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Posts Tagged ‘vertical chin lengthening’

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

Case Study: Combined Vertical and Horizontal Chin Lengthening in Men

Monday, August 30th, 2010

Background: The chin is one of the facial prominences and the most noticeable part of the lower jaw. Horizontal chin shortness has been recognized for many decades and has largely been improved through the use of synthetic implants. Placing an implant on the front edge of the bone is a simple and relatively uncomplicated method of horizontal increase.

Great results can be seen in many profile examples of chin implant augmentation but the chin and the face is more than just a side view. Patients see themselves more commonly in the front view and this perspective is becoming appreciated in chin surgery.The other dimensions of vertical length and transverse width have greater impact in the frontal view and also have an impact on chin appearance. Since a strong chin is a well recognized male facial characteristic, the chin should be enhanced from three-dimensional changes.

Case: This is a 28 year-old male who previously had an implant placed for a short chin. While there was an improvement, he was still not happy with the final appearance. He had an implant that provided 8mms of horizontal advancement. In assessing his chin with computer imaging, his chin was slightly short horizontally by 3mm to 4mms but was also vertically deficient by 5mm to 6mms. He also thought his chin was wide as well.

Given the needed changes to achieve a more pleasing three-dimensional change, it was decided that it could not be predictably done by a bigger implant. An implant could not provide enough vertical length improvement. An osteotomy was planned to not only make these desired changes but to replace what the existing implant has already created.

An intraoral approach was used to both remove the existing implant as well as perform the osteotomy. The existing pocket of the implant had already made most of the dissection needed for the osteotomy cuts. The capsule of the implant pocket was removed, exposing the raw bone surfaces. With a reciprocating saw an angled horizontal cut was made below the mental nerves. The chin segment was downfractured and then moved forward 11mms and opened up vertically 5mms. The backledge of the chin segment was put to the bone of the upper chin bone as a point of rotation for the vertical opening. It was secured using a custom-bent chin osteotomy plate. The chin implant was cut down in size and used as a fill for the step of the chin osteotomy. This was done to prevent further deepening of the labiomental crease.

Chin osteotomies create more swelling after surgery than implants. It usually takes about ten days after surgery until the chin returns to a more normal appearance and three weeks for most of the swelling to go away. While many patients can expect some temporary lower lip numbness, he experienced very little. The improvement in the side view shows the desired moderate horizontal advancement.

In the front view, however, the increase in vertical length is more apparent and gives the chin better facial balance. While it is often stated that the lower face should be 1/3 of vertical facial height, in men the lower facial height should be slightly greater than 1/3 of total facial height.

Case Highlights:

1) Changing the shape of the chin is more than just about horizontal advancement. Vertical length and width of the chin must also be considered for the best aesthetic result.

2) Mild vertical lengthening of the chin can be done with an implant that is secured on the inferior edge of the bony chin.

3)When more than a few millimeters of chin lengthening is needed, an opening osteotomy is best. It can be done to only lengthen the chin or bring it forward as well as with a vertical increase.

4)When a chin implant has failed to achieve the desired aesthetic outcome, a chin osteotomy can be considered which offers greater options for some chin changes.

Dr. Barry Eppley

Indianapolis Indiana

Vertical Chin Lengthening by Osteotomy and Downgrafting

Saturday, July 4th, 2009

When one thinks of a short or small chin, most are envisioning it deficient in the horizontal dimension. (profile view) While this does make up the majority of cases of chin augmentation, there are other dimensions in which a chin can also be ‘short’. The second most common cause of chin deficiency is in the vertical dimension or its height.

A vertically short chin is apparent in several ways. First, there is an apparent small lower face compared to the middle and upper face. As the aesthetically balanced face is divided into equal thirds, the lower third (between the lower lip and the bottom edge of the chin) will look small in height compared to the rest of the face. Second, the labiomental crease (the groove between the lower lip and chin prominence) will often be indented further in or deeper than normal. Lastly, a vertically short chin may also be associated with an underbite although not exclusively so.

Correction of the vertically short chin is primarily done by a chin osteotomy and downgrafting. Placing a chin implant further down on the chin prominence may help a little (a few millimeters) but can not make a big difference. Changing the vertical length of the chin bone addresses the actual problem and is far more effective.

A chin osteotomy is done through an incision on the inside of the lower lip. The chin bone is easily and quickly exposed and the mentalis muscle lifted off. A saw is used to make a horizontal cut way below the roots of the front teeth. The lower end of the chin bone is dropped down and the predetermined amount of vertical length needed (bone gap) is maintained by a small titanium plate and screws. This bone gap is best grafted and the usual choice is hydroxyapatite blocks wedged into the open space. These blocks will eventually become incorporated into the new bone which will eventually fill in between the cut ends of the chin. The mentalis muscle is resuspended up over the plate and the incision closed with dissolveable sutures.

This vertical chin lengthening method can be opened up to almost any distance, from a few mms to up to over a cm. As a general rule, it usually must be at least 6mms or more to see an appreciable change in the height of the chin. The amount of chin lengthening needed can be precisely determined beforehand by simple photographic analysis and a millimeter ruler. Cephalometric tracings are the most exacting method but does require that type of orthodontic x-ray to be available.

While the cost and recovery from a chin osteotomy is more than from a chin implant (an extra week or so of prolonged swelling and chin stiffness), its superior results are worth this short-term sacrifice.  Bringing the lower third of the face into proportionate balance can make for a very pleasing facial change in both profile and frontal views.

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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