Aesth. Plast. Surg. 31:384391, 2007 DOI: 10.

1007/s00266-006-0177-6

Original Article

Sliding Osteotomy Genioplasty for Facial Aesthetic Balance: 10 Years of Experience

Johannes Franz Hoenig, M.D., D.M.D., Ph.D.1

University Hospital and Medical School of Goettingen, Plastic Surgery Center, Paracelsus Clinic, Hannover, Germany

Abstract. The chin, one of the most obvious facial structures, plays an important role in the perception of the face as an instrument of communication. To alter the chin contour in a reliable manner, horizontal sliding osteotomy of the mandibular symphysis with advancement of the mobilized segment is the technique of choice for correction of the anterior posterior deciency. This study describes surgical techniques used in aesthetic and functional surgery of the chin as well as the outcomes. Over a 10-year period, 474 patients underwent orthognathic surgery for correction of their malocclusion. Of these 474 patients, 155 were treated in combination with a sliding genioplasty (SGP) and 37 (29 women and 8 men; average age, 32 years; range, 1847 years) had an isolated SGP. Of these patients, 33 had chin advancement and 4 had chin reduction. The mean chin advancement was a modest 4.5 mm (range, 27 mm), and the mean chin vertical displacement was 3.9 mm (range, 2.54.1 mm). All the patients in the mandibular deciency group had a residual sagittal disproportion of the progonion relative to the subnasale (mean, 7.6 mm) and a newly created vertical disproportion, with mean lower face heights of 67.8 mm compared with mean midface heights of 65.3 mm. The surgical outcome was evaluated by analysis of pre- and postoperative photographs, analysis of pre- and postoperative measurements, and patients self judgment. All the patients healed uneventfully without any major postoperative problems. Paraesthesia of the mental nerves occurs to some degree in almost all patients measured by the Simmon Weinstein diagnostic device. In the single sliding chin osteotomy group, no major branches of the mental nerves were transacted. Paraesthesia was only

transient, usually lasting for only a few weeks. At least 1 year after the operation, normal sensitivity of the lower lip and both sides of the chin was reported by almost all of the patients (93.1%). All who had only a single genioplasty recovered totally from a neurosensory decit. The level of satisfaction was signicantly high for all the patients. The results were judged to be excellent in 73.2% and good in 23.6% of the cases. Only in 3.2% of the cases was it considered to be poor (bimaxillary surgery combined with SGP). The current ndings strongly suggest that SGP is a reliable procedure for achieving harmony of the lower face. In addition, it permits a simplication of facial reconstruction and rejuvenation. The combination of chin advancement and submental recontouring can have a positive eect on facial appearance, provided the increased chin projection is appropriate. Key words: Facial balanceFacial harmonyFacial rejuvenationGenioplasty

Correspondence to J.F. Hoenig, M.D., D.M.D., Ph.D.; Georg-August-University Hospital and Medical School of Goettingen, Robert-Koch-Street 40, 37075 Goettingen, Germany; email: info@professor-hoenig.de

The chin, one of the most obvious facial structures, is the basis for judging human character. A weak chin is associated with femininity, a strong chin with masculinity. Because undesired characteristics are associated with a weak chin, society seems to prefer facial forms with a least some chin prominence, more in men than in women [7,13,18]. Only within the last quarter century have surgical techniques been perfected to alter the chin contour in a reliable manner [1,2,6,8,9,10,12,13,16,21,24]. A variety of surgical techniques for augmenting a contour-decient chin have been described [5,8, 10,15,16,17,21,23,24] since Hofer [11] introduced the horizontal sliding osteotomy of the inferior anterior border of the mandible in 1942.

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Currently, the horizontal sliding osteotomy of the mandibular symphysis with advancement of the mobilized segment is the technique of choice for correction of anterior posterior deciency, known as microgenia (decrease of chin eminence with an essentially normal mandible). This technique achieves harmony of the lower face because the results are predictable and stable [10,13,16,19,21,24]. This article describes the surgical techniques used in aesthetic and functional surgery of the chin and discusses patient evaluation.

prole reference line. A multitude of complex interrelationships among other facial structures must be considered when the position for any part of the face is altered. Consequently, the nal decision as to the position for the chin must be made by evaluating the patient in a clinical setting. Surgical Technique The surgical treatment of the skeletal malformation was carried out under aseptic conditions in a sterile eld and with perioperative antibiotic cover. Systolic blood pressure was maintained below 100 mm of mercury, thus minimizing bleeding. After temporary intermaxillary xation, a vestibular stair step incision of the mucosa was performed 5 to 8 mm labial to the depth of the vestibulum at a right angle to the surface only. Then it was directed horizontally to the alveolar process from one cuspid to the other. The periosteum was incised from beneath the mental foramen as far back as necessary from cuspid to cuspid. The supercial branches of the mental nerve were exposed. The chin prominence was minimally degloved subperiosteally to maximize attachments of the integument to the anterior and inferior border of the mandible while providing accessibility for the planned bone incision without detaching the soft tissue pedicle from the mid symphysis. The planned osteotomy was marked, and the midline vertical reference line was etched into the midsagittal plane of the chin across the osteotomy line. The chin repositioning clamp was applied to the chin and xed with two 6-mm-long screws parasagittally beneath the planned osteotomy line (Fig. 1a and b). The mental nerve and continuous soft tissue aps were retracted and protected while osteotomy of the chin was extended laterally and posteriorly with a reciprocating saw blade (Fig. 2a and b). Once the horizontal osteotomy was started, the bone was sectioned completely as soon as possible with a reciprocating saw. After meticulous control of the bleeders, the osteotomized segment was xed with two miniplates (2 whole plates) applied in the paramedian with monocortical mini screws in the new position (Fig. 3a and b). The chin reposition tool was removed. The new prole was checked, and wound closure was performed with 2 0 nonabsorbable interrupted sutures (Fig. 4). The temporary intermaxillary xation was released, and a pressure dressing was applied for approximately 3 days. Clinical Experience Over a 10-year period, 474 patients with an average age of 21.5 3.7 years underwent orthognathic surgery to correct their malocclusion. Of these pa-

Methods Assessment A face is balanced when the upper middle and lower thirds are approximately equal in size and the structures within each segment are proportional in size and prominence [1,3,10], especially when the length of the nose and the height of the lower face are in balance [3,9]. Therefore, the chin should also be in harmony with the jaw as well as with the structures in the middle third of the face. Anatomically, the chin is the area below the labiomental fold. The vertical portion of the deep point of the labiomental fold has considerable eect on the appearance of the chin. For good balance, it should be located near the midpoint between the superior border of the lip and the inferior border of the chin. This point corresponds to the juncture between the lower and the middle thirds of the lower third of the face. The shape of the labiomental fold is inuenced by all the factors that control lower lip contour, especially bony chin proportion and length, mental muscle thickness, and soft tissue chin thickness [3,4]. A consistent relationship of 1:75 between bone and soft tissue change has been conrmed [14,19,20]. This is supported by our results indicating that minimal soft tissue detachment allows closer correlation of bone and soft tissue movement. The general contour, depth, and height of the submental fold determines the aesthetic appeal. Many landmarks are recommended for determining a normal prominence of the chin. In a cephalic radiography, according to Gonzalez-Ulloa and Stevens, a vertical reference line perpendicular to Frankfurts plane beginning at the nasion provides a convenient reproducible mechanism for determining the relationship of the chin to the remainder of the facial prole. With a normal chin prominence, this line should lie tangential to the progonion. A more common measurement for assessing adequate chin projection is its relationship to the lower lip. A mans chin should approach, but not exceed, a line from the lower vermillion border in repose. A woman chin, however, is ideally situated 2 to 3 mm behind this line [10]. However, analysis of facial aesthetics is more complex than simply using a single

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Fig. 1. (a) Schematic drawing of the sliding genioplasty (SGP). The osteotomy is performed with a reciprocating saw 3 to 4 mm beneath the mental foramen. Note the temporary intermaxillary xation to ensure a stable position for a precise osteotomy. The chin repositioning clamp is xed to the chin segment with two 6-mm screws beneath the osteotomy line. (b) Intraoperative view of the SGP. The mental nerves are protected while the osteotomy is performed.

Fig. 2. (a) Schematic drawing of the sliding genioplasty (SGP). The inferior bone segment has been displaced downward. The genioglossus and mylohyoid muscles come into view. (b) Intraoperative view of the SGP. The inferior segment, which is xed to the chin repositioning clamp, is displaced downward. Note the protruding genioglossus muscles along with some fat in the middle of the osteotomy gap.

Fig. 3. (a) Schematic drawing of the sliding genioplasty (SGP). The inferior segment has been advanced. It is xed in the new planned position with two paramedially applied osteosynthesis plates. The chin repositioning clamp is still in place. (b) Intraoperative situs of the SGP. The chin has been advanced 5 mm anteriorly and 2 mm downward. The resulting gap will reossify during the next 3 months.

tients, 134 underwent bimaxillary surgery, and 41 also underwent a sliding genioplasty (SGP). A total of 128 patients underwent isolated mandible advancement to improve malocclusion and mandible retrusion. Of these patients, 61 were treated in combination with SGP advancement. A total of 57 patients underwent correction of their mandibular protrusion by a setback of the mandible. In this group, the mandibular setback was combined with SGP and chin advancement in 16 cases. Single SGP with chin advancement to harmonize the prole

(microgenia) was performed for 37 patients (29 women and 8 men) with an average age of 32.3 years (range, 1847 years). In this group, 33 patients had chin advancement and 4 had chin reduction (Table 1). All the patients underwent a thorough, individualized preoperative evaluation for a correct diagnosis and evaluation of the malocclusion. The surgical outcome was evaluated by analysis of pre- and postoperative photographs, analysis of preand postoperative measurements, and patients selfjudgment.

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Table 1. Surgical correction of the facial prole with or without a sliding genioplasty (SGP) Surgery Without SGP With SGP 41

Fig. 4. Schematic drawing of the sliding genioplasty (SGP). The chin repositioning clamp has been removed. The mucoperiosteumis sutured while the intermaxillary xation is still maintained.

Single bimaxillary surgery 134 Bimaxillary surgery plus SGP advancement Single mandibular 128 advancement Single mandibular advancement plus SGP advancement Single mandibular setback 57 Single mandibular setback plus SGP advancement Single SGP with chin advancement Single SGP with chin setback Total number of patients: 474 319

61 16 33 4 155

Results The median follow-up time was 5.4 years. Immediate healing was achieved without complications or adverse reactions. The mean chin advancement was a modest 4.5 mm (range, 27 mm), and the mean chin vertical displacement was 3.9 mm (range, 2.54.1 mm). All the patients in the mandibular deciency group had residual sagittal disproportion of the progonion relative to the subnasale (mean, 7.6 mm). The newly created vertical disproportion involved mean lower face heights of 67.8 mm compared with mean midface heights of 65.3 mm. All the patients healed uneventfully without any major postoperative problems. Infection after horizontal sliding osteotomy was uncommon. As may occur with any degloving exposure of the mandible, supercial dehiscence of the mucosal incision with exposure of the underlying bone occurred in 15 of the 474 patients. Four of these patients had undergone SGP with more than a 5-mm advancement of the chin. Two of them also had Beta-Tri calcium phosphate (-TCP) augmentation above the sliding osteotomy for correction of the stair step. The surgical wound was irrigated daily through the mucosal wound margins, and antibiotics were prescribed for 5 days. Paraesthesia of the mental nerves occurs to some degree in almost all patients measured with the Simmon Weinstein diagnostic device. In the group that underwent single sliding chin osteotomy, no major branches of the mental nerves were transacted, and paraesthesia was only transient (usually a matter of few weeks) (Table 1). Of all 155 patients who underwent SGP, 131 (84.52%) showed disturbances of the mental nerve 1 month postoperatively (Table 2). At least by 1 year after the operation, normal sensitivity of the lower lip and both sides of the chin was reported by almost all except 15.48% of

Table 2. Nerve disturbances of 155 patients 1 and 12 months after sliding genioplasty (SGP) in combination with jaw surgery Patients with nerve Patients with disturbances after nerve disturbances Follow-up period after SGP (%) (months) SGP (n) 131 24 84.52 15.48 1 12

Table 3. Nerve disturbances of 37 patients 1 and 12 months after isolated sliding genioplasty (SGP) Patients with nerve Patients with nerve disturbances after disturbances after Follow-up period isolated SGP (n) isolated SGP (%) (months) 14 0 37.83 0 1 12

these patients. In particular, all the patients who underwent only an isolated SGP recovered totally from any neurosensory decit (Table 3). The level of satisfaction was signicantly high for all the patients. The result was judged to be excellent by 73.2% of the patients and good by 23.6% of the patients. Only 3.2% of the patients judged it to be poor. Nearly 90% of the patients who underwent isolated SGP estimated the results to excellent. In light of the experience gained to date, the long-lasting results seem to be excellent. Figures 5 to 12 illustrate the indications and results. Discussion Genioplasty has gained popularity as a means of enhancing chin projection [10,12,21,24]. It is a useful

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Fig. 5. (a) Lateral view of a 19-year-old girl with mandibular retrusion and hypoplasia of the chin. (b) View of the same patient 4 weeks postoperatively after mandibular and chin (sliding genioplasty [SGP]) advancement.

and frequently applied technique in the armamentarium of the aesthetic facial surgeon [22]. It can alter the position of the chin in a three-dimensional manner. The goal of surgery is to create a stable, pleasing chin contour that provides an anatomically correct skeletal shape. Many variations of the horizontal sliding osteotomy may be adopted to meet the individuals aesthetics needs. But the fact that the inferior alveolar canal curves superiorly as it approaches the mental foramen makes it mandatory that the horizontal osteotomy be positioned 2 to 3 mm below the inferior edge of the mental foramen to prevent injury to the neurovascular bundle. Therefore, a moderate decrease in the vertical dimension of the chin can be achieved by oblique sliding osteotomy. By angling the bone cut superiorly, the inferior segment can be transposed forward and upward to reduce the chin height approximately 5 mm. When larger height reductions are indicated, a horizontal wedge of bone is removed above the horizontal sliding osteotomy. The anterior height of the osteotomy is dictated by the direction that the segment must move to produce the desired chin contour and prominence. If only horizontal augmentation is desired, the osteotomy should be performed parallel to the natural horizontal plane. Horizontal and vertical augmentation may be accomplished by directing the anterior part of the osteotomy below the natural horizontal. Shortening is produced by directing the anterior base cut incision above the natural horizontal. When it is not feasible to direct the osteotomy at the necessary angle and still maintain the desired thickness of the segment, a wedge osteotomy may be used to shorten the chin and alter the direction of forward movement. An interposition bone graft

Fig. 6. A 20-year-old patient with a severe skeletal deformity of the jaw (long face syndrome) showing protrusion of the mandible, retrusion of the maxilla, and hypoplasia of the chin. (a) The lateral view. (b) The frontal view. Postoperative (c) lateral and (d) frontal views of the same patient 8 weeks after surgery. To correct the patients open bite and jaw malformations and to improve his prole, aesthetic and functional corrections of the jaws were performed. This included bimaxillary surgery combined with a sliding genioplasty (SGP). The maxilla was advanced, and the height was reduced. A setback of the mandible was performed, and the chin was advanced and reduced in height. Note the harmonizing of the facial prole.

likewise permits lengthening the chin while segment thickness is maintained. Bone substitutes such as -TCP above the sliding osteotomy segment may be indicated to prevent formation of a deep angular labiomental fold [10]. The more extensive the advancement performed, the greater is the tendency to produce a deep angular labiomental fold because of the larger step created above the advanced segment. By sculpting -TCP from cuspid to cuspid to achieve this step, the resulting soft tissue fold may be corrected to the desired form (Fig. 11b and e). In cases of chin setback, small posterior movements have a minimal eect on the contour of the mandibles inferior border, and gradual remodeling of the repositioned segment restores the contour of the mandibles inferior border to normal. Only when the amount of correction exceeds 3 to 4 mm are the

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Fig. 9. Lateral view of a 53-year-old woman with hypoplasia of the chin and a fatty neck (a) before and (b) 4 weeks after surgery. Liposuction in combination with chin advancement (sliding genioplasty [SGP]) resulted in a youthful neck contour and facial prole harmony.

Fig. 7. A 22-year-old patient with hemifacial microsomia of the face. The maxilla and the mandible are tilted to the left (a) with a hanging occlusion line (b). (c,d) Postoperative views after bimaxillary surgery that involved removal of a triangle bone segment on the right side of the maxilla in combination with a Le Fort I osteotomy, a sagittal split osteotomy of the mandible, and an oblique SGP. Note the the chin midpoint brought back to the midsagittal plane, the corrected hemifacial microsomia, and the harmony achieved in the facial proportion.

Fig. 10. Lateral view of a 38-year-old woman with hypoplasia of the chin (a) before and (b) after SGP. To achieve a harmonized prole, a sliding genioplasty (SGP) was performed, bringing the chin 6 mm forward and shortening the height by 3 mm.

Fig. 8. (a) Lateral view of a 20-year-old patient with severe mandibular retrusion and sublabial fold. (b) Lateral view of the same patient 3 months after a 13-mm mandibular advancement in combination with a sliding genioplasty (SGP).

posterior portions of the mobilized segments usually shortened to maintain the desired contour of the skin at the inferior border of the mandible. In cases of chin advancement, studies have shown that the edges of the advanced segment are remodeled and rounded o after 6 to 12 months. The anterior projection of the segment remains stable [15]. Excessive subperiosteal dissection of the inferior mental symphysis area to facilitate the bony surgery produces unpredictable changes in the soft tissue drape, and chin ptosis may occur as a consequence. Avoiding this complication, a more predictable change in the soft tissue is achieved by keeping the soft tissue attached to the inferior anterior border of the repositioned segment [10,13]. Preserving the soft

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Fig. 11. (a) Lateral view of a 19-yearold patient with an obtuse neck and a severe chin retrusion. (b) Intraoperative view showing that sliding genioplasty (SGP) with chin advancement of 8 mm resulted in a stair step deformity, which was corrected by augmenting of bone substitutes. The bone substitutes were xed paramedially with small osteosynthesis screws. Allowing better access to the operation eld, the chin repositioning clamp is still in place holding the lip away. (c) Lateral view of the patient 4 weeks after chin advancement (SGP). Note the harmony of the prole and the improvement in neck contour. Lateral plane radiograms (d) before and (e) after surgery. Note the advancement of the lower chin segment as well as the xation and the correction of the stair step deformity by augmenting bone substitutes placed on the inferior chin segment.

tissue attachments to the anterior aspect of the mobilized segment maximizes the soft tissue change in the vertical facial dimension and provides predictable treatment planning [1,13]. If the chin is narrow transversely, advancement will tend to make the face appear even more tapered.

Conclusion The lower jaw, especially the mentum, plays an important role in the perception of the face as an instrument of communication [7]. Horizontal sliding genioplasty is a reasonable option, but should be considered only when the surgeon is well trained in the technique and the deformity merits its use. Sliding genioplasty results in aesthetic and functional changes to the chin and perioral areas [19,21]. The procedure combines osseous and soft tissue reconstruction to produce a superior result, which is especially important for individuals with bilabial incompetence [19]. The combination of chin advancement and submental recontouring can have a positive eect on facial appearance, provided the increased chin projection is appropriate. Genioplasty is considered to be an easy and reliable procedure for achieving harmony of the lower face [24]. Together with other authors, we recommend the sliding genioplasty as a practical alternative to alloplastic chin augmentation [1,10,21,24].

Fig. 12. (a) Lateral view of a 48-year-old patient with a severe protrusion of the chin and hump deformity of the nose before and after surgery. The nasal hump was removed; the tip of the nose was reduced and elevated; and the inferior chin segment was osteotomized and set back several millimeters. (b) Lateral postoperative view 12 weeks after surgery. (c) The intraoperative situs. The inferior chin segment is xed in the new posterior position with two paramedially applied osteosynthesis plates. For better access, the chin reposition clamp is still in place.

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