High cheekbones and a strong jaw line have had a long history of allure.  Chin and cheek implants enhance a facial profile by improving the overall proportion and balance of the face.  With chin implants (mentoplasty), the face can be shaped and the profile improved.  Cheek implants (malarplasty), also known as malar (high cheek) or submalar (low cheek) augmentation, can add shape and definition to the face.  Utilizing permanent chin and cheek implants can provide a rejuvenated, youthful facial profile.

Reasons for Considering a Chin and/or Cheek Implant:

• Extend or enlarge the chin if the chin is recessed or small.
• Create a more defined facial profile if the jaw, chin, or cheeks lack distinction.
• Bring the various aspects of the face into proportion.
• Round out the cheeks if they are hollow due to heredity or aging.
• Accent the upper cheeks making them appear higher and fuller.

General Procedure

With chin surgery, an implant is inserted in front of the jawbone in order to augment the chin or jaw.  A small incision is made inside the mouth to allow the implant to be positioned in a pocket just under the skin.  An alternate location for this incision is below the chin (on the outside).  Chin surgery is commonly performed along with rhinoplasty (nose surgery).  With cheek augmentation, incisions are usually inside the mouth.  Cheek implant surgery may also be performed in conjunction with a facelift.  

Recovery Process

Immediately after surgery, the face may have bandages or tape.  Generally, post-operative instructions call for rest and limited movement.  Keeping the head elevated during the initial recovery phase is also important.  Patients may experience some swelling and bruising of the face which can be eased by using cold compresses on the first day.  A liquid diet may be required for a few days, as chewing may be difficult.  While complications are rare, patients can minimize potential problems by carefully following the post-operative directions given after surgery.  The substance used for chin and cheek implants is made of durable material that the body doesn't reject.

CHIN SURGERY

The chin is rather simple anatomically, and it would seem simple to alter in any dimension. And yet it is deceptively complex in its interrelationships with surrounding structures. Although there are a number of analyses to describe the perfect the chin, surgical correction to ideal is not always necessary or even indicated. Surgery on the chin, called genioplasty, ranges from simply placing an implant, to surgery and/or orthodontic procedures not directly involving the chin itself. To three dimensionally harmonize the chin with other facial features is the goal. A brief review of the influences of various factors affecting chin contour will illustrate the preoperative evaluation.

If the maxilla is vertically long (vertical maxillary excess), the chin appears deficient, as it is rotated posteriorly almost as much as the excess maxillary height. The converse is true regarding the “short face syndrome”, which rotates the chin antero-superiorly. As the maxillary anterior teeth support the lips, the anterior-posterior position of the maxilla is also important. Naturally, the overbite and overjet relationship is also key factors, as are upper and lower incisor show.

Normally, the lower lip is slightly posterior to the upper lip, but on the same vertical line as the chin prominence in Caucasians. The lower lip posture, thickness, angulation and height (from the labiomental fold) are major factors affecting chin appearance. For example, if the labiomental fold is relatively high, the usual dimensions of a chin implant or chin advancement would cause the chin to appear overly large. If the lower lip is vertical, rather than having a normal forward inclination, then reduction of the chin prominence would obliterate the labiomental fold.

If the distance from the neck to the chin is short, then reduction of chin prominence would not optimize the profile - even if the chin is prominent in relation to the rest of the face. The same is true if the throat angle, from neck to submental area, is oblique.

Finally, the chin pad itself is evaluated. Multiple skin irregularities may be due to mentalis muscle contracture (“mentalis strain”), caused by lip incompetence. If this is the case, lip incompetence must be addressed primarily, usually by decreasing lower facial height or correction of incisor procumbency. The normal chin pad thickness is 8 to 11 millimeters. And yet, surgical alteration of chin pad thickness is fraught with risks of irregular contours

Evaluation of the chin during animation, especially while smiling, is also important. Some people have a horizontal smile, which can be associated with flattening and downward movement of the chin, causing a drooping (ptosis) of the chin below the submental contours. Others have chin ptosis without smiling, and for a few, this ptosis is a complication of prior chin surgery, such as removal of a chin implant. The classic ptotic “witch’s chin” can be improved by removal of some submental subcutaneous tissue, often with simultaneous placement of a small chin implant. When chin ptosis is due to loss of anterior mandibular ridge height, causing loss of some of the mentalis muscle origin, correction is much more difficult^{1, 2, 3}.

Most commonly, patients desire more chin prominence. And if evaluation reveals that the occlusion and other facial proportions are normal, adding to chin prominence is simpler and less risky than other dimensional changes. The primary methods of increasing chin prominence are placement of a chin implant, or a sliding advancement genioplasty. Each procedure has its benefits and risks. To place an implant is surgically simple and inexpensive, and often the long-term benefits are significant. A variety of sizes and shapes are available, such as”extended contour” implants which also augment the part of the mandibular border just posterior to the chin itself. Silicone implants (which this author does not use) can cause resorption of the underlying bone and even devitalize lower incisors. Although some surgeons feel that they can prevent this through “proper” implant placement, other authors not believe this can be prevented except by using different materials. Imperfect implant placement, rotation of the implant, interference with mental nerve function (paresthesia), loss of mentalis muscle support (ptosis), worsening of mentalis strain and lower lip position, damage to teeth or periodontal structures, and infection are other potential problems with chin implants.

Bony osteotomy and sliding genoiplasty has the advantage of tightening the digastric sling, which improves neck contour. The angle of the osteotomy is important, as it affects vertical chin movement. There are multiple variations to address specific problems. The risks are somewhat similar to implant placement. Sliding genioplasty causes an offset along the mandibular inferior border below the bicuspid region, and this can be problematic for some people, depending on the amount and direction of bone movement. However, the final profile is natural and predictable with this method. In addition, the vertical height and the width of the chin can be addressed, at least to a moderate extent, with sliding genioplasty. Graft material can be placed between segments, or into bone step-offs created by the osteotomy. If bony chin height is reduced excessively (by removal of bone between segments), the excess soft tissue may become ptotic. Caution must be observed when the genioplasty segment is moved posteriorly, as this may loosen the digastric sling, causing a worsening of neck contour. And such posterior movement may result in visible or quite palpable bony prominences at the ends of the osteotomy along the mandibular inferior border.

Removing and contouring excess bone from a prominent pogonion is less predictable than the methods for chin augmentation described above. And reduction of the facial skeleton can have an “aging effect” for some people because excess soft tissue and skin can result. However, this method can be used to improve chin contour without having an adverse effect on the neck or mandibular border. It can also remove “square” edges from the bony chin.

If the chin soft tissue pad is unusually thick, the periosteal surface of this tissue can be contoured if no other technique appears reasonable. But there is a risk of irregular contour, mentalis muscle fasciculations, and mentalis muscle malfunction or ptosis of the chin. There is, as yet, no ideal soft tissue filler to soften the labiomental fold when adjacent structures do not require modification. There are several methods of producing the midline chin dimple (Kirk Douglas chin) by contouring the chin pad. When a dimple occurs in the center of the chin naturally, it is due to a separation of the mentalis muscles. Normally, these muscles decussate extensively in the midline.

Thus, the chin, like other body parts, can be changed significantly in size, shape and position, but not without risks or modification of adjacent structures. The chin is an important facial component.

1. Zide, B. M., Pfeifer, T. M., and Longaker, M. T. Chin surgery I: Augmentation – The allures and alerts. Plast. Reconstr. Surg. 104: 1843, 1999

2. Zide, B. M., Longaker, M. T. Chin Surgery II: Submental Ostectomy and soft tissue excision. Plast. Reconstr. Surg. 104: 1854, 1999

3. Zide, B. M., Boutros S., Chin surgery III: Revelations. Plast. Reconstr. Surg. 111: 1542, 2003