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Archive for the ‘sliding genioplasty’ Category

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

OR Snapshots – Vertical Lengthening Genioplasty

Wednesday, October 19th, 2016

 

Chin augmentation is traditionally thought as a choice between a chin implant and a sliding genioplasty. While seen as the two procedure choices for chin reshaping they are not really interchangeable. Besides the difference between synthetically augmenting the bone vs actually cutting and moving the bone, they can achieve different dimensional chin changes.

The one movement that a sliding or bony genioplasty can do much better than an implant is changing the vertical dimension of the chin.  While it is obvious that an implant can not shorten the chin, it historically could not lengthen it very well either. That has changed more recently with vertical lengthening chin implant styles. But the intraoral genioplasty remains an historic mainstay for increasing the vertical length of the lower face. (chin)

vertical-lengthening-genioplasty-intraop-dr-barry-eppley-indianapolisDone through an intraoral mucosal incision, the chin bone is cut well below the level of the lower tooth roots. An opening wedge is performed by dropping down the chin bone to the desired vertical distance that is needed to create the aesthetic result. In most cases the vertical gap that needs to be created is at least 7mms. Much less does not produce a very obvious vertical lengthening. The amount the vertical gap can be opened is only limited by the length of the fixation plate used and what other chin dimensions need to be changed if any.

A debatable issue with vertical chin lengthening is whether the bone ago created between the two chin segments needs to be filled in. In small gaps in the range of 5mms or less grafting of the defect is probably not needed. The body will fill it in on its own. But larger bone gaps should be grafted. I prefer to use allogeneic cadaveric bone grafts which conveniently come in wedge forms that can fit nicely as an interpositional bone graft.

Interpositional Gtafting in Vertical Lengthening Genioplasty

Saturday, September 10th, 2016

 

The sliding genioplasty is a well known chin augmentation procedure that is commonly used for horionzontal advancement. But cutting and moving the chin bone can be done for other dimensional changes of which vertical lengthening is also a good indication. Historically vertical lengthening of the chin could only be done with an opening bony genioplasty.

When the chin bone is fractured and moved downward it is held into its new position by a plate and screws. Such fixation devices can increase the vertical length of the chin up to 1 cm or more. This leaves a large bone gap between the two cut bone edges. The question has always been at what amount of opening should the gap be filled and with what material?

There is no exact science that tells us what size bone gap in a vertical lengthening genioplasty can heal in on its own and what size bone gap can not. The chin does have a remarkable capacity to create bone from its two cut bone edges. As a general rule I do not  place any interpositional material for bone gaps less than 6mms. But larger amounts of vertical chin expansion merit some graft material to aid bone healing

While a bone graft would be the ideal material to place into a vertical lengthening genioplasty, harvesting a bone graft for an elective aesthetic procedure is not appealing. A wide variety of alloplastic materials have been used instead of which hydroxyapatite granules and blocks are the most common.

vertical-lengthening-genioplasty-with-interpositional-bone-graft-dr-barry-eppley-indianapolisvertical-lengthening-genipplasty-with-interpositional-bone-graft-oblique-view-dr-barry-eppley-indianapolisAn other graft option is that of tissue bank or cadaveric bone. Available from a variety of tissue banks in the U.S., processed solid wedges of corticocancellous bone are available for human implantation. These are excellent interpositional graft choices for a vertical lengthening genioplasty. Placed behind the fixation plate in the central opening of the bone, they not only add to structural stability but provide a scaffold for bone ingrowth. The entire opening wedge of the genioplasty does not need to be grafted, only the largest gap in the center. The wedge shape of the corticocancellous bone makes it an ideal fit for this type of bony opening.

The options for filling the  bone gap of a vertical lengthening genioplasty are either hydroxyapatite blocks or tissue back bone. Both can be very effective and their cost differences are not significant.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Three-Piece Total Jawline Augmentation

Tuesday, September 6th, 2016

 

Background: Total jawline augmentation refers to changing the entire look of the mandible. This could mean that the entire jawline has to be changed that can only be done by a custom wrap around jawline implant. But not everyone needs augmentation of all areas of the jawline. Many patients just need to change the three ‘corners’ of the jaw, the chin and the two jaw angles.

A three-piece approach to total jawline augmentation most typically refers to the use of chin and jaw angle implants. A variety of chin and jaw angle implant styles and sizes now exist that can meet the dimensional needs of most patients. Jawline implants can add width, vertical length and horizontal projection. But the one dimension that no jawline implant can achieve is a shortening effect.

The one dimension in jawline reshaping that requires a reductive approach is vertical chin shortening. Many very recessed chins are actually vertically long because of the backward rotation of the entire mandible due to an underdeveloped ramus. While a chin implant can add the necessary horizontal projection, it can not make it shorter. Placing the chin implant high to try and create this effect will lead a fullness under the augmented chin and will not really make it appear vertically shorter.

Case Study: This 38 year-old male presented for improvement in the shape of his jawline and lower third of his face. He had a recessed and long and a narrow jawline shape.

Total Jawline Augmentation result front view Dr Barry Eppley IndianapolisUnder general anesthesia he initially had a sliding genioplasty performed with a 10mm forward movement 5mms of vertical shortening. Bilateral jaw angles implants were placed that primarily added 7mms of width but only 1mms of vertical lengthening.

Total Jawline Augmentation result side view Dr Barry Eppley IndianapolisTotal Jawline Augmentation results oblique view Dr Barry Eppley IndianapolisHis result shows the impact of widening his jawline but also shortening it anteriorly. This combination creates a broader and more masculine appearing lower third of his face. While the chin change significantly improved his profile, it is the jaw angles that added the most to his front and three-quarter views.

He had a long chin due to its recessed position. While a chin implant could have been used that would have maintained his vertically long face and would also have required the jaw angles to be vertically elongated as well. To help shorten his overall face a sliding genioplasty is a better choice because it can shorten the lower third of his face on the front part of the jaw.

Highlights:

1) Total jawline augmentation refers to the three corners, the chin and the two jaw angles.

2) A sliding genioplasty with jaw angle implants is a three piece approach to total jawline augmentation.

3) A sliding genioplasty is better than a chin implant when the forward movement of the chin needs vertical shortening as well.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Inferior Border Shave of the Setback Sliding Genioplasty

Thursday, July 28th, 2016

 

Background: The sliding genioplasty is a well known bony reshaping procedure of the chin. It is best recognized for increasing horizontal projection and vertically lengthening the chin. But it can also be used for many other dimensional changes changes of the chin bone such as asymmetry correction, vertical shortening as well as decreasing its width.

One of the least common uses for a sliding genioplasty is to decrease chin projection or for horizontal chin reduction. While the chin bone can be moved backward and even reduced in height at the same time, this method of chin reduction is prone to creating other aesthetic problems. While the bone can be reduced, the enveloping soft tissues remain and can become ‘redundant’ This means that a submental bulge can appear from underlying shortening and the soft tissue chin pad may develop ptosis. These are well recognized soft tissue problems with the setback sliding genioplasty.

A less recognized but equally significant potential aesthetic issue is disruption of the mandibular plane. Regardless of the actual angle of this mandibular line, it is usually straight from the angle to the chin. But when the chin bone is moved backwards this straight line becomes disrupted and a v-shaped inferior border line results. This is because the back end of the osteotomy lines moves below the existing inferior border line. Unlike the notch (inverted V) that can occur when sliding genioplasty is moved significantly forward, a setback sliding geniopasty causes the V deformity due to the bump of bone not below the line.

Inferior Border Shave afetr Setback Sliding genipoplasty x-ray Dr Barry Eppley IndianapolisCase Study: This 23 year-old female had a prior history of a setback sliding genioplasty to reduce a prominent chin. This left her with a bulge under her chin and a rounded lower facial appearance. A lateral cephalometric x-ray showed that this bulge was caused by the back end of the sliding genioplasty which protruded below the inferior border of the mandible.  A line could be drawn to show the location of the bone removal need to make the jawline smooth.

Inferior Mandibular Border Reduction intraop Dr Barry Eppley Indianapolisinferior border mandibular shave specimenUnder general anesthesia through a small submental incision, a reciprocating saw was used to take down the bulge along the inferior border of the jawline behind the chin. The bone was sequentially taken down until a straight line was restored from the front edge of the chin back to the jawline behind the bone bulge.

The sliding genioplasty is not usually the best chin reduction technique for a horizontally excessive chin. If done the back end of the downfractured chin segment should be removed to avoid a bulge along the lower edge of the jawline. It can also be removed secondarily through a subental incision which provides straight line access to most successfully perform it.

Highlights:

1) A setback sliding genioplasty can often cause a negative v-shaped alteration of the mandibular plane angle.

2) An inferior border shave and straightening of the mandibular plane angle can be done.

3) A shave of the anterior inferior border of the mandible is best done through a submental approach in many cases.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Jumping Genioplasty

Wednesday, April 20th, 2016

Background: A sliding genioplasty is the most well known of all the facial osteotomies and also the most commonly performed. It is done for various chin augmentation and reshaping purposes. It if often compared to a chin implant and doctors often tout one versus the other for aesthetic chin augmentation. But the reality is that both have their place and their benefits vs liabilities must be evaluated on an individual basis.

Sliding Genioplasty Indianapolis Dr EppleyThe advantage of a sliding genioplasty is that it is very versatile in terms of dimensional changes of the chin. The bone cuts can be devised to bring the chin forward, make it vertically longer, widen or narrow it or almost any combination thereof. With the use of today’s plate and screw designs, the genioplasty no longer just as to ‘slide’ forward to make for a stable dimensional change to the chin.

In a sliding genioplasty the amount of forward movement of the chin is limited to the anteroposterior thickness of the mandibular symphysis. In order to maintain bone contact between the upper and lower chin segments, the back edge of the downfractured and mobilized chin segment should stay in contact with the front edge of the stable upper bone segment. In doing so, the amount of horizontal advancement as well as the ability to vertically shorten the chin has its limitations.

Case Study: This 15 year-old petite female was born with a congenital condition that caused her lower jaw to be severely underdeveloped. Even though she was a teenager her dental condition did not permit her lower jaw to be brought forward as would be the ideal surgical treatment.

Teenage Jumping Slidinmg Genioplasty result side view Dr Barry Eppley IndianapolisUnder general anesthesia, an intraoral approach was made to the chin. A low level horizontal bone cut as made below the mental foramens. In bringing the chin bone forward in a traditional sliding genioplasty, the small size of the chin did not make as much horizontal advancement as desired nor did it shorten the chin enough. The downfractured chin bone was then brought forward and ‘jumped’ in front of the upper chin segment and sat on top of it like a chin implant. The pedicled chin segment was secured to the bone by  two lag screws.

Teenage Jumping Sliding Genioplasty result front view Dr Barry Eppley IndianapolisJumping Sliding Genioplasty result oblique view Dr Barry Eppley IndianapolisHer six month result showed a noticeable horizontal advancement as well as a vertical shortening. The amount of horizontal chin advancement is still less than desired btu an improvement nonetheless. Hopefully she will be able to undergo a mandibular advancement in the future.

A jumping genioplasty is an older form of the traditional sliding genioplasty. It is rarely used today since the introduction of rigid plate and screw fixation. But in very small chins that need significant horizontal advancement and vertical shortening it can still be used.

Highlights:

1) A sliding genioplasty is a well known chin augmentation procedure that cuts and moves the symphysis of the mandible forward.

2) A jumping genioplasty maximizes the horizontal advancement of the chin bone while simultaneously shortening its vertical height.

3) In chins that are short because of significant jaw underdevelopment, they are often too long vertically as well.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Four-Piece Total Jawline Augmentation

Sunday, December 20th, 2015

 

Background: The desire for a more pronounced and visible lower jawline exists in both men and women. The surgical methods to do so are more commonly requested by men particularly when it comes to a substantially larger jawline change. Making a jawline more evident focuses on increasing the size and shape at its ‘corners’, that of the projecting chin and the back ends at the bilateral angles.

When creating a total jawline augmentation effect, there are two basic approaches.  The historic and still most commonly used method is a three implant approach of independently placed chin and jaw angle implants. In some cases the chin implant may be substituted with a siding genioplasty. The newer method of jawline augmentation is the fabrication and placement of a one-piece custom made jaw implant that wrap around the chin from angle to angle. It is the preferred method of total jawline augmentation given the preoperative designing of the implant and its smooth one-piece construct. But cost considerations may lead some patients to still undergo the classic three implant method.

Chin and jaw angle implants exist in standard styles and sizes. While for some patients these historic standard chin and jaw angle implant styles will effectively work, newer implants styles offer improved total jawline augmentation results for many patients. Newer vertical lengthening jaw angle implants have allowed for increased visible angularity of the back part of the jaw. When vertical elongation of the chin is needed either newer vertical lengthening chin implants can be used or the historic approach of an opening sliding genioplasty. When significant vertical and horizontal chin augmentation is needed, chin implants and a sliding genioplasty can be combined.

Case Study: This 25 year male wanted a total jawline change. Not only was his lower jaw horizontally short but it was vertically deficient as well. This was evident in the short chin and large overbite which are directly related. When he opened his mouth slightly the improvement in his chin and jaw height could be seen confirming the needed vertical dimension of his chin and jawline.

Chin and Jaw Angle Jawline Augmentation result side viewChin and Jaw Angle Jawline Augmentation result oblique viewUnder general anesthesia, he had an opening sliding genioplasty (7ms done and 7mms forward) with a chin implant overly (5mm horizontal augmentation) done through an intraoral approach. Through posterior intraoral incisions jaw angle implants that added 7mm vertical length and 5mm width were placed.

At one year after surgery the improvement in his jawline could be appreciated. Ideally longer vertical lengthening jaw angle implants would have improved his result and are being considered. The sliding genioplasty and chin implant overlay produced a satisfactory improvement to the front part of his jawline

Total jawline augmentation can be effectively done using a non-custom implant approach. It can require the thoughtful application of newer chin and jaw angle implant styles and the selective use of sliding genioplasty techniques.

Highlights:

  1. Total jawline enhancement consists of front (chin) and back (jaw angle) augmentation.
  2. Preformed chin and jaw angle implants is the historic and standard approach to total jawline enhancement.

3. Vertical chin augmentation in total jawline enhancement can be done by a combined sliding genioplasty with a chin implant overlay.

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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