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Posts Tagged ‘chin ptosis’

Mentopexy Correction of the Witch’s Chin Deformity

Monday, September 21st, 2009

The chin and its appearance in profile plays an important role in how the face is perceived. The chin is, of course, composed of how much the bone portion of it protrudes and how thick and tightly adherent the attached soft tissues are. Together they make the chin profile. While bony deficiencies of the chin are common and easily improved with an implant, loose or sagging soft tissues require a more thoughtful approach.

Sagging soft tissues of the chin, also known as a witch’s chin deformity (as uncomplimentary as that is) or chin ptosis, is the result of a loss of attachments. One cause is that of aging, particularly in the person who wears dentures, where the jawbone has resorbed down to the point of loss of the upper mentalis muscle attachments. In the younger patient, however, the most common reason is that of implant removal and/or replacement from a prior chin augmentation procedure. The chin tissues have been lifted off to initially place the implant and its subsequent removal has created a loss of muscle attachments…and then it just sags off of the bone. This situation should not be a surprise as it is analogous to that of breast implants and envisioning what happens if they are simply removed later.

Correction of the witch’s chin (chin ptosis) is through a procedure known as a mentopexy, the resuspension of chin tissues onto the bone. However, there are several types of mentopexies and a careful examination of the chin anatomy is needed to determine the exact problem. The key question is what type of bony chin support is there and does the patient want to keep their chin bone position or do they want to increase it.

In the aged chin, in particular, the amount of chin projection is usually satisfactory. It is a matter of improving the soft tissue attachments to the bone. While I have done an ‘upward’ resuspension to the bone of the hanging soft tissues, the long-term success of that procedure in my hands has not been good. Therefore, I prefer a ‘down and under’ approach of removing loose skin and muscles from a submental incision and tightening it on the underside of the chin. (submental tuck-up) That is a  much more predictable that removes what is loose rather than trying to suture it back up. The aging chin often has a vertically short mandible which is why resuspension is less successful.

The chin ptosis that occurs from an implant removal poses different considerations. Does the patient still want increased chin projection or not. If not, the  a submental tuck-up approach as above is done. Often a scar already exists under the chin and it is merely lengthened a bit. If more chin projection is still desired, then a chin osteotomy (osteoplastic genioplasty) may be done and is the preferred technique in my Indianapolis plastic surgery practice. Rather than using an implant again, the bone is moved (which helps support the sagging soft tissues) and the mentalis muscle and chin tissues is reattached on top and behind it to the fixation plate that is needed. A chin implant can still be used in this case but a limited submental tuck-up will likely still be needed.

Dr. Barry Eppley

Indianapolis, Indiana 

 

Plastic Surgery Correction of Chin Ptosis

Saturday, April 4th, 2009

A chin that sags over the line of the jaw (chin bone) is called chin ptosis. (ptosis is medically defined as a sagging of a body part) While some people have this naturally, most of the time it is due to the soft tissues of the chin sliding downward for a reason. This can occur from simple aging, loss of one’s lower front teeth, and due to different surgical procedures of the chin. A few people actually have pseudo- or perceived chin ptosis which occurs as a result of a natural deep crease below the lower lip (submental crease) which makes the chin look ptotic (particularly when smiling) even though it is not.

Successful correction of chin ptosis can usually be done for those problems caused by prior surgeries. Chin surgeries that are well known to cause soft tissue sagging include the intraoral placement of implants, removal of an overly large implant and bony reductions. Other less common causes include intraoral access for repair of mandibular symphysis and parasymphyseal fractures and vestibular lowering procedures (preprosthetic surgery) in preparation for improved lower denture fit.

Treatment is  based primarily on resuspension or tightening of the mentalis muscles  with or without hard tissue chin expansion. For sagging caused by intraoral access to the chin, the mentalis muscles must be brought back up into their original anatomic position. The intraoral route of access to the chin always divides the upper attachments of the mentalis muscles. (some surgeons put them back well while others do not) This is why the submental (under the chin) skin approach for chin implants is always better with a very acceptable scar and why I use it in my Indianapolis plastic surgery prasctice.  It is not always easy to find good muscle to sew to and this is why a bone-anchoring technique with titanium screws or Mitek suture anchors is my preferred method for a ‘high’ reattachment.

If chin implant removal is the cause of sagging, replacement with a new implant alone may be satisfactory. Or if the patient no longer wants an implant but still desires an augmentation, moving the chin bone forward as a natural ‘implant’ may create enough expansion to fill out and elevate the sagging chin tissues. A chin osteotomy is an excellent opportunity to elevate the muscles as well as the plates and screws used to hold it in its new place are good anchoring points for the muscle.

Chin reduction procedures are especially prone to chin sagging problems after. The lower attachments of the mentalis muscle must be divided to access the chin bone. Once the bone is reduced by burring, the muscle and sometimes skin must be shortened and reattached. Usually tightening the muscle across the reduced bone and reattaching it to the muscle on the underside of the chin is adequate. If not, bone holes can be made on the inferior ledge of the chin bone onto which the muscle can be reattached.

 he chin is unique in that the mentalis muscle is attached and suspended across it  both above and below the chin prominence. The skin and fat are attached to the underlying muscle and follow its position on the bone. If the muscle sags, so does the appearance of the chin. The key to correction of chin ptosis is management of the mentalis muscle attachments in most cases.

Dr. Barry Eppley

Indianapolis, Indiana


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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