CHIN AUGMENTATION AND GENIOPLASTY

DONALD J. ANNINO, JR, MD, DMD

The position of the chin plays an important role in facial esthetics. It can be modified in two ways. The first is by adding material to it and the second is by a horizontal sliding osteotomy. They both have their indications and limitations. The horizontal sliding osteotomy is the most versatile, however, and should be a part of the armamentarium of all facial plastic surgeons.

The position of the chin is important in establishing correct facial proportions. The chin gives the appearance of strength to the face. It should not be too shallow or too deep. Absolute measurements are not as important as the facial proportions. Facial balance is critical for good facial aesthetics. Anatomically, the chin is considered as the area below the labiomental crease. However, this can be hard to determine; therefore most surgeons consider the entire lower-lip-chin complex when they evaluate facial balance and aesthetics. In the frontal view, the ideal length of the upper lip should be half the distance from the stomion to the menton. Also stated as the lower lip and chin complex is two thirds the lower portion of the face. The lower facial height (from the subnasale to the menton) should be 57% of the total facial height from the nasion to the menton. Analysis of the chin aesthetics should be three dimensional and involve the anteroposterior, transverse, and vertical planes. This is evaluated by obtaining a detailed history and physical examination, standard facial photographs, and lateral and posteroanterior cephalograms. The dental occlusion must be carefully assessed. A genioplasty does not affect the occlusion, and some patients with significant malocclusion are more appropriately treated with orthodontistry and orthognathic surgery to correct their dentofacial disharmony. A cephalometric tracing is extremely helpful in predicting the amount of deficiency or excess of the chin. After cephalometric studies have been obtained there are many ways to evaluate the position of the chin. Multiple facial analyses, using cephalometric tracings, have been proposed 1-s (Fig 1). They all have their proponents. When evaluating the chin, the following general deformities can be seen. The chin can be too large (macrogenia), too small (microgenia), or asymmetrical. These deformities can occur either vertically, horizontally, or as a combination of both. Two basic techniques are used to change the shape and position of the chin. The first is with the use of an implant, either autologous or alloplastic, and the second is with a horizontal sliding osteotomy. In the appropriate patients, both techniques have their place. The use of implants is common because they are easy to use and less intimidating to many physicians. Many alloplastic and autogenous materials have been used to

From the Department of Otolaryngology, Tufts University School of Medicine, New England Medical Center, Boston, MA. Address reprint requests to Donald J. Annino, Jr., MD, DMD, Department of Otolaryngology,750 Washington St, Box 850, Boston, MA 02111. Copyright 1999 by W.B. Saunders Company 1043-1810/99/1003-0010510.00/0 224

augment the chin. The aUoplasts include silicone, hydroxyappetite, polyethelene terephthalate, high-density polyethylene (HDPE), and polytetrafluoroethylene (PTFE). 6-8 The materials can be broken down into those that are solid and those that are porous. Solid implants such as silicone do not allow ingrowth of tissue, and the surrounding capsule that develops helps hold the implant in place. The porous implant materials are PTFE, HDPE, polyethylene terephthalate, and hydroxyapatite. They allow fibrovascular tissue growth into the implant to help secure it in position. However, immobilization is needed for a minimum of 6 weeks to allow the tissue ingrowth. In general, all implants have the drawbacks of capsule formation, underlying bone resorption, and the risk of extrusion and infection.9 In addition, the soft tissue response is less predictable than the response with a horizontal sliding osteotomy. It has been reported that up to 20% of patients will be aware of the implant's presence at all times. 1Autogenous materials are also used and include bone and cartilage. They have the risks of resorption, infection, and the need for a second surgical site. Augmentation genioplasty can be performed with the patient under local anesthesia, intravenous sedation, or general anesthesia. There are two basic approaches for performing an augmentation genioplasty. The approach can be either via an intraoral or a submental skin incision. In either case a subperiosteal pocket is created just large enough to accommodate the implant. Care is taken to ensure the implant is centered in the midline. To be sure the implant will not migrate, it can be secured in position with two screws. The use of alloplastic material for augmentation has definite limitations. It is indicated only for patients with a true horizontal deficiency that is mild. It is not recommended for patients with vertical discrepancies, horizontal excess, large horizontal deficiencies, or any asymmetry. Therefore, a horizontal sliding osteotomy is the procedure of choice for most patients with horizontal a n d / o r vertical excess or deficiency, or asymmetries. Results with the horizontal sliding osteotomy are predictable and stable, and the procedure eliminates the use of an implant. The majority of this discussion focuses on this technique. Once it has been determined that a patient's facial profile is not correct and a horizontal sliding osteotomy is considered, preoperative planning is required. Cephalometric tracings are imperative. A tracing of the lateral cephalogram is performed, including key anatomic landmarks. A template of the tracing of the chin alone is also made and is repositioned on the complete tracing to find the correct

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEADAND NECK SURGERY, VOL 10, NO 3 (SEP), 1999: PP 224-227

FIGURE 1. Cephalometric tracing of a 20-year-old man. Gonzales-UIIoa and Stevens, Steiner, and Ricketts analyses have been done. According to Gonzales-UIIoa and Stevens (line A), the soft tissue nasion perpendicular should line up with the soft tissue pogonion. Ricketts (line B) believes the upper lip should be 4 mm and the lower lip 2 mm posterior to a line from the nasal tip to the soft tissue pogonion. Steiner (line C) recommends the upper and lower lips should rest on a line through the midportion of the collumella and the soft tissue pogonion. In this patient, all analyses show that he is retrognathic. Ideal treatment is with orthodontistry and orthognathic surgery. The other option is a genial advancement with a horizontal sliding osteotomy.

movement needed for proper positioning of the chin. The exact outline of the osteotomy is chosen by advancing the chin template of the tracing to the proposed chin position. The average height of the sliding horizontal osteotomy is usually between 10 and 15 mm at the anterior aspect of the symphysis at the point of greatest chin prominence. Too short a segment will result in a pointed, unaesthetic chin, and too large a segment will result in a large blunted chin with a high labiomental fold. Ideally, a point 2 mm above the pogonion is chosen for the anterior aspect of the osteotomy. Care must be taken to ensure that tooth roots are not injured in the osteotomy. A rule of thumb is that the tooth root will be approximately twice the length of the crown of the tooth. The canines have the longest roots in the dental arches.
SURGICAL TECHNIQUE

mucosa halfway between the vermillion border and the depth of t h e labial vestibule. The periosteum is sharply incised and the symphysis exposed (Fig 2). It is always best to allow as much soft tissue to remain attached to the genial segment as possible. A broad inferior and anterior soft tissue pedicle should be left attached to the segment to ensure adequate blood supply and maximize soft tissue Correlation. A compromise should be m a d e to allow adequate visualization of the proposed osteotomy site yet leave as much soft tissue attached as possible. The mental nerves are best protected b y identifying them and by using careful atraumatic retraction: Injury can result from stretching, avulsion, or sectioning of the nerves. Even with care and protection of the nerve, paresthesias are common and can last for 6 to 12 months. 15,16 Poor exposure, excessive traction, and inadequate protection are the most common causes of nerve injury. Before creating the osteotomy, a midline vertical reference mark is always etched into the midsagittal plane with a bur (Fig 3). This creates a reference line to aid in positioning the mobilized genial segment Correctly in the midline. The osteotomy is begun 10 to 15 m m above the inferior portion of the chin in the midline, based on the proposed angle and length of the osteotomy from the preoperative planning. The osteotomy is ideally placed above the point of greatest chin prominence. A reciprocating saw is used for the bony cut. The osteotomy is angled and placed so that it will pass at least 5 mm inferior to the mental foramen to avoid injury to the inferior alveolar nerve. This is necessary because the mandibular canal and the inferior alveolar nerve within it ascend from a more inferior position as they approach the mental foramen. A fine osteotome is used to ensure the saw cut is complete, but an osteotome should never be used to complete the osteotomy, as this will increase the chance of an unfavorable cut. The posteromedial section of the osteotomy is always the most difficult to complete and is best done with the saw. When the osteotomy is complete, the genial segment is positioned according to the preoperative plan. The vertical reference line will help avoid asymmetries. The genial segment is secured to the main portion of the mandible with either wires, position screws, or plates and screws.

Originally described as an extraoral approach by Hofer in 1942,11 the procedure was reported as an intraoral approach in the 1950s by Trauner and Obwegeser. 12 Many other authors have contributed to its popularity and technique.13, I4 A horizontal sliding osteotomy can be performed with the patient under either general anesthesia or local anesthesia with intravenous sedation; however, general anesthesia is used most commonly. An incision is made in the labial
DONALD J. ANNINO

FIGURE 2. An incision is made halfway between the vermillion border and the depth of the vestibule. The periosteum is sharply incised, and the mental nerves are identified. Only enough soft tissue is elevated to view the proposed osteotomy site. A vertical reference line is made in the midline. 225

FIGURE 3. The osteotomy is made with a reciprocating saw. The saw cut is performed at least 5 mm below the mental foramen to protect the mental nerves. More soft tissue elevation is present than is routinely done.

osteotomy at the necessary angle, a wedge osteotomy can be performed to shorten the chin and change the direction of the forward movement. On the other hand, an interpositional bone graft m a y also be used to lengthen the chin in the vertical dimension while maintaining ideal segment thickness. The a m o u n t of soft tissue change is never equal to that of the change in the bone. This is true not only with the horizontal sliding osteotomy, but also with alloplastic implants. Soft tissue advancement is more predictable with horizontal sliding osteotomy than with alloplastic material. M a n y studies have been done to assess the amount of soft tissue change that occurs with m o v e m e n t of the bone. One to one advancement of the soft tissue with the bone is never achieved. Instead the soft tissue advances only 60% to 88% of the bone. T M The more soft tissue left remaining attached to the bone, the closer the agreement between the soft tissue advancement and bone. Complications that can occur with horizontal sliding osteotomies include unfavorable osteotomies, nerve injuries, bleeding, and malpositioning of the mobilized segm e n t Y All of these can be minimized or eliminated with proper planning and technique.

Position screws offer the more rigid fixation with the least a m o u n t of hardware and are therefore the m e t h o d of choice (Fig 4). The soft tissue is closed in two layers. A supportive pressure dressing is placed for the next 5 days. Antibiotics are routinely given perioperatively and 5 days postoperatively. Drains are not routinely used, but if they are needed, % inch bulb suction drains are brought out through the submental crease and removed the next day. As stated previously, the horizontal sliding osteotomy is the most versatile procedure to correct chin deformities and can be adapted to fit most situations. The a m o u n t of augmentation is limited by the thickness of the symphysis, the angulation of the proposed osteotomy, and the anterior soft tissue attachment. If it is impossible to angle the

CONCLUSION

Augmentation genioplasty is appropriate for mild horizontal microgenia. However, horizontal sliding osteotomy is the most versatile procedure to correct chin deformities. It can be used to lengthen or to shorten the chin in both vertical and horizontal planes or to correct asymmetries of the chin. A horizontal sliding osteotomy can also increase the projection of the chin to a greater extent than alloplastic materials alone and with a more natural result. In addition, the soft tissue response is more predictable. However, with this technique careful preoperative planning m u s t be done, and the surgical plan must be followed exactly. When this is accomplished, horizontal sliding genioplasty is a simple procedure with reproducible results that should be part of the a r m a m e n t a r i u m of all facial plastic surgeons.

REFERENCES

"C

FIGURE 4. A lateral view showing position screws securing the advanced segment in place.

1. RickettsRM: Esthetics,environment and the law of lip relation.Am J Orthod 54:272-289,1968 2. Steiner CC: Cephalometricin clinicalpractice. Angle Orthod 29:8-29, 1959 3. Burstone CJ: Lip posture and its significancein treatment planning. Am J Orthod 53:262-284,1967 4. Gonzalez-UlloaM, Stevens E: Role of chin correctionin profileplasty. Plast ReconstrSurg 41:477-486, 1968 5. Reidel RA: An analysis of dentofacial relationships. Am J Orthop 43:103-119,1957 6. MoenningJE, WolfordLM:Chin augmentationwith various alloplastic materials: A comparative study. Int J Adult Orthod Orthognath Surg 4:175-187,1989 7. Karras SC, WolfordLM: Augmentation genioplasty with hard tissue replacement implants. J Oral MaxillofacSurg 56:549-552,1998 8. McColloughEG, Horn DB, Weigel MT, Anderson JR: Augmentation mentoplasty using mersiliene mesh. Arch Otolaryngol Head Neck Surg 116:1154-1158, 1990 9. Cohen SR, Mardach OL, Kawamoto HK: Chin disfigurementfollowing removal of alloplasticimplants+Plast ReconstrSurg 88:62-66,1991 10. Feldman JJ: The ptotic (witch's) chin deformity: An excisional approach. Plast ReconstrSurg 90:207-217,1992 11. Hofer O: Die operative Behandlung der aveolare retraktion des

~)26

CHIN AUGMENTATION AND GENIOPLASTY

12.

13. 14. 13.

Unterkiefers und ihre Anwendungsmoglichkeit fur prognathie und mikrogenie. Dtsch Z Mund Kieferheilk 9:130,1942 Trauner R, Obwegeser HL: The surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty. Part I. Surgical procedures to correct mandibular prognathism and reshaping of the chin. Oral Surg 10:677-689, 1957 Converse JM, Wood-Smith D: Horizontal osteotomy of the mandible. Plast Reconstr Surg 34:464-471,1964 Hinds ED, Kent JN: Genioplasty: The versatility of horizontal osteotomy. J Oral Surg 27:290-300,1969 Lindquist CC, Obeid G: Complications of genioplasty done alone or

in combination with sagittal split ramus osteotomy. Oral Surg 66:13-16,1988 16. Nishsioka GJ, Mason M, Van Sickels JE: Neurosensory disturbance associated with the anterior mandibular horizontal osteotomy. J Oral Maxillofac Surg 46:107-110,1998 17. Polido W, Regis LDC, Bell WH: Bone resorption, stability, and soft tissue changes following large chin advancements. J Oral Maxillofac Surg 49:251-256,1991 18. Ewing M, Ross RB: Soft tissue response to mandibular advancement and genioplasty. Am J Orthod 101:550-555,1992

DONALD J. ANNINO

227