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Esthetic contouring of the mentolabial fold as an adjunct to the osseous sliding genioplasty
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J Oral Maxillofac Surg 55:1023-1025, 1997
Esthetic Con touring of the Men tolabial Fold as an Adjunct to the Osseous Sliding Genioplas ty LOUIS
S. BELINFANTE,
occlusal plane, starting at the inferior mandibular border just below the first molar. The corticotomy is made to a point in the midline, approximately 1.5 cm above the inferior border, depending on the esthetics the surgeon hopes to achieve. A similar cut is made on the contralateral side to join the first cut at the vertical midline reference line. Three right-angle retractors are introduced into the wound so that both the lateral end points at the inferior border and the midline can be visualized simultaneously. The corticotomies are visualized best if the operating table is dropped to its lowest point, and the surgeon looks down directly into the wound. If the bony cuts are correct, the table is returned to its prior position, and the corticotomy is converted into an osteolomy. The inferior segment is than advanced and positioned as determined preoperatively. If vertical reduction is needed, a parallel osteotomy is performed and the intervening wedge is removed. Stabilization of the inferior segment can be achieved with screws, wire, rigid fixation, or combinations. If increased chin height as well as horizontal advancement are needed, a “stepped’ ’ chin plate fixed with screws may be used in the midline, while wire fixation placed as far laterally as possible is used to achieve three-point stability. Once fixation has been accomplished, the implant (Medpore Biomaterial Wedge, Porex Surgical Inc, College Park, GA) is tried in its position. A 5-mm, 7-mm, or 9-mm wide implant is placed on the step created by the osteotomy (Fig 1). The implant is designed so that its inferior aspect is seated on the advanced segment, and the anterior portion of the wedge tapers backward as it rises superiorly so that it will fit under the reconstituted mentalis muscle. However, modifications in shape may need to be made on an individual basis. Before handling the implant, gloves should be thoroughly rinsed to rcmove powder and other foreign material. The implant should be placed in a basin of clear, sterile, physiologic saline (approximately 8 to 10 mL) to which 2
Many times when performing a genioplasty, the resultant mentolabial fold becomes too acute. This usually occurs because of the discrepancy between the residual mandible and the anterior sliding segment. To overcome this problem, an implant can be placed that obliterates the dead space above the newly created step and transforms a potentially acute mentolabial angle into one that is more obtuse and esthetic. The following is a description of this procedure. Technique With the patient under general anesthesia or heavily sedated, and with a local anesthetic containing epincphrine infiltrated into the proposed surgical site for pain reduction and hemostasis, a layered incision down to bone is made with an electrosurgical knife or scalpel approximately 1.5 cm inferior to and parallel with the attached gingiva. The lateral end points of the incision are in the area of the mesial aspect of the canine teeth bilaterally. A degloving procedure is performed down to the inferior mandibular border and laterally to the area of the second molars. Great care is used to identify, isolate, and avoid trauma to the mental neurovascular bundles. It is important to expose the inferior border as far posteriorly as the second molar region so that there is adequate visibility when the osteotomies are performed. This will aid in producing a symmetrical bone cut. A vertical corticotomy is made in the midline from the inferior border superiorly for approximately 1.5 to 2 cm. This cut will act as a reference mark when the inferior segment is moved anteriorly. A second corticotomy is created with the reciprocating saw at approximately right angles to the bone, and parallel to the * Private practice, Atlanta, GA. Address correspondence and reprint requests 200 Galleria Parkway, NW, Suite 1710, Atlanta, 0 1997 American
Association
to Dr Belinfante: GA 30339.
of Oral and Maxillofacial
DDS*
Surgeons
027s2391/97/5509-0024$3.00/0
1023
1024
FIGURE
ESTHETIC
1.
Anterior
view
CONTOURING
OF THE
MENTOLABIAL
FOLD
of the three sizes of implant.
Lincomycin (Upjohn Co, Kalamazoo, MI) has been added, assuming the patient is not allergic to the medication. If the surgeon wishes to alter the curvature, the implant will become more malleable in hot water. Once the surgeon believes that the implant is properly positioned and is tension free along with the proper curvature, fixation can be accomplished with screws placed on either side of the midline in the nonosteotomized segment (Fig 2). The skin is then redraped over the implant for final visualization of the symmetry and shape of the chin. Also, the relationship of the chin to the other facial subunits should
FIGURE retrogenia.
FIGURE
2.
Stabilization
of the implant
with
two screws.
3. A, Preoperative view of a 23-year-old woman with B, Postoperative view 15 months after the procedure.
be noted, as well as the total facial appearance. Once the surgeon is satisfied with these esthetic parameters, a double wound closure is always performed: muscle to muscle with 3-O chromic sutures and mucosa to mucosa with 3-O or 4-O chromic sutures. A systemic antibiotic, pain medication, and an antiinflammatory agent are usually prescribed postoperatively.
LOUIS
1025
S. BELINFANTE
Discussion In the last 20 months, nine implants have been placed without incident. To date, there have been no signs of postoperative infection, radiographic evidence of bone or tooth resorption caused by implant pressure,
and no dehiscence of the implant through the tissues or discernible physical movement. The implant has been accepted by the patient on both an esthetic and tactile basis. In all cases: an esthetic balance between the osteotomized segment and the mentolabial fold has been achieved (Fig 3).
‘
.
J Oral Maxillofac Surg 55:1023-1025, 1997
Esthetic Con touring of the Men tolabial Fold as an Adjunct to the Osseous Sliding Genioplas ty LOUIS
S. BELINFANTE,
occlusal plane, starting at the inferior mandibular border just below the first molar. The corticotomy is made to a point in the midline, approximately 1.5 cm above the inferior border, depending on the esthetics the surgeon hopes to achieve. A similar cut is made on the contralateral side to join the first cut at the vertical midline reference line. Three right-angle retractors are introduced into the wound so that both the lateral end points at the inferior border and the midline can be visualized simultaneously. The corticotomies are visualized best if the operating table is dropped to its lowest point, and the surgeon looks down directly into the wound. If the bony cuts are correct, the table is returned to its prior position, and the corticotomy is converted into an osteolomy. The inferior segment is than advanced and positioned as determined preoperatively. If vertical reduction is needed, a parallel osteotomy is performed and the intervening wedge is removed. Stabilization of the inferior segment can be achieved with screws, wire, rigid fixation, or combinations. If increased chin height as well as horizontal advancement are needed, a “stepped’ ’ chin plate fixed with screws may be used in the midline, while wire fixation placed as far laterally as possible is used to achieve three-point stability. Once fixation has been accomplished, the implant (Medpore Biomaterial Wedge, Porex Surgical Inc, College Park, GA) is tried in its position. A 5-mm, 7-mm, or 9-mm wide implant is placed on the step created by the osteotomy (Fig 1). The implant is designed so that its inferior aspect is seated on the advanced segment, and the anterior portion of the wedge tapers backward as it rises superiorly so that it will fit under the reconstituted mentalis muscle. However, modifications in shape may need to be made on an individual basis. Before handling the implant, gloves should be thoroughly rinsed to rcmove powder and other foreign material. The implant should be placed in a basin of clear, sterile, physiologic saline (approximately 8 to 10 mL) to which 2
Many times when performing a genioplasty, the resultant mentolabial fold becomes too acute. This usually occurs because of the discrepancy between the residual mandible and the anterior sliding segment. To overcome this problem, an implant can be placed that obliterates the dead space above the newly created step and transforms a potentially acute mentolabial angle into one that is more obtuse and esthetic. The following is a description of this procedure. Technique With the patient under general anesthesia or heavily sedated, and with a local anesthetic containing epincphrine infiltrated into the proposed surgical site for pain reduction and hemostasis, a layered incision down to bone is made with an electrosurgical knife or scalpel approximately 1.5 cm inferior to and parallel with the attached gingiva. The lateral end points of the incision are in the area of the mesial aspect of the canine teeth bilaterally. A degloving procedure is performed down to the inferior mandibular border and laterally to the area of the second molars. Great care is used to identify, isolate, and avoid trauma to the mental neurovascular bundles. It is important to expose the inferior border as far posteriorly as the second molar region so that there is adequate visibility when the osteotomies are performed. This will aid in producing a symmetrical bone cut. A vertical corticotomy is made in the midline from the inferior border superiorly for approximately 1.5 to 2 cm. This cut will act as a reference mark when the inferior segment is moved anteriorly. A second corticotomy is created with the reciprocating saw at approximately right angles to the bone, and parallel to the * Private practice, Atlanta, GA. Address correspondence and reprint requests 200 Galleria Parkway, NW, Suite 1710, Atlanta, 0 1997 American
Association
to Dr Belinfante: GA 30339.
of Oral and Maxillofacial
DDS*
Surgeons
027s2391/97/5509-0024$3.00/0
1023
1024
FIGURE
ESTHETIC
1.
Anterior
view
CONTOURING
OF THE
MENTOLABIAL
FOLD
of the three sizes of implant.
Lincomycin (Upjohn Co, Kalamazoo, MI) has been added, assuming the patient is not allergic to the medication. If the surgeon wishes to alter the curvature, the implant will become more malleable in hot water. Once the surgeon believes that the implant is properly positioned and is tension free along with the proper curvature, fixation can be accomplished with screws placed on either side of the midline in the nonosteotomized segment (Fig 2). The skin is then redraped over the implant for final visualization of the symmetry and shape of the chin. Also, the relationship of the chin to the other facial subunits should
FIGURE retrogenia.
FIGURE
2.
Stabilization
of the implant
with
two screws.
3. A, Preoperative view of a 23-year-old woman with B, Postoperative view 15 months after the procedure.
be noted, as well as the total facial appearance. Once the surgeon is satisfied with these esthetic parameters, a double wound closure is always performed: muscle to muscle with 3-O chromic sutures and mucosa to mucosa with 3-O or 4-O chromic sutures. A systemic antibiotic, pain medication, and an antiinflammatory agent are usually prescribed postoperatively.
LOUIS
1025
S. BELINFANTE
Discussion In the last 20 months, nine implants have been placed without incident. To date, there have been no signs of postoperative infection, radiographic evidence of bone or tooth resorption caused by implant pressure,
and no dehiscence of the implant through the tissues or discernible physical movement. The implant has been accepted by the patient on both an esthetic and tactile basis. In all cases: an esthetic balance between the osteotomized segment and the mentolabial fold has been achieved (Fig 3).