California Society of Plastic Surgeons
Annual Meeting 1987 Chin Augmentation combined with Submental Lipectomy and Platysma Approximation
Fred Suess, M.D. San Francisco, California
The lower third of the facial profile, consisting of the lower lip, chin and submental area plays a critical role in the Aesthetic Evaluation of the face. In the assessment of this unit, the neck is essentially always included. The inseparable quality of this region is underlined by the emphasis made in our literature on cervico-facial rhytidemtomy.
The purpose of this presentation is to demonstrate the synergism that chin augmentation combined with submental lipectomy and platysma approximation can have in enhancing the lower third of the facial profile.
Mario Gonzalez-Ulloa emphasized the role of the chin n profile plasty. He reviewed the application of the Frankfort plane and zero meridian of the face to evaluate chin refraction. Treatment of hypogenia with implant augmentation is a long standing, well established aesthetic procedure. Many authors including Gonzalez- Ulloa (May 1986), Pitanguy (Nov. 1068), Snyker, Couters, Kaye and Gradinger (June 1978) have written extensively on this subject.
Snyder and other have also presented papers on cervico-Mentoplasty with Rhytisectomy (oct. 1974), as well as submental Rhytidectomy. (Nov 1978) - They emphasized the importance of cervico-mental aesthetics.
Connell (In March 1978) emphasized the importance of "contouring" the neck in rhytidectomy by lipectomy and a muscle sling.
In December 1980, Ellenbogen and Karlin presented extensively on restoring the youthful neck. Singer, in 1983, demonstrated very nicely his technique for treatment for the "young" fatty neck, and in 1984, Lewis indicated his experience in applying liposuction to "Lipoplasty of the neck". Whether by liposuction or direct excision, this is an effective method of contouring of the neck and submental area.
Chin augmentation via a submental incision is a very effective means to treat hypogenia as well as lengthen the lower third of the face. (Chan)
Combining mentoplasty with Cervico-Facial Rhytidectomy is a useful adjunct in enhancing results in appropriate patients. (Anita Gaspar)
Patients with adequate chin projection who have submental-cervical fullness, but who do not desire rhytidectomy, submental lipectomy with platysma placation offers a viable alternative. (Krasny) I would like too describe my technique and experience with fifteen patients in whom chin augmentation was combined with submental lipectomy and plastysma approximation. Rhytidectomy was not performed in any of these patients either because the surgeon judgment, the patients desire, or a combination of both. (Meeker)
The area to be undermined and defatted is marked pre-operatively. The appropriate pre-operative markings for the chin augmentation are also made including the midline and desired line of greatest projection. In addition, the inferior margin of the mandible is also marked. When the chin augmentation pocket I dissected, this line is hugged as closely as possible in order to avoid injury to the mental nerves. A 2.5 to 3 cm Linear incision is made just inferior to the submental crease. The submental and cervical skin is undermined leaving a thin layer of fat on the skin flaps.
I find it most effective to perform, as much as possible, an EN-Block surgical submental-cervical lipectomy. Once the bulk of fat has been excised, additional scissor and forceps trimming and contouring is performed. At this point, if there is loose redundant tissue on medial border of the platysma it is trimmed. After this, the platysma is undermined in the area that a wedge excision is to be made. This wedge is excised at the level diagrams the pre-operative marking indicates a desired opening of the cervico-mental angle. If submental fat is present, it is also trimmed, but cautiously, so as to not produce an excessive hollow. Insulated forceps and the bovie are used to obtain hemostasis. At this point, Liposuction is used to additionally defat and contour laterally and inferiorly. If any septal bands appear to create dimpling or teatering they are cut. At this point, any surface irregularities are treated by excision under direct vision or suctioned. Most commonly, a 3 cm, 3 holded cannula is sued. The medial borders of the platysma are plicated from the submental incision down to the platysma wedge excision with interrupted inverted 3-0 nylon sutures. A moist gauze is placed over the dissected tissue and attention is directed to the chin augmentation. Using wide double skin hooks, the skin incision is deepened through the soft tissue down to the mandible with the cutting current of the bovie and scalpel. The central mention is dissected superiorly so as to allow comfortable seating of the implant. Narrow lateral extension pockets are made on the mandible to securely hold the implant.
Test sizers are used to evaluate which of the 4 sizers of the McGhan anatomical style 1 chin implants is to be used. Once this has been placed and judged satisfactory, it is secured in the midline. The cervical area is rechecked for hemostasis. At this point, a double layered closure of the soft tissue over the implant is made and the skin is closed. Axeroform and telfa dressing is placed over the incision. Appropriate taping is placed over and around the implant. An elastic neck strap is placed over the submental and cervical area. All of the following procedures were performed under intravenous sedation and local anesthesia on an out-patient basis in the surgeon's office operating suite.
All of the patients are counseled with regard to a possible extended period of firmness and surface irregularities. In addition, possible mental nerve injury and risks of bleeding, infection and scar formation are reviewed. Patients with marginal skin tone are counseled extensively and when appropriate the benefits of combined Rhytidectomy are emphasized.
Post operatively, ultrasound and massage are used liberally starting the second post operative week. When needed, celestone soluspan is used to treat unresolving high spots or firm areas.
Complications include paresthesias and paresis of the lower lip lasting 2-4 weeks, none were permanent. Hematomas requiring evacuation occurred in one patient in the series of fifteen.
Advantages and disadvantages in patients with borderline skin tone the chin implant seems to pick up some of the laxity especially with patients over forty, thus achieving a satisfactory result. In selected, well counseled patients who are not candidates or do not desire a rhytidectomy, chin augmentation combined with submental lipectomy and platysma placation offers a safe, effective means of significantly enhancing the lower third of the facial profile.
Fred Suess M.D.
San Francisco, California