Operative Technique in Plastic Surgery – Kevin C.Chung

DIFFERENTIAL DIAGNOSIS
■ Stenosis/collapse of the external nasal valve
■ Stenosis/collapse of the internal nasal valve
■ Septal deviation
■ Septal spur formation
■ Inferior turbinate hypertrophy
■ Nasal mass or polyp
PATHOGENESIS
■ Intranasal deformity may result from congenital development, traumatic
injury, or iatrogenic insult. Changes in nasal support and physiology may occur
with aging resulting in NAO.
■ Traumatic injury to the nasal septum may be classified by fracture patterns.3
■ High-impact trauma is associated with multiple septal fractures and
displacement from the maxillary nasal spine.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Relevant history in the obstructed patient includes laterality, timing and
duration, worsening or alleviating factors, perennial or seasonal response, prior
nasal surgery or trauma, and associated symptoms.
FIG 1 • A. Diagram of the external nasal valve. Nasal
ala constitutes the lateral valve, whereas the columella
creates the medial aspect. Note the ideal basal

aesthetic line. B. Diagram of the internal nasal valve.
Amalgamation of the caudal edge of the upper lateral
cartilage to the dorsal septum creates the valve. Note
the ideal dorsal aesthetic line.
■ Progressively worsening symptoms and associated epistaxis should raise
concern for neoplasm.
■ Inspection of the nasal airway begins with study of the nasal base at rest and
during respiration.
■ The external valve is assessed initially.
■ Inspection should reveal a patent nostril, free of obstruction.
■ At rest, the lateral nostril (nasal ala) should demonstrate a stable, convex
architecture.
■ The medial nostril (lateral columella) should exhibit ideal BALs.
■ External valve stenosis may be the result of obstruction from either of these
directions.
■ Assessment during respiration is also performed to determine if collapse of
the external valve is responsible for symptoms.
■ Inspection of the internal nasal valve is accomplished with a nasal speculum.
Care must be used to avoid widening of the valve on speculum insertion.
■ The upper lateral cartilage caudal margin can be readily appreciated through
the nasal mucosa.
■ The angle created by the junction of this caudal margin and the dorsal septum
is assessed.
• A narrow angle at baseline suggests stenosis of the valve.
■ Collapse of the internal valve on respiration may also be identified as a cause
for NAO. The Cottle test can confirm internal valve insufficiency.
■ Evaluation of the septum also begins at the nasal base.
■ Deviation of the caudal septum to either side can obstruct the external valve.
■ Palpation and manipulation of the columella will clearly identify caudal
septum position.
■ Examining the dorsal septum and septal body is performed with nasal
speculum.
■ Deviation of the dorsal septum is determined as this may cause stenosis of
the internal nasal valve.
■ The body of the nasal septum is surveyed for deviation and spur formation,

either of which may cause NAO.
■ The inferior turbinate is next examined also with use of a speculum.
■ Turbinate size, position, and tissue characteristics should be noted.
■ A large, boggy inferior turbinate with a bluish hue is associated with allergic
response. These patients will likely have some degree of refractory symptom
despite surgical reduction.
■ The location of turbinate hypertrophy guides surgical reduction and should
be noted.
■ Topical oxymetazoline is applied to determine the response to medical
decongestant.
■ If topical treatment results in symptom resolution, a medical management
trial is warranted. This often includes topical steroids and routine nasal toilet.
■ Intranasal examination should also rule out less common etiologies of nasal
obstruction such as nasal polyps and neoplasms.
IMAGING
■ Although plain radiographs and computed topography can be used to evaluate
nasal septum and turbinate position, they are not routinely required. NAO is a
clinical diagnosis that results primarily from a focused history and physical
examination.
■ If concerns arise of other NAO causes, such as neoplasms or polyps, proper
consultation and imaging are warranted.
NONOPERATIVE MANAGEMENT
■ Patients who display any suggestion of an allergic component to their NAO
should undergo a medical trial.
■ Patients with allergic rhinitis are typically treated with reduced exposure to
allergens, nasal irrigation with saline sprays, nasal steroids, and occasionally
oral antihistamines.
■ Severe cases may benefit from immunotherapy.
■ Otolaryngology consult should be considered.

FIG 2 • A. Palpation and inspection of the nose can
provide information on tip support. B. Help determine
caudal septal position.
■ Reassessment of these patients after 6 weeks of medical treatment should then
be performed.
■ If symptoms persist in the presence of obvious physical obstruction(s),
surgical correction of the airway should be considered.
SURGICAL MANAGEMENT
■ Surgeons should approach the nasal airway in a methodical manner.
■ Preoperative assessment identifies the areas of concern as listed above.
■ A detailed operative plan should be outlined to correct each of these
problematic sites.
■ Surgeons should be cognizant of the potential to create iatrogenic obstruction
and avoid such sequelae.
Preoperative Planning
■ Following proper diagnosis, patients are to be educated on anticipated
outcomes.
■ Structural deformities of the nasal valves, septum, and turbinates are easily
corrected with septorhinoplasty.
■ However, patients with any physiologic component to their NAO should be
counseled about potentially persistent symptoms.
■ Examination of the nose under anesthesia is performed prior to local injection
and prepping of the patient.
■ Both visual and tactile examination of the tip and columella is completed
(FIG 2A).

■ Palpation of the tip helps to determine support and cartilage integrity.
■ Gentle manipulation of the columella from side to side can help determine
caudal septal position and soft tissue volume (FIG 2B).
Positioning
■ Once in the operating room, the patient is intubated and positioned on the
table.
■ The most cephalic portion of the head extends just beyond the table.
■ The stretcher may be placed head up to 15 degrees to minimize venous
pooling in the operative field (FIG 3).
■ A throat pack is gently placed and removed at surgery conclusion.
■ Local anesthetic with epinephrine is injected into the planned incision sites.
Approach
■ Treatment of the nasal airway can be accomplished through an open or closed
rhinoplasty.
■ A closed approach is often used to improve alar support with grafts,4 correct
deviation of the septal body, and treat inferior turbinate hypertrophy.
■ The open approach rhinoplasty provides better visualization to the dorsal
septum and internal nasal valve.
■ The following techniques will be described as if all areas of the nasal airway
are being corrected during an open approach septorhinoplasty.
FIG 3 • Positioning of the patient for septorhinoplasty.

T E C H N I Q U E S
■ Septoplasty
■ A transcolumellar incision is connected to bilateral infracartilaginous
incisions to open the nasal envelope, exposing the nasal bones and cartilages.
■ Dissection is continued to the anterior septal angle.
■ Bilateral mucosal flaps are elevated away from septal cartilage and bone.
■ It is of the utmost importance to dissect directly on the surface of the
septum as it is a bloodless plane.
■ Once there is broad exposure of the septum, the upper lateral cartilages are
separated from the dorsal septum.
■ Prior to resecting the septal body, it is necessary to perform any planned
reduction of dorsal or caudal septum.
■ This sequence ensures that at least 1 to 1.5 cm of L strut can be preserved
for nasal support.
■ With preservation of adequate L strut, the deviated septum or spur can be
resected (TECH FIG 1A).
■ A Cottle elevator is used not only to elevate the septal flaps but to
disarticulate the bony cartilaginous junction.
■ There is significant variation in bony cartilaginous junction patterns.3
■ Using scalpel, the marked septum is resected.
■ This cartilage can be used to create spreader grafts and alar contour grafts.
■ At the end of surgery, the mucosal flaps are placed together using a weaving
transmural septal suture (TECH FIG 1B).

TECH FIG 1 • A. Preservation of adequate septal
support is crucial. It is equally important to ensure
preserved caudal septum rest sufficiently on the
maxillary spine. B. Illustration of a weaving septal
suture to approximate the septal mucosal flaps. Most
commonly, a gut suture on a straight needle is used.
■ Internal Nasal Valve Repair
■ Spreader grafts are an effective method of repair for internal nasal valve
stenosis or collapse.
■ Once the upper lateral cartilages are separated from the dorsal septum
(TECH FIG 2A), grafts can be readily placed and secured.
■ Graft length requires that they extend from underneath the nasal bones to the
level of the internal valve. This can easily be measured when creating the
grafts.
■ Graft width is often 2 to 3 mm but may be balanced with aesthetic goals.
■ If widening of the middle nose is to be avoided, grafts may be placed lower,
thus allowing the upper lateral cartilages to advance over the grafts and join
the dorsal septum (TECH FIG 2B).

■ Once in position, the grafts are sutured with 6-0 polydioxanone suture.
TECH FIG 2 • A. Separation of the upper lateral
cartilages from the dorsal septum is required to place
an internal nasal valve spreader graft. The overall goal
is to widen the valve angle and increase support
during respiration. B. Spreader grafts should extend
from underneath the nasal bones to the internal nasal
valve. They may be positioned lower if widening of the
middle nose is of great concern.
■ External Nasal Valve Repair
■ Repair of the lateral external valve involves fortification of the nasal ala.
■ Several different cartilage grafts have been described, but the alar contour
graft 4 is suitable for most situations.
■ These grafts are typically created 2 mm wide and 8 to 10 mm in length.
■ The ala is then carefully retracted with a double-prong skin hook.
■ Fine scissors are used to create a pocket just cephalic to the alar rim margin
(TECH FIG 3A).
■ Repair of the medial external nasal valve involves classifying the existing
deformity.5
■ These deformities may be abnormal volume and/or position of the caudal
septum, medial crura, and columellar soft tissue.1
■ The caudal septum can be freed from adjacent soft tissue and inspected.
■ Straightening of a deviated caudal septum may be accomplished with

excision when appropriate.
■ If excision is not a viable option, scoring and repositioning to the midline
with suture fixation are performed.
■ Abnormal or premature medial crura footplate flare is corrected using the
medical crura footplate approximation (MCFA).6
■ The MCFA includes making stab incisions at the site of footplate flare.
■ Then, the footplates are weaved together with polydioxanone suture, after
which the incisions are closed (TECH FIG 3B).
■ Understanding tissue dynamics of the lower lateral cartilages is important
when influencing medial crura shape and position.7
TECH FIG 3 • A. Alar contour grafts are a reliable way
to improve structural support of the lateral external
nasal valve. B. Treating a base deformity of the
columella with the MCFA can help widen the nasal
valve and create ideal BALs.
■ Turbinoplasty
■ When treating hypertrophy of the inferior turbinate, the goals are tissue
reduction and preservation of function.

■ A scalpel is used to make an incision on the anterior surface of the inferior
turbinate.
■ The incision is carried posterior to the extent that allows introduction of
bone-removing forceps.
■ An elevator is used to dissect the overlying soft tissue away from turbinate
bone.
■ Bone and possibly erectile tissue in the location of obstruction are then
removed.
■ The wound is irrigated and the mucosa laid back into native position.
■ The flap can be sutured back into place when needed.
■ Submucosal resection (turbinoplasty) allows for bulk reduction to increase
nasal airflow while preserving crucial mucosal function.
■ An elevator is then used to lateralize both inferior turbinates (TECH FIG 4).
This move should be highly controlled.
TECH FIG 4 • Following resection of excess bone and
erectile tissue, the turbinate is outfractured in a
controlled manner.
PEARLS AND PITFALLS

Relevant
anatomy
■ Understand the four common sites responsible for nasal
obstruction: (1) external nasal valves, (2) internal nasal valves,
(3) nasal septum, and (4) inferior turbinates.
Proper
diagnosis
■ Perform a focused history and physical to determine if NAO is a
structural problem, physiologic problem, or combination.
Nasal valve
physiology
■ Repair of nasal valves (internal and internal) often involves
structural strengthening with cartilage grafts.
Comprehensive
septal
assessment
■ Evaluation of the septum requires attention to the (1) dorsal
septum, (2) caudal septum, and (3) septal body.
Principles of
turbinate
technique
■ Goals of turbinate hypertrophy treatment include reduction of
tissue bulk with preservation of mucosal function.
POSTOPERATIVE CARE
■ Functional reconstruction of the nasal airway typically requires placement of
intranasal splints in addition to external splint.
■ Splinting of the nasal airway provides additional support for the internal nasal
valves and nasal septum. Moreover, the splints stabilize the lateralized
turbinate and may circumvent adhesion formation between raw surfaces.
■ The splints are removed at 1 week, and saline nasal sprays are continued for
the next 4 weeks.
OUTCOMES
■ Nasal valve reconstruction with spreader and alar grafts has been shown to be
highly effective in treating nasal obstruction.
■ Septoplasty, while effective for treatment of deviation in most patients, has
been shown to be less satisfactory in those patients who also have allergic
rhinitis.
■ Turbinoplasty via submucosal resection has been shown to lower nasal
resistance and preserve mucosal function.
COMPLICATIONS
■ Nasal valve repair may be complicated by graft malposition and associated

deformity.
■ This may manifest as dorsal irregularity in the case of spreader grafts or
alar/soft triangle deformity with alar contour grafts.
■ Inferior malposition of spreader grafts may actually worsen nasal obstruction
if they occlude the nasal valve.
■ Septal surgery may be associated with perforation from injury to opposing
mucosal surfaces.
■ Adhesion formation may occur when two opposing raw surfaces are created.
■ Epistaxis and recurrent symptoms are also potential complications of nasal
airway surgery.
REFERENCES
1. Lee MR, Malafa M, Roostaeian J, et al. Soft tissue composition of the
columella and potential relevance in rhinoplasty. Plast Reconstr Surg.
2014;134:621-625.
2. Roostaeian J, Unger JG, Lee MR, et al. Reconstitution of the nasal dorsum
following component dorsal reduction in primary rhinoplasty. Plast Reconstr
Surg. 2014;133:509-518.
3. Lee MR, Inman J, Callahan S, Ducic Y. Fracture patterns of the nasal septum.
Otolaryngol Head Neck Surg. 2010;143:784.
4. Unger JG, Roostaeian J, Small KH, et al. Alar contour grafts in rhinoplasty: a
safe and reproducible way to refine alar contour aesthetics. Plast Reconstr
Surg. 2015;137:52-61.
5. Lee MR, Tabbal G, Kurkijan J, et al. Classifying columellar deformities in
rhinoplasty. Plast Reconstr Surg. 2014;133:464e.
6. Geissler P, Lee MR, Unger J, et al. Reshaping the medial nostril and
columellar base: five-step medial crural footplate approximation. Plast
Reconstr Surg. 2013;132:553-557.
7. Lee MR, Geissmer P, Cochran S, et al. Decreasing nasal tip projection in
rhinoplasty. Plast Reconstr Surg. 2014;134:41e-49e.

72
CHAPTER
Section XII: Facial Skeletal
Augmentation with
Implants
Chin Augmentation With
Implant
Daniel A. Cuzzone and Barry M. Zide
DEFINITION
■ Chin augmentation encompasses genioplasty with the use of mandibular
osteotomies as well as placement of implants in the form of grafts or alloplastic
materials. Herein we do not discuss osteotomies.
■ The chin is a defining feature of the lower one-third of the face that connotes a
sense of strength to the face.
■ Correction of microgenia is desired in about 20% to 25% of patients
undergoing rhinoplasty, with the goal of balanced facial symmetry.
■ Implant-based augmentation of the chin may be performed with a variety of
implant-based materials, each with its own set of benefits and perceived
deficiencies (TABLE 1).
■ Osteotomies to advance the lower border of the symphysis may accomplish
the same thing, but the risks and benefits of each are not described herein.
ANATOMY
■ The chin, as an anatomical subunit, is composed of the sublabial area and the
pad.
■ The mental nerve is the terminal branch of the inferior alveolar nerve. It is a
branch of the third division of the trigeminal nerve and is responsible for
sensation of the lower lip, portions of the chin pad, and menton (FIG 1A, blue

area) except for a small area that is supplied by a sensory branch off the nerve
to the mylohyoid (see FIG 1A, pink area; FIG 1B).
■ The location of the mental foramen can be variable (FIG 2).
■ Anatomical studies have demonstrated that the mental foramen is located
inferior to the second mandibular premolar in about 50% of adults, between the
first and second premolar in 25%, and posterior to the second premolar in 25%
of the remaining population.
■ It is located about halfway between the alveolar ridge and the inferior border
of the mandible (8 to 10 mm from the inferior border) and is between 2 and 3
cm lateral to the midline.
■ It may be lower in vertically short height mandibles.
■ The mentalis muscles are paired mimetic muscles that elevate and compress
the chin against the anterior mandible and indirectly raise the lower lip (FIG
3).
PATHOGENESIS
■ Congenital and acquired factors may contribute the most to a hypoplastic
mentum.
■ Aging
■ Dentures that cause trauma to the mentalis origin may lead to soft tissue ptosis
and poor projection.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A pertinent history and physical exam are instrumental in optimal operative
outcomes and should include an appreciation for the patient’s aesthetic goals,
history of prior facial surgery, or orthodontic/orthognathic treatment, and a
comprehensive facial examination.
■ Point by point assessment of the lower third of the face1–3
■ Lip eversion and position
■ Occlusion
■ Static chin pad thickness (normal 9 to 14 mm)
■ Labiomental fold depth and height
■ Dynamic chin pad motion while smiling (the pad may be effaced and in some
cases may descend)
■ Symphyseal narrowness
■ Assessment of lip position should be noted.
■ Normal interlabial gap is up to 3.5 mm.

■ Normal lower incisal show at rest is 2 to 3 mm.
■ Normal upper incisor show is up to 3.5 mm in males and up to 5.5 in
females.
■ Lower facial height should be noted. Sagittal implant projection will give the
face a longer appearance; conversely, if the chin is deficient sagittally but long,
an implant will not work well.
■ Symmetry of the chin should be noted as well as skin irregularities.4
Table 1 Implant Subtypes and Characteristics
Material
Trade
Name
Tissue
Interface Pros
Cons
Complicatio
Polydimethylsiloxane
Silastic
(silicone
rubber)
Fibrous
capsule
Easily
carved,
easily
placed
and
removed
Bone
resorption
(if too
high),
seroma,
exposure
Malposition,
extrusion,
infection (ma
be salvaged
High-density porous
polyethylene
MEDPOR
Su-Por
Limited
tissue
ingrowth
Versatile
Difficult to
remove;
requires
hardware
Malposition,
extrusion,
infection (no
salvageable
FIG 1 • A. Sensory distribution of the mental nerve seen
in blue and the contribution of the sensory branch of the
never to the mylohyoid in pink. B. Course of the

sensory branch off the nerve to the mylohyoid (denoted
by the dotted white circle).
■ Dimpling may be seen after previous surgery, injury, or facial lesion such as
Bell palsy.
■ Assess in repose and during animation both from the frontal and profile
view.
■ When the chin symphysis is narrow, bony advancement may be inadvisable vs
prosthetic augmentation.
■ Dental occlusion
■ Prominent teeth may evert the lower lip, producing a more acute labiomental
fold. A vertically high implant may worsen this. Also, a skeletally deep bite
may seem to shorten the face with the occlusion, allowing the upper teeth to
push the lower lip forward.
IMAGING
■ High-definition preoperative photography is important for photo
documentation and for perioperative planning.
■ Views that should be obtained include frontal and lateral, with and without
smile. The smile view shows how the chin pad moves dynamically.
■ Radiographic evaluation is often reserved for secondary surgical procedures,
with short mandibles where the mental foramina may be low, or to evaluate
prior hardware.

FIG 2 • Mental nerve as it exits from the mental foramen
in the body of the mandible at about the level of the
second premolar.
IMPLANT SELECTION
■ Ideally, only small and medium silicone implants should be utilized because
the larger ones tend to result in more erosion.
SURGICAL MANAGEMENT
Preoperative Planning
■ Single oral or intravenous dose of antibiotic is provided as per the surgeon’s
preference.
■ Implant-based chin augmentation can be performed under local anesthesia
with oral sedation or with intravenous sedation with proper supervision.
■ For intraoral placement, Peridex is prescribed starting 2 days prior to surgery,
and a presurgical Betadine rinse with a few drops of peppermint oil may be
helpful as a prep.
Positioning
■ Supine with neck extension, which can be achieved with the use of a shoulder
roll
Approach
■ Chin augmentation can be performed either through an external submental
incision or via an intraoral incision at the gingivolabial sulcus.
■ At least a 2.5- to 3.5-cm incision is needed for porous implants.
■ External submental incisions allow more control regarding implant placement,
and the incision can be used for cervical procedures.
■ Intraoral incisions eliminate a visible scar, but the problem of asymmetric
intraoral placement (especially with silicone) or improper placement level may
lead to more resorption.
■ Implant placement is technically more difficult.
■ A 2-layered closure is required (muscle and mucosa).
■ The incision can be designed vertically or horizontally.
■ Single or two-piece implants (usually porous) may be utilized. Two-piece

implants have flexibility in design and accommodates to the shape of the
patients. With intraoral placement of a porous implant, the incision must be
larger and intraoral rinse prep is required.
FIG 3 • A. The upper part of the mentalis muscle
contains horizontally directed fibers that stabilize the
lower lip (arrow). The oblique lower fibers allow the lip
to pout. B. The mentalis muscle is a paired muscle that
elevates and compresses the lip. C. It may have many
configurations, ranging from complete overlap to
divergence leading to a cleftlike appearance of the chin.
T E C H N I Q U E S
■ External (Submental) Approach to Chin
Augmentation
Markings
■ The facial midline is marked extending from the chin pad to the submental
area.
■ A submental incision roughly 3.5 (for porous polyethylene) or 1.5 cm (for
silicone) is marked near or in the submental crease (TECH FIG 1).
■ Bilateral inferior alveolar nerve blocks are performed using 1% lidocaine
with 1:100 000 of epinephrine, with or without bupivacaine.

■ The submental incision and preperiosteal space are injected with a 50:50
mixture of 1% lidocaine and 0.5% bupivacaine with 1:100 000 epinephrine.
Porous Polyethylene Implant Precontouring
■ While the local anesthetic takes effect, the implant is precontoured.
■ The upper portion is pared down (30%–50%) using a bur or knife (TECH
FIG 2A,B).
■ Note: Su-Por is softer and easier to carve.
■ The lateral wings are reduced and tapered as necessary (TECH FIG 2C).
■ The upper edge anteriorly is tapered at a 45-degree angle using a bur (TECH
FIG 2D).
■ The implant is divided in half, and a pilot hole is drilled in each side, 3 to 5
mm from midline (TECH FIG 2E).
■ A second hole may or may not be necessary between the first hole and the
end of the implant.
TECH FIG 1 • Marking the facial midline, from
labiomental fold to hyoid, and the intended incision.
(From Warren SM, Spector JA, Zide BM. Chin surgery
VII: the textured secured implant—a recipe for
success. Plast Reconstr Surg. 2007;120(5):1378-
1385, with permission.)
Incision and Exposure
■ A no. 10 or 15 blade is used to incise and deepen the submental incision to

the inferior border.
■ Needle electrocautery dissection is usually employed down through the
subcutaneous tissue to the periosteum. The soft tissue should be cleared from
the mandibular border from canine to canine with cautery (TECH FIG 3A).
■ A periosteal elevator is used to elevate the periosteum, and at the end of the
dissection, the elevator is lifted to open the pocket farther (TECH FIG 3B).
TECH FIG 2 • A,B. The upper 30% to 50% of the
textured implant is removed so that the implant will
provide projection only at the pogonion. C. The lateral
projection of the textured implant is trimmed and then
tapered. D. Returning to the upper portion of the
implant, a bur is used to taper the upper edge at a 45-
degree angle. E. The implant is divided in the midline,
and two drill holes are placed in each half of the
implant. The first drill hole is approximately 3 mm from
the midline, and the second drill hole is halfway
between the first hole and the end of the implant. (B–
E: From Warren SM, Spector JA, Zide BM. Chin
surgery VII: the textured secured implant—a recipe for
success. Plast Reconstr Surg.(2007);120(5):1378-
1385, with permission.)

TECH FIG 3 • A. Electrocautery is used to clear the
mandibular border from canine to canine, and then a
periosteal elevator is used to complete the distal
pocket. B. At the most distal extent of the dissection,
the elevator is levered up to complete the pocket. C. A
sterile no. 2 pencil is a good way to mark the midline.
(A,B: From Warren SM, Spector JA, Zide BM. Chin
surgery VII: the textured secured implant–a recipe for
success. Plast Reconstr Surg. 2007;120(5):1378-
1385, with permission.)
■ Subperiosteal dissection is continued laterally with care not to injure the
mental neurovascular bundle that may be viewed. Lateral dissection as
required from the midline is performed.
■ This dissection is repeated on the contralateral side.

■ The midline is marked on the menton using electrocautery, bur, drill, or a
sterile pencil (TECH FIG 3C).
Implant Placement
■ The left or right half of the implant is inserted into its respective pocket, and
the central portion is aligned with the midline of the menton.
■ According to implant thickness, titanium screws are used for fixation
medially.
■ The medial screw is placed through the predrilled pilot hole and partially
tightened to allow the lateral part to be positioned.
■ The lateral screw placement holds the implant along the inferior border.
■ Both screws are tightened and countersunk so that the screw head is below
the surface of the implant (TECH FIG 4A).
■ By only partially tightening the medial screw first, the implant position
laterally can be decided perfectly.
■ This procedure is repeated on the contralateral side (TECH FIG 4B).
■ A dependent drain and a Canfield jaw bra are used for porous implants.
■ Silicone implants can be placed as a single unit and secured to the
periosteum with a suture.
■ Some operators use screws or pins for fixation, but trauma may cause the
implant to split.
■ The incision is closed in three layers: muscle, subcutaneous tissues, and skin.
TECH FIG 4 • A. The central portion of the implant is
aligned with the midline menton mark, and a screw is
drilled and sunk through the medial pilot hole. This
screw is partially tightened. Then, the lateral segment

of the implant is exposed and held exactly along the
inferior border. The second screw (lateral) is placed
through the predrilled implant pilot hole. B. Both
screws are tightened completely and countersunk so
that the screw heads are below the implant surface to
allow for further reduction of the anterior surface of the
implant, if necessary (note that neither screw has yet
to be satisfactorily countersunk in this image). (From
Warren SM, Spector JA, Zide BM. Chin surgery VII:
the textured secured implant—a recipe for success.
Plast Reconstr Surg. 2007;120(5):1378-1385, with
permission.)
■ Intraoral Approach to Chin Augmentation
■ A midline marking is placed at the level of the pogonion.
■ Further markings include the inferior margin of the mandible and the points
where lateral undermining would be sufficient.
■ Inferior alveolar nerve blocks are performed using 1% lidocaine with 1:100
000 epinephrine.
■ Local anesthetic is instilled into the lip mucosa extending to the menton and
laterally.
■ A no. 15 blade or needle electrocautery is used to make a horizontal or 2 cm
vertical or horizontal midline incision on the lip beyond the gingivobuccal
sulcus.
■ It is paramount that at least 4 mm of a gingivomuscular cuff be left to
facilitate two-layer closure.
■ The incision is then carried down to the mandible ensuring that the mentalis
muscle can be reattached.
■ A subperiosteal pocket is developed using a periosteal elevator.
■ The pocket width is made slightly larger than the implant, but the midline
should match the size of the implant correctly.
■ The implant is marked in the midline to ensure central positioning.
■ The implant is then inserted into the pocket and placement is confirmed

along the inferior border.
■ The incision is closed in two layers to ensure independent closure of the
muscle and then mucosa.
■ An external jaw bra is placed.
PEARLS AND PITFALLS
Aesthetic
considerations
■ The key is to bring balance to the lower one-third of the
face
Assessment
■ Lip eversion
■ Occlusion
■ Static chin pad thickness
■ Labiomental fold depth and height
■ Dynamic chin pad motion while smiling
Dissection
■ Avoid damage to the mental nerves by understanding
their anatomic position.
External submental
approach
■ Minimize the length of the horizontal incision to what is
needed.
Intraoral approach
■ Vertical or horizontal incisions can be used.
■ Resuspend the mentalis muscle.
POSTOPERATIVE CARE
■ An elastic chin support is worn for 3 days.
■ Drain removal (for porous implants) at day 1 or day 2 (if used).
■ Soft diet, cool packs to the area, oral hygiene (eg, Peridex, for intraoral
approach), and head elevation for 7 days. For an intraoral incision, liquids are
continued for 36 hours postoperatively, followed by a transition to a regular
diet.
■ For intraoral placement, the patient continues the use of Peridex swish and spit
for 5 days.
■ Suture removal between 4 and 7 days postoperatively with the placement of
Steri-Strips.
■ Patients are seen within 1 week postoperatively and subsequently at 1, 3, 6

months, and 1 year.
■ Patients should be questioned on the presence of numbness; if present, it
should improve within 2 to 3 weeks of the operation.
OUTCOMES
■ Improvement in chin projection and labiomental fold definition is expected
following primary implant-based chin augmentation (FIG 4).
■ The goal should be to provide lower pogonial projection and a labiomental
fold that is not hyperacute.
COMPLICATIONS
■ Surgical site infection has been reported between 5% and 7%.3,5
■ Silicone implants may be salvaged in the setting of infection, which is
usually the result of unattended bleeding or poor closure.
■ Hematoma—rare.
■ Capsular contracture is more common with Silastic implants after removal
compared to porous polyethylene implants because of tissue integration in the
latter. Management may require removal, placement of a different type of
implant, or osseous genioplasty.
■ Nerve injury often manifests as lower lip numbness. This is often the result of
stretch, compression by implant, or transection of the mental nerve.
■ Improvement is usually seen within 2 to 3 weeks. If symptoms persist beyond
3 weeks, trimming of the implant, implant pocket check, or direct nerve
evaluation should be pursued.6
■ Paresthesias may occur if there is malposition of the implant leading to
impingement of the mental nerve. As stated, management often necessitates
repositioning or trimming of the implant.

FIG 4 • A,B. Preoperative views of a 22-year-old male
with deficient lip eversion, an angle I class I occlusion,
and microgenia. The patient underwent primary
augmentation with a Medpore implant through a
submental incision. C,D. Postoperative views
demonstrating achievement of normal chin projection
and improved labiomental fold definition. It should be
noted that the patient also underwent a supraplatysmal
and subplatysmal lipectomy. (From Warren SM, Spector
JA, Zide BM. Chin surgery VII: the textured secured
implant—a recipe for success. Plast Reconstr Surg.
2007;120(5):1378-1385, with permission.)
■ Chin ptosis may result from damage and insufficient repair of the mentalis
muscle, thereby resulting in chin ptosis, lip ptosis, drooling, and increased
incisor show. This is more likely with an intraoral approach. Chin pad ptosis
may occur following implant removal, overly large pocket, or excessive
burring. The capsule may contract and lead to a “balling” appearance. Removal
of excess submental adipose and mentalis plication or repositioning may be
necessary.7
■ Mentalis dysfunction may manifest as either muscle spasm or dimpling of the
skin of the chin. Botulinum toxin injections may address dimpling of the
mentalis muscle.3

■ Bone resorption may occur with implant placement.
■ Associated with more bone loss with implant placement above the thick
inferior border
■ Implant malposition
REFERENCES
1. Warren SM, Spector JA, Zide BM. Chin surgery VII: the textured secured
implant—a recipe for success. Plast Reconstr Surg. 2007;120:1378-1385.
2. Zide BM, Pfeifer TM, Longaker MT. Chin surgery: I. Augmentation—the
allures and the alerts. Plast Reconstr Surg. 1999;104:1843-1853.
3. Sinno S, Zide BM. Chin ups and downs: avoiding bad results in chin
reoperation. Aesthet Surg J. 2017;37:257-263.
4. Aston SJ, Smith DM. Taking it on the chin: recognizing and accounting for
lower face asymmetry in chin augmentation and genioplasty. Plast Reconstr
Surg. 2015;135:1591-1595.
5. Strauss RA, Abubaker AO. Genioplasty: a case for advancement osteotomy. J
Oral Maxillofac Surg. 2000;58:783-787.
6. Zide BM. The mentalis muscle: an essential component of chin and lower lip
position. Plast Reconstr Surg. 2000;105:1213-1215.
7. Garfein ES, Zide BM. Chin ptosis: classification, anatomy, and correction.
Craniomaxillofac Trauma Reconstr. 2008;1:1-14.

73
CHAPTER
Techniques for Placing
Malar Implants
Erez Dayan, Dev Vibhakar, and Michael J. Yaremchuk
DEFINITION
■ Prominent malar bones are considered attractive and youthful in most cultures.
■ The malar area is a dynamic anatomic region of the face composed of
underlying skeletal support, adipose tissue, and mimetic muscles of facial
expression.1
■ Characterization of the domelike shape of the malar area is largely subjective
due to the lack of anthropometric and cephalometric landmarks. The inability
to define “average” or “normal” for the malar area makes selection of implant
shape, size, and position challenging.
■ Malar augmentation using alloplastic implants yields an aesthetic benefit in
select patients with relative malar hypoplasia.2,3
ANATOMY
■ Skeleton
■ The malar eminence is the most projecting portion of the zygoma. Its
convexity extends from lateral to the infraorbital foramen to the midaspect of
the zygomatic arch.
■ It is perforated in its midaspect by the zygomaticofacial foramen for the
passage of the zygomaticofacial nerve and vessels.
■ Muscles
■ Muscles of the midface largely provide facial expression. Those that are freed
from their origins during malar augmentation elevate the upper lip and include
zygomaticus major, zygomaticus minor, levator labii superioris, and levator
anguli oris (FIG 1).
■ Nerves

■ The infraorbital nerve exits the maxilla through the infraorbital foramen and
travels beneath the levator superioris and above the levator anguli oris. Its
branches supply the skin of the lower lid, the side of the nose, most of the
cheek, and the upper lip. This nerve must be identified and preserved.
■ The zygomaticofacial nerve exists through a small foramen located on the
lateral aspect of the malar bone. It supplies a small portion of the skin of the
upper cheek. It is routinely sacrificed during malar augmentation.
PATHOGENESIS
■ Most frequently, patients who present for malar augmentation are within
normal range and desire more definition, angularity, or balance to their facial
contour.
■ Studies have demonstrated retrusion of the midface and mandibular skeleton
with aging, thus supporting alloplastic augmentation of the skeleton as a
component of the facial rejuvenation armamentarium.
■ Malar deficiency is often part of a generalized midface deficiency requiring
soft tissue evaluation and treatment. As aging occurs, the retaining ligaments of
the midface attenuate and soft tissues atrophy, leading to deflation and descent
of the malar soft tissue complex.3,4
■ Functionally, malar projection provides a platform to support overlaying the
soft tissue as well as provide some protection against lower lid descent (FIG
2).
■ Patients with craniofacial deformities often have functional and aesthetic
consequences requiring more invasive osteotomy and skeletal repositioning
rather than malar alloplastic augmentation. However, in skeletally deficient
patients with normal occlusion, alloplastic augmentation is often a more
appealing option due to its less invasive surgery.5

FIG 1 • A,B. Relevant facial musculature and intraorbital
nerve in relation to malar implant placement.
FIG 2 • A,B. Malar implant position on bony skeleton.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Physical examination should analyze both skeletal and soft tissue components,
as well as overall facial balance. Asymmetries should be noted and
demonstrated. It is helpful to review life-sized photos with the patient to define
aesthetic concerns and goals.
■ History should be obtained for any active or prior history of
immunosuppression, connective tissue disorders, coagulopathy, facial trauma,
and implanted facial hardware before surgery. Patients should also be asked
regarding recent injections of neuromodulators or fillers (temporary or
permanent).
■ Patients with excessively thin skin, history of irradiation, or sinus disease are
poor candidates for alloplastic malar augmentation.
■ Patients may present with a desire to enhance aesthetics of other aspects of
their face (ie, nose, periorbital region). The surgeon should be able to
accurately diagnose malar deficiency and assess its contribution to the overall
midface harmony to the patient.
■ Malar skeletal augmentation is not a substitute for soft tissue augmentation or
repositioning.

IMAGING
■ In general, radiologic assessment is not needed. Size and position of malar
implants are based on the aesthetic judgment of the surgeon.
■ In patients with significant asymmetries, CT imaging may provide an
advantage of multiplane views, three-dimensional reconstruction, life-sized
models, and the manufacture of custom implants.
NONOPERATIVE MANAGEMENT
■ Although fat grafting and synthetic filler injections are logical nonoperative
techniques that may aid in restoration of soft tissue volume loss, they have a
limited role in simulating the effect of increased skeletal projection.
■ The aging process impacts both the soft tissue and skeletal components of the
malar region. Depending on patient needs, either or both soft tissue and
skeletal augmentation may be appropriate to restore youthful facial contours. It
is important for the clinician to be able to differentiate the two. For example, if
skeletal augmentation is performed for a patient who requires soft tissue
augmentation, it will result in an overly defined appearance. On the other hand,
performing fat grafting or filler injections for a patient who requires skeletal
augmentation will result in a spherical shape with inadequate definition.
SURGICAL MANAGEMENT
Preoperative Planning
■ Informed consent should include risks of infection, extrusion, displacement,
asymmetry, deformation, hematoma, seroma, and motor/sensory nerve injury,
as well as the risks of anesthesia.
■ Prior to the induction of anesthesia, the area desired for augmentation is
determined with the patient in a sitting position. This is marked on the surface
of the skin.
■ The authors’ preference is to use general endotracheal or nasotracheal
anesthesia. This allows optimal preparation of the operative site and control of
the airway. The use of local anesthesia and sedation is an alternative.
■ Silicone rubber and porous polyethylene are the predominant implant
materials.
■ The senior author prefers porous polyethylene implants (FIG 3). The implant
material is semiflexible to conform to underlying bone when fixed with
screws. Its porosity supports fibrovascular ingrowth, which avoids the

potentially soft tissue distorting capsule formation inherent in smooth surface
implants.
■ The preferred implants are designed to avoid impingement on the infraorbital
nerve. Registration tabs aid in symmetric placement.
FIG 3 • Porous polyethylene malar implants.
Positioning
■ Patients are placed supine on the operating room table at a 90-degree
perpendicular position relative to the anesthesiologist to allow for maximal
exposure.
Approach
■ Malar augmentation may be performed through intraoral, coronal, or eyelid
approaches.
■ The operative approach depends on surgical preference, implant size, implant
placement, and previous facial surgeries.
T E C H N I Q U E S
■ Preoperative Preparation
■ Prior to antiseptic preparation and draping, a dilute solution of lidocaine and
epinephrine (1:100,000) is infiltrated into the operative site for postoperative
pain control and, most importantly, for intraoperative hemostasis.

■ Intravenous cephalosporin or ciprofloxacin antibiotic prophylaxis is
administered approximately 30 minutes preoperatively.
■ 0.12% chlorhexidine gluconate oral rinse is prescribed for daily use
beginning 3 days preoperatively and including the day of surgery.
TECH FIG 1 • A. Transconjunctival approach to
placement of malar implants. B. Screw fixation of
malar implant via lower eyelid approach with care to
avoid infraorbital nerve. (Printed with permission from
©Mount Sinai Health System.)
■ Periorbital Approach
■ The senior author prefers a transconjunctival retroseptal approach with
lateral canthotomy (TECH FIG 1A).
■ Wide subperiosteal dissection of the area to be augmented is performed, with
identification and preservation of the infraorbital nerve.
■ Implants are available with registration tabs that align with the lateral orbital

rim and proximal zygomatic arch. This allows symmetric placement.
■ Screw fixation immobilizes the implant and obliterates any gaps between
implant and skeleton (TECH FIG 1B). Gaps between the implant and
skeleton result in unanticipated increase in malar projection.
■ The transconjunctival incision is realigned, the lateral commissure
reconstructed, and the orbicularis and skin overlying the lateral orbital wall
closed in layers.
■ If chemosis is a concern, a temporary tarsorrhaphy stitch of 5-0 nylon is
placed until the chemosis is resolved.
■ Intraoral Approach
Gingivobuccal Sulcus Incision and Dissection
■ An upper sulcus incision is made far enough above its apex to allow
sufficient tissue for a secure closure after implant placement.
■ The dissection is carried to the maxillary bone where the periosteum is
incised.
■ With careful attention to and identification of the infraorbital nerve,
subperiosteal dissection is performed over the malar eminence, up to the
infraorbital rim, and onto the zygomatic arch nearly up to the
zygomaticotemporal suture (TECH FIG 2).
■ All efforts are made to avoid excessive bleeding and hematoma formation
that predisposes to prolonged recovery and infection.
Pocket Formation
■ Subperiosteal pocket dissection should allow for visualization of anatomic
landmarks and proper placement of the implant.
■ The surgeon should aim to create a pocket slightly larger than the implant
itself.
■ Of note, extending a malar implant onto the zygomatic arch has a significant
impact on midfacial width.
■ Implants can be trimmed and contoured with a scalpel or high-speed bur
intraoperatively to suit the individual needs of the patient:

TECH FIG 2 • Upper gingivobuccal sulcus and lower
eyelid approach to placement of malar implants.
(Printed with permission from ©Mount Sinai Health
System.)
■ Hot sterile saline (70°C/106°F) can be used to soften the porous
polyethylene implant for further contouring.
Fixation of Implants
■ Once satisfactory implant position is achieved, position is ensured with
screw fixation of the implant to the skeleton (TECH FIG 3):
■ Penetration of the sinus with the screw is of no clinical significance.
■ The position of the implant relative to the infraorbital nerve is always
visualized at the end of the procedure to be confident that any sensory deficit
in the postoperative period reflects retraction-related trauma to the nerve,
which is temporary, rather than implant impingement on the nerve, which

will be permanent.
■ The wound is irrigated with antibiotic solution prior to closure.
■ The intraoral incision is closed with interrupted full-thickness resorbable
sutures.
TECH FIG 3 • A. Screw fixation of malar implant via
superior gingivobuccal sulcus approach. B. CT scan
demonstrating unsatisfactory position of implant-
asymmetry is not uncommmon.

PEARLS AND PITFALLS
Patient
selection
■ Implant augmentation best corrects malar skeletal deficiency. Its
effect on surface irregularities such as lower eyelid wrinkles or
secondary bags is limited.
■ Skeletal augmentation is not a substitute for soft tissue augmentation
or resuspension.
Surgical
approach
■ Extended eyelid approach provides direct visualization of the
skeleton and therefore optimal exposure for symmetric implant
placement.
Implant
selection
and
position
■ Extension of a malar implant onto the zygomatic arch impacts
midface width.
■ Inadequate exposure of the three-dimensional midface skeleton is a
common error predisposing to implant malposition, implant
asymmetry, and infraorbital nerve impingement.
■ Registration tabs resting on the infraorbital rim and zygomatic arch
assure symmetric implant placement.
Implant
fixation
■ Screw fixation assures stable implant position.
■ Screw fixation applies the posterior surface of the implant to the
surface of the bone, obliterating any gaps between the implant and the
skeleton. Gaps result in unanticipated increases in projection of the
implant.
Asymmetry
■ Direct visualization of the area to be augmented, incorporation of
registration tabs into implant design, and screw fixation limit
likelihood of asymmetry.
■ Minor asymmetries are often aesthetically inconsequential due to
overlaying malar soft tissue.
Hematoma
■ All efforts are made to avoid hematoma predisposing to infection.
POSTOPERATIVE CARE
■ Suction drains (round no. 10 French) if used are removed the morning after
surgery. A supportive tape dressing is placed postoperatively and removed the
morning after surgery.
■ Oral antibiotics are prescribed for 7 days after surgery (cephalexin 500 mg
q8h).
■ When intraoral incisions are used, patients are asked to eat a soft diet for 72
hours postoperatively.

■ Frequent mouthwashes are advised as well as careful tooth brushing.
■ Patients are instructed to refrain from strenuous exercise for 2 to 3 weeks
postoperatively.
■ Significant edema, in the known absence of hematoma, may be treated with a
standard steroid taper prescribed for 6 days.
■ The patient is instructed to apply iced compresses to the area for 48 to 72
hours and to sleep with the head of bed elevated greater than 30 degrees or
with three or four pillows.
■ Follow up is at 1-, 2-, and 4-week intervals. Thereafter, long-term follow-up is
at 6 months and 1 year.
OUTCOMES
■ Appropriate patient selection and sound surgical technique provide most
patients with satisfactory aesthetic outcomes (FIGS 4 and 5).
COMPLICATIONS
■ Implant malposition, implant asymmetry, and sensory nerve dysfunction are
avoided with wide subperiosteal exposure, direct visualization, registration tab
implant design, and screw fixation. Although it is often cited that bone
resorption underlying the implant is a complication, it is rarely clinically
significant with malar implants.
■ Infection rates after facial implant surgery are low (less than 2%) when the
techniques outlined in this chapter are employed. Acute infection is best
managed by implant removal. Bacterial biofilm formation on the implant
precludes antibiotic and host resistance efficacy. Antibiotic treatment will
suppress the infection during treatment but will not cure it.
■ Late infections (greater than 3 months post-op) have not been experienced in
the senior author’s experience. It is hypothesized that infections that are
clinically manifested after 1 month reflect small bacterial contaminations at the
time of surgery that are suppressed by host defenses and the postoperative
antibiotic regimen.

FIG 4 • Before (A) and 2 year after (B) placement of
malar implants.

FIG 5 • Before (A) and 1 year after (B) placement of
malar, chin, and mandible implants.
REFERENCES
1. Matros E, Momoh A, Yaremchuk MJ. The aging midfacial skeleton:
Implications for rejuvenation and reconstruction using implants. Facial Plast
Surg. 2009;25:252-259.
2. Raschke R, Hazani R, Yaremchuk MJ. Identifying a safe zone for midface
augmentation using anatomic landmarks for the infraorbital foramen. Aesthet
Surg J. 2013;33(1 suppl):13-18.
3. Yaremchuk MJ, Doumit G, Thomas MA. Alloplastic augmentation of the
facial skeleton: an occasional adjunct or alternative to orthognathic surgery.
Plast Reconstr Surg. 2011;127:2021-2030.
4. Shaw RB, Katzel EB, Koltz PF, et al. Aging facial skeleton: aesthetic
implications and rejuvenation strategies. Plast Reconstr Surg. 2011;127:374-
383.
5. Yaremchuk MJ. Secondary malar implant surgery. Plast Reconstr Surg.

2008;121:620.

74
CHAPTERMandible Implants
Michael J. Yaremchuk, Dev Vibhakar, and Erez Dayan
DEFINITION
Patients with three types of skeletal morphology can benefit from implant
augmentation of the mandibular body, angle, and ramus. These skeletal
morphologies include those with:
■ Normal dimensions. Most patients who desire mandible augmentation have
lower face horizontal dimensions within normal range. These patients either
desire a wider lower face (increased bigonial distance) or desire more
definition and angularity to the mandibular border.1
■ Skeletal deficiency. Approximately 5% of the population in the United States
has skeletal mandibular deficiency leading to a class II occlusal problem. Most
of these patients can have their dental relationships corrected by orthodontic
treatment, which leaves their skeletal contours deficient. These patients can
have their mandibular contours improved with implant augmentation.
■ Surgically altered anatomy. Patients with mandibular deficiency who have had
their class II malocclusion corrected by osteotomy and rearrangement remain
deficient, but in another way.2 Resultant displeasing postoperative contours
include step-offs at the osteotomy sites and malposition of the aesthetically
important angle and ramus. Alloplastic implants, particularly those designed
and manufactured by computer imaging, can be used to improve contour in
these cases.
ANATOMY
■ All transverse facial dimensions are greater in men than in women with the
greatest difference being the bigonial distance.2
■ Skeletal anatomy

■ The aesthetically important portions of the mandible are the chin and ramus.
The chin determines lower face height and projection in the midline, and the
ramus determines lower face width (FIG 1A).
■ The mental foramen from which the mental nerve exits lies approximately at
the interspace between the two premolars and about midway in the height of
the dentulous adult mandible (FIG 1B).
■ Muscular anatomy (FIG 1C)
■ The four muscles of mastication are predominantly responsible for movement
of the mandible and include masseter, temporalis, medial pterygoid, and
lateral pterygoid muscles. The only muscles of mastication encountered
during mandibular augmentation are the masseter and indirectly the medial
pterygoid which together form the pterygomasseteric sling.3
■ The buccinator is also encountered during exposure for mandibular
augmentation. It is principally a muscle of the cheek and forms the lateral
wall of the oral cavity.2,3
■ Nerve anatomy (see FIG 1B,C)
■ Inferior alveolar nerve is a branch of the mandibular nerve (V3). It enters the
mandibular canal alongside the inferior alveolar vessels through the
mandibular foramen, which is located in the lingual aspect of the ramus
approximately halfway between its anterior and posterior borders. It is
important to visualize the path of the inferior alveolar nerve when placing
screws to immobilize mandibular implants.3 This nerve (now termed the
mental nerve) exits at the mental foramen. It provides sensation to the
ipsilateral portion of the lower lip.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Detailed history should include skeletal trauma, orthodontic therapy, or
orthognathic procedures.
■ Physical examination should explore occlusal relationships, skeletal contour,
and relation of the mandible to other facial contours.
■ Life-size posteroanterior and lateral photographs can be helpful when
discussing aesthetic concerns and goals with the patient.
■ Sample implants and model skulls are useful to demonstrate the application
and visual impact of facial implant.
IMAGING
■ Posteroanterior and lateral cephalograms provide useful data to aid in choosing

an implant to best suit the patient.
■ Three-dimensional computerized tomographic scans and the models obtained
from their data can be invaluable in designing implants to correct asymmetries
associated with congenital, posttraumatic, or postsurgical deformities (FIG
2A,B).
NONOPERATIVE MANAGEMENT
■ Soft tissue augmentation in the form of autogenous fat grafts or synthetic
fillers can simulate the visual effect of skeletal augmentation to camouflage
limited skeletal deficiencies.2–4
■ More aggressive soft tissue augmentation may expand the volume of the soft
tissue envelope but at the expense of skeletal definition.2
FIG 1 • A. Boney anatomy and relationships of the
mandible. B. Relationship of mental foramen to dental
anatomy. C. Muscular anatomy of the mandible.

SURGICAL MANAGEMENT
Preoperative Planning
■ Patient history, physical examination, possible imaging, and review of patient
photographs as well as pictures of others deemed attractive by the patient are
all part of the preoperative planning.
■ Numerous implant designs are available to change the shape of the mandible
in three dimensions: bigonial width, ramus height, and body length, as well as
the inclination of the mandibular border.
■ Informed consent should include intrinsic risks and benefits of mandibular
augmentation, such as the possibility of infection, extrusion, displacement,
asymmetry, deformation, hematoma, seroma, motor/sensory nerve injury, as
well as the risks of anesthesia.
■ Prior to the induction of anesthesia, the area desired for augmentation is
determined with the patient in a sitting position. This is marked on the surface
of the skin.
■ 0.12% chlorhexidine gluconate oral rinse is prescribed for daily use beginning
3 days preoperatively and including the day of surgery.
Positioning
■ Patients are placed supine on the operating room table at a 90-degree
perpendicular position relative to the anesthesiologist to allow for maximal
exposure.
FIG 2 • A,B. Custom implants designed using CT scan
data to correct irregularities and imbalance after

orthognathic surgery.
T E C H N I Q U E S
■ Preoperative Preparation
■ Prior to antiseptic preparation and draping, a dilute solution of lidocaine and
epinephrine (1:100 000) is infiltrated into the operative site for postoperative
pain control and intraoperative hemostasis.
■ Intravenous antibiotic prophylaxis is administered approximately 30 minutes
preoperatively. Oral equivalents are continued for 5 days after surgery.
■ The authors’ preference is to use general nasotracheal anesthesia. This
allows optimal preparation of the operative site and control of the airway.
However, skeletal augmentation can be performed with local anesthesia and
sedation.
■ The face and oral cavity are prepared with an iodine solution after placement
of the throat pack.
■ Incision
■ A generous intraoral incision is made at least 1 cm above the inferior
gingivobuccal sulcus on its labial side to expose the ramus and body of the
mandible (TECH FIG 1A).
■ The anterior ramus and body of the mandible as well as their inferior borders
are freed from their soft tissues in a subperiosteal plane. Care is taken to
avoid minimal disruption of the pterygomasseteric sling. Disruption of the
sling will result in roll-up of the masseter with an unsightly midramus bulge
(TECH FIG 1B).
■ If the mental area is also being augmented, a submental incision is made for
access and exposure of the anterior mandible (TECH FIG 1C).
■ The inferior alveolar nerve is visualized in its anticipated path to avoid its
injury during screw fixation of the implant (TECH FIG 1D).
■ As determined preoperatively, the implant can be trimmed with a scalpel or
bur before its placement on the mandible.

TECH FIG 1 • A. Placement of intraoral incision, at
least 1 cm above the inferior gingivobuccal sulcus for
optimal exposure. B. Soft tissues are elevated off the
anterior ramous and body of the mandible in
subperiosteal plane. C. Submental incision for
genioplasty. D. Anatomic relationship of inferior
alveolar nerve is anticipated to avoid injury during
screw fixation of the implant.
■ Implant Positioning and Fixation

■ Registration features at the inferior and lateral borders of the implant aid in
appropriate implant positioning (TECH FIG 2A).
■ Once satisfactory positioning of the implant is achieved, the implant is fixed
to the mandible with titanium screws.
■ A clamp designed to stabilize the implant to the mandible is useful in
maintaining implant position during screw fixation (TECH FIG 2B).
■ Intraoral screw fixation requires aggressive soft tissue retraction.
■ This limited access obligates the fixation screws to be placed obliquely.
This oblique screw placement obligates screws to be from 8 to 14 mm in
length.
■ Screw placement should anticipate the expected path of the inferior
alveolar nerve (TECH FIG 2C).
■ When an external approach is preferred for screw fixation, access is obtained
through stab wound incisions made in the neck skin.
■ The one or two fixation screws not only immobilize the implant but also
eliminate any gaps between the posterior surface of the implant and the
anterior surface of the mandible (TECH FIG 2D):
■ Gaps result in unanticipated increases in effective implant augmentation.
■ Gaps may arise when there are prominences on the surface of the
mandible. This is often the case at the oblique line of the mandible body.
Reduction of these prominences allows for congruent application of the
implant to the mandible.

TECH FIG 2 • A. Registration tabs of inferior and
lateral borders of implant aid in correct positioning. B.