Chin Surgery

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Chin Surgery can be one of the most striking cosmetic facial procedures. Many individuals have very recessive profiles due to the fact that their lower face and jaw have not developed properly. This is frequently a genetic situation and other family members may exhibit similar traits.

In addition to complimenting the profile, chin surgery can also tighten and enhance the sagging or fatty tissues in the neck. Many chin surgery patients also require minor liposuction which enhances the chin and addresses fatty or sagging neck skin.

Chin implants can be placed from an incision inside the mouth for a completely hidden scar. They can also be placed through the skin under the jaw using a small incision. This images illustrates both incision approaches.

chin implants in a variety of sizes, Richmond VAThe simplest approach to chin augmentation is the placement of a chin implant. This minor operation is performed in the office with IV sedation. The procedure takes about 30 minutes and requires a 5-10 day recovery. New technology in biomaterials has shown silicone implants to be very successful and extremely well tolerated by the body. The new chin implants are natural feeling and follow the contours of the normal jaw line. These new type of implants are known as anatomic implants which means they come in many shapes and sizes to personalize the aesthetics of each patient.

When chin implants are properly inserted and fixation is used, the result is permanent. It takes about 25 minutes for the procedure and if for some reason the patient wants it removed or replaced, this can be done in 10 minutes with local anesthesia. Not many cosmetic procedures are both permanent but reversible!

Contemporary chin implants come in a vast array of sizes and shapes to allow the surgeon and the patient many options in facial enhancement.

The implants can be placed through an incision inside the mouth to avoid a scar on the face or under the chin in the natural skin crease. After chin surgery, the patient will experience minor swelling, bruising and temporary numbness of the lower lip. These conditions usually resolve over 1-2 weeks.

Advantages of Silicone Implants

  • Can be placed from the inside of the mouth without ANY facial scar.
  • Simple procedure that takes about 20 minutes.
  • Is a safe, predictable and permanent procedure when using screw fixation.
  • Can be easily removed in 5 minutes if the patient desires
The photograph on the right shows a contemporary anatomical implant. The implant is anchored to the jaw with a single microscrew which keeps it in place and prevents migration. Many surgeons do not use screw fixation and this can result in movement of the implant and an unnatural result.  In addition, a lose implant can cause the underlying bone to dissolve.  This is something I have not experienced due to the fact that we secure all implants.

ImplanTech Silicone Chin Implant, Richmond VA

ImplanTech Silicone Chin Implant


We commonly see out of town and international patients for cosmetic facial surgery including chin and neck liposuction procedures. Generally they can come to Richmond the day before their surgery, have surgery the following day and return home the next. The patient shown here came in from NYC for several days for chin surgery.


When is a patient not a candidate for a chin implant?

Many patients with a deficient chin (retrogenia) have dental or jaw misalignment (overbite).  Some patients are best treated with orthodontics and jaw repositioning (orthognathic surgery).  Many patients do not desire this type of treatment and want a simple chin implant.  Although many patients are good candidates for chin implants, some are not.  Patients that have a deep mentolabial fold (the crease below the lip and above the chin) may not be good candidates and patients that have the lower lip that is behind the upper lip may not be good candidates.

Placing an implant in patients with deep mentolabial folds or lips that are not in line can actually make them look worse as the chin point sticks out in an unnatural manner.  A patient with this type of situation should be treated with a lengthening genioplasty (see topic on this page) to add vertical height to the chin.  The patient shown on the left  had a chin implant placed and instead, should have had a lengthening genioplasty to augment the chin in the vertical and horizontal direction.


A deep mentolabial fold or lip misalignment may indicate that the patient is not a good candidate for a chin implant and should be treated with a lengthening genioplasty.

If the lower lip is considerable behind the upper lip, the patient may not be a good candidate for a chin implant and may be better suited for a sliding genioplasty.


“Chin implants don’t work?

Unfortunately, many surgeons will say that a given procedure “does not work” when in reality they should say “I am not proficient at that operation”.  Many surgeons are too proud to admit that just because they are not good at something does not mean that someone else is.  When I finished my maxillofacial surgery residency, I was taught that “chin implants don’t work”.  I was told they “get infected, move around, cause the bone to dissolve and will eventually fail.”  When I entered private practice in 1983, I sat down and tried to identify the factors that contribute to this supposed failure.  After a while it became quite obvious that there were four main problems that caused implants to fail.

Reason #1: Improper implant shape

Older style chin implants were not “anatomic”.  This means that they were not made to fit the underlying bone in a precise and cosmetic manner.

The older style implants were sometimes merely hunks of silicone or other material that was not shaped to fit the jaw and did not cover enough of the jaw.

The not only produced a compromised cosmetic result, but the shape was not conducive to the implant lying on a stable base or to resist movement. This shows an old style “button” implant next to a contemporary anatomic implant.  The longer implant has a more stable base for biocompatibility and aaesthetics.

Reason #2: Improper implant biomaterial

Surgeons familiar with the orthopedic literature know that materials can play a huge role in biocompatibility and implant survival.  Silicone implants are the most biocompatible.  Rejection is rare and they are easy to put in and take out. Some implants are made of porous materials and they can be almost impossible to remove as they become ingrown to muscle and other tissue and fragment upon attempted removal.  Never put something in that you cannot take out!  Silicone implants are extremely easy to remove if desired.

Reason #3: Unfixated (unsecured) implants

P6052677Another very important orthopedic principle is fixation.  A chin implant is subject to many forces.  Think about how much we use our lips and mouth and the muscles in this area.  These muscles and related funciton can be very powerful and move unsecured implants.  Any implant that rests on bone and is mobile (even micromovement) can cause severe inflammation of the bone leading to bone loss.  A general rule is that any implant that is not fixated (secured to the bone with a screw) may be viewed by nature as a foreign body and the immune system will do it best to get rid of that foreign body.  By simply securing the chin (or cheek) implant to the underlying with a single microscrew (sometimes a second anti rotation screw is used), this movement can be minimized or avoided. Some surgeons claim they secure the implant with a suture, but this is not the same or as secure as using a screw as a suture still allows movement because it is not a solid fixation.  After placing hundreds of chin implants over a 30 year period, I can testify that it is extremely rare to see failure or bone problems with screw retained silicone implants.  This image shows a silicone chin implant placed through a very small chin incision with a microscrew fixation of the implant to the bone.  See the section below for more information on why screw fixation is important.

The following images are from a patient that had an implant placed by another surgeon.  The implant was over trimmed and was “fixated” with a suture.  It is easy to see that the implant was mobile which would not have happened if screw fixation was used.  While not every implant will have problems when not secured with screws, most of the problems I see are from implant mobility or displacement.  This can be avoided by using 1-2 micro fixation screws.

The left image below shows two major implant mistakes.  The implant is too small and non anatomic in the left picture.  The right picture shows the implant secured with suture instead of screws and hence it is loose and mobile. The right picture below show the problem implant placed by another surgeon and the new anatomic implant placed by  Dr. Niamtu and stabilized  with a micro fixation screw.

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Reason #4: Improper technique by the surgeon

Figure+89Like any surgical procedure, the competence of the surgeon can have a lot to do with the result.  Experienced facial implant surgeons are aware of the implant position in three dimensions.  Silicone implants are made to fit the jaw or cheeks in a very precise position and if this is not followed, the implant will not look or feel right.  Obvious asymmetry is visible when the implants are tipped or not placed in the intended position.

The images on the right show a model of improper placement in the vertical plane.  Note that on the  picture A (taken from the tongue side) shows the implant extends below the border of the jaw.  Sometimes this is done intentionally, but this will frequently produce a noticeable step that that most patients do not like.  The image in figure B show an implant placed to high above the jaw border.  Again, this will produce an unnatural result as well as a crooked appearance.  The average patient needs the implant placed exactly on the border of the mandible (jaw).

Figure+97Also common are surgeons not placing the implant in the correct position in the horizontal plane.  This leads to the implant being tipped and obviously can skew the intended result.  The implant does not look as good and frequently appears tilted to one side or the other.  This is also very noticeable to the patient when they feel one side of the implant compared to the other.  The right side image shows a model of chin implants that were not placed in the proper position in the horizontal plane resulting in a tipped, uneven and unnatural result.  Dr. Niamtu frequently corrects similar problems from improperly placed implants from around the country.  It should be noted that sometimes it is impossible for various reasons to control implant position and minor asymmetries can occur, but major malpositon is a complication and should be corrected.  Fixating implants with microscrews can prevent improper implant position after surgery.  During surgery it is the care and expertise of the surgeon that makes the difference.

The images on the right show a chin implant placed by another surgeon that is malpositioned.  The top images show the actual CT scan and the bottom images show an outline of the implant to better visualize the problem.  Not only is the implant not properly positioned in the vertical and horizontal plane but it is also in close contact to the mental nerve (shown as red dots) which can cause pain and numbness.  It is difficult to say if the implant was placed this way or moved after surgery because it was not secured with microscrews.  In any event, the cosmetic and functional value of the implant is compromised and the surgery will likely need to be redone.  This is something that I see on a regular basis with cheek, chin and mandibular angle implants.  I have fixed many of similar cases. Even the best surgeons may have some asymmetry of an implant but small displacement is generally not a problem.

Inexperience and the Wrong Size Implants

Obviously, the success of any implant procedure has to do with placing the correct size and shape implant.  Females don’t look good with masculine implants and vice versa.  Volume, taper, extension, thickness and height are just some of the factors that experienced implant surgeons take into account when matching the proper implant with the patient’s desire.  Although custom implants are sometimes required, most often, the surgeon can customize the “off the shelf” implant by sculpting it to best match the patient.

The patient below presented to Dr. Niamtu and was unhappy with her chin implant that was done elsewhere.  The main problem with the bulky and  masculine chin implant was that it simply did not fit the patient.  Dr. Niamtu removed this implant and placed an off the shelf implant that he trimmed to fit the patient better.

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The above and below images show a patient with an improperly sized implant that was replaced with a more suitable size and shape for the patient.

chin-implant-case-1b

This section illustrates only a few of the many nuances that can affect successful chin implant success.  Patients considering chin or cheek implants should do enough research to find a surgeon who realizes the pearls and pitfalls of proper implant technique.  Next time you hear a patient or surgeon say “chin implants don’t work” they can be asked about their knowledge and proficiency of the aforementioned factors that can make or break a cosmetic facial implant case.  As you browse the Chin Implant Gallery you can see that chin implants, in fact, do work and I have hundreds of patients that can back that up.

Changing Lower Facial Height

SLIDING GENIOPLASTY

  genioAn additional way of moving a chin forward or backward is called a SLIDING GENIOPLASTY. This procedure is performed from an incision inside the mouth below the lower lip. The sliding genioplasty is used in more severe cases or in cases where the chin needs to be lengthened or moved backward. Dr. Niamtu makes an incision in the  inside of the mouth and advances or moves back the bony chin segment. This segment is then secured with a micro bone plate. The photograph below shows a model of a sliding genioplasty. The SLIDING GENIOPLASTY advances the patient’s actual chin by moving the lower portion of the Jaw. This procedure will not only advance the chin forward, but it will also increase the lower 1/3 facial height. The picture to the left shows a model of the sliding genioplasty where the lower part of the chin is cut and moved forward (to increase the chin) or backward (to decrease the chin).

While many patients need more chin in the horizontal direction (back to front) some patients need an increase in the vertical dimension of their chin (bottom to top). Patients with a shortened lower facial height lack the proper aesthetics for a natural chin and lip support. Their lower lip looks folded over and unnatural.

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The image below illustrates advancement genioplasty in teh vertical and horizontal planes.


The patient below demonstrates what he desires for profile enhancement.  His lower face needs lengthening as he demonstrates by pulling down.  This can only be achieved with a genioplasty and not with chin implants.

The patients below are shown before and after vertical and horizontal advancement genioplasty



Dr. Niamtu discusses the important differences between treatment with genioplasty versus chin implants


IMGP2476Patients that have short lower facial third frequently also have a deep mentolabial fold (between the lip and chin).  Chin implants cannot be successfully used in this type of patient.

The picture to the left shows a 10 mm increase in the vertical length of the chin at the time of the operation.

IMGP2477For larger lengthening procedures a bone graft may be used.  The image to the right shows the bone plates that stabilize the bone cut and hold the bone graft in place.  Using bone plates provides excellent rigid fixation which makes healing faster and prevents movement of the chin.  Bone will eventually heal and fill in around the gap and the plates.  Although 95% of patients do not need any fill for the gap, extremely large bone gaps may require a bone graft to fill the void and stabilize the result (right photo). 

The before and after images below show several cases of chin lengthening and advancement from sliding genioplasty.

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Before and After Chin Advancement and Lengthening

Two

Before and After Chin Advancement and Lengthening

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Before and After Chin Advancement and Lengthening

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The Patient above underwent a lengthening genioplasty which lengthened and feminized her chin and profile

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Before and After Genioplasty Cases


Mandibular Angle Implants

Many patients are deficient in the lateral (side) portion of the jaw. This gives them weak facial form. Mandibular angle implants can provide a more square, contoured or chiseled appearance for the lower face.

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Mandibular angle implants can be used to create a more angled look in both males and females.  Some patients are born with rounded posterior jaw features and mandibular angle

implants can make the face more angular.  Johnny Depp, Colin Farrell, and Leonardo DiCaprio and Brad Pitt are commonly referenced when well defined mandibular angles are discussed.  It is important for patients to realize that although mandibular angle implants may broaden the lower face, they are not going to make a person look like a “model” or give a sculpted jawline to someone who does not have the anatomical basis for such a change.  In other words, some patients look like “models” because their heredity and a combination of desirable features.   Facial implants in themselves cannot account for all these features.

Figure+106Mandibular angle implants can generally be placed using stock “off the shelf” implants.  These are available in various sizes and shapes to accommodate a wide range of patients.  In some cases more precision or customization is desired and the patient and or surgeon may want to customize the result.

This can be done by fabricating custom computer generated implants.  This actually can be done for cheek, chin and other facial implants.  Dr. Niamtu has an in office CT scanner that can make 3D scans which can be used to make a custom model of the jaws.

The implants are then made to this custom jaw model and should be a perfect and precise custom for that patient.  Image A to the right shows a custom implant that is being planned and figure B shows the actual finished implants on the CT model.

Mandibular angle implants can be used “off the shelf” and come in several sizes or can be customized on computer generated models to perfectly fit the patient.


The patient below had 12 mm ImplanTech mandibular angle implants placed.

I am proud to have contributed to this special day



The patient below desired a wider lower face and more angled jawline and was treated by Dr. Niamtu.

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Facial Proportion

Facial proportion is one of the key components of beauty.  Look at the picture below.  This was  from a study done in Germany.  A picture of a female was altered 25% in terms of proportions in each box.  That means that the size, shape and spacing of the features changed.  The images were then shown to 1,000 college students and they were asked to pick the most attractive picture.  100% of the people chose number 5 or 6.  This shows the power of proper proportion to the overall perception of beauty.

The patient below underwent cheek and chin implant surgery by Dr. Niamtu and no other treatment.  This case is an excellent example of how small changes in facial proportion can make big differences in overall beauty.


Chin Asymmetry

chin asymmetry, jaw asymmetry, chin surgery, Richmond VASome patients have crooked chins that are not lined up with the normal facial structures. The chin may be off yo the side giving the face an asymmetric appearance. This can be corrected or improved by moving the chin tip to the left or right. The image shows a patient with jaw asymmetry with her chin off to the right. This has been corrected with chin surgery and was realigned by moving the chin back to the midline as shown in the photo on the right side of the image. Click on the image to enlarge.

Some patients present with asymmetries or situations where the jaw line is uneven.  This condition can be improved with implants as well.  Sometimes these patients will have depressions in front of their jowls that make them look older.  Dr. Niamtu can customize a standard off the shelf chin implant and by using only the sides of the implants, can fill in these depressions.  This image shows a patient with pre jowl depressions, the yellow figures indicate the size and position of the “implant tails” placed to fill in this void and the right side images shows the patients result after surgery.