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Archive for the ‘chin reduction’ Category

Patient Testimonials: Chin Reduction

Sunday, November 17th, 2013

 

CHIN REDUCTION

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!

Carmen

Knoxville, Tennessee

Commentary

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.

Dr. Barry Eppley

Indianapolis, Indiana

The Role of the Chin in Profileplasty

Sunday, July 28th, 2013

 

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.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Vertical Chin Reduction by Submental Ostectomy

Tuesday, April 16th, 2013

 

Background: The chin is the prominent and most protruding structure of the lower face. It is a three-dimensional facial part that can have excesses and deficiencies of either the amount of projection, width or in its height. Because of the soft tissue that wraps around the chin bone, excessive or big chins pose greater aesthetic challenges than that of the small chin.

Having a big chin can involve any (or all) of the three dimensions and the surgical technique to reduce it varies based on these dimensions. In order of difficulty, the wide chin is the simplest to effectively change and the horizontal overprojecting chin can be the most challenging. The vertically long chin offers an intermediate level of difficulty, and like the chin that sticks out too far, the biggest challenge is how to predictably shrink the enveloping soft tissue to avoid a postoperative sag.

The vertically long chin can be reduced by two methods. The traditional approach is to use an intraoral osteotomy (genioplasty) and remove a wedge of bone either from above or below the osteotomy cut. The main advantage of this technique, besides the avoidance of an external scar, is that the soft tissue attachments to the underside of the chin bone are not disrupted. The alternative approach is to remove the bone from below through a submental incision, detaching and then reattaching the neck and chin soft tissues after the bone is removed. The advantage of this approach is that any redundant soft tissues of the chin can be directly removed and tightened and the superior attachments of the mentalis muscle is not disrupted.

Case Study: This 40 year-old female wanted a shorter and less long chin. She had a chin implant placed at the time of a previous rhinoplasty, at the suggestion of her surgeon, but it made her chin too big and it was subsequently removed. Despite its removal, she still wanted an even shorter chin. She acknowledged that she already had a small chin, by everyone else’s standards, but to her it was still too big. She just wanted the bottom part of it ‘cut off’.

Under general anesthesia, a 3.5 cm incision was made behind the submental skin crease. The soft tissue attachments to the bottom of the chin were detached and the exits of the menral nerves identified. A reciprocating saw was used to remove an 8mm segment of he bottom portion of the chin bone. The bone edges were smoothed with a rotating burr. Drill holes were made in the outer cortical edge of the chin and sutures were used to resuspend the strap muscles of the neck . Excess skin, fat and mentalis muscle was removed from the back side of the incision and the a layered soft tissue closure done, tucking it under the submental area.

Her postoperative course had the typical swelling which ensues with some expected temporary skin numbness. By 3 weeks after surgery, most of her swelling was gone but it took a full 6 weeks to see the final result and have all feeling return to normal. When seen at 3 months afetr surgery, she had a noticeable vertical chin reduction and no soft tissue tissue sag.

The submental ostectomy approach to vertical chin reduction is an effective alternative to the more traditional intraoral bony wedge resection approach. It may be the preferred approach when substantial soft tissue tightening is needed in addition to the bone reduction or a previous intraoral reduction procedure did not produce satisfactory results.

Case Highlights:

1) The length of the chin can be successfully reduced like other chin dimensions.

2) Vertical reduction of the chin can be done through either an intraoral wedge ostectomy/genioplasty or a submental ostectomy, of which the intraoral approach is the most common.

3) The submental vertical chin reduction removed the lower end of the chin bone as well as excises and resuspends the soft tissue chin pad and upper neck tissues.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Female Chin Reduction

Monday, March 5th, 2012

Background:The chin is the dominant feature of the lower third of the face. When in good balance with the rest of the face it is an asset and a pleasing feature. When it is short or weak, it makes the face profile too convex and suggests a weak nature to the person. When it is too prominent, the facial profile becomes concave and makes the midface look retruded. Eitherway the chin plays a major role in facial appearance

Macrogenia, or overgrowth of the chin, creates a lower face that is out of balance with the upper and middle facial thirds. Most cases of macrogenia are a combination of excessive horizontal and vertical bone development. While macrogenia can be a reflection of an overall lower jaw overgrowth as evidenced by a Class III malocclusion, most larger chins occur in isolation. In women, the position of the chin should be slightly convex in profile and not too vertically long. Too much chin projection creates too strong of a lower face and a more masculine look.

Correction of a large chin is more complex and difficult than correction of an underdeveloped or small chin. While the bone reduction is fairly straightforward, whether by osteotomy or burring reduction, management of the excess soft tissues is another matter.In small chin reductions, the soft tissue will shrink and adapt to the new bone shape. But in large chin reductions, the soft tissues will not shrink enough and will sag if not removed or tightened. This can create the classic ‘witch’s chin deformity’.

Case Study: This 33 year-old female felt her chin was too big and wanted it reduced. She had a slightly concave facial profile, a vertically long chin, and a normal occlusion. In doing an imaging analysis based on photographs, the amount of chin reduction needed was a minimum of 8mm horizontal reduction and a 6mm vertical reduction. This amount of bony movement was felt to be too much for an intraoral osteotomy in which the soft tissues would only bunch up with the backward or reverse sliding genioplasty.

Under general anesthesia, a submental approach to her chin reduction was done. Through a curved 4 cm skin incision, the chin bone was widely exposed. A fine burr was initially used to make a deep vertical bone cut in the midline down through the outer cortex of 8mms in depth. A burr was then used to remove the side portions of the remaining chin bone down to the same level and tapering it into the prejowl area. From the inferior edge, the chin bone was burred down 6mms. A wedge of skin, muscle and fat was removed from the front edge of the incision and the muscle layer was then put back together and tightened over the lower edge of the reshaped chin bone. The skin was then closed and a tape dressing and ice pack applied.

She had a fair amount of chin swelling after surgery that took three weeks before any amount of chin reduction could be appreciated. After three months, a very evident reduction in the size of the chin would be appreciated.

Of the two methods for chin reduction, the submental approach is the most versatile. It allows not only for better bony chin reshaping but permits soft tissue reduction and tightening as well. Failure of the soft tissues to adhere tightly to the new reduced bony chin shape will result in an unsightly soft tissue sag.

Case Highlights:

1) A large and prominent chin consist of both excess bone and soft tissue. Both must be managed for a successful chin reduction procedure.

2) Most chin reductions are best done from a submental approach where the bone can be reduced in all dimensions and the soft tissues tightened.

3) Chin reduction surgery involves a temporary period of swelling and several months to see the final result.

Dr. Barry Eppley

Indianapolis, Indiana

Chin Narrowing by Lateral Tubercle Reduction

Sunday, November 13th, 2011

A square chin and jawline is considered desireable in a male but not so in a female. It is also deemed unattractive in certain ethnicities such as in the Asian face as well as in the male to female transgender face. Reduction of a square jawline is often perceived as that of the jaw angles. While jaw angle reduction surgery has a role to play in facial contouring, it only provides some narrowing in the posterior mandible or back part of the jaw. It has no slimming effect in the front part of the jawline in the chin area.

 

Narrowing of the chin or front part of the lower face can be done by several methods, all of which require bone reduction. If a chin osteotomy (osteoplastic genioplasty) is being done, the width of the chin will naturally narrow when the chin bone is brought forward and/or vertically lengthened. But not everyone needs horizontal or vertical chin lengthening so an osteotomy can be ineffective. The other approach is direct burring reduction of the chin or mandibular tubercles. By reducing the bony sides of the chin it can be narrowed in the frontal view.

 

When doing an osteotomy to create a chin narrowing effect, it is important to realize that the bone will not narrow behind the osteotomy cut. This also is where a step-off can be created at this junction which is most evident when horizontal advancements are done. As the bone edge of the downfractured chin segment moves forward, this step-off can be created. It can be a difficult area to reach for smoothing out this step-off and there is risk to the mental nerve which is very close by. This is why it is helpful to make that osteotomy cut back as far as possible to extend the natural narrowing effect of the advancing osteotomy and avoid a prominent step-off.

 

Reducing the sides of the chin can be done by either burring or saw reduction. Using a saw always removes more bone quickly with less risk of injury to the mental nerve. The more relevant question is whether it is done through an incision inside the mouth or from an external submental incision from below. Most of the time an intraoral approach is used if only the sides of the chin need to be reduced. But when an overall chin reduction is being done reducing height and/or projection, a submental approach is used so that the extra soft tissues can be managed by excision and redraping to prevent postoperative sagging or ptosis.

 

To achieve a more slim feminine lower face, reduction of the jawline must be considered as a whole. Changing the width of the chin from a more square to a tapered shape creates an essential change in the frontal view. Barring the need for horizontal or vertical lengthening of the chin, burring or saw reduction of the sides of the chin can be done from either an intraoral or submental approach.

 

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Horizontal Chin Reduction in a Female

Friday, July 9th, 2010

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.

Case Highlights:

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.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Bone Reduction Surgery

Monday, February 1st, 2010

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.     

Barry L. Eppley, M.D., D.M.D.

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 

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

Plastic Surgery Correction of Chin Ptosis

Saturday, April 4th, 2009

A chin that sags over the line of the jaw (chin bone) is called chin ptosis. (ptosis is medically defined as a sagging of a body part) While some people have this naturally, most of the time it is due to the soft tissues of the chin sliding downward for a reason. This can occur from simple aging, loss of one’s lower front teeth, and due to different surgical procedures of the chin. A few people actually have pseudo- or perceived chin ptosis which occurs as a result of a natural deep crease below the lower lip (submental crease) which makes the chin look ptotic (particularly when smiling) even though it is not.

Successful correction of chin ptosis can usually be done for those problems caused by prior surgeries. Chin surgeries that are well known to cause soft tissue sagging include the intraoral placement of implants, removal of an overly large implant and bony reductions. Other less common causes include intraoral access for repair of mandibular symphysis and parasymphyseal fractures and vestibular lowering procedures (preprosthetic surgery) in preparation for improved lower denture fit.

Treatment is  based primarily on resuspension or tightening of the mentalis muscles  with or without hard tissue chin expansion. For sagging caused by intraoral access to the chin, the mentalis muscles must be brought back up into their original anatomic position. The intraoral route of access to the chin always divides the upper attachments of the mentalis muscles. (some surgeons put them back well while others do not) This is why the submental (under the chin) skin approach for chin implants is always better with a very acceptable scar and why I use it in my Indianapolis plastic surgery prasctice.  It is not always easy to find good muscle to sew to and this is why a bone-anchoring technique with titanium screws or Mitek suture anchors is my preferred method for a ‘high’ reattachment.

If chin implant removal is the cause of sagging, replacement with a new implant alone may be satisfactory. Or if the patient no longer wants an implant but still desires an augmentation, moving the chin bone forward as a natural ‘implant’ may create enough expansion to fill out and elevate the sagging chin tissues. A chin osteotomy is an excellent opportunity to elevate the muscles as well as the plates and screws used to hold it in its new place are good anchoring points for the muscle.

Chin reduction procedures are especially prone to chin sagging problems after. The lower attachments of the mentalis muscle must be divided to access the chin bone. Once the bone is reduced by burring, the muscle and sometimes skin must be shortened and reattached. Usually tightening the muscle across the reduced bone and reattaching it to the muscle on the underside of the chin is adequate. If not, bone holes can be made on the inferior ledge of the chin bone onto which the muscle can be reattached.

 he chin is unique in that the mentalis muscle is attached and suspended across it  both above and below the chin prominence. The skin and fat are attached to the underlying muscle and follow its position on the bone. If the muscle sags, so does the appearance of the chin. The key to correction of chin ptosis is management of the mentalis muscle attachments in most cases.

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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