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Chin up

Article-Chin up

Key iconKey Points

  • More chin implants are being performed in conjunction with other cosmetic facial rejuvenation procedures
  • However, surgeons can also expect to see more patients with implant-related complications, including bony erosion secondary to a silicone implant

Dr. Wood-Smith
NEW YORK — With growing appreciation that chin augmentation can enhance the outcome for some patients undergoing cosmetic facial rejuvenation procedures and a desire to meet that need with minimally invasive techniques, more chin implantations are being performed. However, as a result, surgeons can anticipate seeing an increasing number of patients with implant-related complications. As with all cosmetic procedures, proper patient selection and meticulous surgical technique are the keys to avoiding complications.

Donald Wood-Smith, M.D., F.A.C.S., F.R.C.S.Ed., and Sharon Giese, M.D., F.A.C.S., spoke with Cosmetic Surgery Times about chin augmentation and managing implant-related complications.


Dr. Giese
Both Dr. Wood-Smith and Dr. Giese strongly favor using a silicone implant over the porous material devices that are available because the fibrovascular tissue ingrowth allowed by the latter can make them difficult to remove if explantation is necessary. However, both doctors believe bony erosion, which is rare but one of the most significant complications of chin implant surgery, is more likely with the silicone implants. PATIENT SELECTION Dr. Wood-Smith, chairman, Department of Plastic Surgery, New York Eye & Ear Infirmary, and a private practitioner in New York, says that he first saw patients with bony erosion secondary to a silicone implant over three decades ago, 12 to 24 months after the devices first became available. Since then, he continues to see one or two cases a year. Dr. Wood-Smith estimates that in at least 90 percent of individuals who develop erosion, poor patient selection is the underlying cause.

"Bony erosion occurs when the implant is pushed into the mandible because of excessive overlying pressure, and it may even result in impingement on the nerve roots of the teeth. Therefore, first and foremost, surgeons need to consider the skin tension across the chin — there should be some laxity — and whether the implant size considered can be safely accommodated given the skin tension," explains Dr. Wood-Smith.

As a corollary, the amount of advancement needed should be taken into consideration. Candidates for an implant are individuals who would benefit from a modest increase in chin projection because they will not require an excessively large implant. "The best candidate for a chin implant is the young woman or man who comes in for a rhinoplasty, has a fairly well-balanced facial structure, but who is determined during review of the planning photos as likely to benefit with a slight amount of chin augmentation. Some individuals need a more significant increase in projection, but use of a large implant is just asking for trouble. In my opinion, a horizontal osteotomy [sliding genioplasty] is a better procedure in that situation," Dr. Wood-Smith says.

A horizontal osteotomy is also the proper corrective procedure, after implant removal, for a patient who presents with bony erosion from a silicone implant, Dr. Wood-Smith says.

"Once the implant has eroded back into the bone, the roots of the teeth are placed at risk if they are not impinged on already. Whether the implant will continue to erode back is anybody's guess, but I believe in that situation it is unreasonable to leave the implant in place. The fact that there is a significant amount of bony erosion already is indicative that the implant has been subject to an amount of pressure that is greater than ideal. The sliding genioplasty will better stretch the skin envelope and seems to better resist pressure from the overlying tissues," he says.

Implant migration is another complication that can occur with chin implants, and that problem is associated with an error in surgical technique. Dr. Wood-Smith believes it is secondary to dissecting a too-large pocket rather than failing to anchor the implant.

SURGICAL TECHNIQUE Both Dr. Wood-Smith and Dr. Giese prefer performing the implantation using an intraoral approach. Compared with insertion through an external submental incision, the intraoral approach completely avoids any visible scar, takes less time, and requires no fixation techniques if the pocket is properly dissected.


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