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Posts Tagged ‘chin surgery’

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

Vertical Reduction of the Long Chin

Thursday, August 20th, 2009

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 roots  downward.

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. 

Dr. Barry Eppley

Indianapolis, Indiana 

Plastic Surgery Correction of Chin Clefts

Wednesday, July 8th, 2009

Midline clefts of the chin are both a desired as well as a disliked facial feature. For some patients who have these chin clefts naturally, they would like the depth of the cleft softened or even completely removed.  Such a procedure, chin cleft reduction, is possible.

 

Contrary to popular perception, clefts of the chin are not primarily caused by an underlying cleft or defect in the chin (mandibular symphysis) bone. While some chin clefts do have a notch or indentation in the underlying bone, most do not. The cleft in the skin is caused by a separation or dehiscence of the paired mentalis muscle as it comes together over the chin. Technically, it is not a true separation but a failure of the muscle to come together during development as occurs in non-cleft patients.

 

The depth of the chin cleft is a reflection of the magnitude of the muscular split. In complete muscle separations, the chin cleft can be quite deep or indented with the edges of the skin completely turned in with little subcutaneous tissue between the cleft and the underlying bone. This understanding has relevance to how it may need to be corrected. Less deep chin clefts do not have such severe skin indents or inturning as the muscle is split less completely and more tissue exists between the cleft and the underlying bone.

 

Correction (reduction) of chin clefts is done through an incision inside the mouth just above where the lower lip starts from the depth of the vestibule. The muscle is elevated off of the bone down to the underside of the chin bone. One can see the actual separation of the mentalis muscle. Muscle is freed up on both sides of the cleft and is sewn together across the muscle separatikon with dissolveable sutures. It is important to overcorrect or give it a little pucker as there will be some relaxation after surgery. This maneuver will certainly soften and reduce the depth of a chin cleft but may not completely get rid of it.

 

I have found that the best chin cleft corrections come from simultaneous chin bone manipulations as well. Whether it is a chin implant placement or a chin osteotomy, changing the shape of the underlying bone (advancements or vertical lengthening) has a positive effect on the outcome of chin cleft correction.

 

When the chin cleft quite deep, some consideration may need to be given to doing external skin incisions as well. Incising along the edges of the chin cleft, with or without a dermal-fat graft placed underneath, and bringing the external skin edges together gives the best correction. But at a price of an external scar…which may or may not be worth it. Some patients would argue that a fine line scar that is less indented is not as problematic as a very deep chin groove.

 

Conceptually, it is best to think about chin cleft surgery as a reduction of it, not a complete elimination. In my Indianapolis plastic surgery practice, this is a concept that I emphasize about this surgery. Some chin clefts will nearly disappear, the deepest ones are merely reduced. (unless one is willing to accept an external skin scar.  

 

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

 

 

Extreme Chin Augmentation with Combined Implants and Osteotomies

Wednesday, May 20th, 2009

The treatment of a short chin is most commonly done with a synthetic implant. When the chin deficiency becomes larger, some plastic surgeons will move the small chin bone forward (osteotomy) to avoid using a larger chin implant. Both approaches are highly successful for chin augmentation and the use of either one is based on the degree of chin shortness, the surgeon’s experience, and the amount of surgery a patient wants to undergo.

In some rare cases of chin deficiency, neither an implant or an osteotomy are completely satisfactory. The magnitude of the chin deficiency may not allow the chin to come close to the most aesthetically ideal horizontal position. The thickness of the chin bone may be less than the chin deficiency or off-the-shelf chin implant options do not have enough thickness. While custom-designed chin/mandibular implants are one option for this problem, the amount of synthetic material needed may not be savory for some patients or their plastic surgeons.

In such cases of large chin deficiencies, the fundamental problem is always that the overall mandible is short. These patients are best treated by orthodontics and subsequent mandibular advancement osteotomies, with or without additional chin augmentation done at the same time. However, some patients do not have the resources for this standard approach or are seen later in life when they are not willing to undergo that multi-year treatment plan.

One option I have found helpful in my Indianapolis plastic surgery practice in these large chin deficiencies is to do a combination of an osteotomy with an implant in front of it. This type of ‘extreme’ chin surgery gives a horizontal result that is greater than either one alone. Adding an implant to an osteotomized and stabilized chin segment adds little extra time and no extra dissection to the procedure. The implant should be stabilized onto the chin bone with screws as it will easily displace if not done so.

Over the years, I have performed 11 such cases without any postoperative problems. I have observed no infections, implant shifting, or problems with the osteotomy healing. The chin skin will look quite stretched for awhile but it does eventually relax. Feeling to the lip and chin will be affected for awhile, primarily due to the osteotomy, but I have had no long-term complaints about permanent numbness.

Extreme chin surgery is reserved for those patients who cannot undergo proper treatment for a short jaw but still want aesthetic improvement. A large underbite will still exist after surgery. This combination of chin osteotomy/implant offers a less expensive option than a custom-design implant with less implantation of synthetic material.   

Dr. Barry Eppley

Indianapolis, Indiana

Lateral Chin Ostectomies – Narrowing the Broad or Wide Chin

Wednesday, April 29th, 2009

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.

Dr. Barry Eppley

Indianapolis, Indiana

Options for Chin Reduction Surgery

Sunday, March 1st, 2009

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

Indianapolis, Indiana

Chin Augmentation Surgery – What To Expect Right After

Wednesday, January 7th, 2009

Enhancing one’s chin with an implant is a common plastic surgery procedure. The simple placement of a synthetic implant on the front of the chin (mandibular symphysis) bone can make a dramatic difference in how the lower jaw looks and in the appearance of the lower face and neck. While chin augmentation  is a very straightforward operation, there are some common side effects that will occur after surgery which will go away with time.

Despite the fact that a chin implant and the incision through which it is placed is small, it will definitely make the chin sore after surgery.  This is because it is necessary to lift the chin muscle (mentalis) off of the bone to position the implant in place. The soreness will go away in a week or so as the muscle pain settles down but the chin will feel stiff for awhile.  One may also notice some unusual muscle movements or ‘spasms’  as the chin muscle heals over the implant. This is the result of the muscle adapting to being stretched over the size of the implant.

Some moderate swelling of the chin is to be expected for a few weeks but bruising is rarely seen. If bruising occurs, it is mild and usually appears below the chin in the neck.

There almost always is some numbness after the chin implant procedure. The skin over the chin, and sometimes part of the lower lip, may feel numb for awhile after surgery. This occurs because the small branches of the mental nerve, which supplies feeling to the lower lip, front teeth, and chin, are stretched from the surgery. In some cases, the big end of this nerve where it comes out of the bone may be affected from placing the side wings of the chin implant. In either case, the feeling will return within a month after surgery.

Between the numbness and the muscle stretching in the chin, some patients will notice that their lower lip may appear or move a little differently after surgery. This effect can be disturbing but it is only temporary.

Dr. Barry Eppley

Indianapolis, Indiana

Chin Reduction Surgery for Horizontal Excess

Monday, December 22nd, 2008

The chin represents one of the five main prominences of the face, also including the nose, brow ridges/forehead, cheeks, and jaw angle.  It is the defining feature of the lower face. Augmentation or enhancement of a recessed or weak chin is a common plastic surgery procedure that is made fairly simple through the placement of a synthetic implant. Correction of a large or too prominent of a chin, however, is not only less commonly done but is more difficult to do successfully.

A prominent chin has both excess hard and soft tissue. This means that the bone not only has to be reduced but the muscle and skin must be shortened and tightened as well.  If the soft tissue of the chin is not properly addressed in a reduction, it will sag off of the reduced bone after surgery resulting in what is known as a ‘witch’s chin’ deformity.

Chin implant surgery is traditionally done through an incision under the chin in the submental crease. But in a chin reduction procedure, this incision should be moved back a bit accounting for the removal of some submental skin at the end of the procedure. Once the chin bone is exposed, the excess chin is burred down the amount estimated beforehand. Usually it takes at least 6 to 8mms to make a significant difference. It is important to make sure that the bone removed extends far enough to the sides and is tapered to keep the chin from being too square. Once the bone is removed, excess mentalis muscle is removed and this muscle flap is sutured to the underside of the chin to the platysma muscle. Making this a tight muscle closure is important. Redundant overlying submental skin is then removed and closed as well. The soft tissue closure is just as important as the bone removal.

This approach works well for a horizontal chin excess. A vertical chin excess or a long chin, however, requires an intraoral approach with an interpositional wedge osteotomy for its correction. This is a completely different operation with removal and repositioning of bone rather than a simple burring down technique.

Dr. Barry Eppley

Indianapolis, Indiana

Aesthetic Orthopedic Surgery of the Chin

Saturday, October 4th, 2008

Moving the chin bone is the simplest of all the cosmetic facial bone procedures. Because the chin is easy to get to through the mouth and there is little in the way to get there, cutting and moving the chin bone (the tip of the front of the lower jaw) is relatively easy do and commonly done. Besides cutting and moving the bone forward to create more chin prominence, bone manipulations of the chin can be much more than just traditional horizontal augmentation.

 

When the chin bone is cut and dropped down, there are many different shaping procedures that can be done to it. By making a horizontal bone cut below the front teeth, the chin can be changed in length. A wedge of bone can be cut out and the chin brought back up to shorten it in height. Conversely, the chin can be lengthened by placing a bone graft or a piece of synthetic bone in between the two cut ends to make the chin vertically longer. If the chin lengthening is relatively small (a few millimeters), nothing may need to be put in the gap between the bone pieces.

 

Aside from height changes, alterations can also be done in chin width. The chin bone once cut and brought down from the rest of the jaw, can be widened or narrowed as well. By removing a piece of bone down the middle of the chin bone, it can be brought together in a more narrowed fashion, Similarly, a bone cut can be made down the middle of the chin and it can be split apart and widened. (similar to what it done for lengthening the height of the chin)

 

With all of these chin changes, small plates and screws are needed to hold the bone segments into the desired positions. This metal hardware is very small and can never be felt from the outside. Over time and with healing, bone overgrows much of these plates and screws. I have never had to remove plates and screws from the chin due to problems with them. They are made of titanium, which is a non-magnetic metal, so there is no concern about ‘setting off the detector at the airport’.

 

Orthopedic surgery of the chin offers some advantages over more simple chin implants, particularly in changing the dimensions of chin shortening, chin narrowing, and chin lengthening. These are chin changes that implants can not do as their effects are additive, not reductive.

Dr. Barry Eppley

Indianapolis, Indiana 

 

 

Chin Augmentation by Osteotomy (Sliding Genioplasty)

Monday, November 5th, 2007

 

CHIN ADVANCEMENT THROUGH OSTEOTOMIES: WATCH OUT FOR THE MENTAL NERVE

Using cross-sectional anatomic studies of the bony course of the inferior alveolar nerve, significant insight to the execution of osteotomies of the mandibular symphysis (chin) can be obtained. The relatively simple horizontal osteotomy of the anterior mandible (chin) is a very versatile technique for multiple improvements in the shape and projection of the chin and lower face.

An integral part of this procedure is the horizontal angulated cut, usually performed with a reciprocating saw, that goes below the easily identified mental foramen. While some limited postoperative disruption of the nerve’s sensory distribution (feeling) is to be expected due to the dissection, the incidence of permanent numbness of the mental nerve is thought to be very low.

It is historically believed that the course of the inferior alveolar nerve comes directly out of the mental foramen in a straight horizontal projection from its posterior course. This is how it is depicted in most textbooks and anatomic drawings. However, its neurosensory supply goes anterior to the 1st premolar tooth and this may account for the anterior loop that has been discovered in anatomic studies. I have always assumed this direct horizontal nerve exit and usually keep the bony cut only several millimeters from the foramen. In this way, the pedicled inferior bone flap (chin segment) is as large as possible, regardless of the angle of the bony cut. A detailed anatomic study shows that this technical approach, however, may expose some nerve branches to irreversible injury. I have now modify my technique accordingly with a minimum of 4 to 5 mms below the foramen when performing this cut. This should avoid any potential for permanent numbness of the lip or chin and still leaves an adequate amount of bone for plate and screw fixation.

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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