C H A P T E R

22
Mentoplasty
Robert A. Glasgold, MD, Mark J. Glasgold, MD, and Alvin I. Glasgold, MD

HISTORY PERSONAL PHILOSOPHY

Chin augmentation has been performed using autografts, An optimal facial skeletal structure serves as the founda-
alloplastic materials, and mandibular advancement pro- tion for rhytidectomy and other facial rejuvenation pro-
cedures. Autografts are complicated by the need for a cedures. Patients with poor skeletal foundations, as seen
donor site, difficulty with shaping the grafts, and their with microgenia, will not only tend to show certain stig-
unpredictable pattern of resorption [1]. In contrast, allo- mata of aging earlier, such as poor necklines and jowling,
plastic implants have proved to be an easy and reliable but will also obtain less than ideal results from a facelift.
means of augmentation. The most common method of In the appropriate patients, correction of microgenia is
augmentation is with alloplastic implants, including Silas- a critical technique for facial rejuvenation, either as a
tic, Gore-Tex, Mersilene mesh, and Medpore implants stand-alone procedure or in conjunction with facelifting
[2,3]. Silastic chin implants have the longest history of (Fig. 22.1).
continuous use of any of the alloplastic implants. They Alloplastic implantation provides a safe, reliable, and
have been safely used since the 1960s with a high degree relatively simple means for chin augmentation. Ideally the
of satisfaction. Mandibular advancement procedures implant should have a very low incidence of infection or
require specialized equipment and add significant mor- rejection, provide predictable long-term results, and be
bidity to the procedure with little advantage. easy to remove if necessary. Silastic, a nonporous mate-
The most significant evolution in mentoplasty has rial around which a fibrous capsule forms, meets all of
been in implant design. The earliest Silastic implants these criteria [6].
were carved individually by the surgeon. In 1966 Safian Our preferred implants are the extended anatomic (Im-
and Dow Corning introduced the first preformed Silastic plantech), or anatomical (Spectrum Medical), implants;
implants [1]. These implants were equivalent to what for the purpose of this chapter we will be referring to
is now referred to as a curvilinear implant or a central both as “anatomical chin implants.” These implants fill
implant without a lateral component. Augmentation was the central mentum and have lateral arms that fill the
isolated to the central mentum and provided only anterior prejowl sulcus to produce a natural jawline. The lateral
projection. The next important advancement in implant arms on these implants also account for the lower in-
design was the introduction of the anatomic style of cidence of implant shifting relative to the central style
implant by Toranto in 1982 [4]. These types of implants implants. The anatomical style implants are available
have lateral tapering extensions, which wrap around the from each manufacturer in four sizes, providing between
mandible, providing anterior projection of the mentum, 5 and 9 mm of anterior projection. As the implant size
filling of the prejowl sulcus, and an overall recontouring increases, so does the length and bulk of the implant’s
of the mandible. The result is a more natural augmenta- lateral arms.
tion of the chin–jawline complex. These implants are Central implants do not have a lateral extension to fill
available as either anatomical chin implants (Spectrum the prejowl sulcus. In patients with preexisting jowls, the
Designs Medical, Carpinteria, CA, USA) or extended central implant will accentuate the prejowl sulcus, often
anatomical chin implants (Implantech, Ventura, CA, making the jowl appear more prominent. This is the
USA). Realizing the importance of isolated prejowl aug- opposite effect of the extended anatomical chin implant,
mentation in certain patients, Mittleman introduced his which, by filling the prejowl sulcus, will reduce or cam-
prejowl implant, which has a thin central portion and ouflage the appearance of a jowl. In younger patients
provides bulk only in the lateral arms [5]. without jowls, central implants also have the negative
The surgical technique for mentoplasty using alloplas- effect of creating a more pointed appearing chin.
tic implants has not significantly changed in recent years. When performing mentoplasty we routinely have a
The two common surgical approaches are an external 2-mm Silastic extension wafer available [7]. The wafer
technique through a submental incision and an intraoral provides a degree of intraoperative flexibility in terms
technique through a gingivolabial sulcus incision. Both of implant sizing. On intraoperative assessment, if the
approaches are commonly used today, generally deter- patient would benefit from further anterior projection,
mined by the preference of the individual surgeon. a wafer can be placed under the central portion of the
286
 22 Mentoplasty 287

A B
Figure 22.1 (A) Preoperative and (B) 6-month postoperative views of a patient who underwent mentoplasty with a medium extended anatomical
chin implant and facelift.

chin implant, increasing anterior central mentum projec- The anatomy of the chin-jawline complex changes
tion by 2 mm. with age. Soft tissue and bone atrophy in the central
We perform all mentoplasties through a submental mentum can lead to, or exaggerate, the appearance of a
incision. The submental incision hides well and facilitates receding chin. Development or exaggeration of a prejowl
accurate implant placement, particularly for anatomi- sulcus is also caused by atrophy of soft tissue and bone.
cal chin implants, which require a lateral subperiosteal Age-related atrophy of the anterior mandibular groove,
pocket along the anterior-inferior mandibular border. located inferior to the mental foramen, contributes to the
The submental approach also allows for suture fixation prejowl sulcus [5]. Jowl formation, which exaggerates the
of the implant to the mandibular periosteum, thereby pre- depth of the prejowl sulcus, results from ptosis of skin,
venting implant shifting and vertical migration. Implants muscle, and subcutaneous fat.
placed through an intraoral approach are exposed to
oral contaminants and have a greater likelihood for PREOPERATIVE ASSESSMENT
infection.
Deficiencies of the chin are important to assess for both
the older patient seeking facial rejuvenation and the
ANATOMY younger patient desiring an improved facial appearance.
The chin is composed of the overlying skin, subcutaneous A receding chin produces an imbalance of the lower third
fat, muscles, and the mandible. The muscle components of the face and can be corrected with a chin implant.
of the chin are the mentalis, depressor labii inferioris, Increasing chin projection will also improve the patient’s
and depressor anguli oris muscles, all of which are inner- appearance on front view, where a weak lower third can
vated by the marginal mandibular branch of the facial give a rounded, less angular facial appearance.
nerve. The mentalis muscle arises from the incisive fossa The most common abnormality of the chin is micro­
on the mandible and inserts inferiorly into the dermis genia (retrogenia), which refers to an underprojection of
of the chin. The mentalis muscle elevates the chin pad. the chin with normal occlusion. Patients with a receding
The depressor labii inferioris and depressor anguli oris chin have a short hyoid-to-mentum distance, often asso-
muscles arise from the oblique line of the mandible and ciated with an obtuse cervicomental angle. Chin aug-
insert into the lip. Together they act to depress the lower mentation increases the distance from hyoid to mentum,
lip and corners of the mouth, respectively. providing the appearance of a more acute cervicomental
The portions of the mandible relevant to mentoplasty angle (Fig. 22.2). In younger patients with submental
are the symphysis, parasymphysis, and the body of the fullness and good skin tone, the addition of submental
mandible. The mental nerve exits the mental foramen, liposuction can significantly enhance the result of chin
and provides sensation to the chin and lower lip. The implantation (Fig. 22.3).
mental foramen is generally found inferior to the second The simplest and most practical means to determine
premolar [8]. The mental foramen is approximately appropriate chin projection on profile is by dropping a
2.5 cm lateral to the midline, and is located 1 cm above line down from the lower vermilion, perpendicular to the
the inferior border of the mandible. The foramen can also Frankfurt horizontal. Ideally, the pogonion (the anterior
been found at a point midway between the alveolar ridge most projection of the chin) should approach this line.
superiorly and the inferior edge of the mandible. Patients whose projection falls behind this line should
288 MASTER TECHNIQUES IN FACIAL REJUVENATION

A B
Figure 22.2 Preoperative view of a patient with microgenia, displaying (A) a short hyoid-to-mentum distance and a deep prejowl sulcus and (B)
6-month postoperative view following mentoplasty with a medium extended anatomical chin implant.

A B
Figure 22.3 (A) Preoperative profile view of a patient with microgenia, a poorly defined jawline, and a prejowl sulcus. (B) One-year postoperative
profile view after correction with mentoplasty with an extra-large extended anatomical chin implant and submental liposuction.

be considered for augmentation mentoplasty. Patients to evaluate the depth of the prejowl sulcus to determine
should also be evaluated while smiling, as smiling may if it will be completely effaced by a facelift. In the setting
increase projection to a degree that may influence the of more advanced prejowl sulcus volume loss, a rhytid-
choice of implant. The ideal anterior projection is gender ectomy alone may fail to produce the desired jawline.
specific. In women, several millimeters of underprojection These patients should be considered for prejowl sulcus
is acceptable, whereas men can tolerate slight overprojec- augmentation with or without central mentum projec-
tion, providing a stronger chin. Malocclusions should be tion, depending on their chin projection on profile.
noted and, if present, referred for orthognathic evaluation. Analysis of a patient with a receding and aged chin may
Development of a prejowl sulcus is a characteristic reveal volume deficiencies outside of the areas adequately
sign of aging. In a patient with minimal jowl, filling the addressed with an implant. Chin implant placement, and
prejowl sulcus with an implant may give a jawline com- therefore its area of augmentation, is limited superiorly
parable to that achieved with a facelift. In patients with by the mental nerve. Individuals with thin faces and more
a greater degree of jowling, isolated prejowl sulcus aug- significant microgenia commonly have a deep labiomen-
mentation will be inadequate; in these patients a facelift tal sulcus. If ignored at the time of surgery, isolated place-
is needed to get the optimal jawline rejuvenation. Before ment of an alloplastic chin implant may exaggerate the
rhytidectomy for correction of the jowl, it is important depth of the labiomental sulcus. Proper identification and
 22 Mentoplasty 289

A B
Figure 22.4 (A) Preoperatively this patient was displeased with the prominent appearance of the region below her lower lip, which was second-
ary to a combination of microgenia and volume deficiency across the labiomental sulcus. (B) Postoperative appearance following placement of an
extended anatomical chin implant in conjunction with autologous fat transfer across the labiomental sulcus. Midface fat transfer was performed
concurrently. (Photo courtesy Robert Glasgold, MD; reprinted with permission from Glasgold Group, 2014.)

treatment of this deficiency will optimize both the aes- injection (Fig. 22.5). The addition of Botox treatment of
thetic result and the patient’s satisfaction. Autologous the mentalis muscle will further enhance the contour by
fat transfer can be performed concurrently with mento- reducing the hyperdynamic nature of this muscle.
plasty to help soften the sulcus. Alternatively, injectable Digital photography with computer imaging is helpful
fillers can be used postoperatively to address this deficit in the evaluation and consultation. Reviewing a patient’s
(Fig. 22.4). photograph, particularly on profile, will often help the
Patients undergoing mentoplasty should be evalu- patient understand the importance of chin augmenta-
ated for certain preexisting conditions, any of which, tion for obtaining an optimal result. Computer imaging
if present, should be reviewed with the patient so that allows patients to visualize the effect of augmenting the
they are aware of these preoperatively. These conditions chin and filling the prejowl sulcus. For patients who are
include hypesthesia of the chin and lip region, marginal more comfortable with a nonsurgical option, hyaluronic
mandibular nerve weakness, asymmetries of the chin and acid–based fillers provide an effective means of doing
jawline, and contour irregularities of the chin. Superfi- this. Patients are counseled that as a long-term solution,
cial skin contour irregularities are quite common with a preformed alloplastic implant is a more cost-effective
advancing age, and if not addressed in the consultation, option and does not require yearly injections.
their persistence postoperatively may be a source of
patient dissatisfaction. The irregular contour (or “peau SURGICAL TECHNIQUE
d’orange” appearance) is caused by the dynamic nature
of the mentalis muscle, loss of overlying subcutaneous Preoperatively all patients receive intravenous prophylac-
fat, and decreased skin elasticity. Although increasing tic cefazolin or clindamycin, if allergic to penicillin. The
pogonion projection with an implant will have an overall implant is prepared by placing a guide suture through
benefit on the appearance of a receding chin, it will not each end of the implant to facilitate its placement and
correct the irregular skin contour because the implant prevent the tail of the implant from folding upon itself
sits deep to all of the anatomical structures contribut- (Fig. 22.6). A 2-0 silk suture threaded onto a Keith needle
ing to these superficial changes. If the patient desires is passed through the lateral end of the implant, approxi-
improvement in the superficial skin contour, attention mately 3 mm from the distal edge. This is then repeated
should be focused on a combination of reducing men- with a second 2-0 silk suture and Keith needle for the
talis muscle hyperactivity and restoring the overlying contralateral side. Each of the free ends of the 2-0 silk
tissue buffer (i.e., subcutaneous fat and skin) that cam- are rethreaded onto the Keith needle. The implant is
ouflages the muscle. Treatment involves filling superfi- then soaked in a clindamycin-saline solution until its
cial to the mentalis muscle to create a smoother surface. placement.
Injectable hyaluronic acid–based fillers work very well to A submental incision, approximately 2 cm in length, is
smooth contour by injecting into the deep dermis. Deeper designed with its central portion just anterior to the sub-
placement of the filler can improve contour, but not to mental crease and gently curving posteriorly to the crease
the degree that can be achieved with more superficial at the lateral aspects. The superior skin edge is retracted
290 MASTER TECHNIQUES IN FACIAL REJUVENATION

A B
Figure 22.5 (A) This patient presented with superficial irregular contour (“peau d’orange”) and microgenia. Her primary goal was correction of
the contour and she also desired nonsurgical augmentation of the chin. (B) Both the overall contour and projection were addressed by the use of
hyaluronic acid (HA)–based injectable fillers. HA fillers were used in the central mentum, prejowl sulcus, and labiomandibular fold. The superficial
contour was corrected by filling the dermis of the anterior chin with HA fillers, without the use of Botox. (Photo courtesy Robert Glasgold, MD;
reprinted with permission from Glasgold Group, 2014.)

Figure 22.7 The lateral subperiosteal pocket is elevated along the

inferior border of the mandible with a Joseph elevator.

Figure 22.6 Extended anatomical chin implant prepared for place- The lateral subperiosteal pocket is initiated with elec-
ment with a 2-0 silk suture threaded through each of its lateral ends
and onto Keith needles.
trocautery, hugging the inferior border of the mandible.
A Joseph elevator is introduced to elevate the subperi-
osteal pocket (Fig. 22.7). External palpation with the
upward while dissection is carried down through the contralateral hand will help to guide the subperiosteal
soft tissue and muscle. The periosteum is incised at the dissection, ensuring that the pocket remains along the
inferior portion of the anterior surface of the mandible. anterior-inferior border of the mandible to avoid trauma
A cuff of periosteum is preserved at the inferior border of to the mental nerve. Once the pocket is elevated, an
the mandible, to which the implant is eventually sutured. Aufricht retractor (8 × 45 mm) is placed into the pocket
A subperiosteal pocket is elevated centrally, creating a (Fig. 22.8). A Joseph elevator is then inserted into the
pocket that is large enough to accommodate the implant. pocket under the Aufricht retractor and the subperiosteal
We prefer to elevate the central subperiosteal pocket pocket is gently stretched to ensure the implant will fit
using electrocautery. comfortably into the pocket. The subperiosteal pocket is
 22 Mentoplasty 291

Figure 22.8 The lateral subperiosteal pocket is exposed with the

Aufricht retractor.

Figure 22.10 After the implant is fed into the pocket on the right,
traction is maintained on the guide suture to prevent displacement while
inserting the contralateral side.

Figure 22.9 Keith needle, with guide suture, being passed through
lateral pocket and out through the skin at the angle of the mandible.

then elevated on the contralateral side prior to placing

the implant. Figure 22.11 Chin implant placed within the subperiosteal pockets.
After bilateral subperiosteal dissection is completed,
the Aufricht retractor is used to hold open the pocket. the upper central incisors. Manually palpate the implant
The Keith needle with guide suture is passed through the to confirm it lies flat against the mandible and is sitting
subperiosteal pocket under the retractor, aiming toward along the inferior border of the mandible. The degree
the angle of the mandible, and is passed out through the of anterior projection is then evaluated. It is important
skin (Fig. 22.9). The guide suture is grasped by an assis- to remember that the intraoperative appearance can be
tant and gentle traction is provided to guide insertion of affected by swelling from both local anesthetic injection
the implant as it is fed into the pocket with a straight and surgical manipulation. With the patient in a supine
clamp. The guide suture ensures proper placement of the position mandibular recession is exaggerated; the surgeon
lateral tail of the implant, and prevents the thin tail from should correct for this while visually assessing projection
folding on itself. Once the implant is inserted and the by holding the jaw in its proper anatomic position.
Aufricht retractor removed, continued traction is placed If further augmentation is deemed necessary after
on the guide suture to maintain its position during inser- implant placement, an extension wafer (Glasgold Wafer,
tion of the contralateral side (Fig. 22.10). The Aufricht Implantech, Ventura, CA, USA) can be placed to provide
is now placed in the contralateral side and the implant 2 mm of additional anterior projection (Fig. 22.12). The
inserted in the same manner as the first side (Fig. 22.11). extension wafer does not have a central mark; making
Once the implant is inserted, its position should be a nick at its central point on the inferior edge will help
evaluated both by manual palpation and visual inspec- ensure proper alignment. The wafer is then simply
tion. Central placement is confirmed by aligning the inserted under the central portion of the implant (Fig.
central blue mark on the implant with the junction of 22.13). Once correctly positioned it is sutured to the chin
292 MASTER TECHNIQUES IN FACIAL REJUVENATION

Figure 22.12 Extension wafer (Glasgold wafer) for use with anatomic
or extended anatomic chin implants to provide an additional 2 mm of
central anterior projection.

Figure 22.14 The implant is secured inferiorly to the mandibular

periosteum with two 4-0 PDS sutures.

(Fig. 22.15). The muscle is reapproximated over the

implant with interrupted 4-0 PDS sutures. The subcu-
taneous tissues are reapproximated with several inter-
rupted 4-0 PDS sutures. The skin incision is closed with
a running 6-0 Prolene suture.
If chin implantation is performed in conjunction with
a facelift, the mentoplasty is performed first. Once the
chin implant is placed and sutured in, the muscle is closed
prior to proceeding with the subcutaneous submental
dissection to address the submental fat and platysma. If
liposuction is performed, it is done first through a small
incision in the center of the planned submental incision
before extending the incision for the mentoplasty.
In some patients, isolated prejowl augmentation is
needed to achieve a straight jawline. Although preformed
implants for prejowl augmentation are available, we
Figure 22.13 In cases in which the need for further projection is deter- prefer injection augmentation with either autologous fat
mined intraoperatively after implant placement, an extension wafer or a synthetic filling material. When patients undergoing
can be placed under the central portion of the implant to provide an
additional 2 mm of projection.
a facelift need prejowl augmentation, the fat is harvested
and injected into the prejowl sulcus prior to proceeding
with the facelift at the same setting.
implant with two 4-0 polydioxanone (PDS) sutures, each
placed approximately 1 cm lateral to the midline. POSTOPERATIVE CARE
After it has been confirmed that the implant is appro-
priately placed, the implant is sutured to the inferiorly Patients receive a total of 2 days of antibiotic prophy-
based cuff of periosteum with two 4-0 PDS sutures (Fig. laxis. The first dose is given intravenously the morning
22.14). These sutures are placed approximately 1 cm of surgery, followed by one dose of oral cefadroxil that
lateral to the midline. If an extension wafer is used, evening and two more doses on the first postoperative
the 4-0 PDS suture is placed through the periosteal cuff day. If allergic to penicillin, the patient will receive two
and then through both the wafer and overlying implant additional doses of oral clindamycin the days of surgery
 22 Mentoplasty 293

30 years of experience we have had to remove an implant

secondary to infection on only a few occasions. If an
implant is removed because of infection, we will generally
wait a period of 6 months before reimplantation. This
allows sufficient time for swelling to resolve and scar to
form so that sizing for another implant will be accurate.
If the chin appears mildly overprojected during the
postoperative period, the patient should be reassured and
observed over a period of at least 3 months to allow swell-
ing to subside before deciding to downsize the implant.
In the case of undercorrection, an extension wafer can
be placed under the existing implant as described previ-
ously; alternatively, the implant can be replaced with a
larger one.
Asymmetries following augmentation are most com-
monly from preexisting mandibular asymmetries, which
if significant, would ideally have been reviewed with the
patient preoperatively. Implant shifting can occur, and
would most commonly be in the cephalad direction.
Shifting is prevented by using the submental approach,
which allows suture fixation of the implant to the man-
dibular periosteum.
Numbness and paresthesias in the distribution of the
mental nerve are secondary to traction on the nerve during
surgery and are almost universally self-limited, lasting
from weeks to months. Marginal mandibular weakness is
a very rare temporary complication secondary to traction
on the nerve while the implant pocket is being created.
Bone resorption of the central mandible following
alloplastic chin implants has been described. In practice
Figure 22.15 When an extension wafer is used, the wafer and implant this has not been a significant issue [4,9]. To minimize
are first sutured together (the medial sutures). Then the implant and
wafer are secured as a single unit to the mandibular periosteum inferi- resorption, the implant should be placed on the more firm
orly with two 4-0 PDS sutures. cortical bone of the lower border of the mandible [10].
Placement of the implant in a sub- or superperiosteal
position has not been shown to significantly affect the
incidence of bone resorption [10].
and three more doses on the first postoperative day. No
dressing is used for patients undergoing mentoplasty. REFERENCES
Patients are instructed to apply ice to the surgical site. It 1. Safian J. Progress in nasal and chin augmentation. Plast Reconstr
is not uncommon for patients to complain of postopera- Surg 1966;37:446–52.
tive pain; the larger the implant the greater the tendency 2. Adams J. Facial augmentation with solid alloplastic implants. In:
Glasgold AI, Silver FH, editors. Applications of biomaterials in
for patients to experience discomfort. Patients are seen facial plastic surgery. Boca Raton: CRC Press; 1991.
on postoperative day 7, at which time the skin sutures 3. Binder W, Kamer F, Parkes M. Mentoplasty—a clinical analysis of
are removed. alloplastic implants. Laryngoscope 1981;91:383–91.
4. Toranto I. Mentoplasty: a new approach. Plast Reconstr Surg
1982;69:875–8.
COMPLICATIONS 5. Mittleman H. The anatomy of the aging mandible and its importance
to facelift surgery. Facial Plast Surg Clin North Am 1994;2:301–9.
Complications following mentoplasty with alloplastic 6. Silver FH, Maas CS. Biology of synthetic facial implant materials.
implants include infection, over- or undercorrection, Facial Plast Surg Clin North Am 1994;2:241–53.
asymmetry, numbness in the distribution of the mental 7. Glasgold A, Glasgold M. Intraoperative custom contouring of the
mandible. Arch Otolaryngol Head Neck Surg 1994;120:180–4.
nerve, marginal mandibular nerve weakness, and man- 8. Mittelman H. Augmentation of the chin and pre-jowl sulcus. In:
dibular resorption. Infection is very rare, especially with a Terino EO, Flowers RS, editors. The art of alloplastic facial con-
submental approach. It can occur in the immediate post- touring. St. Louis: CV Mosby; 2000.
operative period as well as months to years later. Infection 9. Friedland JA, Coccaro PJ, Converse JM. Retrospective cephalomet-
usually presents as increasing pain, tenderness, or swell- ric analysis of mandibular bone resorption under silicone rubber
chin implants. Plast Reconstr Surg 1976;57:144–51.
ing. Once the infection is identified, treatment includes 10. Pearson DC, Sherris DA. Resorption beneath Silastic mandibular
a course of oral antibiotics. If infection is not resolving implants. Effects of placement and pressure. Arch Facial Plast Surg
with antibiotics, the implant should be removed. In over 1999;1:261–4.