasty are still going to be performed.

The other component of the round face is excessive fat. While removing facial fat alone rarely changes one’s facial shape entirely, it still has a valuable role in facial reshaping surgery. Facial fat removal maximally consists of addressing the three main compartments of the buccal space, perioral mound/jowls and that in the neck..

Case Study: This young female had a very round face and short chin. She had an orthodontically corrected Class II occlusal relationship.

Under general anesthesia she had a 10mm sliding genioplasty advancement combined with buccal lipectomies, perioral and neck liposuction for an overall facial reshaping effort.

Her after surgery results showed a dramatic change in her facial shape with a better defined chin and jawline and much thinner looking face.

The combination of bony augmentation and fat reduction can produce a diametric facial effect which leads to a significant change in one’s facial shape.

Highlights:

  1. Significant facial reshaping often requires a combination of bony augmentation and fat reduction.
  2. A sliding geniopslasty helps the fuller neck by stretching out attached neck muscles.
  3. The combination of buccal lipectomies and personal and neck liposuction are the most fat reduction that can be done in the round face.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Teen Sliding Genioplasty and Step-Off Grafting

Monday, September 11th, 2017

 

Background: The sliding genioplasty is a well known autogenous chin augmentation procedure. When contrasted to that of a chin implant, it has advantages and disadvantages to the alloplastic alternative. Which chin augmentation approach is best for any patient must be decided on an individual basis. Suffice it to say two different chin augmentation techniques exist since neither one is perfect for every patient’s aesthetic chin needs.

One feature of any horizontal chin augmentation procedure is that the depth of the labiomental fold will not be improved and may even get deeper. This is expected as the attachment of the mentalis muscle to the bone, which is the anatomic basis for the presence of the fold, does not change. The down fractured chin segment from a sliding genioplasty is done below the level of the muscle attachment. (even though the muscle must be cut and then reattached to perform the procedure) Thus as the chin comes forward the labiomental fold attachment remains the same. By definition this can make the labiodental fold look perceptibly deeper. Whether his usually negative aesthetic effect will be significant depends on how much chin advancement is done.

In lowering the risk of labiomental fold deepening with a sliding genioplasty, the bone step-off can be filled in with a variety of materials. This is particularly relevant when the chin advancement becomes considerable. There are a variety of alloplastic and allogeneic materials from which to choose.

Case Study: This 15 year-old male had a short chin although an orthodontically corrected Class I occlusion. Given his young age and the degree of horizontal chin advancement needed, a sliding genioplasty procedure was chosen.

Under general anesthesia and through an intraoral approach, a low horizontal bone cut was done and the chin bone advanced 12mms. The bony step-off was filled in with hydroxyapatite bone cement with the mentalis muscle closed over it.

His after surgery result showed an improved lower facial profile with increased chin projection. The depth of the labiomental fold was deeper but not unduly so. It would have been deeper without the fill in with the bone cement.

Hydroxyapatite bone cement is one option for augmenting the underlying bony step-off in a sliding genioplasty. Its only limiting factor is its cost.

Highlights:

  1. The sliding genioplasty moves the bottom portion of the chin bone forward but leaves the superior portion of the bone and the labiomentall fold behind.
  2. The bony step off of the sliding genioplasty can be augmented or filled in with a variety of materials.
  3. Grafting the step off in the advanced chin can help soften any deepening of the labiodental fold.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Extreme Two-Stage Vertical Chin Lengthening

Saturday, April 29th, 2017

 

Background: The sliding genioplasty is a well known chin augmentation technique for horizontal advancement of a short chin. It is used most commonly for the horizontally deficient bony chin. With these forward movements some vertical change can also be affected, either opening it slightly or even vertically shortening it.

A lesser known use of the bony genioplasty is to vertically lengthen the chin. This its actually the simplest movement of the inferior chin segment as it is opened up and elongated using the posterior bony wings as a cantilever. The amount of elongation is based on the vertical width of the bony gap created between the upper and lower segments. The gap is stabilized by a spanning titanium plate with two screws above and below for form fixation. When the bony gap gets to 8mm to 10mms an interpositional bone graft is used to ensure bony healing.

How much one needs to aesthetically lengthen the chin can be determined by preoperatively opening the jaw, find the best chin lengthening effect and then measuring  the distance between the upper and lower teeth edges. (minus any upper incised overbite)  If the vertical distance exceeds 10mm to 12mms, one will ned to consider a two-stage vertical chin lengthening approach.

Case Study: This young male wanted to vertically lengthen his chin. It was determined that 10mm was a good and maximal distance. The horizontal osteotomy was made and the 10mm opening wedge gap stabilized with an 8mm chin step plate that was flattened out. A cadaveric block bone interpositional bone graft was placed in the gap.

Six months later a panorex x-ray shows complete bony consolidation across the graft site as well as at the end of the original osteotomy bone cuts. The bony spaces between the bone graft and the ends remained incompletely filled.

He wanted an additional 10mms of vertical chin lengthening  so a second bony genioplasty was performed. The metal plate and screws were easily removed (non-bony overgrowth) and the chin bone was solid. A horizontal bone cut was made across the original osteotomy line and the chin easily downfractured. It was dropped down another 10mms, fixed with a flattened out 12mm step chin plate and secured with screws. Another interpositional bone graft was placed on both sides of the bony gap.

Interestingly at 20mms of vertical chin lengthening, no lower lip incompetence of strains occurred. Presumably this was because it was a staged bony lengthening approach.

Highlights:

  1. Vertical lengthening genioplasty lengthens the lower third of the face by an opening wedge osteotomy.
  2. When the vertical lengthening of the chin is at 8 to 10mms a cadaveric interpositional bone graft is needed for bony healing
  3. A second vertical lengthening genioplasty can be successfully done after the first one with a final lower third of the face increase of 20mms.

Dr. Barry Eppley

Indianapolis, Indiana

Vertical Lengthening of the Lower Face

Sunday, March 19th, 2017

 

One of the elements of an attractive face is known to be proportions. While some may argue that symmetry is the most important part of facial beauty, symmetry and proportions are really linked. One doesn’t work well without the other.

Facial proportions can be assessed both horizontally as well as vertically. The classic facial thirds applies to vertical relationships with the upper (hairline to brow), middle (brow to base of nose) and lower (base of nose to bottom of chin) thirds being well known. Facial third disruption can occur at all levels and can make the face appear too long or too short.

One reason for a short vertical face is that the lower third is deficient. This can be associated with a more flat mandibular plane angle. This is reflective of the entire lower border of the jaw being short from back to front. It can also occur when the overall lower jaw is underdeveloped and is associated with a horizontal chin deficiency as well as a high jaw angle.

Lengthening of the vertically deficient lower third of the face can be done one of two ways based on the cause of its shortness. The entire lower jawline can be extended by a custom jawline implant that wraps around the lower jaw from angle to angle. The other method is a vertical lengthening bony genioplasty which elongates the front part of the jaw.

Vertical Lengthening Genioplasty with interpositional bone graft Dr Barry Eppley IndianapolisThe vertical lengthening genioplasty is similar to the well know sliding genioplasty except that it does not slide. Rather after the bone cut is completed the lower bone segment is opened up like a hinge and a gap is created between the front edges of the bone based on how much lengthening is desired. The size of the gap is maintained by a spanning plate and screws. If the gap is big enough an interpositonal allogeneic bone graft or hydroxyapatite block is placed.

Vertical Lengthening Genioplasty witrh Interposition Graft x-ray Dr Barry Eppley IndianapolisThis bone gap in an opening vertical genioplasty will eventually fill in with bone but it will take 6 to 12 months to do so.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Sliding Genioplasty with Chin Implant

Thursday, March 16th, 2017

 

Chin augmentation can be done through either placing an implant on top of the bone or moving the actual bone forward. Both are valid chin enhancement techniques and each has their own unique advantages and disadvantages. While there are strong surgeon advocates for both techniques, it is important to remember that not every patient is appropriate for either one and what matters for good results is matching the solution to the problem and not surgeon preference or familiarity with either surgical method.

There are rare instances where a sliding genioplasty and a chin implant can be combined. There are two indications for this composite chin augmentation approach. The first one is when the amount of horizontal chin augmentation desired is more than what a sliding genioplasty alone can produce. This would occur when the thickness of the chin bone is less than what the amount of horizontal bone movement that is needed to create the desired effect can be done. The additional horizontal projection is achieved by placing the  needed implant size in front of the moved chin bone.

The second indication for the composite chin augmentation approach is when one desires a different chin shape than that of the natural bone of the sliding genioplasty. This almost is always when one wants a more square chin shape and the natural chin bone is more round. A more square shaped chin implant, even if it is small, is placed in front of the sliding genioplasty. It is vey difficult, if not impossible in many cases, to make the chin bone more square in external appearance.

Sliding Genioplasty with Chin Implant Dr Barry Eppley IndianapolisWhen placing an implant in front of the sliding genioplasty, it is important to realize up front, that there will be some eventual implant settling into the bone. This is not bone erosion but simply the body seeking to relieve the pressure from the pushback of the stretched chin soft tissue pad. It is a natural and self-limiting biologic process.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Jaw Angle Implants and Sliding Genioplasty

Thursday, March 2nd, 2017

 

Background: Jaw angle implants are enjoying a surge in popularity as patients are seeking improved shapes to their jawlines. Filling in the back part of the jaw offers a good complement to well established chin implants to create a more complete jawline augmentation effect.

Like just about every other facial implant, no one size or style fits all. This applies equally well to jaw angle implants. While the widening version has been around for over twenty years, a newer vertical lengthening style now exists. The key to which jaw implant style to use is the natural anatomy of the mandibular ramus. A highly positioned jaw angle and a steep mandibular plane angle are the indications for extending the jaw angle down through the vertical lengthening style.

While the use of three implants (one chin and two jaw angles) is one method of total jawline augmentation, some patients may not prefer their chin augmentation to be done with an implant. A sliding genioplasty can be combined with jaw implants if that is more favorable for the chin. (severe horizontal chin deficiency, lower lip incompetence, mentalis muscle strain) The consideration must then be given to the smoothness of the jawline since the front end of the jaw implant will not cover the back end of the sliding genioplasty bone cut.

Malpositioned Jaw Angle ImplantCase Study: This 43 year-old female previously had a chin implant and two jaw angle implants placed for a total jawline makeover by another surgeon. Unfortunately the right jaw implant became infected and the left jaw implant was severely malpositioned. The chin implant was fairly well placed but she did not like it because it made her chin too wide and did not improve her presurgical lower lip incompetence, mentalis muscle strain and chin dimpling.

Custom Extended Vertical Jaw Angle Imlpants design Dr Barry Eppley IndianapolisCustom Vertical Jaw Angles vs Standard Widening Jaw Angle Implants Dr Barry Eppley IndianapolisIt was decided to remove her chin implant and replace it with a sliding genioplasty which would better address the functional aspects of her chin deficiency. (as well as making her chin less wide) The style of jaw angle implants would also be changed to be more vertical lengthening and to come far enough forward to cover the notch at the back end of the proposed sliding genioplasty. These jaw implants would need to be custom made using a 3D CT scan.

Under general anesthesia and through an intraoral approach, the chin implant was removed and a sliding genioplasty done in its place. The chin was brought forward 8mms and vertically shortened 3mms. The custom jaw angle implants were also placed intraorally and their anterior ends were positioned over the ends of the sliding genioplasty  to create a smooth and unbroken jawline effect.

A sliding genioplasty can be combined with jaw angle implants. In many cases standard jaw implants may suffice. But for a more assured seamless transition from the jaw implants to the bone of the chin advancement, custom jaw angle implants work best.

Highlights:

1) The wrong jaw angle implant style will still be a failure even if it is well placed.

2) Many women need a vertical lengthening jaw angle implant style and not a widening jaw angle implant style.

3) When combining jaw angle implants with a siding genioplasty, a custom implant design approach is often best.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Sliding Genioplasty for Chin Implant Replacement

Monday, February 13th, 2017

 

Background: Chin implants in females is a common lower facial reshaping procedure. While they add desired amounts of horizontal projection and improve the facial profile, the extended wing designs of today’s chin implant designs can have adverse effects on they look in the front view. While the extensions on the implants are designed to create a natural transition into the jawline bone without a visible stepoff, they add chin width to do so. While this is rarely an issue in men, it can be more frequent aesthetic problem in women.

Women seeking an improved jawline have a different aesthetic goal than men. They do not necessarily seek an angular jawline with visible corners.  (some women may bit not the majority) Rather they usually desire a V-shape to their jawline with a smooth linear line from front to back. As part of that aesthetic goal the chin must be narrow and may even have a more pointy chin or smaller V-shape appearance. This is in contradiction to the look that many chin implant styles give to the augmented chin.

Case Study: This 35 year-old female had a prior history of having chin augmentation done using a Medpor chin implant of 6mm projection placed through an intraoral approach. She never liked the result as it gave her a wide and boxy chin. This did not fit her small petite face well. While it provided adequate horizontal projection, it made her chin too wide and too vertically long. She also developed some lower lip sag and excess tooth show.

Medpor Chin Implant Removal and Sliding Genioplasty Replacement intraop Dr Barry Eppley IndianapolisChin and Jaw Angle Reshaping result front view Dr Barry Eppley IndianapolisChin and Jaw Angle Reshaping result oblique view Dr Barry Eppley IndianapolisUnder general anesthesia her indwelling Medpor chin implant was removed intraorally. To do so it had to be sectioned into multiple pieces and required the removal of 6 titanium screws. It was replaced by a sliding genioplasty that was brought forward 6mm and vertically shortened 3mms. A mentalis muscle resuspension and vestibuloplasty were performed to help with her lower lip sag. Concurrently, vertical lengthening jaw angle implants were placed through posterior vestibular intraoral incisions. The implants added 7mm of vertical length and 3mms of width.

Any form of chin or jawline augmentation must take into consideration the differences be tween male and female jawline shapes as well as the patient’s aesthetic goals. Even a ‘simple’ chin augmentation must take this into consideration as the operation may be a technical success but an aesthetic failure. (as this case illustrates) The entire jawline from front to back must also be considered in an effort to create an improved jawline that fits the patient’s face.

Highlights:

1) Chin implants in females create horizontal projection but often at the expense of too much chin width.

2) A sliding genioplasty can replace a chin implant by providing horizontal projection but with a more narrow chin width.

3) Jaw angle implants can create vertical lengthening with a sliding genioplasty to give a more defined jawline in females.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Medpor Chin Implant Removal

Saturday, November 26th, 2016

 

The use of implants for chin augmentation is the most popular method to achieve enhanced projection of the lower face. Many materials have been used for chin implants and today it usually comes down to the use of either a silicone or Medpor material. There are surgical advocates for both types of chin implants and both can be successfully used under the right circumstances.

Where silicone and Medpor chin implants differ dramatically and unequivocally is if the patient wants the implant removed. The aggressive tissue ingrowth into the Medpor material makes its removal difficult and fairly traumatic to the surrounding tissues. I have read some surgeons who say the material can’t be removed. This is not true, it is just that it is much more difficult than the easy removal of silicone implants.

If a Medpor chin implant is removed, there is often the need to replace it. The question is what should that be. That depends on why the implant was originally placed, its size and shape, and what the patient’s aesthetic goals.

medpor-chin-implant-removal-and-sliding-genioplasty-replacement-intraop-dr-barry-eppley-indianapolisIn this example a small petite female with a very short chin and high jaw angles had a Medpor chin implant placed. The implant produced numerous adverse aesthetic sequelae including a wide and elongated chin. Through an intaoral approach the Medpor chin implant, which was secured by 6 screws, was able to be removed in many pieces. The tissue ingrowth of the wings of the implant had adhered to the mental nerves which required careful separation to avoid nerve avulsion. The chin augmentation replacement was a sliding genioplasty. This brought the chin forward, made it less wide and vertically shortened it as well.

While chin implants are made of different materials, their effectiveness is best determined by the selection of implant style and size. It is important that chin augmentation in females is seen as aesthetically different than that of men. The type of chin implant style that works well in men often does not in females.

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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