Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

Superior Third
Techniques to set back the superior third of the ear require strengthening or recreation of the antihelical
fold by (1) placement of scapha-concha sutures (Mustarde technique), 12 or (2) cartilage scoring
(Stenstrom technique) 13 (Figure 53.4). I prefer scapha-concha sutures because it gives greater control and
more predictability compared to scoring the cartilage. In addition, scoring the cartilage can cause damage
to the cartilage and contour abnormalities. In an adult with very stiff cartilage, scoring may be considered
as an adjunct to weaken the cartilage to facilitate its bending during the placement of sutures. The ear is
folded, and the position of the antihelical fold is marked. Intraoperatively, a 27 gauge needle is used to
transpose the position of the antihelical fold to the posterior cartilage. I typically place three or four 4-0
Mersilene mattress sutures to recreate the fold. It is important not to pull the sutures too tight that can
cause the ear to be positioned too close to the mastoid and create an unnatural sharp antihelical fold. On
front view, the antihelix should have a gentle curve and the helix should be visible behind the antihelix. I
measure the distance from the most superior point of the helix to the mastoid and achieve a distance of
15 mm (±3 mm). Occasionally, the superior third remains prominent despite scapha-concha sutures. In
this situation, one or two sutures can be placed from the scapha to the temporal fascia or conchal
cartilage. Alternatively, scapha and helical cartilage can be excised. 14
FIGURE 53.4 Illustration of operative methods to reduce the prominence of an ear. Anterior (A) and posterior (B) views
showing the position of scapha-concha sutures to strengthen the antihelical fold and set-back the superior 1/3 of the ear (3
lines) as well as concha excision to reduce the prominence of the middle 1/3 of the ear (black ovals). The outline at the junction
of the ear and mastoid on the posterior view represents the skin excision performed to access the ear cartilage.
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Middle Third
Options to set back the middle third of the ear include excision of concha or concha-mastoid sutures
(Furnas technique). 15,16 I prefer a cartilage excision because it reduces the risk of recurrence and weakens
the area to facilitate the antihelix contour provided by the scapha-concha sutures. 16 I have found that
suturing the hard cartilage to the weak mastoid fascia/periosteum has an increased risk of recurrence of
prominence because of suture dehiscence and/or stretching of tissue. I measure the distance from the
midhelix at the level of the root to the mastoid and attempt to achieve a distance 18 (±3 mm).
An approximately 2.0 to 2.5 cm long piece of superior conchal cartilage is removed just below the scapha-
concha sutures. Depending on the amount of prominence, the width of the area can be 2 to 7 mm. The
cartilage defect is repaired with interrupted 4-0 PDS suture. A line of excess skin may be present
anteriorly, but this flattens over time. If more than a 7 mm width of cartilage is removed, then it is
possible that the excess skin anteriorly might be bothersome to the patient and require excision. Care
must be taken to not overcorrect the middle third of the ear to prevent a telephone deformity.
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Lower Third
Lobule prominence is present in approximately one-fourth of patients and is often not appreciated
preoperatively. 17 If the lobule remains prominent after setting back the superior and middle third of the
ear, I first place a Mersilene suture through the area of the tail of the helix to the base of the conchal bowl.
Another option is to extend 
 the conchal cartilage excision inferiorly. A posterior lobule skin excision also
can be performed. 16,18 Finally, a suture can be placed from the posterior lobule to the conchal cartilage.
18,19 The goal is to prevent the appearance of a hockey stick appearance of the ear.
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Closure
Before closing the incision, I ensure that the helix has a straight contour, a telephone deformity is not
present, and the superior helix is visible beyond the antihelix. I also perform repeat measurements; the
superior distance of the helix to the mastoid must be 15 (±3 mm) and the middle distance 18 (±3 mm).
These measurements should have a difference of ≤2 mm between the ears to ensure adequate symmetry.
It is important that the ear is not approximated too close to the mastoid that can cause a deformity. The
incision is closed using interrupted 5-0 Vicryl suture followed by a running 6-0 Chromic suture.
Cyanoacrylate glue and a Steri-Strip are placed.
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Postoperative Care
I place a head-wrap (large piece of cotton over the ear followed by a gauze wrap) that is worn for up to
1 week until the first clinic appointment. I do not attempt to place pressure on the ear with bolster sutures
or pieces of cotton soaked in mineral oil. Patients then are instructed to wear a soft head band at night for
6 weeks postoperatively to prevent accidental anterior displacement of the ear that could dehisce the
antihelical sutures causing recurrent prominence. Six weeks postoperatively scar tissue is strong enough
to maintain the shape of the ear.
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Constricted Ear
A wide spectrum of constricted (e.g., lop, cup) ear anomalies exist. They range from minor helical
problems to a variant of microtia and consist of (1) lidding of the helix, (2) prominence, and/or (3)
reduced size from deficient structures. If possible, I prefer to manage these deformities as low on the
reconstructive latter as possible before considering cartilage grafts and retroauricular flaps. Minor
deformities of the helix can be improved with simple excisions (Figure 53.5). Moderately constricted ears
that contain a sufficient amount of structures may be improved using techniques employed for prominent
ear deformities (Figure 53.6). Generally, the primary morbidity of a constricted ear is that it is prominent.
If the ear is set back by strengthening the antihelical fold and placing sutures from the cartilage to the
mastoid and temporal fascia to lengthen the vertical dimension of ear, the appearance of the child can be
significantly improved. Severely constricted ears that approximate conchal-type microtia require partial
or total auricular construction using cartilage grafts (Figure 53.7).
FIGURE 53.5 Correction of a mildly constricted ear. A. Preoperative image shows abnormal helix covering a portion of the
superior crus of the antihelix. B. Outline for soft-tissue and cartilage excision. C. Intraoperative view following removal of
cartilage. D. Immediate postoperative appearance.
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FIGURE 53.6 Treatment of a moderately constricted ear. A. Preoperative image shows a cupped ear with reduced vertical
height and deficient helix and antihelix. B. Postoperative view after placement of scapha-concha, concha-mastoid, and scapha-
temporal sutures.
FIGURE 53.7 Reconstruction of a severely constricted ear with the absence of the lobule and part of the helix, concha, and
antihelix. A. Preoperative appearance. B. Following first-stage advancement of a retroauricular flap to add soft tissue to the
middle and lower one-third of the ear. The upper one-third of the ear was set back using scapha-concha sutures to recreate the
antihelical fold. C. Appearance after staged placement of a conchal cartilage graft harvested from the contralateral ear. The
outline of the graft is illustrated by the blue marking. D. Appearance after completing the reconstruction. The lower third of the
ear containing the cartilage graft was separated from the retroauricular area using local flaps.
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Cryptotia
Patients with cryptotia have a superior helix that is attached to the postauricular skin without a sulcus. In
addition to causing a deformity, patients have difficulty wearing eyeglasses. Many techniques have been
described to reconstruct the anomaly, including local flaps, skin grafts, and tissue expansion. I prefer
using a one-stage V-Y advancement flap from the scalp to recreate the retroauricular sulcus. 20 This leaves
a hidden scar behind the ear and in the hairline (Figure 53.8). Occasionally, the helical cartilage may be
significantly deformed and require scoring, sutures, and/or grafts to improve its shape.
FIGURE 53.8 Correction of cryptotia. A. Preoperative appearance. B. The normal components of the helix are identified by
pulling the ear outward. C. Outline of the V-Y advancement flap to recreate the retroauricular sulcus. D. Flap raised. E. After
advancement of the flap and closure of the donor site. F. Postoperative view.
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Stahl Deformity
This abnormality describes the presence of a third crus of the antihelix that can cause the helix to have a
pointed appearance. Usually, the anomaly is minor and does not cause psychosocial morbidity. Operative
intervention may be indicated to treat a severe deformity. The anomaly is improved surgically through
an anterior incision at the junction of the helix and scapha. The anterior skin is elevated, and the
abnormal crus is resected (Figure 53.9). 21 If the superior crus of the antihelix is missing, then the excised
crus can be grafted or rotated to reconstruct this structure. Occasionally, patients may have a prominent
ear deformity as well requiring setback otoplasty techniques.
FIGURE 53.9 Correction of a Stahl deformity.% A. Preoperative view illustrating the abnormal one third crus of the antihelix
and a pointed appearance of the helix. B. Intraoperative image of the incision along the junction of the helix and scaphoid fossa
exposing the abnormal crus. C. Following resection of the abnormal cartilage. D. Postoperative appearance illustrates improved
contour of the helix and scaphoid fossa.
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Accessory Cartilage
Accessory cartilage in the preauricular area is the most common ear anomaly. I prefer to remove the
tissue during the neonatal period using local anesthesia in the office to obviate general anesthesia. If an
infant has a large lesion with a wide cartilage base that cannot be easily excised and closed, the procedure
is performed in the operating room. Patients who present after 12 months old as well are managed in the
operating room because it is difficult to restrain the child in the clinic.
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Lobule Abnormalities
Split Ear Lobe
This deformity results from an earring being pulled through the lobule. The cleft is rapidly epithelialized
preventing the edges from reapproximating. Split ear lobes in older children and adolescents can be
repaired with local anesthesia; young children require general anesthesia. The cleft is de-epithelialized
and approximated using absorbable sutures in a straight line. The end of the cleft is closed with a
mattress suture for eversion to prevent a notch from scar contraction. The scar can be repierced 3 months
later when it has achieved its maximal strength. The advantages of repiercing along the scar are that the
scar is camouflaged and if the earring pulls through again, a second scar is not formed. The disadvantage
of piercing the scar is that it is not as strong as the adjacent lobule and thus has a higher risk of pulling
through again.
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Keloid
The ear lobe has a greater risk of forming keloid scars from piercings, compared to other parts of the ear.
Keloids are managed with pressure, corticosteroid injection, and/or resection. Small lesions can be treated
with pressure only. Patients are advised to wear a clip-on earring or purchase a pressure earring designed
for keloids. The pressure device is worn at night when sleeping. A pressure earring is a good first-line
intervention for minor keloids in young children who are less tolerant of undergoing a corticosteroid
injection in the clinic. Older children can be managed with serial triamcinolone injections in addition to
the pressure earring. Large keloids are best managed with resection because pressure/injections will only
give minimal improvement and the patient will continue to have a significant deformity. Families are
educated that resection is exponentially more traumatic to the ear than the piercing that caused the
keloid. Consequently, without close follow-up and the use of postoperative compression and
corticosteroid injections, the keloid will return and can be worse. After resecting the keloid, the patient
wears a pressure earring beginning 2 weeks following the procedure at night. Four weeks
postoperatively, the patient returns for monthly evaluations and possible corticosteroid injections. After
6 months, the patient follows up as needed. Although radiation has been described as a treatment for
keloids, I have not had a patient require this intervention.
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Congenital Deficiency
The most common lobule deficiency is a cleft that causes a deformity and obviates the ability to place
earrings. The cleft is deepithelialized and corrected by advancing the tissue to form a lobule (Figure
53.10). Rarely, a patient can have an absent lobule on the spectrum of microtia. The lobule can be
constructed using staged skin flaps from the adjacent neck, or by placing a conchal cartilage graft. I have
found that using cartilage gives the most favorable outcome (see Figure 53.7).
FIGURE 53.10 Congenital lobule deficiency. A. Preoperative view. B. Outline of flap and area of de-epithelialization. C. Prior to
flap advancement. D. Following inset of the flap.
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Complications
Rarely, a skin abrasion or full-thickness wound can occur with ear molding; molding is discontinued
until the area has healed. The most common problem is an unfavorable “cosmetic” outcome. Infection,
hematoma, extrusion of sutures, or wound dehiscence is uncommon. Before reconstructing an ear,
patients/parents must have reasonable expectations. The ears are tolerant to asymmetry, and the primary
goal is to improve their appearance on frontal view.
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Summary
Otoplasty is based on principles. The surgeon must be able to identify the deformity and determine if
there are excess structures, deficient structures, or adequate structures that need to be rearranged.
Although many options often exist to improve a specific type of ear deformity, the simplest technique
often is preferred.
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Questions
1. A 5-year-old girl has an ear anomaly showing poor definition of the superior helix without a
retroauricular sulcus. Which of the following is the most likely diagnosis?
a. Microtia
b. Prominent ear
c. Stahl ear
d. Cryptotia
e. Constricted ear
2. A 5-year-old boy has an ear anomaly showing a pointed helix and a third crus of the antihelix.
Which of the following is the most likely diagnosis?
a. Microtia
b. Prominent ear
c. Stahl ear
d. Cryptotia
e. Constricted ear
3. Which of the following is the most ideal time to initiate nonsurgical molding to correct a
prominent ear deformity?
a. 1 month
b. 3 months
c. 6 months
d. 12 months
e. 24 months
4. Which operative technique is used to recreate the antihelical fold in a patient with a prominent
ear?
a. Cartilage graft
b. Cartilage excision
c. Mustarde sutures
d. Furnas sutures
e. Postauricular flap
5. Which operative technique is used to set back the middle third of the ear in a patient with a
prominent ear?
a. Cartilage graft
b. Cartilage excision
c. Mustarde sutures
d. Stenstrom technique
e. Postauricular flap
1. Answer: d. The patient has cryptotia because the superior helix of the ear is buried underneath the
scalp skin.
2. Answer: c. The patient’s anomaly described is a Stahl deformity.
3. Answer: a. Circulating maternal estrogens in newborns allows the molding of ear cartilage.
Moreover, 1 to 3 weeks is the ideal time to initiate ear molding because the younger the patient, the
more malleable the ear and the more likely the patient will have a favorable outcome. Ear molding
cannot be started at 3 months old or later.
4. Answer: c. Mustarde sutures (also known as scapha-concha sutures) are used to recreate the
antihelical fold. Another method to establish the antihelix is to abrade the anterior aspect of the
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cartilage (Stenstrom technique). A cartilage graft commonly is used to reconstruct deficient areas of
the helix. Cartilage excision minimizes the prominence of the middle third of the ear by reducing the
size of the concha. Furnas sutures also decrease the prominence of the concha by suturing the concha
to the mastoid fascia and periosteum. A postauricular flap is used to cover exposed areas of helical
cartilage.
5. Answer: b. Cartilage excision minimizes the prominence of the middle third of the ear by reducing
the size of the concha. Mustarde sutures (also known as scapha-concha sutures) are used to recreate
the antihelical fold. Another method to establish the antihelix is to abrade the anterior aspect of the
cartilage (Stenstrom technique). A cartilage graft commonly is used to reconstruct deficient areas of
the helix. Stenstrom technique is the scoring of cartilage to make it bend and is a technique used to
strengthen the antihelical fold and set back the superior third of the ear. A postauricular flap is used
to cover exposed areas of helical cartilage.
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References
Zhao, H, Ma, L, Qi, X, et al. A morphometric study of the newborn ear and an analysis of factors related to congenital auricular deformities.
Plast Reconstr Surg. 2017;140(1):147-155.This was a prospective study of 1500 newborns performed at 7 and 30 days of life. Ear anomalies and risk
factors were documented as well as the maturation of ear deformities over time. The investigation provided epidemiological data about the incidence and
natural history of ear anomalies.
Matsuo, K, Hayashi, R, Kiyono, M, et al. Nonsurgical correction of congenital auricular deformities. Clin Plast Surg. 1990;17(2):383-395.
Driessen, JP, Borgstein, JA, Vuyk, HD. Defining the protruding ear. J Craniofac Surg. 2011;22:2102-2108.
Shokrollahi, K, Manning, S, Sadri, A, et al. The prominent antihelix and helix—the myth of the ‘overcorrected’ ear in otoplasty. Ann Plast
Surg. 2015;74(suppl 4):S259-S263.
Tolleth, H. Artistic anatomy, dimensions, and proportions of the external ear. Clin Plast Surg. 1978;5(3):337-345.
Bauer, BS. Nonmicrotia. In: Bentz, M , Bauer, BS , Zucker , eds. Principles and Practice of Pediatric Plastic Surgery. New York, NY: Thieme; 2016.
Matsuo, K, Hirose, T, Tomono, T, et al. Nonsurgical correction of congenital auricular deformities in the early neonate: a preliminary report.
Plast Reconstr Surg. 1984;73(1):38-51.This was the first report for ear molding of auricular anomalies in newborns. This observation lead to the
development of commercially produced ear-molding devices and decreased the need for operative otoplasty in children.
Byrd, HS, Langevin, CJ, Ghidoni, LA. Ear molding in newborn infants with auricular deformities. Plast Reconstr Surg. 2010;126:1191-1200.
Tan, ST, Abramson, DL, MacDonald, DM, Mulliken, JB. Molding therapy for infants with deformational auricular anomalies. Ann Plast Surg.
1997;38:263-268.
Adamson, JE, Horton, CE, Crawford, HH. The growth pattern of the external ear. Plast Reconstr Surg. 1965;36(4):466-470.
Gosain, AK, Kumar, A, Huang, G. Prominent ears in children younger than 4 years of age: what is the appropriate timing for otoplasty? Plast
Reconstr Surg. 2004;114(5):1042-1054.This study prospectively studied 12 patients who underwent otoplasty for prominent ears between 9 months
and 3 years old. The length of the surgically corrected and the normal contralateral ears were the same at follow-up (range 2–7 years). This
investigation showed that otoplasty can be performed in early childhood without inhibiting ear growth.
Mustarde, JC. Correction of prominent ears using buried mattress sutures. Clin Plast Surg. 1978;5:459-464.
Stenstrom, SJ, Heftner, J. The Stenstrom otoplasty. Clin Plast Surg. 1978;5:465-470.
Sinno, S, Chang, JB, Thorne, CH. Precision in otoplasty: combining reduction otoplasty with traditional otoplasty. Plast Reconstr Surg.
2015;135(5):1342-1348.
Furnas, DW. Correction of prominent ears by conchamastoid sutures. Plast Reconstr Surg. 1968;42(3):189-193.
Bauer, BS, Song, DH, Aitken, ME. Combined otoplasty technique: chondrocutaneous conchal resection as the cornerstone to correction of the
prominent ear. Plast Reconstr Surg. 2002;110(4):1033-1040.The authors present a surgical technique that is a fundamental component of many
otoplasty procedures. They describe the resection of conchal cartilage that enables the setback of the middle third of the ear as well as facilitates the
formation of the antihelical fold with scapha-concha sutures.
Ungarelli, LF, de Andrade, CZ, Marques, EG, et al. Diagnosis and prevalence of prominent lobules in otoplasty: analysis of 120 patients with
prominent ears. Aesthet Plast Surg. 2016;40(5):645-651.
Thorne, CH, Wilkes, G. Ear deformities, otoplasty, and ear reconstruction. Plast Reconstr Surg. 2012;129:701e-716e.
Gosain, AK, Recinos, RF. A novel approach to correction of the prominent lobule during otoplasty. Plast Reconstr Surg. 2003;112(2):575-583.
Cho, BC, Han, KH. Surgical correction of cryptotia with V-Y advancement of a temporal triangular flap. Plast Reconstr Surg. 2005;115(6):1570-
1581.The authors present a technique for the correction of cryptotia that uses a one-stage V-Y advancement flap from the postauricular area. This
procedure obviates the need for skin grafts or tissue expansion to recreate the sulcus.
Kaplan, H, Hudson, D. A novel surgical method of repair for Stahl’s ear: a case report and review of current treatments modalities. Plast
Reconstr Surg. 1999;103:566-569.
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C H A P T E R 5 4
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Facial Skeletal Augmentation With Implants and
Osseous Genioplasty
Paul D. Durand and Christopher C. Surek, and James E. Zins
Key Points
Proper preoperative assessment and planning are crucial prior to attempting any modification of the
facial skeleton.
The subperiosteal plane is typically preferred for implant placement.
Incisions should be planned away from the implant pocket.
Two most commonly used materials for facial skeletal augmentation are solid silicone and porous
polyethylene.
Rigid fixation minimizes implant malposition and reduces risk of infection.
Skeletal augmentation should not be viewed as a substitute for soft tissue suspension.
Horizontal osteotomies should be placed at least 5 mm caudal to the canines to avoid tooth root
injury as well as to reduce risk of mental nerve injury.
Mental nerve exits the mandible through the mental foramen, which is located between the first and
second premolars.
Placement of intraoral incision should be 1 cm anterior to the gingivolabial sulcus, allowing for
proper wound closure.
Using a submental incision for alloplastic augmentation genioplasty may reduce risk of infection,
wound dehiscence, and implant migration.
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Facial Skeletal Augmentation With Implants
Preoperative Evaluation
As in any preoperative assessment, a thorough physical examination is of paramount importance.
Aesthetic concerns and expectations should then be discussed. Reviewing photos of the patient’s front,
oblique, and profile proves to be particularly useful for both the surgeon and patient. The facial skeleton
should be assessed for asymmetry and dysmorphology. Minor modifications of the facial skeleton can
significantly accentuate areas of mild asymmetry.
Established anthropometric measurements of balanced faces can provide the surgeon with some objective
basis that can be used in deciding what areas need to be augmented or reduced and to what extent. 1
Recent advances in preoperative evaluation including 3D CT scanning, stereolithographic modeling, 3D
printing, and a variety of other software programs are available. Nevertheless, posteroanterior and lateral
cephalometric radiographs and panoramic x-rays can be particularly useful when planning augmentation
of the chin and mandible. Skeletal dimensions in relation to soft-tissue thickness can be assessed.
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Alloplastic Materials
Aesthetic facial skeletal augmentation is generally performed with alloplastic implants. An ideal implant
material is one that is biocompatible and has minimal interaction with the surrounding tissues, such that
its morphology is maintained after placement. In contrast, skeletal augmentation with autogenous bone
can remodel, in time affecting its size and shape. 2,3
The host tissue response includes some level of capsule formation around the implant being placed. The
most important determinant of the degree of this response is the material in the outer surface of the
implant. Porous implants typically result in less robust capsule formation compared to smooth implants.
Implant migration and adjacent bone erosion also tend to be lower in porous implants. 4,5 Solid silicone
implants offer several advantages over other materials—they can be effortlessly carved to achieve a
desired shape and size, as well as be easily fixated with screws or sutures. Incidence of infection,
although low regardless of the implant type, has been reported to be lower when silicone implants are
used. 6
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Positioning and Immobilization
Implant placement is described in both supraperiosteal and subperiosteal planes (Figure 54.1). The
subperiosteal pocket dissection is preferred as it involves a plane of dissection that is bloodless and safe
relative to surrounding neurovascular structures. Regardless of the area being augmented and the type of
implant used, proper immobilization of the device can provide a more accurate, reproducible result. A
major advantage of screw fixation over the other methods (e.g., sutures) relates to more accurate final
contour because gaps between host bone and the implant are eliminated.
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FIGURE 54.1 Location of various facial implants for skeletal augmentation.
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Midface Augmentation
Most aesthetic facial augmentation occurs in the middle and lower thirds of the face. Augmentation of the
midface can be divided in four major areas: malar, submalar, paranasal, and infraorbital rim.
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Malar
The malar area is a frequent area of alloplastic augmentation. Full cheeks and prominent malar bones are
associated with youth and attractiveness. Patients seeking augmentation of this area can either have
normal anatomy or a true skeletal deficiency of the midface such as congenital deformities. 7 Such
distinction is important, as in the latter case; malar augmentation alone can be insufficient to address the
aesthetic issue at hand. Finally, skeletal augmentation should not be seen as equivalent to soft-tissue
augmentation and resuspension; these are two separate entities that when used appropriately can have a
synergistic effect.
Incision placement for insertion of malar implants can vary and include the intraoral, coronal, or eyelid
routes, all of which have been described. 7 An intraoral approach is preferred as it provides good
exposure and avoids any external scars. When performing an upper sulcus incision, sufficient labial
tissue should be left on either side to allow for a secure, two layered watertight closure. After careful
identification of the infraorbital nerve, dissection is carried out in the subperiosteal plane over the malar
eminence and onto the zygomatic arch. The pocket size can be tailored to the implant being used and its
desired aesthetic outcome. Screw fixation provides for more freedom in pocket dissection and thus
greater exposure at the time of implant insertion. Careful carving of the implant on its posterior surface
and rigid fixation minimize visibility and malposition.
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Paranasal
Deficiency of midface projection can either be congenital or acquired. It is present in individuals who
have undergone cleft surgery, traumatic facial fractures, or due to developmental deformities. In patients
with a relatively normal occlusion, deficient midface projection can be corrected with facial implants. By
increasing nasal base projection, paranasal augmentation serves to open the nasolabial angle and effaces
the depth of the nasolabial fold. When properly placed, paranasal implants can simulate the visual effect
of LeFort I advancement. 8
Paranasal augmentation is done intraorally. To avoid placing incisions directly over the implant, the
upper gingival buccal sulcus incision is made just lateral to the piriform aperture. As with malar
augmentation, dissection is carried out subperiosteally, while the nearby infraorbital nerve is identified
and protected. Screw fixation minimizes asymmetries and malposition. When screw fixation is employed,
care should be taken to avoid the root of the canine. Compromise of the nasal airway can occur if
implants are positioned over the piriform aperture. 8,9
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Infraorbital Rim
The morphology of the infraorbital rim skeleton plays a crucial role in supporting soft tissue of the lower
eyelids and cheeks. Lack of projection of this skeletal component can be responsible for premature
descent of such structures and result in early facial aging. A characteristic “negative” vector, in which the
most anterior projection of the globe lies anterior to the lower lid and malar eminence, is commonly noted
in these individuals (Figure 54.2). This finding is associated with significant risk of lower eyelid
malposition after blepharoplasty. Augmentation of the infraorbital rim can decrease the incidence of
lower lid malposition by reversing the “negative” vector. 10,11
FIGURE 54.2 Globe-orbital rim relationships have been categorized by placing a line or “vector” between the most anterior
projection of the globe and the malar eminence and lid margin. A. Positive vector relationship. In a youthful face with normal
globe-to-skeletal rim relations, the cheek mass supported by the infraorbital rim lies anterior to the surface of the cornea. The
position of the cheek prominence beyond the anterior surface of the cornea is termed a positive vector. B. Negative vector
relationship. In patients with maxillary hypoplasia, the cheek mass lies posterior to the surface of the cornea. The position of the
cheek prominence beyond the anterior surface of the cornea is termed a negative vector. C. “Reversed” negative vector
relationship. Alloplastic augmentation of the infraorbital rim can reverse the negative vector.
Various types of incision can be used for insertion of infraorbital rim implants, including subciliary skin
and skin-muscle flap incisions. If a transconjunctival incision is used, it can be lengthened with a lateral
canthotomy. Better exposure of the midface skeleton can be obtained by incorporating an intraoral sulcus
incision.
Dissection is carried out in a subperiosteal plane. Infraorbital rim implants can be carved to tailor lateral
and medial extension depending on the specific area to be augmented. Screw fixation is beneficial in this
area to avoid implant malposition. Prior to closure, malar soft tissue should be resuspended over the
secured implant. 11
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Temporal Augmentation
The deepest portion of the temporal fossa is the anterior inferior fossa, which is the sphenoid bone
contribution. 12 Facial aging, trauma including previous surgery, weight change, and a variety of other
causes can lead to soft-tissue deficiency of muscle and fat in the temporal fossa. Yaremchuk used
polymethylmethacrylate (PMMA) to fill up temporal depressions. If a previous reconstructive surgery
was performed in the temporal area, access is gained through the old scar and the PMMA is placed over
the deficient muscle. To prevent implant motion, titanium screws are secured along the lateral orbital rim.
If patients have not had surgery or have had the temple used as a remote access to other regions of the
face (i.e., subperiosteal facelift), then the implant is placed beneath the temporalis muscle though an
incision in the temporal hair-bearing scalp. 12,13
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Mandibular Augmentation
Chin
Augmentation of the chin area can have a profound effect on the facial profile. In an ideal face, the upper
lip should be projecting 2 mm beyond the lower lip, whereas the lower lip should be projecting the same
distance beyond the chin. 14 Riedel’s line is a rapid means of assessing the adequacy of chin projection. A
line is drawn tangential to the upper lip and lower lip and the chin should fall on this line (Figure 54.3).
Men tend to have larger, more projected chins compared to women. Placing too large of an implant in a
woman can have an unattractive masculinizing effect and should be avoided. 14–16
FIGURE 54.3 Riedel line.
An ideal chin implant is one that augments the mentum while merging laterally with the anterior aspect
of the mandibular body. As with skeletal augmentation of other facial areas, implant materials used are
either porous or smooth (see Alloplastic Materials section). Extended porous implants have limited
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flexibility and are typically designed in two pieces to allow placement through a reduced incision. 16
Chin implant insertion can be performed through a submental or an intraoral incision (Figure 54.4).
However, we use the submental incision exclusively. The intraoral incision avoids an external scar but
provides limited exposure of the anterior mandible. In addition, the intraoral incision is associated with
superior malposition of the implant and soft-tissue ptosis, and in our opinion it should be avoided. 16 This
is usually secondary to improper mentalis muscle repair at the time of wound closure and results in a
witch’s chin deformity. 17 Regardless of the incision being used, care should be taken to identify and
protect the mental nerves during subperiosteal dissection.
FIGURE 54.4 Representation of a preferred technique for chin augmentation. Through a submental approach, a two-piece
porous polyethylene implant is fixed to the skeleton with titanium screws. This maneuver immobilizes the implant and
obliterates any gaps between the implant and the underlying bone. The implant is being contoured to provide an imperceptible
implant-native mandible transition.
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Other (Body/Angle/Ramus)
Although chin augmentation remains the most popular type of mandibular augmentation, certain patient
populations may benefit from augmentation of other areas. Yaremchuk identifies two main groups of
patients who usually seek such enhancement. The first group includes individuals who display normal
mandibular dimensions in relation to other facial thirds. They perceive a wider lower face as more
attractive and want to emulate the more angular lower face seen in models and actors. The other group
includes those who have an actual deficiency of the mandibular skeleton. They may have a normal
occlusion or may have had malocclusion previously corrected by orthodontics alone. In these patients,
mandibular augmentation of the ramus and body is often paired with an extended chin implant to
address poor mental projection. 18
An intraoral mucosal incision provides adequate exposure of the mandibular ramus and body in the
subperiosteal plane. It can be extended anteriorly if concomitant chin augmentation is being performed.
Care must be taken to identify and visualize the mental foramen. Screw fixation of the implants can either
be done intraorally or through a percutaneous incision for trocar placement (Figures 54.5 and 54.6). A
suction drain is usually placed in the operative site which exits through the postauricular area. 18
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FIGURE 54.5 A. Intraoperative photograph following placement of polyethylene gonial angle implant through an intraoral
buccal sulcus incision. The periosteum is stripped and the implant is contoured to the appropriate shape and taper. The implant
was fixed in place using two screws flush with bone by two titanium screws, one into the gonial angle and the other cephalic in
the mandibular ramus. B. An intraoperative photograph demonstrating the location of the buccal sulcus incision that was utilized
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to perform gonial angle implant placement. It is important to leave an adequate mucosal cuff on the lingual side of the incision in
order to get a good watertight closure. This photo is taken at the end of the operation demonstrating a multilayered closure.
FIGURE 54.6 A, B. An 18-year-old female had a chin implant placed for sagittal microgenia by another surgeon: preprocedure
(left) and 4 months postprocedure (right) photographs. C, D. At age 22, the patient was not satisfied with the aesthetic result, so
the chin implant was removed and horizontal advancement genioplasty for sagittal and vertical microgenia was performed:
preprocedure (left) and 11 months postprocedure (right) photographs. E, F. At 23, the patient underwent gonial angle implant
placement and mandibular fat grafting for jawline contour augmentation: preprocedure (left) and postprocedure (right)
photographs. The postprocedure photo is 7 months following the gonial angle implant placement and 4 months following
mandibular fat grafting.
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Complications in Alloplastic (Implant) Augmentation
Alloplastic implant complications include infection, migration, malposition, and asymmetry. Serious
complications after alloplastic augmentation of the facial skeleton are rare. Bone resorption of adjacent
areas has been reported and is associated with solid implants. Bone resorption is significantly less likely
with porous implants. 19 In his series of 162 patients, Yaremchuk reported an acute infection rate for
implants of 2%. The total reoperation rate was 10% and mostly due to implant malposition, asymmetry,
or displeasing contours. If implant infection does occur, antibiotic treatment alone is usually not
sufficient. In such cases, implant removal is recommended along with an antibiotic regimen. Implants can
be replaced at 12 months after infection cessation. 19
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Osseous Genioplasty
The horizontal genioplasty remains as the second most commonly performed osteotomy of the facial
skeleton, next to rhinoplasty. 20 Compared to prosthetic chin implants, osseous genioplasty allows for a
more powerful and versatile alteration of chin morphology and shape. This includes not only correction
of sagittal deficiency, but also can include vertical lengthening, reduction, and correction of asymmetries.
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Anatomy
To ensure a safe and predictable result in osseous genioplasty, knowledge of muscle attachments and
adjacent neurovascular structures is important. The three muscles that attach to the anterior plane of the
chin include: mentalis, depressor angularis, and depressor labii inferioris. Equally important are muscle
attachments on the lingual aspect of the chin, which include mylohyoid, geniohyoid, and genioglossus. It
is the latter group that contains the perforating branches responsible for maintaining blood supply of the
caudal chin segment following elevation of the anterior periosteum and horizontal osteotomy.
An important structure that is vulnerable to injury during soft-
 tissue dissection and osteotomy is the
mental nerve. A continuation of the inferior alveolar nerve, it exits the mandible via the mental foramen.
The latter is located in the vertical plane between the first and second mandibular premolars. To avoid
injury to the mental nerve, the horizontal osteotomy should be planned at least 5 mm caudal to the
foramen in a caudal-oblique angle. The mental nerve makes a gentle curve as it approaches the mental
foramen. Therefore it lies caudal to the foramen distally and can be injured if a bone cut is made just
below the foramen. 21,22
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Limitations of Alloplastic (Implant) Augmentation
Those favoring alloplastic augmentation over osseous genioplasty cite several theoretical advantages
including: technical ease, less pain, and a relatively low complication risk. Conversely, the horizontal
genioplasty offers potential correction in multiple planes, anterior, posterior, and vertical. Alloplastic
augmentation with chin implants can be effective in correcting mild to moderate volume deficiencies in
the sagittal plane. Major limitations of alloplastic methods occur when trying to correct vertical excess or
any asymmetries of the anterior mandible. Furthermore, osseous genioplasty is more amenable to
surgical revision if such a condition is indicated. In the latter, soft tissue of the chin has not been degloved
and there is no scar capsule formation to address. 16,23
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Preoperative Evaluation and Indications
It is important to note that genioplasty is performed solely to address chin disharmony and should not be
seen as a replacement to orthognathic surgery. Proper preoperative evaluation should include a complete
history and physical examination with special attention to the occlusion. Specific complaints and cosmetic
objectives need to be discussed with the patient. The surgeon should also inquire about previous
orthodontic treatments or prior orthognathic surgery. Comorbid conditions and anesthetic
contraindications are to be weighed in the decision to perform surgery.
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Physical Examination
Physical examination should include appreciation of chin projection, symmetry, and vertical length. In
assessing the vertical dimension of the chin, the lower third of the face should be subdivided using a line
passing through the stomion (Figure 54.7). The distance from the stomion to the menton should be twice
the length of the distance between the subnasale and the stomion.
FIGURE 54.7 Lower facial third division.
Chin projection is better assessed in the profile view using Riedel’s plane. In the latter, a line is drawn
tangential to the upper and lower lip (see Figure 54.3). In a balanced face, this line should touch the most
prominent anterior portion of the pogonion. Chin position in relation to Riedel’s plane dictates the
amount of horizontal microgenia or macrogenia present. 20,24 The lower lip, and not the other structures in
the mid and upper face, determines the extent to which the chin should be advanced. 20 In the sagittal
dimension, it is always preferable to undercorrect than overcorrect, resulting in an aesthetically
displeasing outcome. When advancing the chin, the ratio of soft tissue to skeletal displacement is
generally 3:2. Conversely, the response of soft tissue to a posteriorly repositioned chin is less predictable
and typically 0.5:1. 20,24
Labiomental groove depth should also be evaluated when determining if a patient is a good candidate for
osseous genioplasty; it should measure 4 mm in women and 6 mm in men. Sagittal advancement or
vertical shortening of the symphyseal segment would result in deepening of the labiomental groove.
Conversely, vertical lengthening softens the labiomental crease (Figure 54.8). In the setting of a long lower
face and a deep labiomental fold, correction should include orthognathic surgery rather than osseous
genioplasty alone. 20
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FIGURE 54.8 Preprocedure (left) and postprocedure (right) photographs of a 55-year-old man who underwent vertical
lengthening genioplasty. Note the improvement in lower vertical faical height and softening of the labiomental crease. The
postprocedure photo is 2.5 years after the operation.
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An intraoral examination should be performed to evaluate occlusion and presence of any significant
periodontal disease. The majority of individuals requesting aesthetic enlargement of the chin have class II
malocclusion secondary to mandibular retrognathia. Although prior orthodontic treatment can convert
class II malocclusion into type I, it corrects the underlying skeletal problems. 20 Routine workup includes
a lateral cephalometric and panoramic x-ray and frontal, profile, and oblique photographs at a minimum.
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Surgical Technique
Operative Approach
Although osseous genioplasty can be performed under local anesthesia with intravenous sedation,
general anesthesia with either orotracheal or nasotracheal intubation is recommended. Prior to incision,
the chin is infiltrated using xylocaine with epinephrine solution. An incision is planned at least 1 cm
away from the mandibular buccal sulcus and is 2 to 4 cm in length. The mentalis muscle is exposed after
incising the mucosa and submucosa. Maintaining a 1 cm cuff of mucosa and mentalis in the gingival side
of incision will facilitate later muscle repair and incision closure. After muscle division, subperiosteal
dissection of the anterior mandibular symphysis is performed. Inferior dissection is performed only far
enough for sufficient exposure to performing the osteotomy and subsequent fixation. Complete
degloving of the symphysis is not preferred as reattachment of soft tissues can be unpredictable,
increasing the risk for a witch’s chin deformity. 17 Exposure is carried laterally until both mental nerves
are visualized and posteriorly to the inferior border of the mandible, but not further.
Prior to performing any osteotomies, the chin midline is marked with a bone bur for proper positioning
of symphyseal bone segments at the time of fixation. Horizontal osteotomy should be performed using a
reciprocating saw at least 4 mm below the mental foramina to avoid nerve injury. Retractors can be used
to protect the nerves. The osteotomy is then carried as far posteriorly as possible to prevent excessive
visibility of step-offs in the inferior mandible border. If extensive anterior movement of the chin segment
is anticipated, it might be necessary to detach the anterior belly of the digastric muscles from the lingual
surface. After proper mobilization is achieved, fixation of the bone segment is performed with either plate
and screws or wires (Figure 54.9). 22,23 A temporary drill hole and wire through the anterior surface of the
mobilized segment allows easy handling of the osteotomy.
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FIGURE 54.9 Intraoperative photograph demonstrating screw and plate fixation of a horizontal advancement genioplasty.
Osteotomy patterns vary depending on the type of chin deformity to be corrected (Figure 54.10). For
vertical shortening of the chin, two parallel horizontal osteotomies with removal of the intervening bone
segment are used. The inferior cut is always made first for ease of handling. Conversely, if vertical
elongation is needed, interposing blocks of bone substitute can be inserted into the osteotomy gap
previously created. 22,23 A gap of less than 5 mm needs no interposition implant.
FIGURE 54.10 A. Standard location and orientation of the advancement osseous genioplasty. Note that the osteotomy is
placed well below the mental foramina to avoid injury to the inferior alveolar nerve. The osteotomy extends well posterior to the
vicinity of the molar teeth. The angulation of this osteotomy allows forward advancement of the chin without any vertical
changes. B. Simultaneous advancement and vertical reduction of the chin. Note that the two parallel osteotomies are performed
with an intervening ostectomy. C. Simultaneous advancement and vertical elongation of the chin. The interpositional material
typically employed includes blocks of porous hydroxyapatite. D. Lateral shifting of the symphyseal segment to restore lower
face symmetry.
After appropriate bony fixation is obtained, the wound is irrigated with either dilute povidone-iodine
solution or antibiotic irrigation. Mentalis muscle is then reattached using interrupted sutures, a crucial
step in preventing soft-tissue ptosis and a witch’s chin deformity. 17 Mucosa is then repaired using
chromic sutures until watertight closure is achieved.
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Complications in Osseous Genioplasty
Wound dehiscence and infection are rare after osseous genioplasty. In the setting of a dehiscence without
infection and with no loose or exposed hardware, most resolve without intervention. If infection is
suspected and bone fixation is not loose, localized debridement and irrigation followed by antibiotics
serve to avoid unnecessary removal of hardware. Because this is a vascularized osteotomy, the bone is
not at risk. Hematomas should be promptly evacuated to prevent abscess formation.
More than half of all patients undergoing osseous genioplasty will have some degree of temporary
neurosensory loss. Most of these are due to traction and should return days to weeks after the operation.
If the nerve is cut during surgery, it should be repaired.
Dental complications can also occur. Root exposure can occur if incision is placed too close to the gingiva
and is most likely in patients with gingival resorption. It presents as a caudal retraction of gingival tissue
and results in exposure of the sensitive portion of teeth. Gingival grafting might be needed to treat such a
complication. Tooth devitalization is probably one of the most serious complications after osseous
genioplasty and can be avoided by placing the osteotomy at least 30 mm caudal to the occlusal edge of
the mandibular canines. 22
Soft-tissue ptosis is usually secondary to improper mentalis muscle repair at the time of wound closure
and results in a witch chin’s deformity. It can be corrected by excising soft tissue through an elliptical
incision in the submental area. Lower lip retraction resulting in increased lower incisor show can also
occur secondary to improper mentalis muscle repair. Correction can be achieved through an intraoral
incision and cephalically suspending anterior periosteum. 17,25
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Questions
1. Riedel’s plane corresponds with a line connecting the most projected points of the upper and lower
lip to what structure?
a. Nasal tip
b. Labiomental crease
c. Pogonion
d. Base of nasal ala
2. Inadequate reapproximation of the mentalis muscle following genioplasty surgery can lead to
what deformity?
a. Inability to depress the oral commissure
b. Inability to pucker lips
c. “Witch’s chin” abnormality
d. Decreased ability to suck from a straw
3. Which of the following tooth root apexes is at greatest risk for damage during osteotomy at the
time of sliding genioplasty?
a. Bicuspid
b. Central incisor
c. Lateral incisor
d. Canine
e. First molar
4. A 22-year-old man is evaluated for lower facial asymmetry. He is scheduled to undergo sliding
genioplasty. At the time of osteotomy, the nerve more likely to be injured exits mandible adjacent to
what landmark?
a. Canines
b. Between lateral and central incisors
c. Between second and third molar
d. Between first and second premolars
e. Between lateral incisors and canines
5. A 34-year-old woman with class I occlusion comes for orthognathic evaluation. She is displeased
with her lower face profile. On examination, isolated retrogenia and moderate vertical mandibular
excess are noted. Which is the most appropriate genioplasty for this particular patient?
a. Advancement with horizontal osteotomy only
b. Advancement with inferiorly angled osteotomy
c. Alloplastic augmentation, extraoral approach
d. Alloplastic augmentation, intraoral approach
e. Advancement with horizontal osteotomy and downgrafting
1. Answer: c. Riedel’s line is a rapid means of assessing the adequacy of chin projection. A line is
drawn tangential to the upper lip and lower lip and the chin should fall on this line (see Figure 54.3).
2. Answer: c. During wound closure in genioplasty, the mentalis muscle is then reattached using
interrupted sutures; this is a crucial step in preventing soft-tissue ptosis and a witch’s chin deformity.
If this deformity occurs, it can be corrected by excising soft tissue through an elliptical incision in the
submental area.
3. Answer: d. The canine tooth root is the longest tooth root and therefore is at risk during sliding
genioplasty. Tooth devitalization is probably one of the most serious complications after osseous
genioplasty and can be avoided by placing the osteotomy at least 30 mm caudal to the occlusal edge
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of the mandibular canines.
4. Answer: d. The mental foramen is located between the first and second premolars. Note that the
mental nerve makes a gentle curve as it approaches the mental foramen. Therefore, it lies caudal to
the foramen distally and can be injured if a bone cut is made just below the foramen. Horizontal
osteotomy should be performed using a reciprocating saw at least 4 mm below the mental foramina
in order to avoid nerve injury.
5. Answer: b. This patient has microgenia and therefore needs horizontal advancement. Given that
she has vertical excess of the mandible, an angled osteotomy, and possible wedge excision can be
performed to help normalize vertical height of the mandible. Patients with retrogenia and vertical
mandibular deficiency would be best suited for genioplasty and downgrafting to increase vertical
mandibular height (answer e). Patients with normal mandible vertical height and isolated microgenia
would receive a horizontal advancement without vertical height manipulation.
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References
Farkas, LG, Kolar, JC. Anthropometrics and art in the aesthetics of women’s faces. Clin Plast Surg. 1987;14:599.Classic article exploring the
importance of anthropometric dimensions in female face aesthetics.
Chen, NT, Glowacki, J, Bucky, LP, et al. The roles of revascularization and resorption on endurance of craniofacial onlay bone grafts in the
rabbit. Plast Reconstr Surg. 1994;93:714.
Saulacic, N, Bosshardt, DD, Jensen, SS, et al. Impact of bone graft harvesting techniques on bone formation and graft resorption: a
histomorphometric study in the mandibles of minipigs. Clin Oral Implants Res. 2015;26(4):383-391.
Maas, CS, Merwin, GE, Wilson, J, et al. Comparison of biomaterials for facial bone augmentation. Arch Otolaryngol Head Neck Surg.
1990;116:551-556.
Yaremchuk, MJ, Chen, YC. Enlarging the deficient mandible. Aesth Surg J. 2007;27(5):539-550.
Carboni, A, Gasparini, G, Perugini, M, et al. Evaluation of homologous bone graft versus biomaterials in the aesthetic restoration of the
middle third of the face. Minerva Chir. 2002;57(3):283-287.
Whitaker, LA. Aesthetic augmentation of the malar midface structures. Plast Reconstr Surg. 1987;80:337.Another classic article that reviews
various preoperative and technical aspects of facial aesthetic augmentation with a focus on the midface.
Yaremchuk, MJ, Israeli, D. Paranasal implants—correct midface concavity. Plast Reconstr Surg. 1998;102:1676-1684.
Yaremchuk, MJ. Secondary malar implant surgery. Plast Reconstr Surg. 2008;121:620.Offers a complete examination of how to deal with implant-
related complications of the malar area, with a focus on secondary revision surgery.
Jelks, GW, Jelks, EB. The influence of orbital and eyelid anatomy on the palpebral aperture. Clin Plast Surg. 1991;18:193.
Yaremchuk, MJ. Infraorbital rim augmentation. Plast Reconstr Surg. 2001;107:1585.
Vaca, EE, Purnell, CA, Gosain, AK, Alghoul, MS. Postoperative temporal hollowing: is there a surgical approach that prevents this
complication? A systematic review and anatomic illustration. J Plast Reconstr Aesthet Surg. 2017:70(3):401-415.
Gordon, CR, Yaremchuk, MJ. Temporal augmentation with methyl methacrylate? Aesthet Surg J. 2011;31(7):827-833.
McCarthy, JG, Ruff, GL. The chin. Clin Plast Surg. 1988;15:125.
Flowers, RS. Alloplastic augmentation of the anterior mandible. Clin Plast Surg. 1991:18:107-137.
Yaremchuk, MJ. Improving aesthetic outcomes after alloplastic chin augmentation. Plast Reconstr Surg. 2003:112(5):1422-1432.
Zide, BM. The mentalis muscle: an essential component of chin and lower lip position. Plast Reconstr Surg. 1989;83:413.Emphasizes the
importance of properly repairing the mentalis muscle when using an intraoral approach. Describes technique and potential pitfalls.
Yaremchuk, MJ. Mandibular augmentation. Plast Reconstr Surg. 2000;106:697.
Yaremchuk, MJ. Facial skeletal reconstruction using porous polyethylene implants. Plast Reconstr Surg. 2003;111(6):1818-1827.Extensive single
surgeon experience of 162 patients undergoing facial skeletal augmentation. An excellent review of potential complications and their management.
Rosen, HM. Aesthetic guidelines in genioplasty: the role of facial disproportion. Plast Reconstr Surg. 1995;95:463.
Hwang, K, Lee, W, Song, Y, Chung, I. Vulnerability of the inferior alveolar nerve and mental nerve during genioplasty: an anatomic study. J
Craniofac Surg. 2005;16(1):10-14.
Ousterhout, D. Sliding genioplasty: avoiding mental nerve injuries. J Craniofac Surg. 1996:7(4):297-298.
Sawkat, S, Havlik, RJ. An evidence-based approach to genioplasty. Plast Reconstr Surg. 2011:127(2):898-904.
Michelow, B, Guyuron, B. The chin: skeletal and soft-tissue components. Plast Reconstr Surg. 1995;95(3):473-478.
Chashu, G, Blinder, D, Taicher, S, Chaushu, S. The effect of precise reattachment of the mentalis muscle on the soft tissue response to
genioplasty. J Oral Maxillofac Surg. 2001;59(5):510-516.
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PA R T V I
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