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Soft tissue genioplasty Corresponding Authors Dr.Emtenan Al Majid, BDS, SB , OMFS Senior Registrar in Oral and Maxillofacial Surgery Department in Riyadh Military Hospital Academic instructor for Dental assistant Diploma 412 in Riyadh military Hospital Peer-Reviewer in Saudi Medical Journal E mail: [email protected] Tel: 00966-503438268 Dr .Abdullah AlAtel, BDS, MSc, FRADS Consultant and head of OMFS Department in Riyadh Military Hospital Head of training activities in Saudi Board in Oral and Maxillofacial Surgical Department. E mail: [email protected] Tel: 00966-503020274 1 Soft tissue genioplasty ABSTRACT OBJECTIVE: to introduce a new non invasive surgical technique of genioplasty where the mentalis muscle is advanced surgically for some selected indicated patients. METHODS: the technique was carried out in the Department of Oral and Maxillofacial Surgery in Riyadh Military Hospital, Riyadh city, Kingdom of Saudi Arabia 2005. Twenty patients were enrolled and treated with soft tissue genioplasty (intramuscular tightening).preand post operative lateral cephalometric tracing were recorded with 6 years follow up . RESULTS: In all patients, soft tissue analysis of the lower lip and chin in lateral cephalogram were increased in horizontal and vertical dimensions demonstrating a good post operative improvement and patient satisfaction within 6 years follow up. CONCLUSIONS: Soft tissue genioplasty provides superior versatility in surgical alteration of the chin morphology in horizontal and vertical dimensions utilizing mentalis muscle only without any hardware. It is a time saving procedure obtained under local anesthesia. It preserves mentalis muscle attachment without dissection of mental nerve. KEYWORDS: mentalis muscle, genioplasty, intramuscular tightening. 1 INTRODUCTION Osseous genioplasty is an important technique in the surgical alteration of the chin123, although the procedure is stable still it carries some risks of complications4567. In somehow, osseous genioplasty has been overshadowed by the availability and versatility of multiple techniques of chin surgery8910. One of the new methods is introduced by the author, called soft tissue genioplasty where the mentalis muscle is advanced surgically for some selected indicated patients who indicate minor chin advancement with acceptable facial profile. The distinct advantages of this technique include time saving, procedure obtained under local anesthesia , preserving mentalis muscle attachment with favorable cervicomental angle , dissection of mental nerve is prohibited , hardewares are not in need .The fact that the procedure is less technicality demanding when compared to osseous genioplasty and it can be utilized with other surgical procedure as osseous genioplasty or submental liposuction as with all esthetic surgical procedures , the designed results , wishes of the patient and associated risks of the procedure will drive the surgical treatment plan . MATERIALS AND METHODS Pre operative consideration and treatment planning The most critical consideration in the surgical alteration of the chin is the pre operative assessment of the patient11. The wide variance of anatomical configuration provides fertile ground for less than optimal post operative results without understanding of the anatomy and esthetic of this region. The treatment plan of soft tissue genioplasty should include full clinical assessment of patient expectation and objectives, pre operative photographs including frontal, profile and submental perspectives as well as appropriate imaging studies with lateral cephalometric evaluation. Starting from January 2005 till October 2010, twenty female patients medically fit with age ranging from 18-25 years were selected who indicate minimum chin advancement with acceptable facial profile. This procedure is a modification of an original one where all the patients were consented, therefore no need for ethical approval letter. All the patients had post operative follow up for one year. 1 Clinical and radiological examinations Alteration of the profile to achieve appropriate esthetic balance is generally a major objective of the genioplasty procedure and usually offers the largest magnitude of contributions to facial balance clinical and radiological assessment (lateral cephalometric tracing). Particularly the lower facial hight in proportion to the face, as well as the width, shape and orientation of the chin in the frontal view. When measuring the vertical height of the chin and lower lip should be appropriately two third the height of upper lips (subnasalis to stomion) 12. The esthetic zone of the labiomental fold and the consequences of altering this anatomical relationship should be considered when performing genioplasty procedure. The depth of labiomental fold dictated by the projection of the chin as well as lower incisor angulation in relationship to the plane of inferior border of mandible as measured on lateral cephalogram. A posterior position of the chin (pog and pog' in lateral cephalogram) according to zero Gonzales shouldn’t exceed more than 5 mm, otherwise osseous genioplasty is the proper choice. Other orthognathic abnormalities needs to be documented such as mandibular hypoplasia should alert the clinician to consider the necessity of mandibular advancement procedure .camouflage type procedure are only indicated in the events that the patient doesn’t wish to consider orthognathic surgery13. A conservative approach regarding the magnitude of advancement should be adapted. Operative technique Genioplasty procedure may be performed within office based local anesthesia or intravenous sedation technique, or with general anesthesia. In either case, the administration of local anesthesia with vasoconstrictor is critical to provide hemostasis as well as postoperative analgesia. Local infiltration of vestibular region between the mental foramen as well as the attachment of the mentalis muscle will significantly improve the surgical field during the dissection. After administration of local anesthesia, vestibular incision is made extending from the distal aspect of the canine tooth to the distal aspect of the contraletral canine. The incision should be placed approximately 5-7 mm below the level of the attached gingival, within the free gingival (which can be determined by pulling the lower lip outward) 6. The incision should be placed perpendicular to the bony surface of the mandible and oblique incisions are to be avoided. Sub periosteal dissection should be performed to expose mentalis muscle, it is important to avoid transecting the belly of the mentalis muscle as this will result in unwanted hemorrhage and will make the dissection problematic14. Intra muscular tightening of mentalis muscle is performed and raised superiorly for re- attachment using 1/0 dexon (figure 1). The mucosa is then approximated with interrupted or 3/0 vicryle suture. 1 All twenty patients had 6 years follow up with series of photos, lateral cephalometric tracings and documented satisfaction questionnaires as below. Not satisfied at all Extremely satisfied 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 Figure 1.intraoperative mentalis muscle tightening. Results Immediately post operatively there was no edema in the chin, floor of the mouth and submental zone because of the limited area for dissection and short procedure (around 10 minutes). The patients have no neurosensory disturbance because the mental bundle was not dissected in this technique. Post operative cephalometric soft tissue tracing showed significant changes in Vertical and sagittal parameters mostly lower facial height (around 4-6 mm) and thickness of the chin (around 4-7 mm) summaries in Table 1. All twenty patients had 6 years follow up with series of photos, lateral cephalometric tracings and documented satisfaction questionnaires revealing unchanged results with high satisfaction more than 95 %. (Figure 2) Vertical and sagittal parameters Mean pre- operative lateral cephalometric tracing measures in millimeters for twenty patients Mean post operative lateral cephalometric tracing measures in millimeters for twenty patients Difference in millimeters 1 2/3 lower facial height 45 49 4 Position of vermillion border 12 13 1 Exposure of lower incisors 0 2 2 Labiomental fold distance 13 17 4 Lower lip thickness 13 -- -- Thickness of labiomental fold 10 14 4 Thickness of chin 12 15 3 Angle of the fold 0 -- -- Table 1. Vertical and horizontal parameters. Satisfaction score Figure 2: patient’s satisfaction following soft tissue genioplasty. 1 Discussion: soft tissue genioplasty is a new method introduced by the authors when mentalis muscle advanced surgically for some selected patients who indicates minor chin advancement with acceptable facial profile. It is a time saving procedure obtained under local anesthesia preserving mentalis muscle attachment with favorable cervicomental angle without any hardwares and it can be utilized with other surgical procedures as osseous geioplasty or submental liposuction. One of the most important advantages for this procedure is the post operative lack of edema and neurosensory disturbance because of limited dissection of mentalis muscle and mental nerve bundle. In this study, post operative laeral cephalometric soft tissue tracing for the twenty patients showed significant changes in vertical and sagittal parameters mostly lower facial height and chin thickness sustained for up to 6 years follow up with satisfactory results . At the end, patient’s selection, wishes of the patient, designed results and risk of the procedure will drive surgical treatment plan. Case#1 18 years old Saudi female medically fit complaining from small chin, she wants minor surgical procedure under local anesthesia. Pre operative work up Pre-operative frontal and lateral profiles Pre-operative lateral cephalometric tracing. 1 Post operative work up Post-operative frontal and lateral profiles Post-operative lateral cephalometric tracing. Post operative parameters Case # 2 Pre operative photo postoperative photo 1 References 1- Osseous genioplasty technical considerations ; operative techniques in otolaryngology – Head and Neck Surgery , volume 18 issue 3 , September 2007 , pages 181-188 Brett A .Miles, Joseph L. 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