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132
13.7 Complication
andManagement
Infection, implant extrusion, malposition or
migration, irregular contour of the overlying
skin, pain or discomfort, bone resorption, and
hypoesthesia are possible complications of alloplastic implant insertion [9, 10].
13.7.1 Infection
Infection requiring removal of the implant is the
most catastrophic complication of implant.
Infection should be prevented with extra caution
and effort. Implant should be carefully managed
between trial insertion and nal insertion to
reduce the chance of contamination. It should be
kept away from saliva and other oral secretions.
Once any signs of infection are suspected, antibiotics with extra strength and dose should be
started right away and followed up for sufcient
duration. Infection in the setting of alloplastic
implantation has always been an issue of concern, as these materials lack the vascular ingrowth
seen with autologous grafts and additionally
serve as a surface for bacterial colonization and
biolm formation. Implant-related infections
may result in implant removal, and requires further antibiotic treatment and additional wound
management. Reinsertion of implants may be
considered in 6–12months.
13.7.2 Malposition
Malposition or transposition of implants is a
common complication of alloplastic implant
insertion. This complication can be prevented by
precise dissection and xation using titanium
screws. Selection of proper-sized implant is
important. Oversized implant may cause distortion of the contour. Detection of malposition or
displacement is not easily found right after surgery because of edema. Elastoplast tape is frequently used to minimize the implant
S. Park
Fig. 13.8 Marked bony resorption is observed 3 years
after insertion
displacement and reduction of edema. Muscle
pull may play a role in implant migration.
Injection of Botox may help to reduce the hyperfunction of mentalis muscle or masseter in acute
postoperative time.
13.7.3 Bony Resorption
If chin implant over 6mm is used to correct the
problem, there is a high risk of bone resorption.
Other factors include hyperfunction of mentalis
muscle, lip incompetence, and narrow implant
shape. However, likelihood and timing of bone
resorption are highly unpredictable, and regular
follow-up after chin implant is required. Removal
of the implant is recommended if the remaining
cortical bone is scarce and irreversible. Osseous
genioplasty is usually necessary after the removal
(Fig.13.8).
13.8 Discussion
The use of various alloplastic materials such as
silicone, polytetrauoroethylene, methyl methacrylate, Gore-Tex, and porous polyethylene is
commonplace in facial skeletal augmentation.
Solid silicone, in particular, is the most fre-
t.me/Dr_Mouayyad_AlbtousH
13 Alloplastic Modication ofLower Face
133
quently utilized due to its ease of carving during
surgery using simple tools like scissors or a
scalpel. Additionally, silicone implants boast
easy sterilization through steam or irradiation,
with rare occurrences of clinical or allergic
reactions. Despite these advantages, silicone
implants are not without drawbacks. Underlying
bone resorption and brous capsule formation
are potential issues, especially when placed
beneath thin soft tissue. However, these capsules can also offer benets, such as forming a
vascularized protective barrier that facilitates
implant removal without damaging surrounding
tissue when necessary. Secure xation of the
implant with screws is crucial; the depth of
screw xation must be carefully managed to
prevent tearing, loosening, or implant failure.
Utilizing multiple screws is generally recommended for enhanced stability.
The mentalis muscle is often overlooked during chin surgery, yet it plays a signicant role in
post-surgical outcomes. Hyperfunctioning of the
mentalis muscle can lead to lumps, active wrinkles, and overall dissatisfaction post-surgery.
Inadequate repair of this muscle may result in a
attened appearance on the lower anterior surface of the chin and even lead to upward migration of the implant.
In summary, alloplastic implants serve as an
effective means for cosmetic enhancement of
facial features. They offer reliable restoration of
facial proportions and balance. For individuals
seeking aesthetic improvements without undergoing bone surgeries, alloplastic implants pro-
vide a viable alternative, characterized by a
shorter and simpler surgical process and a faster
recovery period.
References
1. Sykes JM, Fitzgerald R. Choosing the best procedure to augment the Chin: is anything better than an
implant? Facial Plast Surg. 2016;32:507–12.
2. Yaremchuk MJ. Facial skeletal reconstruction using
porous polyethylene implants. Plast Reconstr Surg.
2003;111:1818–27.
3. Maas CS, Merwin GE, Wilson J, Frey MD, Maves
MD. Comparison of biomaterials for facial bone
augmentation. Arch Otolaryngol Head Neck Surg.
1990;116:551–6.
4. Wray RC Jr, Moore DL, Weeks PM. The use of silicone chin implants in plastic surgery: a method of
chin augmentation. South Med J. 1974;67:456–60.
5. Gui L, Huang L, Zhang Z. Genioplasty and chin
augmentation with Medpor implants: a report of 650
cases. Aesth Plast Surg. 2008;32:220–6.
6. Godin M, Costa L, Romo T, Truswell W, Wang T,
Williams E.Gore-Tex chin implants: a review of 324
cases. Arch Facial Plast Surg. 2003;5:224–7.
7. Vinal MA, Saladino CN, Ginesin LM.Management
of wide nasofrontal angle with GORE-TEX implants.
Aesth Plast Surg. 1998;22:116–9.
8. Yaremchuk MJ. Skeletal augmentation. In: Neligan
PC, editor. Plastic surgery, vol. 2. 3rd ed. Seattle:
Elsevier Saunders; 2012. p.339.
9. Homsy CA.Complications and toxicities of implantable biomaterials for facial aesthetic and reconstructive surgery. Plast Reconstr Surg. 1998;102:1766–8.
10. Rubin JP, Yaremchuk MJ. Complications and toxicities of implantable biomaterials used in facial
reconstructive and aesthetic surgery: a comprehensive review of the literature. Plast Reconstr Surg.
1997;100:1336–53.
t.me/Dr_Mouayyad_AlbtousH
t.me/Dr_Mouayyad_AlbtousH
Secondary Mandibular Contouring
Surgery
JihyuckLee
14
14.1 Pearls
1. More patients are willing to undergo a secondary mandibular contouring procedure due
to dissatisfactory aesthetic results of the prior
surgery.
2. Lack of a combined narrowing genioplasty
procedure during mandibular contouring may
cause a disproportionately broad chin.
Additional chin-narrowing surgery is required
in such cases.
3. Excessive resection in the mandible angle
region can result in an unnatural and hollow
appearance. Implants may be used to correct
the overly resected jaw contours.
4. Excessive mandible reduction can result in an
unnatural depression of the lower face.
Autologous fat or alloplastic implant may be
used for correcting this volumetric
deciency.
5. Postoperative jawline asymmetry, irregular
and uneven jaw contours and ‘secondary
angle’ formation may result from technical
faults during the surgery. Further bone contouring can improve these aesthetically unfavourable conditions.
6. Alloplastic materials, such as chin implant or
ller are commonly used for altering chin
J. Lee (*)
Center for Facial Bone Surgery, Department of
Plastic Surgery, ID Hospital, Seoul, South Korea
e-mail: face@idhospital.com
shape. Revision of surgery can be done by
removing alloplastic implants or llers and
making an oval and natural jawline through
the osseous genioplasty.
14.2 Introduction
Mandibular contouring surgery, such as the
angloplasty, is known to be the most commonly
practiced procedure in facial contouring surgery
especially among the Asian population [1, 2]. As
the surgery gains its popularity recently, more
patients are willing to undergo a secondary or
revisional mandibular contouring surgery mainly
because of the dissatisfactory aesthetic results of
the prior surgery. These unfavourable results
after a mandibular contouring surgery mainly
occur because of failure to notice the importance
of the balance between the chin and the rest of the
mandible or the balance between the mandible
and the whole face [3–6]. Such overlook in the
facial harmony results in a disproportionately
wide chin due to the lack of an accompanied narrowing genioplasty procedure or a hollow look in
the lower face due to excessive resection of the
mandibular angle. Technical faults during the
surgery can also cause dissatisfactory surgical
outcomes [1, 7, 8]. For example, asymmetry in
the jaw contours or uneven and irregular jawlines
and an unnatural and unsmooth jawline, namely,
a ‘secondary angle’, can be formed after a mandibular contouring surgery [1, 4]. These condi-
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
S. Park (ed.), Facial Bone Contouring Surgery, https://doi.org/10.1007/978-981-97-4992-8_14
t.me/Dr_Mouayyad_AlbtousH
135
136
J. Lee
tions frequently need a secondary contouring
14.3 Case Study
surgery to correct such problems. Throughout the
following texts, conditions that require an additional mandibular contouring surgery are
explained by introducing actual clinical cases.
(A) Insucient Narrowing Eects from the FrontalView
The most common reason for a secondary or revisional mandibular contouring surgery after a
prior mandibular contouring surgery is dissatisfactory narrowing effects especially when seen
from one’s front [1, 2, 4, 6]. The main cause for these problems is the overlook on the importance of the chin. To achieve a slender, harmonic and well- balanced lower face, not only a
conventional mandible angle reduction but also an accompanied chin-narrowing procedure is
required for patients especially with a broad chin. If a narrowing genioplasty is not done concomitantly in these cases, a disproportionately broad chin and poor narrowing effects will be
resulted after the mandible reduction surgery. A ‘mini V-line surgery’ which includes a narrowing genioplasty followed by further reduction of the bony steps at the chin-mandible junction
may be the solution in such cases [4].
Figures 14.1 and 14.2 show a patient who has underwent a secondary mandibular contouring
surgery because of the insufcient narrowing effects from the frontal view. A 28-year-old female
previously underwent a conventional mandibular angle reduction together with a reduction
malarplasty procedure. However, she was not satised with the lower face contour, as her chin
was disproportionately broad looking after the prior surgery. She underwent a mini V-line surgery as the chin was narrowed by the T-osteotomy technique, and further reduction was made
to smoothen the chin-mandibular junction. As seen in the postoperative radiographs and medical photographs, the broad chin was effectively reduced to result in a smooth and feminine
facial contour.
Fig. 14.1 Preoperative
and postoperative
panoramic radiograph of
a 28-year-old female.
The mandibular angles
were reduced during the
prior surgery. The
remaining broadness in
the chin region was
further reduced by an
additional mini V-line
surgery
t.me/Dr_Mouayyad_AlbtousH
14 Secondary Mandibular Contouring Surgery
137
Fig. 14.2 Despite the previous surgery, a broad lower face contour was noticed. Six months after the mini V-line
surgery, the broad chin was effectively reduced to result in a smooth and feminine facial contour
t.me/Dr_Mouayyad_AlbtousH
138
a
(B) Excessive Resection
J. Lee
Some patients and even some surgeons have the misconception that the narrowing effect is proportional to the amount of mandible reduction [2]. That is, some believe that if more amount of
angular bone is resected, more slimming effect will be expected. When the patient has skinny
face, excessive mandible resection results in a hollow lower face. Autologous fat graft is a reasonable solution for correcting the lateral jaw depression. In some severe cases, an alloplastic
implant should be inserted to the overly resected mandible site to restore its natural contour.
Figure 14.3 shows examples of various ready-made Medpor® implants manufactured by
Stryker® (Kalamazoo, MI, USA). Individually customized implants are also available recently.
b
Fig. 14.3 Various ready-made Medpor® implants suited for the mandibular angle. (Lower left) preop X-ray,
after insertion of Medpor implant and xation with screws
t.me/Dr_Mouayyad_AlbtousH
14 Secondary Mandibular Contouring Surgery
(C) Postoperative Secondary Angles
During a conventional mandibular angle reduction surgery, if the ostectomy is abruptly stopped
somewhere in the middle of the mandible body, an unnatural and unsmooth jawline, namely, a
‘secondary angle’, may form and result in an unaesthetic outcome. A long, smoothly curved
ostectomy should have been performed to prevent this condition, as in some troublesome cases,
an additional bone contouring is required to smoothen the secondary angle. In some cases, a
narrowing genioplasty may be accompanied with the procedure.
Figure 14.4 shows a 33-year-old female patient with a prior surgical history of a conventional
mandibular angle reduction. As seen on the oblique view of the preoperative medical photographs, a secondary angle is formed in the middle of the mandibular body. This is caused by a
short and straight-lined ostectomy that leaves an unnatural jawline. This postoperative secondary angle was improved by a secondary mandibular mini V-line surgery. As the chin was further
narrowed with a T-osteotomy technique, the lower border of the mandibular body was further
contoured and smoothened for a slim and smooth facial contour.
Fig. 14.4 A 33-year-old
female patient with a
prior surgical history of
a conventional
mandibular angle
reduction. On the
oblique view of the
preoperative
photographs, a
secondary angle can be
noticed in the middle of
the mandibular body.
The postoperative
secondary angle was
improved by a
secondary mandibular
mini V-line surgery
139
t.me/Dr_Mouayyad_AlbtousH
140
(D) Jawline Asymmetry
In patients with pre-existing jawline asymmetry, bone resection should be differentially carried
out. However, if the asymmetry is failed to be noticed preoperatively, the resultant surgical outcome will also leave asymmetry. Or even in patients with a symmetric jawline, if the ostectomy
procedure was carried out differentially, postoperative asymmetry and a dissatisfactory outcome
will be resulted. Thorough preoperative analysis and accurate intraoperative procedures are
required to avoid postoperative asymmetry, and differently sized ‘guarded’ oscillating saws can
be helpful in such situations [1]. However, if a noticeable asymmetry is complained by the
patient after a prior mandibular contouring surgery, a secondary bone contouring with or without a concomitant genioplasty should be carried out.
Figure 14.5 shows a 26-year-old female patient with a prior surgical history of the mandibular V-line surgery who visited the clinic because of a long and asymmetric chin. Six months
after the rst surgery, a revisional V-line surgery was carried out as the length of her chin was
vertically reduced, and the asymmetric appearance was signicantly improved.
Fig. 14.5 A 26-year-old
female patient with a
prior surgical history of
the mandibular V-line
surgery complained of a
long and asymmetric
chin. A revisional V-line
surgery was carried out,
and the chin was
vertically reduced, and
the asymmetry was
signicantly improved
J. Lee
t.me/Dr_Mouayyad_AlbtousH
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