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The underdeveloped chin
THE UNDERDEVELOPED
CHIN
LESTERW. EISENSTODT, M.D. Assistant
Plastic Surgeon, Newark Beth Israel klospital NEWARK,
I
N a previous article1 sixteen cases of preserved rib cartSage chin impIantations were reported; since then, an additional fifteen transpIantations were performed. It is the purpose of this paper to suppIement the previous report. PIastic surgeons wiI1 agree that the majority of patients with receded chins seek consuItation for nasa1 correction. In the course of examination, the surgeon examines not onIy the patients’ nose but also the other facia1 features and the general stature. A critica survey is made. The forehead, nasofronta1 angIe, nasa1 projection, nasoIabia1 angle, superior maxiIIa, denta projection and chin are observed. IndividuaI anaIysis is made as each face is a unique one. The patient is observed in the relaxed, smiIing, Iaughing and speaking positions. One searches for defects and singles out those facia1 characteristics which are not in proportion. One or more maIfeatures may be present and may or may not Iend themseIves to satisfactory esthetic correction. With the exception of the nose, deformities of the chin are the most common facia1 maIformation. A chin which appears to be underdeveloped requires carefu1 study before a true diagnosis of microgenia is established. FrequentIy a micrognathic appearing lower jaw is not receded. It may appear small but this may only be an apparition, especiahy if the upper teeth are “bucked” or protrude too far in advance of the lower jaw. A chin is underdeveIoped onIy when it is out of proportion with the other facial features. The nose pIays an important rBIe in chin corrections. A prominent nose with a webbed nasoIabia1 angIe can create a smaII lower jaw ihusion. A humped or Iong nose may accentuate a minor chin recession.
NEW
JERSEY
The mere lifting of a nasa1 tip can remove the emphasis from a miIdIy protruded or receded chin. In certain instances, the appearance is eIimin“mouth breather” ated by reducing the nasa1 proMe and eIevating the nasa1 tip without chin correction. OccasionaIIy where a prominent Iong nose and apparent receded chin are present concomitantIy, one is uncertain prior to operation whether or not a chin correction At operation, the nose is is necessary. first corrected and then the chin if deemed necessary. CLASSIFICATION
OF THE
UNDERDEVELOPED
CHIN
From a didactic point of view, hypopIastic chins may be cIassified in five types: (I) UnderdeveIoped in a superior to inferior direction due to decreased height of the body of the mandibIe or absence or recession of the Iower teeth; (2) underdeveIoped in a IateraI to Iateral direction due to decreased width of the body of the mandibIe; (3) underdeveIoped in an anterior to posterior direction due to dwarfing of the menta1 protuberance, absence of the menta1 tubercIes, shortening of the horizonta1 rami or a posterior disIocation of the temporomandibuIar joints; (4) underdeveIoped uniIateraIIy due to a uniIatera1 first branchial arch and cleft maIformation or a unilateral dislocation of the temporomandibuiar joint, and (3) underdeveloped in a combination of two or more of the above. From a surgical point of view, three types of chin recessions are noted depending upon their degree. I. Mildly Receded. If the nose and other facia1 features are in proportion, a chin correction may not be necessary. If 39
40
American Journal of Surgery
Eisenstodt-UnderdeveIoped
Chin
FIG. I. A and B, preoperative photographs; c ‘and D, postoperative photographs after combined rhinoplasty and thin preserved rib cartilage chin implantation.
the nose is prominent, hooked or Iong, nasa1 correction combined with a thin preserved rib cartiIage chin impIant may be indicated. (Fig. I .) 2. Moderately Receded. The Iower teeth are usuaIIy receded giving a “buck tooth ” appearance. The deformity is accentuated when smiIing or Iaughing. The patients are self-conscious and empIoy compensatory cover-up mechanisms such as hiding the face with the hands or turning away
whiIe expressing their emotions. During chiIdhood, orthodontics is the method of treatment. After puberty, if esthetic improvement is desired, a thick preserved rib cartiIage graft may be inserted into the chin to bring the glabeIIa and mentum into a perpendicuIar Iine. (Figs. 2 and 3.) 3. Markedly Receded. This exaggerated deformity gives a comica expression to the face. Stage and movie comedians and circus clowns often burIesque it. Masks and faIse
L’
No.
Eisenstodt-UnderdeveIoped
I
Chin
An~cricanJ~,urn;rl,,ISurg~~v .+1
2. A and B, preoperative photographs; c and D, postoperative photographs after combined rhinoplasty and thick preserved rib cartilage chin implantation.
FIG.
faces used at parties and Mardi Gras imitate it. The patient suffers repeated crueI ridicule. To improve the appearance and dental occlusion simuItaneousIy, an osteotomy through the horizontal ramus with advancement of the Iower jaw mai be performed. Satisfactory esthetic improvement may be obtained by the mere insertion of one or more thick preserved rib cartilage grafts. (Figs. 4 and 3.) Age. Medical men tend to discourage their patients from esthetic facia1 corrections until they are eighteen years of age or over. A c::refuI study of adolescents
will show that the majority of girIs are fuIly deveIoped between the ages of thirteen and fourteen; the breasts are fuIl grown, the ovaries are functioning and the secondary sex characteristics are compIete. The final adult facies is attained at the same age. This period is the idea1 time for facial pIastic surgery as one need not fear further changes of the facial characteristics. The patients can well tolerate the surgery an d make excellent and rapid recoveries. At this age most girIs begin secondar! schoo1. If a facial deformity is present
42
American Journal of Surgery
Eisenstodt-UnderdeveIoped
Chin
A
B
FIG. 3. A, preoperative photograph; B, postoperative photograph after combined rhinoplasty and thick preserved rib cartilage chin implantation.
which the patient wishes corrected, the operation shouId not be denied. It shouId 6 e performed before entering the new schoo1 and beginning a new phase of Iife. Boys mature at a Iater age. Their faciaI features are not fuIIy developed unti1 the ages of fifteen or sixteen. ShouId one be in doubt, procrastination is best. However,
when the features appear to be deveIoped, considering the body as a whore, the operation shouId not be deIayed. TECHNIC
Of aI1 the various procedures surgery, the preserved cartiIage for a receded chin is perhaps
A
FIG. 4. A, preoperative photograph; graph after combined rhinopIasty cartiIage chin impIantation.
B
B, postoperative
photoand thick preserved rib
in pIastic transpIant the most
\‘<,~..l.XXlb’.
No.
I
Eisenstodt-Underdeveloped
Chin
American Journ:~l 01SIITW'Y
43
Frc:. 5. A and B, preoperative photographs; c and D, postoperative photographs after combined rhinopktsty . - and very thick preserved rib cartilage chin implantation.
simpIe, most rapidly performed and most gratifying of aII operations. Preserved cartirage is readily obtainabIe in Iarge quantities; it is kept in readiness in a steriIe soIution and is easy to model. Foreign body reactions from preserved cartilage imphrnted into the chin are a rarity. In most instances, a rhinopIasty is performed concomitantIy with the chin pIastic. The nose is first corrected and
strapped in position; a cast is not applied to the nose so that al1 the facial components may be freeIy visibIe for the chin correction. The gowns, drapes and gloves are changed; the face, chin and neck are again surgicaIIy prepared; another set of steriIe instruments is employed; guide Iines are drawn. The cartiIage ‘is modeIed to size, a11 sharp corners being beveIed. The anterior surface may be Aat as the mentum pad maintains the gracefu1 fullness of the
44
American Journal
orSurgery Eisenstodt-UnderdeveIoped
chin. Procaine with suprarenin is injected and the cartiIage inserted through a smaI1 submenta1 incision. The incision is cIosed and a firm pressure dressing is appIied. A cast IS then modeIed to the nose. The pressure bandage is removed from the chin on the fifth day; upon remova1, the chin is insensitive and appears too Iarge. The sweIIing, however, rapidly recedes. The sensitivity begins to return after a month and is usuaIIy compIete after three months. COMPLICATIONS
Failures or untoward resuIts after preserved rib cartiIage chin transpIantations are not common. Certain comphcations, however, may take place I. Perforation into the Oral Cavity. This may occur in the course of undermining the skin over the mentum. If this happens, the submenta1 incision may be cIosed and the operation terminated. It may then be repeated a month Iater. However, the cartiIage may be impIanted even after ora perforation if peniciIIin is administered concomitantIy. Infection does not usuaIIy occur. 2. Displacement of the Graft. This may occur if a tight immobiIization bandage is not appIied; it occasionaIIy takes place despite it. Extensive undermining or an accidenta bIow before the cartiIage is firmly fixed can dispIace the graft. A secondary operation is then necessary. The cartiIage is Iiberated and repIaced in its proper position. 3. Injection. Infections from preserved rib cartiIage chin transpIants are not common. They occur more frequentIy after autogenous transpIantation of the nasal hump or septa1 cartiIage and bone. In this series, one miId infection occurred which heaIed spontaneousIy in a few days without specific treatment.
Chin
JULY, 1947
4. Vesicular Dermatitis. This is quite commonIy found on the skin of the chin after the remova of the pressure dressing. Specific treatment is unnecessary as the vesicIes disappear in a few weeks. COMMENTS
The microgenic chin is a common facia1 deformity. Satisfactory esthetic resuIts are obtained by preserved rib cartiIage transpIantation. The operation is simpIe, requires IittIe ski11 and entaiIs a minimum of risk. Every individua1 with an underdeveIoped chin who presents himseIf for nasa1 correction shouId have the merits of preserved rib cartiIage chin correction expIained. As a ruIe, patients with hypopIastic chins are frightened and reIuctant to undergo chin correction, but they are not averse to the procedure after the rapidity and simpIicity of the operation is expIained . If the facia1 features are in harmony, with the exception of a receded chin, preserved rib cartiIage chin transpIantation gives a satisfactory cosmetic resuIt. If a nasal and chin pIastic are performed concomitantIy, the esthetic resuIts are often spectacular. An unpIeasant facia1 contour is transformed into a highIy desirabIe one. CONCLUSION
Preserved rib cartiIage was transpIanted into microgenic chins in thirty-one instances. In a11 save one the recovery was rapid, uneventfu1 and gratifying. A single case of infection occurred but heaIed spontaneousIy in a few days without specific treatment. REFERENCE I. EISENSTODT, L.
W. Surgical ma1formation.s. Am. J. Surg.,
correction of chin 71: 491, 1946.
CHIN
LESTERW. EISENSTODT, M.D. Assistant
Plastic Surgeon, Newark Beth Israel klospital NEWARK,
I
N a previous article1 sixteen cases of preserved rib cartSage chin impIantations were reported; since then, an additional fifteen transpIantations were performed. It is the purpose of this paper to suppIement the previous report. PIastic surgeons wiI1 agree that the majority of patients with receded chins seek consuItation for nasa1 correction. In the course of examination, the surgeon examines not onIy the patients’ nose but also the other facia1 features and the general stature. A critica survey is made. The forehead, nasofronta1 angIe, nasa1 projection, nasoIabia1 angle, superior maxiIIa, denta projection and chin are observed. IndividuaI anaIysis is made as each face is a unique one. The patient is observed in the relaxed, smiIing, Iaughing and speaking positions. One searches for defects and singles out those facia1 characteristics which are not in proportion. One or more maIfeatures may be present and may or may not Iend themseIves to satisfactory esthetic correction. With the exception of the nose, deformities of the chin are the most common facia1 maIformation. A chin which appears to be underdeveloped requires carefu1 study before a true diagnosis of microgenia is established. FrequentIy a micrognathic appearing lower jaw is not receded. It may appear small but this may only be an apparition, especiahy if the upper teeth are “bucked” or protrude too far in advance of the lower jaw. A chin is underdeveIoped onIy when it is out of proportion with the other facial features. The nose pIays an important rBIe in chin corrections. A prominent nose with a webbed nasoIabia1 angIe can create a smaII lower jaw ihusion. A humped or Iong nose may accentuate a minor chin recession.
NEW
JERSEY
The mere lifting of a nasa1 tip can remove the emphasis from a miIdIy protruded or receded chin. In certain instances, the appearance is eIimin“mouth breather” ated by reducing the nasa1 proMe and eIevating the nasa1 tip without chin correction. OccasionaIIy where a prominent Iong nose and apparent receded chin are present concomitantIy, one is uncertain prior to operation whether or not a chin correction At operation, the nose is is necessary. first corrected and then the chin if deemed necessary. CLASSIFICATION
OF THE
UNDERDEVELOPED
CHIN
From a didactic point of view, hypopIastic chins may be cIassified in five types: (I) UnderdeveIoped in a superior to inferior direction due to decreased height of the body of the mandibIe or absence or recession of the Iower teeth; (2) underdeveIoped in a IateraI to Iateral direction due to decreased width of the body of the mandibIe; (3) underdeveIoped in an anterior to posterior direction due to dwarfing of the menta1 protuberance, absence of the menta1 tubercIes, shortening of the horizonta1 rami or a posterior disIocation of the temporomandibuIar joints; (4) underdeveIoped uniIateraIIy due to a uniIatera1 first branchial arch and cleft maIformation or a unilateral dislocation of the temporomandibuiar joint, and (3) underdeveloped in a combination of two or more of the above. From a surgical point of view, three types of chin recessions are noted depending upon their degree. I. Mildly Receded. If the nose and other facia1 features are in proportion, a chin correction may not be necessary. If 39
40
American Journal of Surgery
Eisenstodt-UnderdeveIoped
Chin
FIG. I. A and B, preoperative photographs; c ‘and D, postoperative photographs after combined rhinoplasty and thin preserved rib cartilage chin implantation.
the nose is prominent, hooked or Iong, nasa1 correction combined with a thin preserved rib cartiIage chin impIant may be indicated. (Fig. I .) 2. Moderately Receded. The Iower teeth are usuaIIy receded giving a “buck tooth ” appearance. The deformity is accentuated when smiIing or Iaughing. The patients are self-conscious and empIoy compensatory cover-up mechanisms such as hiding the face with the hands or turning away
whiIe expressing their emotions. During chiIdhood, orthodontics is the method of treatment. After puberty, if esthetic improvement is desired, a thick preserved rib cartiIage graft may be inserted into the chin to bring the glabeIIa and mentum into a perpendicuIar Iine. (Figs. 2 and 3.) 3. Markedly Receded. This exaggerated deformity gives a comica expression to the face. Stage and movie comedians and circus clowns often burIesque it. Masks and faIse
L’
No.
Eisenstodt-UnderdeveIoped
I
Chin
An~cricanJ~,urn;rl,,ISurg~~v .+1
2. A and B, preoperative photographs; c and D, postoperative photographs after combined rhinoplasty and thick preserved rib cartilage chin implantation.
FIG.
faces used at parties and Mardi Gras imitate it. The patient suffers repeated crueI ridicule. To improve the appearance and dental occlusion simuItaneousIy, an osteotomy through the horizontal ramus with advancement of the Iower jaw mai be performed. Satisfactory esthetic improvement may be obtained by the mere insertion of one or more thick preserved rib cartilage grafts. (Figs. 4 and 3.) Age. Medical men tend to discourage their patients from esthetic facia1 corrections until they are eighteen years of age or over. A c::refuI study of adolescents
will show that the majority of girIs are fuIly deveIoped between the ages of thirteen and fourteen; the breasts are fuIl grown, the ovaries are functioning and the secondary sex characteristics are compIete. The final adult facies is attained at the same age. This period is the idea1 time for facial pIastic surgery as one need not fear further changes of the facial characteristics. The patients can well tolerate the surgery an d make excellent and rapid recoveries. At this age most girIs begin secondar! schoo1. If a facial deformity is present
42
American Journal of Surgery
Eisenstodt-UnderdeveIoped
Chin
A
B
FIG. 3. A, preoperative photograph; B, postoperative photograph after combined rhinoplasty and thick preserved rib cartilage chin implantation.
which the patient wishes corrected, the operation shouId not be denied. It shouId 6 e performed before entering the new schoo1 and beginning a new phase of Iife. Boys mature at a Iater age. Their faciaI features are not fuIIy developed unti1 the ages of fifteen or sixteen. ShouId one be in doubt, procrastination is best. However,
when the features appear to be deveIoped, considering the body as a whore, the operation shouId not be deIayed. TECHNIC
Of aI1 the various procedures surgery, the preserved cartiIage for a receded chin is perhaps
A
FIG. 4. A, preoperative photograph; graph after combined rhinopIasty cartiIage chin impIantation.
B
B, postoperative
photoand thick preserved rib
in pIastic transpIant the most
\‘<,~..l.XXlb’.
No.
I
Eisenstodt-Underdeveloped
Chin
American Journ:~l 01SIITW'Y
43
Frc:. 5. A and B, preoperative photographs; c and D, postoperative photographs after combined rhinopktsty . - and very thick preserved rib cartilage chin implantation.
simpIe, most rapidly performed and most gratifying of aII operations. Preserved cartirage is readily obtainabIe in Iarge quantities; it is kept in readiness in a steriIe soIution and is easy to model. Foreign body reactions from preserved cartilage imphrnted into the chin are a rarity. In most instances, a rhinopIasty is performed concomitantIy with the chin pIastic. The nose is first corrected and
strapped in position; a cast is not applied to the nose so that al1 the facial components may be freeIy visibIe for the chin correction. The gowns, drapes and gloves are changed; the face, chin and neck are again surgicaIIy prepared; another set of steriIe instruments is employed; guide Iines are drawn. The cartiIage ‘is modeIed to size, a11 sharp corners being beveIed. The anterior surface may be Aat as the mentum pad maintains the gracefu1 fullness of the
44
American Journal
orSurgery Eisenstodt-UnderdeveIoped
chin. Procaine with suprarenin is injected and the cartiIage inserted through a smaI1 submenta1 incision. The incision is cIosed and a firm pressure dressing is appIied. A cast IS then modeIed to the nose. The pressure bandage is removed from the chin on the fifth day; upon remova1, the chin is insensitive and appears too Iarge. The sweIIing, however, rapidly recedes. The sensitivity begins to return after a month and is usuaIIy compIete after three months. COMPLICATIONS
Failures or untoward resuIts after preserved rib cartiIage chin transpIantations are not common. Certain comphcations, however, may take place I. Perforation into the Oral Cavity. This may occur in the course of undermining the skin over the mentum. If this happens, the submenta1 incision may be cIosed and the operation terminated. It may then be repeated a month Iater. However, the cartiIage may be impIanted even after ora perforation if peniciIIin is administered concomitantIy. Infection does not usuaIIy occur. 2. Displacement of the Graft. This may occur if a tight immobiIization bandage is not appIied; it occasionaIIy takes place despite it. Extensive undermining or an accidenta bIow before the cartiIage is firmly fixed can dispIace the graft. A secondary operation is then necessary. The cartiIage is Iiberated and repIaced in its proper position. 3. Injection. Infections from preserved rib cartiIage chin transpIants are not common. They occur more frequentIy after autogenous transpIantation of the nasal hump or septa1 cartiIage and bone. In this series, one miId infection occurred which heaIed spontaneousIy in a few days without specific treatment.
Chin
JULY, 1947
4. Vesicular Dermatitis. This is quite commonIy found on the skin of the chin after the remova of the pressure dressing. Specific treatment is unnecessary as the vesicIes disappear in a few weeks. COMMENTS
The microgenic chin is a common facia1 deformity. Satisfactory esthetic resuIts are obtained by preserved rib cartiIage transpIantation. The operation is simpIe, requires IittIe ski11 and entaiIs a minimum of risk. Every individua1 with an underdeveIoped chin who presents himseIf for nasa1 correction shouId have the merits of preserved rib cartiIage chin correction expIained. As a ruIe, patients with hypopIastic chins are frightened and reIuctant to undergo chin correction, but they are not averse to the procedure after the rapidity and simpIicity of the operation is expIained . If the facia1 features are in harmony, with the exception of a receded chin, preserved rib cartiIage chin transpIantation gives a satisfactory cosmetic resuIt. If a nasal and chin pIastic are performed concomitantIy, the esthetic resuIts are often spectacular. An unpIeasant facia1 contour is transformed into a highIy desirabIe one. CONCLUSION
Preserved rib cartiIage was transpIanted into microgenic chins in thirty-one instances. In a11 save one the recovery was rapid, uneventfu1 and gratifying. A single case of infection occurred but heaIed spontaneousIy in a few days without specific treatment. REFERENCE I. EISENSTODT, L.
W. Surgical ma1formation.s. Am. J. Surg.,
correction of chin 71: 491, 1946.