Chin reduction surgery is sought for those patinets afflicted with a chin that is too strong or protrusive. A large chin can exist in numerous dimensions, albeit being vertically too long, too horizontally forward or too wide. In many cases the chin protrusion is caused by at least two and sometimes all three dimensional excesses.
Intraoral chin reduction is reserved for a minority of large chin patients. A chin that is too vertically long can be reduced by a wedge reduction bony genioplasty. But chins that are too far forward should not be reduced by shaving or setback genioplasties. This will lead to soft tissue chin problems of redundancies and/or chin ptosis. (sagging)
A submental chin reduction is the most effective technique for a chin that needs multiple dimensional changes. It is preferred because it can deal with the resultant soft tissue excess that results from loss of bone support. It also provides direct access for reducing the jawline behind the chin along the inferior border.
The best and simplest method for estimating and planning the bone removal in a submental chin reduction is a panorex x-ray. This x-rays provides visualization of the important mental nerve as it courses through the bone.
With x-ray planning as a precise guide, the measurements can be transferred to the bone during the chin reduction surgery. This will allow the maximum amount of bone removal while protecting the integrity of the mental nerve as it courses through the jawbone.
An after surgery x-ray shows the execution of the exact bone removal plan and how close the path of the nerve is to the underlying bone cut. Comparison of the preoperative planning panorex to the result seen in the after surgery panoex shows how well the surgical bone removal was done.
The use of a panorex x-ray in submental chin reduction is a valuable presurgical tool which is of greatest importance when bone needs to be removed along the jawline behind the chin.
Shaping of the jawline is done for many different reasons. The most common reason worldwide is tapering a wide jawline through a combination of a chin reduction osteotomies and jaw angle shaves or ostectomies. In other patients with just a large or long chin, a chin reduction osteotomy is used.
When the chin is vertically reduced the osteotomy line usually extends to the inferior border of the jawline below the mental foramen or even more posterior. Depending on the amount of vertical chin bone reduction and the angle of the bone cut, the line of the jawline from the jaw angle (back) to the chin.(front) can become non-linear. A bump along the lower edge of the jawline behind the chin can occur because of the location of the vertical reduction. (anterior) This makes the chin vertically shorter in the front but boxy in shape and a fullness (bump) behind the chin on the jawline.
Reduction of this bump or hump on the jawline is best done through a submental approach. This provides the most direct access which is important is re-establishing a straight line along he lower edge of the jawline. This also places the bone work sufficiently below the mental nerve foramen to avoid injury to it. Removing the irregular jawline section is best done with a reciprocating saw to provide a smooth cut.
The submental approach to straightening a ‘crooked’ jawline by an inferior border irregularity or reducing its vertical length is the one most effective approach. Its limitations is that it can not reach all the way back to the ramus or jaw angle area.
While a short chin is both common and easily treated by an implant or bony in most cases, the long or big chin is a much more challenging aesthetic issue. The tissue excess over the front end of the lower jaw makes its reduction fraught with problems of redundancy and potential tissue sag. Where does all the soft tissue go if the bone that is supporting it is reduced or removed?
It is these soft tissue considerations that make an intraoral approach for chin reduction usually problematic. While a pure vertical reduction can be done by a wedge removal bony genioplasty from an intraoral approach, burring reduction or reverse sliding genioplasties ‘create’ soft tissue excesses or tissue sagging. These ‘new’ soft tissue problems will mar any aesthetic change that the bone reduction has accomplished.
A submental approach to chin reduction offers dual management of bone and soft tissue excesses. Through an incision under the chin, the soft tissues are initially freed off of the bone. The chin bone can then be reduced in any dimension whether it is vertical, width or horizontal projection. Once the bone is reduced, the amount of soft tissue excess becomes apparent.
There are two types of soft tissues excesses created by a submental chin reduction. The first is the amount of skin, muscle and fat over the chin prominence that is removed by a submental excision and tuck. The second, which is most manifest in a vertical chin reduction, is the loss of the mandibular attachments to the infrahyoid musculature. If not resuspended there will be a resultant submental fullness due to muscle retraction.
Resuspension of the released anterior strap muscles is done through bone holes placed through the new lower edge of the chin bone. Reattaching this muscle helps tighten the submental area so that its contour fits better to the reduced chin without an abnormal bulge in the submental soft tissue triangle.
‘I got a chin reduction with an incision under the chin few months ago. I wanted to give an update. I think Dr Eppley was right about this approach. The chin is smaller. I think it could be a little bit smaller but I definitely think the procedure was worth it. The scar has gotten smaller and I hope it will completely resolve or at least become less noticeable. As always, I’m satisfied and happy with Dr Eppley’s work. Thanks a lot!‘
Reducing a large chin has historically been a difficult problem. Traditionally chin reductions were attempted from intraoral approaches, burring down the horizontal portion of the chin bone. While perhaps effective for a few macrogenia (large chin) patients with vertical bone excess (osteotomy with wedge bone removal), this approach is inadequate for most. Horizontal bone burring often left a soft tissue excess that subsequently sagged, creating the classic ‘witch’s chin’ deformity. For many large chins, the tissue problem is multidimensional and involves both bone and soft tissue. This is why a submental approach for most chin reductions offers a more effective solution. From underneath the bone of the chin can be both horizontally and vertically reduced if necessary as well as soft tissue excess removed and tightened. All tissues problems of the large chin can be simultaneously treated. This does result in a submental scar and keeping the length if the scar underneath the arc of the symphysis (curved chin bone) is crucial for a satisfying scar outcome.
It is very common that multiple procedures are done on the face at the same time. Whether it be for anti-aging effects or for reshaping a face, combinations of procedures produce more profound changes. This is because the face is made up of many different parts and making significant changes often requires altering more than one facial area.
The benefits of combination facial surgery are commonly seen in nose and chin surgery. Since the nose and chin make up the dominant structures of one’s facial profile, it is not surprise that the combination of rhinoplasty and chin augmentation have become known as a profileplasty. Profileplasty refers to any cosmetic procedure that would improve the appearance of the profile which is an aesthetic and proportionate relationship of the nose, chin and neck. Thus profileplasty is not just rhinoplasty and chin augmentation, although this is the most common one in the young, but also includes a facelift and chin augmentation which is most common in older patients.
It is easy to understand why rhinoplasty can be so important to profile changes as the nose sits at the center of the face. Even very subtle nose changes can be visually appreciated in the profile view. Lowering of the nasal bridge and reshaping the nasal tip in a large nose or augmenting the dorsal line and increasing tip projection in a smaller/flatter nose not only changes the shape of the nose but one’s profile as well.
Just like the nose the chin has an equal, if not greater, impact on one’s profile than even the nose. This is because the chin sits in the middle of the facial profile between the nose and the chin. Whether it is too small or too big, the chin influences the perception of both the nose and the neck. The nose, however, does not influence the appearance of the neck angle and a necklift does not alter the perception of one’s nose shape.
In many patients the best profile changes come from a change in the lower face. Chin surgery can improve facial proportion, creating a better balance between the upper face (forehead, nose and lips) and the neck. As a well known example, even a well shaped nose can seem larger if the face has a smaller chin. Even if some nose changes are done, the more important procedure might be chin augmentation on improving the appearance of the nose.
Chin surgery is often perceived as an augmentative operation but that is a limited view of the different types of available chin surgery. Chin augmentation historically is seen as an increased in horizontal projection, how much forward position of the chin is needed. While this can be done with either an implant to sit on top of the bone or to move the chin bone itself (sliding genioplasty), they change the shape of the chin differently. A chin implant can improve the horizontal projection of the chin but can do little for increasing the length or vertical height of the chin. Often more vertical height is needed when the chin is significantly short. Unlike a chin implant, a sliding genioplasty can not only bring the chin forward but can lengthen or shorten its vertical height as well.
While chin implants have historically lacked the ability for vertical elongation, new chin implants styles will soon be available that provide concurrent vertical lengthening as well. Rather than sitting completely on the bone, these newer designs sit on the ledge of the chin bone (halfway between the front and under edges of the chin bone) to create their effects.
While sliding genioplasties can lengthen the height of the chin, there are limits as to how much the bone can be moved forward. To keep the back of the moved chin bone in contact with the front edge of the fixed chin bone, the amount of bone advancement is usually limited to 10 to 12 mms. Very short chins often need much more than that to achieve an ideal chin position. In these cases a chin implant can be placed on top of the advanced chin bone (implant overlay) to achieve an additional 3mm to 5mms of further horizontal chin projection.
Chin reduction is not as commonly done for profile changes and has a checkered history. The most common chin reduction method is done as an intraoral burring or shaving of the front edge of the chin bone. While simple, it is rarely effective as no more than a few millimeters of bone is reduced and no change occurs in the soft tissue thickness. Often patients complain of seeing no change after this surgery and may even develop some soft tissue redundancy or sagging afterwards. The use of a reverse sliding genioplasty is also ill-advised as, while it does move the whole chin bone back, it pushes the attached soft tissues into the neck creating an undesired bulge.
The most effective chin reductions are done from a submental (under the chin) approach where the bone can be more dramatically reduced in all dimensions if needed and the excess soft tissues excised and tightened. (tucked) While this does create a scar under the chin, it can remain imperceptible if its length remains curved to parallel the shape of the jawline and it stays within the confines of a vertical line dropped down from the corners of the mouth.
When considering profileplasty, or even an isolated chin augmentation or reduction procedure, the use of computer imaging is critical. It can not only confirm which procedures are beneficial but, more importantly, the magnitude of those desired changes. A plastic surgeon can never really know what ‘flavor’ of change any patient desires and such imaging helps to establish what that is. While computer imaging is never a guarantee as to how the final result will look, it provides a method of visual communication to help the surgeon not guess as to the patient’s profileplasty goals.
Background:The prominent position of the chin makes it have a significant impact on one’s facial appearance. While most chin surgery involves implants for a small or horizontally short chin, a larger or more prominent chin is equally disturbing although less common. Because chin reductions are infrequently done, there is less information available on techniques and outcomes for it.
Compared to chin augmentation which is more common in men, chin reduction is more frequently requested in women. Even a slightly too prominent chin is less aesthetically tolerated in women as opposed to men. Long chins, pointy chins, and those that stick out too far are common chin complaints from women. A chin can be too long vertically, too far forward horizontally, have a too wide or too pointy shape, or some combination of several of these features. Diagnosing the exact dimensional problems with the chin is critical is determining the best way to shape it.
Case Study: This is a case of a 35 year-old female who has been bothered by her chin shape since she was a teenager. She felt that is was too long and pointy, particularly in a profile view. She despised her appearance in a picture from the side. She stated that the pointy nature of the chin became worse when she smiled.
In looking at her chin, its shape problems can be identified as largely horizontal (too far forward in profile), slightly long vertically (emphasis on slight), and with a mildly pointy shape. The pointy shape becomes more obvious when she smiles as the soft tissues around the mouth and face are pulled backwards against the hard outline of the chin bone.
Chin reductions always involve bone removal and reshaping. There are only two basic approaches, burring down the bone or cutting off the end of the chin bone and repositioning it. (chin osteotomy) Both of these chin reduction methods must always take into consideration how the surrounding soft tissue will adapt. One must remember that less enveloping soft tissue is needed afterwards. For this reason, horizontal chin reductions are best done by burring and excising and tightening the soft tissue envelope through an incision under the chin. Vertical chin reductions are best done by osteotomies which removes a wedge of bone. The soft tissues of the chin have less risk of excess and redundancy when reduced in vertical height.
Planning for this patient’s chin reshaping showed the desired movements of 7mm horizontal reduction, 2mms vertical reduction and flattening of the lower border to round out its shape. (get rid of the point) The chin reduction was done through a 3 cm long submental incision using a burr to do the reduction. Excess muscle was excised and plicated over the freshly burred lower border. Skin excess was then removed and the incision closed. A chin pressure dressing was used for just 24 hours.
Chin reductions do result in some discomfort, very similar to a chin augmentation with an implant. There are no restrictions after surgery and one can eat and drink unaffected. It takes several weeks for the major swelling to subside and the final result can be appreciated in 6 to 8 weeks. The chin will usually appear tight and look stiff for the first few weeks after surgery.
She was very pleased with her outcome and felt it made a very noticeable change in her chin appearance. She no longer felt that her chin was pointy. With her original chin problem (horizontal), the result is most noticeable in profile views.
1) Chin reductions is largely a female request with the desire to get rid of a prominent chin that is either too long, strong, or both.
2) Horizontal chin reductions are best done by burring and muscle and skin tightening to avoid soft tissue sag. A submental incision is used which results in a well-placed scar.
3) Reducing a prominent chin has about the same recovery time as a chin augmentation. However, it takes longer to see the final result as small amounts of swelling takes months to completely go away.
Changing one’s bony prominences is the primary method for altering the shape of the face. The face is composed of a variety of bones which have convex and concave contours. The external appearance of the face is highly influenced by the convex bone contours. From the brow bone down to the long curvilinear shape of the mandible, there are numerous key bony projection points. (e.g., cheeks, chin, jaw angles)
Most commonly, a variety of plastic surgery operations exist to enhance or increase their projections. Chin, nose, cheek and jaw angle implants are prime examples. It is almost always easier to increase facial bone projection by adding to the bone rather than actually moving the bone. There are also, however, operations that work in reverse…to reduce or deproject these very same prominences.
Facial bone reductions are not as well known and are less commonly done. Unlike augmentations, facial reduction procedures require modification or shortening of the bony prominences. While some can be shaved down, others require actual cutting off or out of bone sections to change the amount of bony projection.
Brow bone reduction is requested when the brows have a very prominent or ‘Neanderthal’ appearance. Mainly this procedure is done in men and in male to female conversions. (facial feminization surgery) This must almost always be done through a frontal hairline or scalp incision. In some cases, the brow bone may be simply burred down but this is unusual. The underlying frontal sinus occupies much of the width of the brow bone so the overlying bone is quite thin. Only if one is modifying the tail of the brow can it be just burred down. The outer table of the frontal sinus must be removed, reshaped, and then put back with tiny plates and screws. The scar from the incisional approach is the key decision in deciding to undergo this operation.
Cheek reduction is about modifiying the front edge of the cheek bone and its arched form back to where it attaches to the temporal bone. Most patients that want cheek reduction are often Asians in an effort to improve their wider face appearances. A vertical bone cut is made through the body of the malar bone and a wedge of bone is removed. The reduced cheek bone is then attached to the maxilla with a four-hole plate and screws. To get the more posterior part of the arch to move inward, the thin attachment of the posterior part of the zygomatic arch is cut with an osteotome and allowed to move inward (by muscle pull) without the need to secure it.
Nasal reduction is achieved by conventional rhinoplasty techniques. A significant part of a nasal hump is actually cartilage and not bone. The key in reductive rhinoplasty is not to overdo it, creating a saddle nose or pinched upper and middle vault appearance. This can result in nasal airway breathing difficulties. When it comes to helping a face look less wide and more sculpted, the nasal dorsum often is better elevated and not reduced.
Chin reduction is done by burring down the genial prominence. While this bone area is simple to get to through a submental incision, chin reductions are notoriously prone to cause soft tissue problems if not done correctly. This is the only facial bony prominence where the soft tissue does not just ‘snap back’ over the bone. If the excess skin and muscle is not removed and readapted back to the reshaped bone, it will sag resulting in the classic ‘witch’s chin deformity. Also, unlike chin bone advancements which can be brought forward 10 to 12 mms or more, retropositioning of the chinbone can not be done as dramatic and is more in the range of 4 to 6mms at best. Going back further than that can have adverse effects on the neck causing undesired fullness.
Jaw angle reduction is most commonly done in Asians like cheek reduction. Through an incision inside the mouth, the angle of the jaw is blunted by an oblique bone cut removing the prominent tip. How much of the tip or angle area is removed is a matter of intraoperative judgment. There is a fine balance between removing too little and completely having no angle at all. A nearly straight line from below the ear to the chin is not desireable either. This is the most uncomfortable of all the facial bony prominences to reduce because the large master muscle must be raised, causing considerable swelling after also.
The chin is the predominant feature of the lower face. Whether it is too short or too long affects the overall look of one’s face. While short chin deformities make up the vast majority of corrections, long chin problems also exist. The overly prominent chin can exist in two dimensions, too far forward (horizontal excess) or too long. (vertical excess)
Chins that are too long vertically are the result of excess bone development. Unlike chins that are too long horizontally, this is usually not an overgrowth problem of the entire lower jaw where a bite deformity (underbite or malocclusion) may also be present. The bone height of the chin (mandibular symphysis) is simply too long from below the tooth rootsdownward.
Vertical chin reductions are all about having to remove bone. It would be less common to consider removing bone by simply shaving down the bottom part of the chin because of the submental scar. But in the right patient who desires an overall three-dimensional chin shape alteration, the ‘inferior’ approach can be quite successful. The historic and most common method of vertical chin reduction is done by removing a wedge of bone between the upper and lower portions of the chin. This does not disturb the soft tissue attachments and the approach is through the mouth so there would be no external scar. The chin bone is put back together in a shortened position with very tiny titanium plates and screws.
Any chin reduction procedure must consider the potential effects of the soft tissue envelope. Much like changing a breast implant to a smaller one, what happens to the expanded or stretched out soft tissue afterwards? In my Indianapolis plastic surgery experience, this is a more significant issue with horizontal reduction but it still must be considered with vertical reductions as well. In either case, the mentalis muscle must be shortened and resuspended tightly. Vertical chin reduction by interpositional wedge removal genioplasty does not require skin shortening by excision unlike most horizontal chin reductions. The finesse part of any bony chin procedure is the management of its soft tissue attachments. Failure to do so will likely result in secondary chin problems.
The chin is the most dominant feature of the lower face. It has significant influence on the perception of facial balance and how the neck looks as well. While the chin may only be thought of as being too small or too big, there are other dimensions to the chin that also play a role in how it looks. Its horizontal position relative to the rest of the face can be an overly simplistic view of its aesthetics. The width of the chin is also important. Men often want a wider chin, women usually desire a chin that is more narrow.
When it comes to building out a chin, whether it be for horizontal length or width, the use of an implant is a simple and very effective method. Reducing chins, however, require manipulation of the bone…specifically removing parts of the chin to change its shape. Subtraction is a slightly more complex maneuver than addition for all facial areas.
Broad chins can be reduced through a technique known as an oblique chin ostectomy. This is a method where bone from the side of the chin along its undersurface is removed. This can be done by burring it down, or more effectively, by sawing away the widest part of the chin and making it blend into the jawline. It can be done from either inside the mouth or from a small incision under the chin. As the bone is removed in a front to back direction, how much bone to remove and how it affects the narrowing of the chin can be seen quite easily. This procedure can be done alone or with any other chin operation, including implants. For a wide and short chin, for example, a central chin implant style can be placed with lateral narrowing to make for a slender narrower chin. This operation does cause some significant swelling, as bone manipulations will do, and some temporary numbness of the chin and lower lip as well.
Narrowing of the chin adds another method of cosmetic jaw enhancement including chin implants, chin, osteotomies, mandibular angle implants, and mandibular angle reduction. Chin narrowing can be done alone or in combination of any other chin/jaw method to create an overall lower jaw shape change. These changes are particularly visible through computer prediction imaging and, in my Indianapolis plastic surgery practice, I make sure that all such patients go through such imaging before surgery.
Chin reduction is a form of chin reshaping surgery that involves changing the size and possibly the shape of the chin in order to make it appear smaller. This surgery may be beneficial to those who have a large chin that looks disproportionate when compared to the rest of the face. A chin may look too large in two dimensions, either being too long vertically or projecting too far forward horizontally. In rare cases, both dimensions of chin enlargement may be enlarged but usually it is one or the other.
Vertical chin enlargement is corrected by a wedge ostectomy of the chin. Through an intraoral approach, the chin bone is exposed and a reciprocating saw is used to remove a horizontal wedge of bone of the desired thickness. Usually it takes at least 5 to 6mms of bone removal if not more to make a real noticeable difference. Small plates and screws are used to hold the shortened chin bone together so that it can heal. The edges of the upper bone cut must be smoothed so it is not able to be felt through the skin. An alternative approach is an inferior border ostectomy done through a submental incision. This can also narrow the chin by lateral ostectomies as well. Good muscle resuspenions and soft tissue excision is the key to a successfulm outcome with this ‘down under’ technique. This is a good approach if there is alreasy an excess of soft tissue tissue over the chin prominence of on the underside of the chin.
Excessive horizontal chin excess is done through a burring down and tissue resuspension technique. Through an incision underneath the chin, the bone is exposed and the desired amount of excess bone removed. Because the attached soft tissues have had to be stripped off of the bone, they must be reattached or sagging (witches chin deformity) will occur afterward. Excess muscle and skin are removed and sutures are used to reattach them tightly to the bone.
All chin reduction methods require careful attention to how the bone is taken down and whether the soft tissues remained attached to the bone. Simple ‘sanding down’ a prominent chin, as has been done by many in the past, will only lead to secondary chin problems.
Frontal and profile photographic analysis should be done before surgery to determine how much bone reduction is needed. Since there is a pretty good linear relationship between bone changes in the chin and changes seen externally, photographic analysis is useful in all types of chin surgery.
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.