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Genioplasty/Mentoplasty
Definition:
A type of cosmetic surgery that is used to improve the appearance of a person's chin (i.e. plastic surgery of the chin).

Includes:
Alternation in the horizontal and/or vertical dimensions of the chin (by horizontal osteotomy of the symphysis, also called sliding genioplasty). 2Chin augmentation using chin implants. 3Chin rounding. 4Direct chin reduction. 5Liposuction may be used to treat a double chin or to remove excessive fat in the chin area and neckline. 6Non-surgical chin reshaping or chin augmentation: An excellent and affordable option for the patients who would like to achieve a more pleasing appearance of their chins without the risks of surgery. Involves the use of dermal filler (Evolence, Restylane) injected to reshape and contour the chin to achieve a natural aesthetic appearance. Treatment is carried out in the out-patient setting and takes 15 - 20 minutes. A local anaesthetic injection is used to ensure that the treatment is as comfortable as possible. Evolence will provide long lasting improvement in chin shape for about 12 months. Restylane dermal filler will provide results that last for 6 to 9 months. Repeat treatments are recommended every 12 18 months to maintain the desired shape. Some side effects or risks may arise following the non-surgical chin augmentation, as mild discomfort, swelling and bruising. Reactions following Restylane or Evolence are rare. Minimal discomfort is expected during the treatment and no bruising should occur with the careful techniques used. Any mild bruising will usually resolve after 1 week. The chin may feel tender for the first 3 5 days.
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Indications:
Surgical goals include creating an aesthetically pleasing facial contour and establishing proportionate facial height. This may entail reduction of a prominent chin or augmentation of a poorly projected chin. Genioplasty is primarily used only for esthetic reasons. Therefore, its use depends on the patients concern about appearance of this area of the face. Often the surgeon has to bring to the patients attention the need for a genioplasty when other facial osteotomies are planned because of the impact that these osteotomies will have on chin prominence. The indications, therefore, are often made apparent by comprehensive treatment planning by the surgeon.

Combinations:
Genioplasty may be done alone or with other surgical procedures. 1Genioplasty is commonly indicated when orthognathic surgery of jaws is planned because of the impact that these procedures will have on chin prominence. 2Genioplasty may be used as a supplement to nose reshaping (rhinoplasty), because a small chin can make the nose appear larger. Genioplasty can be used alone if there is a proper occlusal relationship between the maxillary & the mandibular teeth, and the disharmony of facial profile is only due to receded or overprojecting chin. When facial analysis identifies a patient's profile with facial dysharmony, determine whether an underlying occlusal and skeletal deformity exists, or merely a poorly or overprojected mentum is present. When the poor projection is skeletal in nature, the situation is considered an Angle class II skeletal deformity. The Angle skeletal classification is based on the position of the first molar. In retrognathia, the mesiobuccal cusp of the maxillary first molar is mesial (or anterior to) the buccal groove of the mandibular first molar. If only a hypoplasia of the mandible exists, the term micrognathia is more accurate and should be used. When no skeletal malformation is present, the terms for a recessed chin include retrogenia, microgenia, retruded chin, hypoplastic mentum, and horizontal mandibular hypoplasia. The same holds true for the overprojected chin, eg, prognathia, protruded chin..

Complications and Risks of Chin Surgery:

Complications in the mentoplasty or genioplasty procedures do not occur often. 1Infection in the chin or lip area, usually treated with antibiotics. In rare instances an infection requires surgical drainage. 2Scar tissue formation is also a possibility. 3Over time, portions of the bone may erode; however, this does not typically cause any medical concerns, discomfort, or changes in the appearance of the chin. 4In the genioplasty procedure, wires or plates are removed if they cause discomfort. 5Patients may experience lack of sensitivity (numbness) in the chin or lip area; however, the numbness is usually temporary. In rare cases, sensitivity loss may be permanent.

In the past, various materials have been used to augment the chin, including paraffin, ivory, and methylmethacrylate. Alloplastic implants such as solid silicone (either soft or firm), reinforced expanded polytetrafluoroethylene(e-PTFE), porous polyethylene, and polyester mesh have gained a great deal of popularity through the years as a result of patient and surgeon satisfaction. In the 1980s, some surgeons popularized Mersilene mesh (non-resorbable polyester mesh). A recent 14-year study showed Mersilene mesh to be safe and well tolerated for chin augmentation. At present, many surgeons prefer the customized firm silastic implant. It has a cleft made into the exact anterior center of the implant, a blue line demarcating the vertical center on posterior surface, extremely fine tapered lateral margins (to be not palpable), and a slight concavity on the posterior surface. The purpose of this design is to be easy inserted into a very small opening in the skin or the mucosa. With the slight concave posterior surface, it tends to conform the underlying bone. The blue line helps to center the implant under direct vision when only a small portion of the implant is visible through the incision. The central cleft on the anterior surface allows the surgeon to palpate the center of the implant after the incision is closed to insure that the implant has remained in its position and also helps in the follow-up visits to ensure that the implant has not displaced from its position. It is available in deferent sizes and shapes, the choice of the size and the shape of the implant depends on the amount of the chin augmentation needed. Alloplasts, in general, are easy to place and are less time consuming than a sliding genioplasty, but their application is limited to the mild to moderately retruded chin. Alloplastic chin augmentation is not as popular with oral and maxlllofacial surgeons because of lack of remodeling (i.e., edges may be felt), potential for underlying bone

resorption, and increased risk of infection. It is possible for them to shift position if they are not firmly fixed. These implants may be easily placed under local anesthesia. There are two choices for the incision for placement the chin implants. - The first being intraoral, this incision is placed within the lower portion of the inside of the mouth between the lower gums and the bottom lip/chin area. The incision passes through the mentalis muscle which is latter carefully reapproximated. Although the intraoral incision has the advantages of no visible scar, it runs the risk of a higher rate of infection due to the bacteria present in the mouth. Smoking, gum diseases, poor oral hygiene, or dental caries could cause an infection as well as significantly impede healing. other disadvantages of intraoral incision include larger incision, suture-line irritation and possibility of loss of lip competence (due to poor reapproximation of mentalis muscle). NB: The mentalis muscle elevates and protrudes the chin. It attaches the chin to an area just beneath the tooth roots. An intraoral incision transects this muscle. Reestablishing this muscle is important; otherwise, chin ptosis may ensue. - The second option is extraoral incision or quite simply "under the chin". This incision is placed approximately an inch posteriorly from the front of the chin. The incision is made in a submental crease in an inconspicuous location. About 10-15 millimeters incision is generally sufficient to accommodate implant placement and stabilization. The incision is deepened through the subcutaneous fat layer and muscles layer down to the periosteum, the periosteum is sharply cut and elevated (care should be taken to avoid disturbance of the anterior gingivobuccal sulcus). the If submental lipectomy (liposuction of the under chin area) is performed the liposuction can be performed through the same incision as well. For the alloplastic chin augmentation extraoral submental incision is more indicated because the increased risk for infection with the intraoral incision and subsequent failure of the procedure. After the alloplastic implant material is adapted to the receded chin, it is sutured to the periosteum (screws may be used to fix it in position).

Complication:
Displacement of the implant: may be displaced superiorly obliterating the anterior gingivobuccal sulcus or may be displaced to one side causing asymmetry. In this case the implant should be removed and replaced in the correct position (the use of screws may be helpful to prevent the displacement). 2Infection: culture should be obtained and the proper antibiotic is given. If infection isnt resolved within 10 days the implant should be removed. 3Bone resorption: very common problem. May be little or extensive. 4Improper size selection. 5Mental nerve injury: uncommon complication. 6Hypertrophic scar
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Contraindication:
123Sever periodontal disease. Extreme microgenia. Excess or insufficient vertical height of the chin.

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Labial incompetence.

Definition:
Involves removing a horseshoe-shaped piece of the chin bone and sliding it either backwards or forwards, finally fixing it in place using wires, plates and screws. This type of surgery is usually performed by an oral and maxillofacial surgeon. This procedure has an advantage of using the patient's own tissue. All of this surgery is carried out beneath the tooth roots and therefore does not affect the tooth bearing part of the lower jaw. An x-ray (lateral cephalogram) is needed before surgery is carried out both to measure the degree of bony movement necessary and to see exactly where the tooth roots lie. Also panoramic radiograph is indicated to allow assessment of the position of the roots apices of the lower anterior teeth and the position of the horizontal osteotomy. There are no visible scars externally since the procedure is carried out through the inside of the mouth. There is no need to radically adjust diet during the recovery phase and the dentition is not interfered with. This technique can correct the abnormalities in the 3 dimensions of asymmetry.

Indications:
This osteotomy with minor variations can be used to improve almost every conceivable skeletal abnormality of the chin. Sliding genioplasty should be considered in patients with excess or insufficient mandibular height, extreme microgenia, hemifacial atrophy, mandibular asymmetry, failed alloplastic chin implants.. Advancement sliding genioplasty can be used in patients with sleep apnea due to the posterior position of the tongue in patients with micrognathia (as the tongue is moved forward with the inferior segment, the tongue is attached to the inferior segment by the genioglossus muscle).

Contraindications:
When considering sliding osteotomy, carefully evaluate the teeth and the height of the mandible prior to surgery. Having long teeth with a short mandibular height is a relative contraindication for an osseous genioplasty or an aggressive bony reduction.

Disadvantages:
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Increased surgical time than chin implants. Longer healing time than chin implants. Risk of injury of lower anterior teeth. Loss of lip competence (poor reapproximation of mentalis muscle).

Higher risk for permanent lip numbness than chin implants (due to injury or pressure on mental nerve).
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Technique:
The horizontal osteotomy of the symphysis is often done in conjunction with other major osteotomies and, thus, is frequently accomplished under a general anesthetic. However, it can be performed as a separate procedure on an outpatient basis under sedation and local anesthesia.

Usually the incision for exposing the chin is done intraorally (leaves no visible scars). The mucosal incision is made on the labial side of the vestibule at about 1 cm above its depth and extends posteriorly to the first bicuspids. This incision is carried just below the mucosa to the depth of the vestibule and then angled directly to the labial cortex through the mentalis muscle which is latter carefully reapproximated (as in the figure). Or the incision can be done extraoral horizontally under the chin in an inconspicuous location, to expose the chin.

Periosteum is elevated inferiorly to a point just below the intended level of osteotomy. Laterally the periosteum is elevated to the mental foramen and then extended posteroinferiorly to the inferior mandibular border. The extent of the posterior cortical exposure is generally determined by the position of the mental foramen and the vertical height of the mandible in this area. In many cases this means that it will end in about the first molar area. No attempt is generally made to expose the mental nerve by releasing the soft tissue around it, primarily because the nerve can be small and friable, making inadvertent severing possible. The periosteal elevation behind the foramen is minimized to just that needed for placement of a narrow retractor and the saw blade or bur. The suprahyoid muscles and the lingual mucoperiosteum remain attached lingually providing blood supply to the bone segment.

It is helpful at this point to inscribe a vertical mark (or marks) into the bone across the planned osteotomy site so that the transverse position of the inferior fragment can be more easily oriented after the osteotomy. The osteotomy cut is then made with a reciprocating saw (as in the figure). The length and angle of the horizontal cut can have profound effects on postsurgical results. Further osteotomies or osteoplasties are made after mobilization of the lower segment. the osteotomy is made horizontally below the apices of the lower cupids (as indicated by radiographs) and the mental foramenia at an appropriate angle. If only advancement or retraction of the lower segment is indicated, the osteotomy should be parallel to the occlusal plane of the lower arch till reach the inferior border of the mandible (as in figure A). If adjustment of the vertical dimension is also indicated, then the osteotomy should be directed backward downward to the inferior border of the mandible (as in figure B).

The stabilization of the segment in its new position can be made with cortical wires, circumandibular wires, or plates and screws. H-plate can be used after being preshaped to allow the exact millimeter of movement of the lower segment that was determined preoperatively. Also chin plates can be used.

The wound is irrigated and closed in two layers (muscle and mucosa) with resorbable suture. Tape placed across the lip and chin is maintained for 24 to 48 hours to minimize hematoma formation as well as to help support the suture lines. Patients should be instructed not to pull their lip to minimize dehiscence of the wound.

Alternative Techniques:
Horizontal deficiency of the chin A) The basic procedure (as in the figure). The length of the cut posteriorly has important esthetic consequences. Most notably larger advancements require a larger cut to the first or second molar region. This permits a smoother line to the inferior border of the mandible.

B) A midsagittal osteotomy of the inferior fragment may be helpful in preventing the prominence of the posterior ends of the fragment, relative to the body of the mandible, as the fragment is advanced (as in the figure).

C) A narrower chin point can also be obtained by taking a wedge of bone out from the lingual aspect of this cut (as in the figure).

D) Overlapping an advanced inferior fragment on the lateral cortex of the symphysis allows both an increase in horizontal

prominence as well as a decrease in the anterior mandibular vertical height (as in the figure).

E) Larger advancements of the inferior fragment can be obtained by double or triple osteotomies, rotation of the fragment combined with a graft at the posterior gap, and bone graft between the symphysis and the fragment (as in the figure E, F, G).

Horizontal excess of the chin H) Horizontal chin excess is traditionally treated by moving the inferior fragment posteriorly. Depending on the angle of the cut this will also increase facial height. Sometimes when this is done it is necessary to remove the posterior ends of the inferior fragment to prevent unsightly protrusions from the inferior border of the mandible (as in the figure). I) When the patient has normal facial height, the plane of the osteotomy should parallel the Frankfort horizontal or natural head position, if at all possible. The

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anterior chin projection can be reduced by using V-shaped or parallel osteotomies cut in a more vertical plane, with the middle segment removed (as in the figure). Vertical excess of the chin J) Vertical symphyseal excess can be reduced by removing the middle segment of bone when the plane of two parallel osteotomies is more horizontal (as in the figure).

K) These cuts, however, do not always need to be parallel and in fact should be designed to fit the particular structural problem. This design also permits the correction of a mild horizontal deficiency that is combined with a mild vertical excess (as in the figure).

L) This skeletal problem can also be corrected by making a single osteotomy more vertical and moving the segment anteriorly and forward (as in the figure).

Vertical deficiency of the chin M) Vertical deficiency can be handled only by some type of interpositional material, with either bone grafts or implants (as in the figure). Even the use of plates alone to hold the fragment in a lower position has been suggested.

Complications:
1Non-union. 2Risk of injury of lower anterior teeth. 3Loss of lip competence (poor reapproximation of mentalis muscle). 4Higher risk for permanent lip numbness than chin implants (due to injury or pressure on mental nerve).

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