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S. Park
contouring the mandible’s medial edge without
risking injury to the inferior alveolar nerve.
In addition to excessive narrowing of chin,
excessive ostectomy on the distal portion of the
proximal segment in mandible contouring can
create a double contour due to a bony gap. Since
it is very difcult to correct this deformity, it is
recommended not to over-resect the distal portion of the proximal segment, and if needed,
additional rasping can be performed to reduce the
remaining edge.
Soft tissue damage around the lateral aspect of
the geniosegment during the procedure can also
lead to thinning of soft tissue and subsequent
adhesion, contributing to the appearance of double contouring. In cases where double contouring
is due to a bony step, it can be corrected by augmentation with fat graft or alloplastic materials
such as silicone, Gore-Tex, and MEDPOR.If the
cause is soft tissue adhesion, releasing the adhesion can improve the appearance. The author
often uses layers of Gore-Tex to camouage bony
gaps or depressed soft tissue. However, if the
double contouring results from soft tissue sagging, especially from the cheek along the mandibular border during post-surgical recovery,
laser-assisted liposuction and lifting procedures
are recommended. These procedures, detailed in
another chapter (Chap. 15), can effectively
address the sagging and improve the contour.
10.8 Discussion
The decision whether to just reducing mandible
or to performing V-line surgery is difcult for
both patients and surgeons. First of all, surgeons
should differentiate the patients whose chin must
be corrected. If chin is too wide, short or long, or
retrogenia or progenia, concomitant genioplasty
is recommended in mandible reduction surgery.
If geniomandibular junction is at to concave,
mandible angle reduction alone can improve
overall lower facial line. So this is a relative indication of V-line surgery. If patients request more
slender chin shape according to their preference,
it is also a relative indication. Overall facial har-
mony regarding the width–height ratio is an
important consideration.
Performing a central strip chin osteotomy,
which involves a horizontal cut and two vertical
cuts, is a straightforward and safe procedure for
surgeons with basic craniofacial surgical skills.
However, precision is key. Inaccurate execution
can lead to misalignment of the bone edges,
resulting in suboptimal bone union. Therefore,
for surgeons who are not fully experienced in this
technique, it’s advisable to avoid creating multiple pieces, overly small segments, or asymmetric
shapes during the osteotomy. Ensuring accurate
alignment and stability of the bone segments is
crucial for optimal healing and achieving the
desired aesthetic outcome.
The amount of central resection should be
individualized depending on the width of the chin
and the patient’s need. In our practice, it ranged
from 4 to 14mm. Resection is usually symmetric
in width and shape. However, in case of asymmetry, the center of the strip was lateralized to the
more prominent side. The design of central strip
resection can also be altered from rectangular to
trapezoidal and made to modify the shape of the
chin narrower. Advancement or setback of the
chin is also possible if a change of prole is
required.
Creating a smooth transition from the genioplasty segment to the lateral contouring part,
without leaving any bony step-off or protuberance, is a challenging aspect of the combined
genioplasty and mandibular contouring procedure. In some cases, patients with fatty faces and
chins have reported immediate postoperative
issues with soft-tissue bunching. However, this
complication tends to resolve over time. Partial
dissection and redraping of the soft tissue attachments around the chin area have proven effective
in mitigating these issues and enhancing the
overall outcome of the procedure.
References
1. Yang DB, Song HS, Park CG. Unfavorable results
and their resolution in mandibular contouring surgery.
Aesth Plast Surg. 1995;19:93.
10 The V-Line Surgery: Narrowing Genioplasty withMandible Reduction
101
2. Baek SM, Baek RM, Shin MS. Renement in aesthetic contouring of the prominent mandibular angle.
Aesth Plast Surg. 1994;18:283.
3. Satoh K. Mandibular contouring surgery by angular
contouring combined with genioplasty in orientals.
Plast Reconstr Surg. 1998;101:461.
4. Satoh K. Mandibular contouring surgery by angular
contouring combined with genioplasty in orientals.
Plast Reconstr Surg. 2004;113:425.
5. Chen T, Khadka A, Hsu Y, Hu J, Wang D, Li J.How
to achieve a balanced and delicate lower third of the
face in orientals by mandibular contouring. J Plast
Reconstr Aesthet Surg. 2013;66:47–56.
6. Li J, Hsu Y, Khadka A, Hu J, Wang Q, Wang
D. Surgical designs and techniques for mandibular
contouring based on categorisation of square face
with low gonial angle in orientals. J Plast Reconstr
Aesthet Surg. 2012;65:e1–8.
7. Li J, Hsu Y, Khadka A, Hu J, Wang D, Wang
Q. Contouring of a square jaw on a short face by
narrowing and sliding genioplasty combined with
mandibular outer cortex ostectomy in orientals. Plast
Reconstr Surg. 2011;127:2083–92.
8. Hsu YC, Li J, Hu J, Luo E, Hsu MS, Zhu
S. Correction of square jaw with low angles using
mandibular “V-line” ostectomy combined with outer
cortex ostectomy. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2010;109:197–202.
9. Park S, Noh JH. Importance of the chin in lower
facial contour: narrowing genioplasty to achieve a
feminine and slim lower face. Plast Reconstr Surg.
2008;122:261–8.
10. Baek RM, Han SB, Baek SM. Surgical correction of the face with the square jaw and weak chin:
angle-to-chin bone transfer. Plast Reconstr Surg.
2001;108:225–31; discussion 232.
11. Park S. Classication of chin in terms of contour
and width and preference in Korean. In: 61st Annual
Meeting of Korean Society of Plastic Surgery. 2007.
p.355
12. Gianni A, D’Orto O, etal. Neurosensory alterations
of the inferior alveolar and mental nerve after genioplasty alone or associated with sagittal osteotomy
of the mandibular ramus. J Cran Maxillofac Surg.
2002;30:295–303.
13. Westermark A, Bystedt H, et al. Inferior alveolar
nerve function after mandibular osteotomies. Br J
Oral Maxillofac Surg. 1998;36:425–8.
The Mini V-Line Surgery
SanghoonPark
11
11.1 Pearls
1. Typically, conventional mandible contouring
surgery integrates a chin-narrowing procedure
with mandible angle reduction, a combination
popularly known as “V-line surgery.” This
renowned approach aims to sculpt a more
rened and aesthetically pleasing jawline.
2. In instances where a patient presents with a
disproportionately wide chin, yet without an
excessive mandible, an effective strategy is to
narrow only the anterior part of the mandible.
This selective approach allows the preservation of the mandible angle, leading to a wellbalanced lower facial prole.
3. For patients dissatised with the outcomes of
previous mandible contouring surgeries,
“mini V-line surgery” emerges as a suitable
corrective procedure. This technique focuses
on rening the chin and anterior mandible
area, catering specically to those needing
subtle enhancements.
4. The “mini V-line surgery” is conducted under
general anesthesia. The process involves narrowing genioplasty using the T-osteotomy technique, followed by a detailed reduction of bony
steps at the chin-mandible junction, ensuring a
seamless and natural jawline contour.
S. Park (*)
Center for Facial Bone Surgery, Department of
Plastic Surgery, ID Hospital, Seoul, South Korea
e-mail: spark@idhospital.com
5. While generally successful, this surgery can
entail certain postoperative complications.
Common issues include transient neurosensory loss, soft-tissue sagging, surgical site
infections, and hematoma formation. More
serious, albeit less common, complications
can include asymmetry, over- and undercorrection, malunion or nonunion of the bone
segments, and even facial paralysis.
6. Surgeons engaged in planning lower face contouring surgeries should consider incorporating the “mini V-line surgery” into their
repertoire. This technique is particularly benecial in achieving harmonious and aesthetically pleasing results, especially in cases
where patients require minor adjustments or
are seeking revisions from previous contouring procedures.
11.2 Introduction
Ever since its introduction in 1989, the mandible
reduction surgery is one of the most commonly
performed facial bone contouring surgeries nowadays [1]. And now, many surgeons recognize the
importance of considering the mandible as a
whole, and numerous efforts, for example, the
“V-line ostectomy” or “V-line surgery,” have
been made to reduce the lower face, more
balanced and aesthetically pleasing [2–7]. In certain cases, simply adjusting the chin without con-
© 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_11
103
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S. Park
ventional mandible angle reduction may lead to a
more balanced and harmonious feminine lower
face contour [8]. In patients without a prominent
angle when seen from the side or the front, the
angle reduction may be unnecessary. Furthermore,
in patients who do not want to undergo extensive
surgery that includes the mandible angle, simple
chin-narrowing surgery may be ideal. Mandible
surgery focusing overly on the mandible angle is
one of the most common reasons for unsatisfactory results after mandible contouring surgery [9,
10], in which a patient’s simple manipulation of
chin can improve the quality of the previous
surgery.
The so-called mini V-line surgery can be an
effective surgical approach to achieve a slim and
feminine face in these properly selected patients
[8]. Indications for the mini V-line surgery are as
follows: (1) patients who want to leave their mandible angle unchanged, (2) patients with a
U-shaped face in which the chin is broad but
without an excessive mandible angle either from
the lateral view or the frontal view, and (3)
patients with a dissatisfactory aesthetic outcome
after previous mandible reduction surgery [8].
11.3 Surgical Technique
Surgical procedures are conducted under general
anesthesia with orotracheal intubation. An intraoral vestibular incision is initially made, following an inltration with a 1% lidocaine and
1:100,000 epinephrine solution. Subperiosteal
dissection is executed to reveal the midsymphyseal region, being mindful to retain a substantial soft tissue attachment to the bony chin.
This approach ensures adequate blood supply to
the bone segments and enhances the effectiveness
of the chin-narrowing procedure. The
T-osteotomy technique, as illustrated in Figs.11.1
and 11.2, is employed for chin-narrowing [6].
Fig. 11.1 Surgical procedures of the mini V-line surgery
11 The Mini V-Line Surgery
105
Fig. 11.2 Intraoperative photographs of the mini V-line
surgery. A horizontal osteotomy line and two vertical
osteotomy lines are designed (top left). Osteotomies are
carried out with a reciprocating saw (top right). After
The osteotomy lines are strategically placed, with
the horizontal line situated at least 5mm below
the mental foramen. This precaution is taken to
prevent inadvertent nerve damage, as indicated
by the inferior alveolar nerve’s pathway on the
panoramic radiograph. Two vertical osteotomy
lines, perpendicular to the horizontal one, are
then marked. A reciprocating saw is the recommended tool for these osteotomies. Previous
studies at the authors’ institute report an average
horizontal chin narrowing of 9.7 mm, with the
maximum being 16mm. Post removal of the central bone segment, the lateral bone segments are
realigned and xed centrally using titanium
microplate and screws. For patients preferring a
less conspicuous approach and opposed to metal
xtures, biodegradable screws offer a viable
alternative for xation [11]. Adjustments such as
anterior advancement or posterior setback of the
chin are considered during the narrowing process, especially if facial prole corrections are
removing the middle bone segment, the two lateral bony
segments are xed with a microplate and screws in the
center (bottom left). Bone segments removed during surgery (bottom right)
necessary. Additionally, concurrent vertical
lengthening or shortening of the chin is possible,
depending on the facial ratios assessed preoperatively or intraoperatively [12, 13]. This comprehensive approach caters to both aesthetic desires
and functional needs of the patients.
Narrowing the chin creates a bony step at each
side of the chin–mandible junction, and it’s
important to smooth out this discontinuity for an
even jawline and to lessen palpability. This
requires additional lateral incisions near the original intraoral incision for chin narrowing. These
incisions are deliberately separated to reduce the
risk of direct nerve injury during surgery. Through
these incisions, subperiosteal dissection is performed for clear visual access from the chin–
mandible junction to the mandible angle.
Utilizing a “guarded” oscillating saw is recommended for accurately marking the osteotomy
line (Fig.11.3) [8, 14]. This saw, with a shielded
small blade, is chosen based on the size of the
106
S. Park
bony step and the proximity of the lower mandible border to the nerve route. It allows for precise, uniform bone resection, while minimizing
the risk of over-resection and nerve damage. The
resection’s posterior extension is critical to
ensure a smooth jawline, extending either to the
mid-mandible body or just anterior to the gonion,
depending on the mandible’s shape, mandible
plane steepness, and the extent of chin narrowing. If the resection doesn’t extend far enough
posteriorly, it can result in an unnatural “secondary angle,” leading to an unsatisfactory aesthetic
outcome [8]. Once the osteotomy line is marked
with the guarded saw, larger oscillating saws
complete the bone resection. Further mandibular
corticectomy can be performed for additional
mandible body narrowing if required (Fig.11.4)
[8]. This careful approach ensures an aesthetically pleasing and harmonious jawline.
11.4 Key Technical Points
1. The T-osteotomy technique for chin narrow-
ing demands that the horizontal osteotomy be
aligned perpendicular to the facial midline,
ensuring it is positioned at least 5mm below
the mental foramen for safety.
Fig. 11.3 The use of “guarded” oscillating saws. The
guarded saw has a small oscillating saw that is shielded at
various distances: 2, 3, 4, 5, and 6 mm (top). The saw
helps the surgeon to perform the bony resection precisely
while avoiding over-resection and nerve injury (middle).
Further bone resections are completed by serial use of
larger oscillating saws (bottom)
Fig. 11.4 Preoperative panoramic radiograph (left). Follow-up radiograph 1day after surgery (right)
2. Deciding the amount of central chin narrow-
ing involves considering various aspects such
as chin width, the path of the inferior alveolar
nerve, and individual patient preferences. In
practice, the authors have observed that the
typical amount of horizontal narrowing aver-
11 The Mini V-Line Surgery
107
ages around 8 mm, with a range from 4 to
14mm.
3. The resection’s position is usually central, but
adjustments may be made off-center to correct any asymmetry present in the chin.
4. Adjustments in the chin’s anteroposterior
position or alterations in vertical chin length
can be simultaneously conducted alongside
the chin-narrowing process.
5. Smoothing out the bony step at the chinmandible junction is critical to ensure a seamless transition and minimize palpability. This
is achieved by starting osteotomy using
guarded oscillating saws from distal to proximal direction. A guarded oscillating saw is
recommended for uniform, precise bony
resection that minimizes the risk of overresection and potential nerve damage.
108
11.5 Case Study
Case 1
A 26-year-old woman was planned for the mini V-line surgery. Although her mandible angles
were not very prominent with a gonial angle of 130°, the accentuated chin broadness gave her a
rather masculine appearance. The chin was narrowed by 10mm and simultaneously vertically
shortened by 2mm to achieve good facial proportions. Additional upper blepharoplasty was
performed concomitantly. Her relatively broad lower face had a more slender and feminine
postoperative contour after surgery (Fig.11.5).
Fig. 11.5 Preoperative
view of a 26-year-old
woman (left).
Postoperative view at
6months after mini
V-line surgery (right)
S. Park
11 The Mini V-Line Surgery
Case 2
A 33-year-old woman with a prior surgical history of a conventional mandible angle reduction
was planned for the mini V-line surgery. Despite the previous surgery, there is an asymmetry in
the lower face. Chin was narrowed by 11mm of and set back by 2mm. A concomitant reduction
malarplasty was done. After surgery, the patient’s disproportionately wide lower face contour
had a more harmonious and feminine appearance (Fig.11.6).
Fig. 11.6 Preoperative
view of a 33-year-old
woman with a prior
surgical history of a
conventional mandible
angle reduction (left).
Postoperative view at
6months after mini
V-line surgery (right)
109
110
S. Park
11.6 Complications
andManagement
Postoperative complications in mandible contouring surgery can vary in severity and occurrence. A notable complication frequently
observed is transient neurosensory loss.
According to a study from the authors’ institution
[8], approximately 27.0% of patients experienced
decreased sensation in the lower lip region immediately post-operation. However, it’s reassuring
to note that all sensations normalized during the
follow-up period, with no reports of permanent
neurosensory decits. To minimize the risk of
unintentional nerve injury, certain precautions
are recommended, such as dividing the intraoral
incision into three parts, ensuring the horizontal
osteotomy is performed at least 5mm below the
mental foramen during genioplasty, and using
guarded oscillating saws during ostectomy at the
chin-mandible junction.
Surgical site infections, reported in 2.0% of
cases [8], were successfully managed conservatively. Severe complications like hematoma
requiring surgical intervention, unexpected fractures, malunion or nonunion of bone segments,
facial paralysis, and trismus were not observed in
the mentioned study [8].
Cosmetic issues post-surgery can also arise.
Jowl redundancy, for instance, has been noted
as a problem in some cases. To address this,
additional submental laser-assisted liposuction
has been effectively employed. Mentalis hyperactivity, encountered in 4.8% of patients [8],
was identied as a temporary issue, resolving
within a 3-month period. In cases where mentalis hyperactivity is prominent, focal injection
of botulinum toxin into the hyperactive muscle
may prove benecial. Moreover, some patients
opt for adjunctive facial contouring surgeries in
conjunction with chin-narrowing surgery.
Procedures like reduction malarplasty, autologous fat grafting, laser-assisted liposuction, and
thread lifting are commonly performed simultaneously, enhancing the overall aesthetic outcome [8].
11.7 Discussion
When embarking on mandible reduction surgery,
especially for patients desiring a slimmer, more
feminine facial appearance, the emphasis is often
placed on the mandible angle by both surgeons
and patients. Solely focusing on reducing the
mandible’s volume through conventional bone
contouring surgery that includes the mandible
angle may lead to irreversible aesthetic dissatisfaction [2, 6, 8, 9].
In this context, mandible contouring surgery
should pivot more toward chin modication, with
the inclusion of the posterior part of the mandible
being considered a variable option [2, 6, 8, 9].
This approach necessitates starting from chinnarrowing surgery and a critical decision by the
surgeon on whether or not to simultaneously
reduce the mandible angle. Such a decision must
be based on a comprehensive evaluation of the
patient’s facial structure and aesthetic goals,
ensuring that the nal outcome harmoniously
aligns with their desired appearance.
In the context of revisional mandible contouring surgery, addressing patient dissatisfaction from previous surgeries is a key concern. A
common complaint is that their faces did not
achieve the desired slimness after surgery.
Additionally, many of these patients complained
disharmony between their reduced lower face
and an accentuated broadness of the chin, which
can be attributed to the limitations of conventional mandible reduction surgery. Mini V-line
surgery emerges as an effective solution in these
scenarios. When planning revision surgeries, it
is crucial to avoid excessive reduction of the
mandible angle, as further resection could result
in an unnatural aesthetic outcome. Instead, chinnarrowing surgery with good harmony with previously reduced mandible should be the
preferable intervention [8, 9].
Surgeons undertaking revisional surgeries
must exercise caution due to potential complexities introduced by previous surgeries. These complexities can include irregular lower borders of
the mandible, thinning of the outer cortex, and a