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Archive for the ‘sliding genioplasty’ Category

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

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


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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