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Posts Tagged ‘bony genioplasty’

The Aesthetics of the Chin and Its Relationship to the Face

Tuesday, July 3rd, 2012

The chin creates the dominant effect on the appearance of the lower face. Thus, it has a major effect on facial balance and appearance. When out of proportion to the rest of the face, it can create a perception that other facial features are the culprit when it is really at fault. Understanding the proper relationship of chin shape and projection helps one plan for the right procedure when attempting to improve one’s facial appearance.

The most aesthetically pleasing chin is almost always simplistically perceived as falling on a vertical line that drops down from the nasion or junction of the nose and forehead. While this measure of chin position does have considerable value, today’s understanding of chin aesthetics is far more complex and truly three-dimensional. The ideal chin should have an oval shape in women and a more square shape in men. The upper part of the chin has a concave form that curves outward into a convexity (representing the thicker soft tissues of the chin pad) before it turns inward again at its lower edge.

The horizontal position of the chin should lie directly under where the lower lip pouts outward. With adequate projection, it can make the nose look smaller which is why it is frequently augmented in a reductive rhinoplasty. When a chin is weak or horizontally short, it can make other facial features look bigger, often creating a wider or more square facial shape. When the chin is too big or horizontally forward, the rest of the face can look recessed or more flat.

The frontal shape of the chin is very gender-specific. Women should have a more angular or narrow chin but not too pointy. (or too narrow) The greatest width of the chin should lie well within vertical lines drawn down from the canines or eye teeth. Men should have a wider or more square chin whose width can be out to vertical lines dropped down from the corners of the mouth. In the frontal view, the length of the chin is another important aesthetic element. To be in proper facial balance, the height of the lower face is always stated as being no greater than 1/3 of the total height of the face. But the lower 1//3 of the face is comprised of by more than the chin proper. By this standard, the height of the chin proper should constitute no more than ½ of the lower third facial height.

The appearance of the chin is also affected by the rest of the jawline and neck. Jowls or too much fat and hanging skin along the jawline makes the face look more square which is not the fault of the bony chin. It also makes the jawline heavy and can even create the illusion that one is overweight. This is particularly true when there is submental or neck fullness as well. The back part of the jawline or jaw angles impacts how the chin looks from the frontal view. Wide flaring jaw angles can make the chin look too narrow whereas diminuitive or non-flared jaw angles can make the chin look wide.

When considering any facial surgery, it is important to consider the aesthetics of the chin and how it impacts or is affected itself  by the rest of the facial features. Chin surgery can have a major impact on improving facial balance.   

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Vertical Lengthening of the Short Chin by Bony Genioplasty

Sunday, August 28th, 2011

Background:The shape and projection of the chin is an important facial feature. As the chin sits as a prominence on the lower edge of the face, it has multiple dimensions associated with its shape. While commonly perceived as having only a horizontal component to it, and treated most commonly with an implant if it is too short, this overlooks its vertical and width dimensions. Chins can also be too vertically short or long as well as too wide or too narrow.

The lower face, of which the chin is a significant component, should ideally make up 1/3 of total facial height. When the lower face is vertically short, it is almost always because the bony height of the chin is too small. There are some uncommon exceptions, such as a small maxilla where the lower jaw over rotates with a resultant malocclusion, but this is easy to spot. The vertically short chin can occur regardless of its horizontal dimension presenting with either microgenia, normal chin projection or macrogenia.

The chin that is too vertically short is commonly seen in combination with some degree of horizontal deficiency. The amount of vertical and horizontal shortness determines whether an implant or an osteotomy is the better treatment. With just a few millimeters of deficiency in either dimension, an implant can readily treat both with good positioning on the lower end of the chin bone and proper implant style selection. Anything more than a minor deficiency is best treated by a lengthening osteotomy.

Case Study: This 35 year-old male wanted to improve his ‘weak’ chin. On examination he had both a vertical (8 to 10mms) and horizontal (5mms) chin deficiency. This made his lower face look short and gave his chin a short squat appearance. Computer imaging confirmed that a vertical chin lengthening procedure would improve his facial aesthetics.

Under general anesthesia, a horizontal chin osteotomy was done through an intraoral approach. The downfractured chin segment was vertically lengthened by 8mms and brought forward 5mms. It was held into position with a modified step titanium chin plate to create these dimensional changes. A hydroxyapatite block was shaped with a burr to create a wedge fit between the upper and lower chin segments. It was put in place after the chin segment had been stabilized by the plate. The mentalis muscle was reapproximated over the plate-bone-block chin construct and the mucosa closed.

After a chin osteotomy, considerable swelling ensued which took close to three weeks to return to a more normal appearance. The lower lip had some temporary numbness which was expected and the chin felt very stiff and unnatural for about a month after surgery. It took a good six weeks until the chin felt more normal and a natural part of his face again.

While the improvement in the chin’s appearance was immediate, critical analysis at 3 months after surgery showed the final result. He had complete return of all feeling and lower lip and mentalis muscle movement at that point. In seeing him at two years after surgery, the improvement was maintained as expected.

Case Highlights:

1) The second most common chin deficiency is in the vertical dimension. It can be seen in both the frontal and profile views and will likely have a horizontal problem as well.

2) The only method for significant vertical lengthening of the chin is an osteotomy with or without an interpositional synthetic graft.

3) Vertical chin lengthening can be combined with other dimensional movements including horizontal advancement and width narrowing or expansion.

Dr. Barry Eppley

Indianapolis, Indiana

Jawline Surgery and Facial Derounding

Saturday, June 11th, 2011

One recent high profile facial change reported in the media is that of Bristol Palin. At a dinner in Washington in late April, she was reported to be unrecognizeable. Something was very different about her face. She had a distinctly more angled jaw and sharpened chin. It was speculated that she had a facelift, fillers or even implants in her cheeks.

What did she have done? According to the 20 year-old reality star, she had corrective jaw surgery. While she acknowledged that it changed her look, the surgery was done for medical necessary reasons. She underwent the procedure so her lower jaw and teeth could align properly. In essence she had a pre-existing malocclusion (underbite) that was treated by a mandibular (jaw) advancement. (sagittal split ramus osteotomy, SSRO) It is impossible to know how big of a jaw advancement she had done, but judging by her preoperative profile pictures, probably in the range of 4 or 5mms at best. But this procedure alone would not account for her new profile and jawline.

She likely may have had the additional cosmetic procedures of neck/submental liposuction and a chin or genioplasty procedure. What type of chin reshaping she had can only be speculated, but it likely was a chin osteotomy as opposed to a chin implant. It is very common to do a chin osteotomy as a complementary procedure to a jaw advancement osteotomy. This is because the same equipment is used for both procedures and if you are asleep for one bone cutting procedure, it makes sense to cut and move the chin bone as well. This is also a good opportunity to perform a natural bone moving procedure that will heal and never pose any problems in the future in a very young patient, unlike the risks (albeit very low) of having a synthetic chin implant.

The other giveaway that it might be a chin osteotomy is the shape of the new chin. The chin is more narrowed, almost a bit pointy, and there is a slight inward indentation as the chin moves around into the side of the jaw. This is a look that a chin osteotomy (osteoplastic genioplasty) can create as the end of the chin bone moves forward. It frequently will create a more narrow chin as the u-shape of the chin bone moves ahead of the rest of the arc of the lower jaw. A chin implant usually does not create as much chin narrowing and makes the sides of the chin wider not more narrow, unless a central chin button style implant is used.

Because she had jaw surgery, she may well have lost some significant weight in the 6 week recovery phase. As one can not eat or chew normally for this period of time, all patients will lose some weight. A 10 or 15 weight loss could account for her overall thinner face, regardless of whether neck liposuction was done.

This conversion of her round face to one that is more oval occurs because of the triple effect of three changes; a more prominent chin, a trimmer neck profile and a more narrow submalar (below the cheeks) area. While Bristol Palin achieved this result by jaw and chin bony advancement and neck liposuction and/or surgically-induced weight loss, the more common ‘facial derounding’ surgery uses a slightly different approach. The more traditional approach uses chin implant augmentation, neck liposuction and buccal lipectomies.

Dr. Barry Eppley

Indianapolis, Indiana

A Narrowing Genioplasty for Making The Square Face More Slender

Monday, April 25th, 2011

The perception of a square face usually has much to do with the shape of the jaw. A square lower face is largely influenced by the width of the jaw from the chin back to the jaw angles. This may or may not be associated with a horizontally short jaw as well. While this is a common aesthetic facial concern in Orientals, it may also be seen in other ethnic groups as well. In those seeking a change from this appearance, their goal is a more narrow and slender appearing face which changes the shape from square to an oval.

The traditional approach to narrowing a wide or square lower face is jaw angle reduction surgery. An outer cortex ostectomy technique is preferred over complete angle amputation. While this can have a narrowing effect, the results are limited exclusively to the posterior part of the face where the jaw angles exist. This may not make a face appear slender as the chin and anterior jawline area unchanged. For some patients, this is an important area to combine with jaw angle reduction and is often overlooked in the surgical planning of facial slimming.

Chin osteotomies can have a significant influence in changing the frontal appearance of the lower face. The traditional forward movement of the downfractured chin segment gives a measureable narrowing effect as its u-shape is brought forward. When combined with some vertical elongation, this effect can be further maximized. But not every face needs visible horizontal or vertical movement of the chin and it may not be asesthetically advised.

Chin osteotomies can also be done just for narrowing its width. By removing a central bone segment (up to 1 cm) from the mobilized chin segment, it can be brought back together in the midline and secured together. This is a far more effective method of width reduction than burring. This is because the effect of burring is limited by the location of the mental nerves. Once the chin segment is narrowed, smoothing of the bone edges along the osteotomy lines is needed to prevent step-offs that can later be felt through the skin.

One caveat about bony chin narrowing is management of the attached soft tissues. When you have less bone support, soft tissue prolapsed and redundancies are possible. This can occur in the jowl areas as well as the floor of the mouth muscles. The genioglossus muscles must be resuspended to the chin as they are detached with central chin bone resection. The mentalis muscle should also be securely reattached to prevent any sagging of the jowls or chin pad. As it turns out, both muscles are sutured to the same place…the plate and screws used to secure the chin osteotomy in the midline.

The entire jaw contributes to a wide and square face for some patients. A narrowing sliding genioplasty can be a valuable addition to a jaw angle reduction in the goal of making a more slender jawline that has more of an oval appearance.

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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