Chin augmentation with cervical flaps associated with rhytidoplasty
Aumento mentoniano com retalho cervical associado à ritidoplastia

INTRODUCTION

The chin plays a major role in the contour of the lower third of the face; its absence or excess causes an aesthetic rupture and break in facial harmony. The chin morphology is determined by osseous components and soft tissues, which vary with sex and age. Most of the aesthetic changes of the chin are evident mainly in the local osseous component¹.

Generally, most complaints encountered in medical practice emphasize discontent with the cervical region. However, without identifying the disproportions of the chin components in the local context, it is up to the physician to ascertain the correct interpretation and suggest the best management for each patient.

OBJECTIVE

To describe a new technique for chin augmentation using a cervical flap associated with rhytidoplasty.

METHODS

This study was a prospective evaluation of 11 female patients between the ages of 40 and 65 years who underwent a chin augmentation with cervical flaps between January 2017 and January 2018, performed by the author through private services (Ferreira Segantini Plastic Surgery–Day Hospital).

We conducted our analysis with the aid of photographic documentation of the patients who underwent the procedure.

Surgical Technique

All the surgeries were performed under local anesthesia with sedation, with the patient in the supine position. The process for making the cervical flap precedes the rhytidoplasty, and in some cases, prior liposuction of the cervical region may be performed.

The flap proposed in this technique is located on the cervical midline and consists of segments of the platysma muscle and fatty tissue of the submental space. The base of the flap measures approximately 2.5 cm and begins in the upper submental region, extending inferiorly by 4 to 6 cm (Figures 1 and 2).

Figure 1 - Flap positioning.

Figure 1 - Flap positioning.

Figure 2 - Making the flap.

Figure 2 - Making the flap.

After detaching the cervical skin and making the flap, we began the posterior superior dissection of the flap in the median subperiosteal region of the mandible, 1.5 to 2.0 cm above the mental protuberance². Next, we evaluated the cavity size and volume offered by the flap, which allowed us to make adjustments if necessary (Figure 3).

Figure 3 - Evaluated the cavity size and volume offered by the flap.

Figure 3 - Evaluated the cavity size and volume offered by the flap.

Having made the flap and cavity, we rotated the flap in a posterior superior direction and then affixed it using a transcutaneous needle (e.g., Reverdin) in the upper midline of the cavity (Figure 4). The suture was made with 4.0 mononylon using only a small hole to bury the suture knot.

Figure 4 - Flap fixation it using a transcutaneous needle.

Figure 4 - Flap fixation it using a transcutaneous needle.

With the flap attached to the cavity, the base of the flap was stitched to the periosteum of the transition from the mental to submental regions, and the platysmal bands are closed at the midline, where they meet at the base of the flap in a T-stitch (Figure 5), allowing us to proceed to treating the upper and midface (Figure 6).

Figure 5 - Base the flap was stitched to the periosteum of the transition from the mental to submental

Figure 5 - Base the flap was stitched to the periosteum of the transition from the mental to submental

Figure 6 - Treating the upper and midface.

Figure 6 - Treating the upper and midface.

Postoperative care was similar to that in conventional rhytidoplasty associated with chin implantations.

RESULTS

All the patients underwent a cephalometric analysis, which, in turn, plays a major role in the assessment of the relationship of the chin with other bone structures and soft tissues of the face.

For this study, we considered the imaginary lines created by Frankfurt (horizontal) and Gonzales-Ulloa (vertical and tangent to nasion) (Figure 7).

Figure 7 - Cephalometric analysis, lines horizontal created by Frankfurt and vertical of Gonzales-Ulloa.

Figure 7 - Cephalometric analysis, lines horizontal created by Frankfurt and vertical of Gonzales-Ulloa.

All the patients presented good recovery and did not present with any complications in the immediate or late postoperative period.

All the patients evidenced an improvement in chin projection, ranging from 32.5% to 60% in relation to the Gonzales-Ulloa line and cervical contour (Figures 8-10).

Figure 8 - Patient 57 years, preoperative and postoperative 21 days, 6 months and 1 year.

Figure 8 - Patient 57 years, preoperative and postoperative 21 days, 6 months and 1 year.

Figure 9 - Patient 40 years, preoperative and postoperative for 3 months and 6 months.

Figure 9 - Patient 40 years, preoperative and postoperative for 3 months and 6 months.

Figure 10 - Patient 58 years, preoperative and postoperative for 21 days and 6 months.

Figure 10 - Patient 58 years, preoperative and postoperative for 21 days and 6 months.

DISCUSSION

Many procedures have been used to aesthetically improve the lower third of the face, producing efficient results with an effective increase in chin projection.

Silicone implants have been applied the most, as it demonstrates efficient results and are easy to handle. However, approximately 50% of the patients present with bone erosion³ due to local compression of the prosthesis. The most frequent complications include choosing the wrong implant size, prosthetic displacement, infection, extrusion of the implant, sensitive alterations in the lower lip, and impaired chin muscle function, where intraoral access⁴ is responsible for most complications.

In well-selected cases without occlusion problems, basilar osteotomy⁵ exhibits excellent results. Despite the low incidence of complications⁶, patients do not generally accept the procedure owing to fear of bone manipulation.

Despite the easy application, the use of fillers such as hyaluronic acid has temporary results and, in some cases, can cause intense and sometimes prolonged erythema, papulopustular polymorphic acne, intense edema, skin nodules⁷, and necrosis⁸. Regardless of their associated low incidence rates of complications and easy treatment, fillers performed with fat grafting⁷ may show partial or total reabsorption and asymmetries, and some cases might require several sessions to obtain a good result.

Among the strategies to improve chin contour with autologous tissues is the proposal by Viterbo and Brock in 2013⁹ to perform “gliding mentoplasty,” which includes intraoral access and easy execution, and can be performed in isolation without a greater approach to the face. Nevertheless, it may be insufficient in cases that require a volumetric increase.

In comparison with the other procedures, chin augmentation with the use of the cervical flap has been shown to be effective, with real gains in anterior projection, durability, and enthusiastic acceptance by the patients. Furthermore, we have yet to observe any complications.

CONCLUSION

Although making the flap requires a little more experience and surgical time, its results and acceptance are encouraging. By eliminating the use of synthetic materials, reducing costs, and improving safety and durability, a more refined mandibular contour and a more natural chin projection can be achieved.