Facial Contouring/Implants

SURGERY OF THE CHIN
A well defined chin helps give balance to the face and creates a major part of one’s profile. When people look in the mirror, most focus on the size and shape of their noses, their ears, sagging jowls, or fine wrinkling of the skin. But even though few examine their chins with the same discerning eye, having a “weak chin” is certainly not an asset. Surgeons who specialize in rhinoplasty, or surgery of the nose, are often the first to suggest that changes in chin size or shape may enhance a profile as much as rhinoplasty. It is common for the facial plastic surgeon to recommend chin surgery in addition to nose surgery when the surgeon sees that chin augmentation is necessary to achieve facial balance and harmony. Fortunately, this is a relatively straightforward procedure that can make a major difference.

If you are wondering how chin surgery could improve your appearance, you need to know how the surgery is performed and what you can expect from this procedure. This pamphlet can address many of your concerns and provide you the information to begin considering chin surgery.

Successful facial plastic surgery is a result of good rapport between patient and surgeon. Trust, based on realistic expectations and exacting medical expertise, develops in the consulting stages before surgery. Your surgeon can answer specific questions about your specific needs.

IS CHIN SURGERY FOR YOU?
As with all elective surgery, good health and realistic expectations are prerequisites. It is also key to understand all aspects of the surgery. A pleasing, balanced profile can be achieved by inserting an implant or moving the bone forward to build up a receding chin, or by reducing a jutting or too prominent chin. The result can be greater facial harmony and an increase in self-confidence.

Another possibility for improvement through chin surgery is submental liposuction in which excess fatty tissue is removed to redefine the chin or neckline. When there is a contributing problem of dental malocclusions or birth defects in the structure of the jaw itself, surgery of the jaw can improve the form and function of the lower face and greatly enhance appearance.

Your consultation can help you decide on the type of surgery that addresses your concerns. Your surgeon can also provide information on new medical techniques for chin surgery and offer recommendations for supplementary surgery that can ensure the greatest improvement.

MAKING THE DECISION FOR SKIN SURGERY
Whether you are interested in chin surgery for functional or cosmetic reasons, your choice of a qualified facial plastic surgeon is extremely important. During the consultation, your surgeon will thoroughly examine your chin and jaw to pinpoint problems. In some instances, the surgeon will suggest chin surgery as a supplement to rhinoplasty because a small chin can make the nose appear larger. Your surgeon will weigh other factors that could influence the outcome of surgery such as age, skin type, and attitudes toward surgery. The surgical procedure will be described in detail along with reasonable projections. If you opt for surgery, your surgeon will describe the technique indicated, the type of anesthesia to be used, the surgical facility, any additional surgery, and risks and costs.

UNDERSTANDING THE SURGERY
To augment the chin, the surgeon begins by making an incision either in the natural crease line just under the chin or inside the mouth, where gum and lower lip meet. By gently stretching this tissue, the surgeon creates a space where an implant can be inserted. This implant, made of synthetic material that feels much like natural tissue normally found in the chin, is available in a wide variety of sizes and shapes. This allows custom fitting of the implant to the configurations of the patient’s face. After implantation, the surgeon uses fine sutures to close the incision. When the incision is inside the mouth, no scarring is visible. If the incision is under the chin, the scar is usually imperceptible.

In chin reduction surgery, incisions are made either in the mouth or under the chin. The surgeon sculpts the bone to a more pleasing size. For orthognathic surgery, the surgeon will make an incision inside the mouth and reposition the facial bones. The procedure, depending on the extent of the work, takes from less than an hour to approximately three hours.

WHAT TO EXPECT AFTER THE SURGERY
Immediately after surgery, the surgeon usually applies a dressing that will remain in place for two to three days. You will experience some tenderness. Post-operative discomfort can be controlled with prescribed medications. Chewing will probably be limited immediately after chin surgery, and a liquid and soft food diet may be required for a few days after surgery. Most patients feel a stretched, tight sensation after the surgery, but this usually subsides in a week.

After approximately six weeks, most swelling will be gone, and you can enjoy the results of your procedure. Rigorous activity may be prohibited for the first few weeks after surgery. Normal activity can be resumed after approximately ten days.

Facial plastic surgery makes it possible to enhance your appearance and eliminate signs of premature aging that undermine self-confidence. By changing how you look, facial plastic surgery can improve your self-image.

Insurance does not generally cover surgery that is purely for cosmetic reasons. Surgery to correct or improve genetic deformity or traumatic injury may be reimbursable in whole or in part. It is the patient’s responsibility to check with the insurance carrier for information on the degree of coverage.

© Copyright 2000 American Academy of Facial and Reconstructive Plastic Surgery

Complications of Augmentation Mentoplasty :
A Review of 11095 Cases
Frank J. Scaccia, MD, Allan, MD, Daviv W. Stepnick, MD

ABSTRACT: Augmentation mentoplasty is an increasingly common procedure for reshaping the mental contour. Because there is little information comparing the efficacy and potential complications of the varies techniques and submitted it to 1246 Fellow of the Americans Academy of Facial Plastic and Reconstructive Surgery. Ninety-two surgeons (7.4%) respond and described results of 11,095 mentoplasty procedures. The complication rate was 7.6% with both intraoral and extraoral approaches producing similar morbidity. Complications were least with silicon prostheses and most with acrylic and Proplast prosthesis. The search for superior materials continues.
Key Words: Retrognathism, Chin/su, Implant, artificial, Mandibular prosthesis, Surgery, plastic/ae

The primary goal for the facial plastic surgeon is to create an aesthetically balanced and pleasing facies. An area often overlooked by both patients and surgeon is the chin. Augmentation mentoplasty may benefit up to 25 percent of patients undergoing reduction rhinoplasty.

A wide variety of materials are available for chin augmentation. The ideal implant has a “natural” consistency and minimal resorption capacity; is easily placed and secured; and secured and results in minimal morbidity. Autografts and homografts, once commonly employed, have lost popularity due to problems with absorption and predictability. Alloplastic implants, introduced later, initially included substances such as heavy metals, ivory and paraffin which fell into disuse because of technical difficulties, stiffness, lack of stability and tissue reaction. Materials currently approved include Silastic, nylon (Supramid), Teflon (Proplast), acrylics, silicon and Dacron (Mersilene). Anecdotal reports describe various problems associated with several of these implants; deciding which implant is best for the patient is often difficult.

Further confusion exist about surgical approaches; the effects intraoral versus extraoral and subperiosteal versus extraosteal placement are ill defined. Some surgeons believe that there is less infection with an extraoral approach while other have found no significant difference from the intraoral approach. Bone resorption occurs whether implants are placed either sub – or supraperiosteally. No single-institution prospective study would provide enough data for statistical comparisons; our large scale study retrospectively compares the available options.

Method
A questionnaire survey was submitted to 1246 Fellows of the American Academy of Facial Plastics and Reconstructive Surgery. Fisher’s exact one tailed test was used in statistical analysis.

Results
Ninety-two surgeons responded (7.4%) describing 11,095 mentoplasty procedures. Surgeons fees and patient satisfaction are depicted in Table 7.

The sample size for sliding genioplasty was such that meaningful statistical analysis was not possible. Eighty – nine percent of respondents reported performing mentoplasty prior to rhinoplasty.

Case Report
A 57 year-old white woman came to our clinic desiring aesthetic improvement. She demonstrated blepharochalasis, jowl formation, submental fullness, and microgenia augmentation mentoplasty via an external approach with a silicon rubber implant and standard postoperative taping. The surgeon was uneventful. The surgeon chose not to perform facial suction lipectomy. Immediately upon removal of the tape, which was retained for 4 days, some asymmetry and superolated migration of the implant was noted despite obvious improvement in chin prominence.

The patient was dissatisfied with the appearance of her chin and requested removal of the implant. After a period of 3 months to enable scar maturation in the prosthetic area, the implant was removed through the original submental incision. Capsule formation at the implant site afforded some residual correction without the asymmetry that had been noted. Although the patient is quite satisfied with the appearance of her chin, achievement of a better result would necessitate minor additional projection.

Comment
The surgeon must direct some attention to the chin in the effort to achieve facial harmony; absence of normal chin projection is not only unattractive, but it is often associated with a weak character.

A recessed chin is classified as either microgenia the chin eminence is decreased while the mandible is essentially normal. In micrognathia the underlying maxillomandibular disproportion often results in malocclusion. It is essential in these more severe cases that the patient be encouraged to first seek orthodontic correction of these problems.

Many landmark are recommended for determining normal prominence. Gonzalez-Ulloa and Stevens describe a vertical line, meridian, which is perpendicular to Frankfort’s plane and began its nasion. With a normal chin promises, this line should line tangential to the pogonion. A more common measurement assessing adequate chin projection is its relationship to the lower lip. A man’s chin should approach a line from the lower vermilion border in repose. A women’s chin however is ideally situated 2 mm to 3 mm behind this line. Other guidelines suggested include Rickett’s law, Steiner’s plane, and Holdway’s H-Line. Identifying these skeletal deficiencies and planning therapeutic intervention can be confusing.

The greatest controversy appears to focus on the surgical approach to augmentation mentoplasty. Several authors recommended the submental external approach due to reduce morbidity, while others describe similar complication rates between intraoral and external approaches. In our study the infection rates was slightly higher with the intraoral approach; however, the malposition rate was lower with the intraoral approach. This may possibly be due to the superior exposure with the with the intaoral approach, allowing more precise placement of the prosthesis. The necessity to remove an implant so placed was not significantly increased over that of the external approach. This finding suggests that most infections can be successfully treated conservatively with antibiotics. If the implant must be removed, the remaining capsule will often provide adequate residual augmentation.

The external approach seems especially suited to cases in which a scar is already present, submental liposuction is planned, or the patient wears dentures. Otherwise, the intraoral approach is a good alternative and will avoid the possibility of an unacceptable scar. No real difference in morbidity was found between the two routes.

Several reports described the potential for bone resorption under alloplastic chin implants. Our survey attempted to differentiate the occurrence rate with subperiosteal versus supraperiosteal placement. Most respondents admitted to rarely checking postoperatively for radiographic changes and as a result, minimal resorption was noted with both techniques. However, there was some indication of slightly improved malposition rate when the implant was palced subperiosteally.

Various materials are available for augmentation mentoplasty. In the past, many surgeons use autografts. In our surgery, only two respondents reported experience with cartilage and bone, their result were acceptable but small sample size prevented meaningful conclusion. During the past 15 years, allografts have become the material of choice by most plastic surgeon. In our survey, silicone rubber was found to be by far the most popular type of implant. Silicon has been criticized because the resulting incidents of infection and were considerable, yet our survey does not reflect these findings. Silicon gel, the second most popular type of implant, also caused few complications.

The highest rate of complications was seen with Proplast. As mentioned above, the small sample size precluded definitive conclusions; however, our data suggested that caution be exercised about this choice. Acrylic is also associated with a high incidence of complications and probably should be avoided.

Extended anatomical prostheses were used by many respondents. Advocates believe that these implants allow for a more natural mandibular contour, especially when significant anterior correction is required. Malpositions were somewhat more frequent than was the case with silicon prostheses. Remarkably, however, no mental nerve injuries were reported.

Sliding genioplasty has gained popularity as a means of enhancing chin projection. Incidence of complications up to 20 percent has been reported; nevertheless, proponents believe that asymmetries, severe microgenia, and vertical disproportion are more effectively managed, while operative time is relatively brief and patient satisfaction high. Our survey points to a higher complication rate compared to implant placement.

Cost to the patient, operating time, patient satisfaction, and patient ability to tolerate local anesthesia were analyzed for each of the three techniques. Little difference was noted between the intraoral and extraoral approaches. Sliding genioplasty, on the other hand, required a longer operating time and involved greater difficulty for the patient in tolerating the procedure under local anesthesia.

Our response rate of 7.4% was certainly less than we had hoped for. While we recognize the limitations of our study, a single institutional prospective study would not have yielded the number of patients necessary for meaningful statistical comparisons. Although the results reflects to a certain degree the biases of the respondents, the large sample size permits comparison of the various techniques and associated complications.

Conclusions
1. Silicon appears to be a reliable and safe product while caution should be used with acrylic and Teflon products.
2. Both external and internal approaches appear equally effective and are associated with similar morbidity. Slightly lower infection rates can be expected with the external submental procedures.
3. The most common complication is malposition, with the subperiosteal approach resulting in a slightly lower malposition rate compared to supraperiosteal placement.
4. Sliding genioplasty is a reasonable option, but should be considered only when the surgeon us well versed in the technique and the deformity merits its use.