TECHNICAL STRATEGY
Captain America’s Shield Genioplasty
Valerio Ramieri, MD, PhD, Valentino Vellone, MD,y Sara Marianetti, DDS,
and Tito M. Marianetti, MD
osteotomy in the possible deepening of the mentolabial fold that
Abstract: The chin represents one of the most important determi- can result quite unesthetic. Normally, the extent of this deformity
nants of the facial aesthetics. Like many aesthetic parameters, the increases with the amount of the inferior segment advancement
‘‘ideal’’ chin has changed in history regarding projection and and with the dissection of the mentalis muscle when this muscle is
prominence. From the retrusive profiles of the Renaissance, stron- not reattached in his position at the end of the surgery.3 If the deep
ger and more defined mandibular contour are nowadays desired mentolabial fold will combine with ptosis of the premental soft
both by masculine and feminine population. tissue and with the notching at the posterior margin of the sliding
This change in the ideal references plays an important role in genioplasty osteotomy, then a deformity called ‘‘witch’s chin,’’ as
described by Gonzalez-Ulloa4 in 1972, will develop. Various
diagnosis and treatment planning. Various techniques for chin
strategies have been proposed to overcome this problem. Either
augmentation have been described, using both alloplastic materials autologous graft or alloplastic implants have been used.5,6 An
and osteotomies. interesting osteotomy variant, so-called chin shield osteotomy,
An interesting osteotomy variant, so-called chin shield osteot- has been described by Triaca et al7 to avoid a deep mentolabial
omy, has been described by Triaca et al to avoid a deep mentolabial fold. We describe herein the use of a shield plate, very similar in
fold. The authors describe herein the use of a shield plate, very his form to Captain America’s shield, that can at the same time
similar in his form to Captain America’s shield, that can at the same provide bone fixation and soft tissues sustain in the mentolabial
time provide bone fixation and soft tissues sustain in the mento- fold region, preventing the invasion of the gap between the bone
labial fold region, preventing the invasion of the gap between the fragments by the connective tissue, as it happens in a guided bone
bone fragments by the connective tissue, as it happens in a guided regeneration procedure.
bone regeneration procedure.
SURGICAL TECHNIQUE
The incision runs horizontally in the lower lip mucosa, 1 cm labial
Key Words: Chin genioplasty, osseous genioplasty, sliding to the sulcus to allow sufficient submucosal tissue for closure. The
genioplasty extent of the incision is from cuspid to cuspid. The dissection is
carried out perpendicular to the mucosal incision in order to
(J Craniofac Surg 2021;32: 708–710)
preserve the mentalis muscle as much as possible. A reference
stich on the mentalis muscle is put on both sides before transecting
T he chin represents one of the most important determinants of
the facial aesthetics. Like many aesthetic parameters, the
‘‘ideal’’ chin has changed in history regarding projection and
it. After the identification of the ramus labialis of the mental nerve,
the incision in continued down to the bone. The periosteum is then
elevated to the inferior mandibular border anteriorly and to the
prominence. From the retrusive profiles of the Renaissance, mental foramen posteriorly. A reference mark in the midline and
stronger and more defined mandibular contour are nowadays two lateral vertical marks are made using the oscillating saw. The
desired both by masculine and feminine population. This change osteotomy is performed below the mental foramen and as much as
in the ideal references plays an important role in diagnosis and possible posterior to it, on both side of the mandible. The posterior
treatment planning.1 Various techniques for chin augmentation extent of the osteotomy is very useful to reduce the possible gap at
have been described, using both alloplastic materials and osteo- the end of the osteotomy and the consequent hourglass esthetic
tomies.1 The most frequently used osteotomy for the correction of deformity or the appearance of the so-called witch’s chin in frontal
the retruted chin is the horizontal sliding genioplasty, first view. A reciprocating saw is used to carry the horizontal extended
described by Hofer in 1942.2 Since then, various modification sliding osteotomy. Care is taken to protect lingual periosteum end
to the sliding osteotomy have been introduced. Furthermore, posterior soft tissues. The chin segment is then advanced and
different alloplastic materials have been implemented for chin lowered. To secure and fix it we decide to use the plate normally
augmentation. Nowadays, the indications for each technique still used by neurosurgeons to close the burr holes (Fig. 1A). This plate
remain controversial. One of the main critiques to the sliding was like a shield and allowed not only to stabilize the chin fragment
but also to prevent the soft tissue to invade the space of the
From the Ortognatica Roma; and yDepartment of Odontostomatological osteotomy gap, like a guided bone regeneration procedure
and Maxillofacial Sciences, ‘‘La Sapienza’’ University of Rome, Rome,
Italy.
Received May 6, 2020.
Accepted for publication July 8, 2020.
Address correspondence and reprint requests to Valentino Vellone, MD,
Dipartimento di Scienze Odontostomatologiche e Maxillo-Facciale,
‘‘La Sapienza’’ Università di Roma, Via Pietro da Cortona, 8, Roma,
00196, Italy; E-mail: valentino.vellone@gmail.com
The authors report no conflicts of interest.
Copyright # 2020 by Mutaz B. Habal, MD
ISSN: 1049-2275 FIGURE 1. (A) Genioplasty with burr hole cover. (B) 1-year post-op Lateral
DOI: 10.1097/SCS.0000000000006952 X-ray. (C) 1-year post-op frontal X-ray.
708 The Journal of Craniofacial Surgery Volume 32, Number 2, March/April 2021
Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery Volume 32, Number 2, March/April 2021 Captain America Shield Genioplasty
(Fig. 1B and C). Three or 4 screws are normally used. In all case, we to a marked mentolabial fold. The depth of this fold could be
also use 2 additional stronger lateral plates to better stabilize the expressed as a linear measure, while a very important factor to
chin segment. Then, the mentalis muscle is precisely reattached, as express the harmony of this region is the value of the nasolabial
suggested by Chaushu et al3 and eventually the vestibular oral angle. This angle could be affected by the mandibular incisor
incision is closed with resorbable suture. proclination and to the thickness of the inferior lip and the chin
pad. All surgical procedure that increases vertically the mentolabial
MATERIAL AND METHODS height will augment the value of the mentolabial angle. If surgery
A retrospective analysis was performed on medical charts of reduces the anterior mandibular face height, the effect will be the
patients who underwent genioplasty from June 2017 to deepening of the fold and the decrease of the angle. The normal angle,
September 2019. associated with a good facial appearance, is between 1078 and 1188.8
In the considered period, 28 patients underwent genioplasty. In our patients the mentolabial angle was not so altered in the
Among these, 15 patients underwent bilateral sagittal split osteotomy, preoperative measured values because on the one hand it would
whilst the remaining 13 genioplasty only. In 25/28 cases an advance- have been very large because of the chin retrusion, on the other hand
ment genioplasty was performed. Among those subjects, we used the this was compensated by the reduced vertical height of the lower face.
shield plate in 11 patients (7 males and 4 females, mean age: 20.4 Most of the improvement with the alloplastic technique is related
years). All these last-mentioned patients were affected by chin to the materials and to different and custom-made shapes of the
retrusion and reduced vertical dimension of the inferior lower face. implants. Patients are generally satisfied with the outcome of both
All patients underwent a preoperative thin cut (0.6 mm) axial techniques, but some Authors have demonstrated better degree of
Cone Beam Computed Tomographic (CBCT) scan. The data were satisfaction and less complications rate in patients who underwent
recorded in a generic Digital Imaging and Communications in osteotomies.1 One of the unesthetic and bothersome changes associ-
Medicine (DICOM) format and transferred to a Dolphin Imaging ated with genioplasty are the notching at the inferior border of the
Software 12.0 a dedicated software for orthognathic Virtual Surgi- mandible at the lateral end of the sliding osteotomy behind the chin
cal Planning (VSP). The software reformats the DICOM images segment, that could accentuate the soft tissue jowls. To avoid this, a
into 3D STL file. The scan was oriented by anatomic symmetry prolonged osteotomy behind the mental foramen similar to a chin
landmarks and orthognathic planning was performed. wing osteotomy could be performed.9 The other frequent deformity
Patients were photographed from frontal, oblique, basal, and associated with advancement genioplasty is the excessive depth of the
lateral view preoperatively, at 6 months post-operatively, 1 year mentolabial angle. To prevent this deformity, various materials both
post-operatively and annually thereafter. alloplastic and autologous have been used putting them in the
The average follow-up time was 1.2 years ranging from 7 months mentolabial fold region. Non-absorbable silicone implants have been
to 3 years. used for many years, but they present many problems such as bone
The study was undertaken with the understanding and written erosion, displacement and infection.10 Extraoral bone grafts from
consent of each participant according to principles of the Declara- Iliac crest, cranium, tibia, rib and intraoral grafts from retromolar,
tion of Helsinki. ramus and cortical bone of the genial segment in genioplasty have
The outcome variables studied in the group of the 11 patients in also been used.5 A visor osteotomy of the anterior mandible with a
whom the shield plate was used were labiomental angle, the depth coronal displacement of the pedicled bone fragment has also been
of labiomental fold and any post-operative complication like asym- proposed to support mentolabial fold and improve labial compe-
metric chin, infection, plate/screw extrusion, paresthesia, relapse tence.6 Another modification of the classic sliding genioplasty
or nonunion. osteotomy is the chin shield osteotomy, proposed by Triaca et al.7
The vitality of lower incisors was tested by electronic This technique consists of an advancement of a cephalic anterior
pulp tester. mandibular segment along with the chin segment. This osteotomy is
Patients were asked to complete an anonymous in-office ques- not easy to perform, but it could help to avoid a deep mentolabial fold
tionnaire at 6-months of follow-up. The patients’ satisfaction with and to improve labial competence.
the final shape of their facial aspect was evaluated by this ques- The shield plate could have a guided bone regeneration effect,
tionnaire. A 4-point scale was used, with the ratings as follows: 4: based on the same principle of using barrier membranes for main-
excellent; 3: good; 2: fair and 1: poor. taining space over a defect, preventing connective tissue from
invade the defect, allowing in this way the bone regeneration.
Our technique has the same basic concepts of the chin shield
RESULTS genioplasty, but it is easier to perform and in our hands, it is very
No post-operative complications like infection, plate or screws effective in the correct definition of the mentolabial angle and
extrusion, nonunion and asymmetry of the chin were observed. mentolabial fold’s depth.
Only 3 patients referred persistent paresthesia that regressed spon-
taneously at 3 moths follow-up in 2 patients and at 7 months follow-
up in the other patient. No change in lower anterior teeth vitality CONCLUSION
was detected. The mean value of the nasolabial angle was 109.98 The use of the shield plate in advancement and lowering genioplasty
(SD: 15.6; range: 88–132) in the group of the 11 patients in whom is a good option to prevent the deepening of the mentolabial fold
the shield plate was used. The mean post-operative value was and to obtain good aesthetic results.
111.48 (SD: 5.6; range: 103–121). The mean linear depth of the
mentolabial fold resulted 6.9 mm (SD: 3.8; range: 2–13) in the
preoperative and 5.1 mm (SD: 0.7; range: 4–6). REFERENCES
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# 2020 Mutaz B. Habal, MD 709
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Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
