|Year : 2011 | Volume
| Issue : 3 | Page : 414-421
Osseous genioplasty: A case series
Sanjeev N Deshpande, Amarnath V Munoli
Department of Plastic Surgery, Gokuldas Tejpal Hospital, Mumbai, India
|Date of Web Publication||15-Dec-2011|
Sanjeev N Deshpande
Department of Plastic Surgery, 401, Rukmini Sadan, Hanuman Cross Road, Near Shivaji School, Vile Parle (E), Mumbai - 400 057
Source of Support: None, Conflict of Interest: None
Introduction: The chin (mentum) is vital to the human facial morphology as it contributes to the facial aesthetics and harmony both on frontal and lateral views. Osseous genioplasty, the alteration of the chin through skeletal modification, can lead to significant enhancement of the overall facial profile. Aim and Study Design: A case series was designed to study the long-term results of osseous genioplasty in Indian patients with regard to patient satisfaction, complications, and long-term stability. Materials and Methods: All subjects who underwent osseous genioplasty either alone or as a component of orthognathic surgery between January 1992 and December 2010, with a minimum follow-up of 2 years, were included. The genioplasty was performed using standard protocols of assessment and execution. Post-operative evaluation included patient satisfaction, complications and radiological evidence of long-term stability. A comprehensive score was formulated for the purpose of the study. Results: Thirty-seven subjects underwent osseous genioplasty with at least 2 years of follow-up in the study period. This included 17 male and 20 female subjects, with a mean age of 22.8 years (15-52 years) and a mean follow-up of 3 years 4 months (2 years to 4 years and 11 months). Nineteen subjects underwent isolated genioplasty while 18 underwent genioplasty as a part of orthognathic surgery. The procedures included advancement (22), pushback (9), side-to-side (4) and vertical reduction (2) genioplasty.Thirty-six subjects (97.3%) were extremely pleased with the results with only one subject expressing reservations, without, however, demanding any further procedure. There were no significant complications. The osteotomised segment was well maintained in its new position with good bony union and minimal resorption. Overall, 35 (94.6%) cases had excellent results and 2 (4.4%) cases had good results, according to the comprehensive score. Conclusions: Osseous genioplasty is a safe and effective means of creating a beautiful and balanced facial profile by producing alterations in the chin morphology with minimal complications and excellent and stable long-term results.
Keywords: Chin deformity; mentoplasty; osseous genioplasty
|How to cite this article:|
Deshpande SN, Munoli AV. Osseous genioplasty: A case series. Indian J Plast Surg 2011;44:414-21
| » Introduction|| |
The chin (Latin mentum) along with the nose and two malar eminences constitute the four "aesthetic outposts" of the human face, rising above the otherwise unremarkable facial profile, enhancing the facial outline and providing well-recognized landmarks of beauty-both for the artist painting or sculpting the human form and for the plastic surgeon attempting to enhance facial features. A well-aligned, symmetrical and perfectly projecting chin , adds as much (if not more) 'aesthetic value' and youthfulness to the face as a perfect nose or high cheek bones. In addition, it can influence, to a great extent, the apparent length of the face and the nose. ,, Osseous genioplasty ,, (or mentoplasty), i.e., surgical correction of chin abnormalities by skeletal modification, has the potential of causing refreshing changes in facial harmony with minimal effort. The following is a review of the results of osseous genioplasty performed either in isolation, or as a part of major orthognathic procedure, by a single surgeon, in Indian patients.
| » Materials and Methods|| |
From February 1992 to December 2010, 39 subjects underwent osseous genioplasty-either alone or as part of a major orthognathic procedure. Of these, 37 cases had a follow-up of at least 2 years and were included in the study, while the two cases with follow-up of less than 2 years were excluded. The sample included 17 male and 20 female subjects with age at the time of surgery ranging from 15 to 52 years (mean age, 22.8 years). The follow-up period ranged from 2 years to 4 years 11 months with a mean follow-up of 3 years 4 months.
Of the 37 subjects, osseous genioplasty alone was performed in 19, while the remaining 18 underwent genioplasty as a part of major orthognathic surgery. All the patients included in this study presented with complaints of chin deformities (retruded or protruding chin), either alone or in association with facial dysmorphism and occlusal abnormalities, and genioplasty was planned either as the primary surgical treatment or as a component of orthognathic surgery, respectively.
In all cases, an orthopantomogram and lateral cephalogram (in addition to 3D reconstructed plain CT scan of face in recent cases since its wide-spread availability) along with frontal and profile view photographs of the subject were obtained and evaluated pre-operatively. This included (but was not restricted to) studying the relation of standard reference points (Pogonion, Glabella, Subnasale) on lateral cephalogram and planning the proposed movement on cephalometric tracings. In cases needing orthognathic procedures, the pre-operative work-up included evaluation of occlusion, construction of dental models, orthodontic manipulation, and model surgery as necessary. A couple of representative cases [Figure 1] and [Figure 2] illustrate the pre-operative planning on cephalometric tracings and the execution of the same on cephalograms.
|Figure 1: Planning an advancement genioplasty-lateral cephalogram; (a) pre-operative cephalogram; (b) post-operative cephalogram; (c) pre-operative cephalometric tracing confirming retruded pogonion; (d) post-operative cephalometric tracing showing advanced bone segment restoring a better chin morphology; and (e) pre-operative planned osteotomy and advancement on tracing|
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|Figure 2: Planning a pushback genioplasty in conjunction with mandibular set-back in a case of prognathism. (a) Pre-operative lateral cephalogram; (b) post-operative cephalogram; (c) pre-operative cephalometric tracing showing Class 3 occlusion and mandibular prognathism; (d) post-operative tracing showing restoration of Class 1 occlusion and better chin profile with genioplasty; (e) pre-operative planned mandibular setback; and (f) pre-operative planned push-back genioplasty|
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In addition to enquiries regarding the exact wishes of the patient vis-a-vis his or her facial appearance, specifically the chin, pre-operative counseling involved explaining the merits and de-merits of the procedure including the possibility of temporary or permanent anaesthesia or paresthesia in the mental nerve distribution. All procedures were performed under general anaesthesia. In cases involving simultaneous orthognathic surgery, the maxillary and/or mandibular osteotomies and manipulations with rigid fixation were always completed and the chin re- assessed before performing the genioplasty.
Pre-operatively a single dose of antibiotic was administered intravenously which was continued for 3 days in cases of isolated genioplasty, and 5 days in cases with orthognathic procedures.
After packing the throat, the lower lip was everted to expose the gingivo-labial sulcus and after infiltration of diluted solution of adrenaline (1 in 200,000), an incision was made from one canine to the other, leaving a 0.5-1 cm cuff of mucosa beyond the gingivo-mucosal junction.
Leaving an adequate cuff of muscle toward the tooth roots, sub-periosteal dissection was performed to expose both mental foramina and the lower border of mandible, taking care not to strip the symphysis of all its soft tissue attachments. This soft tissue pedicle ,, is vital for long-term viability of the osteotomised segment.
The mid-line was marked by drilling a groove with a fissure burr. A curvi-linear horizontal osteotomy was performed, beginning at the lower border as posteriorly as possible, passing 6 mm below the mental foramen, skirting across the midline below the tooth roots to the lower border on the opposite side. The osteotomy was performed either with a fissure burr or with reciprocating and oscillating saws, ensuring that the cortex on both sides was cut.
Once the osteotomy was completed, the detached symphyseal segment was moved as per the requirement-advancement (sliding/jumping), pushback, sideways-and fixed in place using either stainless steel wires or a mini-plate bent to shape on table to match the osteotomy step. A pictorial representation of the influence of the direction and orientation of the osteotomy on chin movement is presented in [Figure 3].
|Figure 3: Influence of the orientation of proposed osteotomy on the vector of movement of chin segment: (a) horizontal osteotomy cut resulting in a vertical chin movement in addition to advancement or pushback; (b) oblique osteotomy cut maintaining vertical height during chin advancement; (c) excessively oblique osteotomy reducing vertical height in addition to advancement|
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After confirming rigid fixation, the lower border of the mandible was palpated for any obvious step-deformity which was smoothed with a burr. The gingivo-labial sulcus incision was closed in two layers with absorbable sutures followed by chin strapping as shown [Figure 4] to minimize post-operative swelling.
|Figure 4: Post-operative chin strapping to reduce edema and aid reattachment of labiomental soft tissues|
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Post-operatively patients were advised soft diet, antiseptic gargles, and continued strapping for 5 days following which they could return to their daily routine.
The post-operative results of the genioplasty were evaluated with reference to 3 criteria, i.e. patient satisfaction, maintenance of bony and soft tissue correction and complications, each of which was given a score between 1 and 3 as follows:
Patient satisfaction-score A
Patients were questioned regarding satisfaction with their post-operative facial appearance specifically with regard to the position, size and projection of the chin and the responses were scored as
1 = not satisfied, 2 = pleased and 3 = extremely pleased.
Maintenance of bony and soft tissue correction- score B
The immediate post-operative and the most recent follow-up lateral cephalograms were compared to determine the presence and magnitude of any movement or resorption of the osteotomised symphyseal segment, which were scored as
1 = relapse or resorption of > 5 mm.
2 = relapse or resorption of 2-5 mm.
3 = relapse or resorption of <2 mm.
which were scored as
3 = minor, i.e., none or transient (<6 weeks) hypoesthesia/anaesthesia in mental nerve distribution with complete recovery,
2 = moderate, i.e. prolonged (6 weeks-6 months) mental nerve sensory loss or with partial recovery only, wound dehiscence.
1 = major, i.e. long-term/permanent mental nerve sensory loss, infection, need for re-operation due to dissatisfaction.
A Comprehensive Score was formulated by adding scores from all three categories with the results categorized as: Excellent (scores 8 and 9), good (scores 6 and 7) and poor (score < 6).
| » Results|| |
Thirty-seven subjects underwent osseous genioplasty with a follow-up of at least 2 years, of which 17 (46%) were male and 20 (54%) were female, with ages ranging from 15 to 52 years (mean, 22.8 years). Nineteen patients (51%) underwent the procedure in isolation while in the remaining 18 (49%), it was part of a major orthognathic procedure. The mean follow-up was 3 years 4 months with the shortest and the longest being 2 years and 4 years 11 months, respectively.
The proportion of patients undergoing the various maneuvres at the chin were as follows-advancement 22 (~59%), push-back 9 (~24%), side-to-side 4 (~11%) and vertical reduction 2 (~6%).
Overall, 36 subjects (~97%) were satisfied with the procedure, with 34 (~92%) being extremely pleased and 2 (~5%) being pleased.
[Table 1] and [Table 2] suggest that all categories of patients including those in whom genioplasty was performed in isolation and those in whom it was part of a larger procedure, male and female, those with advancement [Figure 5] and [Figure 6], push-back [Figure 7] or side-to-side movement [Figure 8] and [Figure 9], were satisfied with the procedure. Only one patient, a case of severe retrognathia reported displeasure over the 'insufficient' advancement of his chin. However, he did not demand either a reversal or a redo of the procedure. In this case, the patient had been advised and had refused orthognathic bi-maxillary surgery to achieve a better balance between the severely retruded mandible and maxilla and had opted for a genioplasty instead.
|Figure 5: Bilateral sagittal split osteotomy with asymmetric genioplasty for left mandibular hypoplasia in a 26-year old male subject: pre-operative (a-c) and 2 years 6 months post-operative (d-f) frontal, profile and basal views|
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|Figure 6: Sliding advancement genioplasty for retruded chin in a 23-year-old male subject: Pre-operative (a, b) and 2 years 2 months post-operative (c, d) frontal and profile views|
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|Figure 7: Mandibular setback with genioplasty for prognathism in a 20- year- old female subject: pre-operative (a, b) and 2 years post-operative (c, d) profile photographs with immediate post-operative lateral cephalogram|
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|Figure 8: Mandibular setback with osseous genioplasty for laterognathism with Class 3 malocclusion in a 25-year-old male subject: Pre-operative (a, b) and 2 years 9 months post-operative (c, d) frontal and worm's eye views|
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|Figure 9: Mandibular setback with genioplasty for chin asymmetry in a 24-year-old female subject: pre-operative (a, b) and 3 years post-operative (c, d) frontal photographs and lateral cephalograms|
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|Table 1: Distribution of number of patients undergoing osseous genioplasty in isolation and as a part of orthognathic surgery and those with excellent and good results|
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|Table 2: Distribution of number of patients according to the type of procedure performed and those with excellent and good results|
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There was only one instance (2%) of prolonged (more than 6 months) hypoesthesia in the mental nerve distribution in a male subject who underwent asymmetric genioplasty as a part of bi-maxillary surgery for craniofacial microsomia; but, over 2 years the sensations were back to normal. There were no cases of implant exposure, asymmetry, requests for reversal of procedure or relapse/recurrence of the pre-operative deformity.
Comparison of immediate and late (>2 years) post-operative radiographs [Figure 10] confirmed stable maintenance of chin movement with the magnitude of relapse/resorption in all cases being <2 mm.
|Figure 10: Bilateral sagittal split osteotomy for mandibular asymmetry with advancement genioplasty: pre-operative (a), immediate post-operative (b) and late (4 years) post-operative (c) lateral cephalograms demonstrating well-maintained advancement and minimal resorption. Note the long screw used for fixation of ramus osteotomy in the region of mandibular molar tooth which was exposed and needed removal|
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The comprehensive score suggested that the result of osseous genioplasty was excellent (scores 8 and 9) in 35 cases (94.6%) and good (scores 6 and 7) in the remaining 2 (4.4%) cases.
| » Discussion|| |
The human chin or mentum has always been a sign of courage and optimism. A 'strong chinned' man has always been associated with a strong will and character. Even the artists of yore depicted men of honour-kings and war generals-with prominent chins in their paintings and sculptures. The practice of keeping a 'french' beard over the mentum to enhance a receding chin is all but well known.
The human chin is subject to numerous morphological variations , in the sagittal (retrogenia or prognathism), vertical (micro or macrogenia) and transverse (asymmetry) planes. These variations may be restricted to the chin or may be a part of a generalized craniofacial disorder, e.g. Craniofacial microsomia, Treacher-Collins syndrome. The caveats of facial aesthetics ,, describing the ideal position and dimensions of the chin are well known. The chin forms the inferior limit of the visible facial form, and its length contributes greatly to the overall impression of the length of the face, , i.e. long/short face. Also, the chin projection in profile can contribute immensely to the harmony and aesthetics of the face-the role of a retruded chin in emphasizing a prominent nasal dorsum is just one example of the same.
With the chin occupying a place of such significance in the human facial profile, it comes as a great surprise that it has been often neglected when alterations or improvements in profiles have been demanded by patients. It was not until the 1940s that surgeons began thinking about altering the contour of the chin in order to improve facial features. In 1942, Hofer,  for the first time, described the 'anterior horizontal osteotomy' of the mandible in order to reposition the distal chin segment in a more desirable position. His procedure, however, was performed on a cadaver through an extra-oral route and the article carried no pictures. Sir Harold Gillies  treated a patient with Treacher-Collins-Franchetti syndrome in 1947 with an open-approach genioplasty. It was in 1957 that Obwegeser  published a report describing the procedure of trans-oral osseous genioplasty, thus obviating the need for external scars.
Concomitant with the development of osseous genioplasty, the option of onlay genioplasty also became very popular. Historically, various materials have been used to augment the chin, including paraffin, ivory, and methylmethacrylate, to name a few. Modern surgeons initially used autogenous materials including bone grafts (iliac crest) and costochondral grafts as onlay grafts for augmentation of the mentum. However, over time, it was observed that most of these grafts underwent resorption since they were non-vascularised and inserted under the tight soft tissue envelope of the labiomental tissues.
This fuelled the race for use of alloplastic materials and over the decades, all kinds and varieties of alloplasts have been used to augment the mentum-silicone, PTFE,  polyamide mesh,  mersilene mesh,  and HDPE.  Alloplastic implants afforded several advantages-easy availability without donor site morbidity, easy to shape and mould as needed, easy to place, less time consuming.
However, alloplasts cannot escape the bane of artificial materials in the human body, i.e. infection, extrusion, exposure.  In addition, chin implants have been shown to cause symphyseal resorption , which may necessitate removal or revision of the implant over time. Specific to genioplasty, alloplastic chin augmentation can only correct mild-to-moderate cases of chin retrusion. In cases of severe retrognathia, the risk of symphyseal resorption is prohibitively high, while in cases of chin asymmetry, vertical height discrepancy and macrogenia, alloplasts have no role to play. 
Osseous genioplasty, on the other hand, is an extremely versatile procedure which can correct the entire range of chin deformities in all three planes  -including sagittal (retrogenia, prognathism), vertical (microgenia, macrogenia) and transverse (asymmetry). Adjusting the plane and extent of the mandibular osteotomy, ,,, along with appropriate addition (bone grafting) or removal (reduction genioplasty) of bone permits the surgeon to achieve a wide range of alterations in the symphyseal anatomy in order to get the desired result. The varied terminology of the possible movements of the osteotomised symphyseal segment [sliding, jumping, step-laddered/two-tiered, interpositional, oblique, centering, wedge genioplasty] only emphasizes the multitude of options it places at the disposal of the surgeon in order to attain a stable and aesthetic mentum.
In addition to its versatility, osseous genioplasty offers the obvious advantage of using autogenous material; i.e. the symphyseal bony segment with its retained soft tissue attachments; to alter the chin, thus obviating the necessity and adverse effects of alloplasts. Not only is the autogenous bone devoid of the problems of extrusion, but also, since it is vascularised through its muscular attachments on the inferior and lingual aspects, its survival and long-term results are far superior , to free bone grafts. With modern systems of osteosynthesis (malleable titanium miniplates and screws), retaining the symphyseal segment in its corrected position is extremely easy and quick. Use of electrical drill systems with their ergonomically shaped saws (sagittal, reciprocating and oscillating) has reduced the time taken for osteotomy tremendously. As a result, osseous genioplasty today, in experienced hands, takes almost the same time as an alloplastic chin augmentation and can be easily performed as a day-care procedure.
There are several reports ,,,, of the stable and excellent aesthetic results of osseous genioplasty in a variety of settings. Various authors have reviewed long-term data and found osseous genioplasty to be a safe, simple yet powerful and effective means of altering the chin profile.
In this study, a comparison of the comprehensive scores revealed that
- Osseous genioplasty created a pleasing, desirable aesthetic chin (as evidenced by the SCORE A > 2) in 36 (97%) cases.
- The procedure provided satisfactory results irrespective of the pre-operative morphology or deformity of the chin and the direction or magnitude of movement needed for correction [Table 1].
- The bony and soft tissue movements produced by osseous genioplasty remained stable over long periods as shown by SCORE B > 2 in all cases.
- Osseous genioplasty was associated with only minor complications with significant complications in only 1(2%) case.
- Overall, osseous genioplasty provided excellent (scores 8 and 9) results in 35 (94.6%) cases and good (scores 6 and 7) results in 2 (4.4%) cases.
| » Conclusions|| |
In our study, we found that osseous genioplasty is an extremely versatile instrument of change of human chin morphology - it offers the surgeon the ability to mould the native chin into the desired and near ideal form with commensurate ease, irrespective of the pre-operative deformity, with excellent and sustained long-term results.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2]