Dr Terino - Chins

The chin and the lower third of the face is the second most important area that creates an appearance of attractiveness and beauty.

A chin that is too small gives a person an appearance of a weak personality and is also usually accompanied by an unattractive shaped lower lip and mouth. A chin that is too large can be attractive and strong looking and command attention, that in our society symbolizes a very dominant personality. But, when it is overly large, it can destroy overall facial attractiveness, which balances the other structures of the face, cheek and nose regions.

Chin implants originated in the 1950s and 1960s prior to any major cosmetic surgery consumption by the American people. While it is true that eccentric, rich and famous, or otherwise unusual personalities went to a few plastic surgeons in Universities and major medical centers around the country to request appearance changes, many, if not most of these people were considered to have psychological or emotional disorders and only a few surgeons considered trying to help them by changing their appearance, such as in the chin region or the nose region.

Otherwise, early forms of chin implants were made from many different materials in an attempt to reconstruct the bony framework of the chin after serious injuries, accidents, war wounds and cancers, in which parts were destroyed, removed, or disfigured. Very few of these materials worked well and nearly all had many problems that did not make them useful for a healthy cosmetic surgery patient.

Transplanting bone from the patient’s own body was a more complicated operation that was accompanied with major pain, discomfort and scarring at the site from which the bone was taken as well as major problems with bone grafts in the face shrinking and being absorbed, so that a cosmetic effect was not satisfactory. Therefore, very few materials have persisted as harmless and useful for using as implants for cosmetic changes and face contours.

Silicone rubber is the most popular material by far that has been demonstrated in scientific surveys of plastic surgeons around the world to be used 3:1 over other materials, notably one called Porex (a.k.a. Medpor). Silicone rubber implants are easy to insert and easy to exchange or remove with minimum difficulty if necessary or desired. They are sealed with an overlying cover of scar tissue to the bone that makes them feel and look like bone.

This natural appearance of chin implants has only come about in the last 30 years due to the innovative work of Dr. Edward O. Terino, facial implant pioneer, who in addition to his own 30-year-old practice, is now also affiliated with the Hospital Group Plastic Surgeons.

In the late 1970s and early 1980s, Dr. Terino conceived of developing implants for the face in many areas such as the cheek, chin, underneath the eyes and elsewhere, which were anatomically designed to fit imperceptibly to the bones of the face and appear and feel natural.

Dr. Terino’s work has been acclaimed both nationally and internationally by plastic surgeons who acknowledge him as the authority in this field.

A chin implant procedure is minimally invasive mostly through a small 1-inch incision underneath the chin that becomes nearly invisible after healing. Occasionally, an incision can be made inside the mouth to place the implant, but this approach is not as good for people who need larger implants for a more generous increase in the size and shape of their chin which can be accompanied by more risks of damage to the delicate nerves that give feelings to the lower lip and chin.

In the hands of an experienced implant surgeon, there are very few problems associated with chin implants. Working through a small incision limits the view for the surgeon and in a rare case the implant might be slightly out of position. This often does not reveal itself externally, but only when patients carefully feel the implant and are unhappy about this situation. If they then demand perfection, a good surgeon may try to improve the position as much as possible with a second small corrective procedure, usually done under local anesthesia.

Dr. Terino has developed chin implants to make chins project more, have a round appearance, a square appearance, give a wider look to the face and lengthen a face vertically.

Your consultation with a Hospital Group plastic surgeon will include computer imaging of your own face to give you an idea of what you might look like with any one of the above implants. It also should include your demonstrating to the surgeon what your ideal scene for the shape of a chin would be by providing him with pictures or photographs of faces, which you think are similar to your own or which you want to try to imitate.

A chin implant procedure will take 30 minutes to 1 hour maximum for an experienced plastic surgeon and for an initial surgery. Should any changes or revisions be necessary, this time may need to be extended because of the occurrence of scar tissue, which is present after any surgery and makes a delicate cosmetic surgery operation, more risky, therefore, the surgeon has to perform a secondary procedure with extreme care and precision.

The improved appearance from a chin implant will show up immediately, but the surgeon cannot necessarily determine before or during the operation which implant will satisfy the patient’s goal. The swelling which occurs during any cosmetic procedure and especially any implant procedure of the face or breasts makes the judgment and experience of the surgeon the most important factor in the choice of a proper implant.

However, the improved appearance will be obvious for the patient within a week or two after surgery and at times the patient may feel that the implant is a little large or a little small. The final definition of the chin shape will not occur for several months and therefore, patients should be fully informed that they should not make an initial judgment or criticism.

Medical device implants within the body can always be attacked by infection somewhere else in the body therefore, heart valves and other artificial materials always carry some risks throughout the patient’s life; however, most of the time with face implants if trouble is going to arise, it will occur within the first 6 months.

Dental procedures, even cleaning of teeth, penetrates the gums and the bacteria laden saliva in the mouth gets into the blood stream and circulates in the body for approximately 24 hours. Therefore, a knowledgeable face implant, as well as breast implant surgeon should warn the patient that they should go on antibiotics prior to and for 24 hours after any dental procedure.

The shape of a chin is particularly significant from the standpoint of the patient’s profile in relationship to their nose size and shape. That is why the chin implant was the first significant face implant to be developed by plastic surgeons when cosmetic nose surgery first originated 2/3 of a century ago.

The improvement in a patient’s attractiveness and beauty can be 100% with a good nose refinement. In patients who need it, however, this attractiveness will be boosted to 500% with the use of a proper chin implant.

Venus De Milo and the Cherubic women, painted by the artist Rubens, are symbols of ideal feminine faces and figures of past cultures. Today the standards have dramatically changed. In the new millennium male images have superhero characteristics. Jaw lines like those of Captain Marvel, Superman, Lone Ranger, Batman, and others are easily found in fashion magazines, television, soap operas, and cinema. The images of Kirk Douglas, Eroll Flynn, and Gregory Peck have been replaced by the jutting jaws of Mel Gibson, Brad Pitt, and new generation of other strong masculine faces. The Amazonian, exotic facial contours of Wonder Woman are typified today by Michelle Pfeiffer, Cameron Diaz, Rebecca Romijin Stamos, and others.

Cosmetic surgery has achieved respectability. A growing population of upwardly mobile, affluent patients in a younger age group from 20 to 50 are demanding surgical alternatives to their inherited facial characteristics. Their interest especially pertains to midface and jawline contours. Whereas nasal surgery and chin implants have been well accepted by plastic surgeons and the public for 20 to 30 years, more extensive alterations of the entire soft tissue and the skeletal contours of faces are now becoming a sought after commodity. The most commonly requested changes are stronger, more square, angular jawlines and more accented midface and malar bone structures.

INTERRELATIONSHIPS OF REGIONAL AESTHETIC SEGMENTS

Attractive facial appearance depends upon the balance of several aspects of facial architecture. There are three major regions of volume and mass which critically define the aesthetics of facial appearance. The interrelationship of the size and shape of these creates a balance which is recognized by others as “attractive.” The nose, malar/midface and chin/jawline regions are the most significant promontories of which determine the facial harmony and balance which can be called beauty.

Diminution or enhancement of any of these volume/mass elements directly and inversely affects the aesthetic importance of the others. Early plastic surgeons regarded profile as a major determinant of attractiveness. A profile consists only of nasal and chin projection. Profiles are two dimensional only. A more artistic and sculptural perception of the face is now emerging to understand that the volume/mass significances of the malar bones, the midfacial soft tissues, and the lower mandible jawline segment all interact to create aesthetic beauty in three dimensions.

As nasal prominence is reduced, the relative size of the malar/midface and mandibular aesthetic units become more visually importance. Accentuation of the malar/midface diminishes the apparent size of the nose and chin. Enhancement of both the mandible and the malar/midface segments lessens the relative magnitude of the nose. Therefore, the strength and volume characteristics of each major facial promontory affect the relative balance of each to the other.

ZONAL ANATOMY & REGIONAL DEFICIENCIES OF THE LOWER-THIRD FACIAL ASETHETIC SEGMENT

The definition of a “premandible space” is “that anatomic region which when augmented creates significant change in the shape and volume contour of the lower-third Face jawline aesthetic unit”. Defining segmental zones within this space gives the surgeon the ability to perceive deficiencies in contours which can be improved by choosing specific implants to produce a chin and jawline shape of the patient’s preference. Since the 1960’s, chin implants have been placed centrally between the mental foramina. This location is called the Central Mentum (CM). Traditional implants have been oval or elliptical in shape. When these were placed in the central segment along, they mostly produced abnormal, unnatural, round protuberances which are unattractive.

A midlateral zone (ML) within the premandible space is defined as extending laterally and posteriorly from the mental foramen to the oblique line of the horizontal ramus of the mandible. When this zone is augmented alone, it produces widening of the jawline to whatever degree is presurgically determined. When it is augmented in addition to the Central Mentum Zone (CM), a widening of the entire anterior ½ or 2/3 of the jawline contour results. The precise contour of the anterior jawline can be created by shaping anterior implants in a more pointed, round or square dimension, because of the many different jawline contours that are potentially possible. The author originated in the early 1980’s the first series of anatomic extended implants designed to give surgeons the ability to create many different jawline contours.

A posterolateral zone (PL) is a third zone of the premandible space which encompasses the posterior ½ of the horizontal ramus, including the angle of the mandible and the first four centimeters of the ascending ramus. Implants of variable dimensions can produce different shapes of the posterior angle jawline to enhance sculptured definition. A specific mandibular angle implant has been designed for this region.

A fourth and final anatomic region is the submandibular zone (SM). It is traditionally taught that chin augmentation cannot increase the vertical height of the face in the lower-third facial segment. In 1986 the author challenged this concept by developing a submandibular implant which wraps around the bony inferior margin of the mandible to increase the vertical distance from the lower lip to the inferior chin line by 4mms. This implant also produces 4mms of anterior posterior projection. It augments the submandibular zone (SM) and adds volume beneath the mental foramen. They can,therefore, significantly assist in improving aging prejowl jawline deficiencies.

Experience has demonstrated that properly sized, shaped and positioned implants can supply appropriate mass and volume to the several zones of the mandible and, therefore, can produce significant and predictable contour changes of the lower-third of the face. These techniques can minimize the need for orthagnathic bony surgical alterations as long as the dental occlusion is acceptable or has been corrected by orthodontia. Moreover appropriate size alteration of the lower-third mandibular facial segment will minimize or even eliminate the need for nasal bridge reduction in rhinoplasty.

PREOPERATIVE PLANNING

The key to successful facial contouring is determined by effective communication with the patient. A surgeon must completely understand a patient’s desired contour changes. Facial implant patients have specific perceptions about their midface, cheek and jawline contours. They are meticulous in their observation of details. Facial images from fashion magazines or other sources, as well as photographs of the patient, perhaps modified by them, are extremely useful and necessary to understand a patient’s specific expectations. At the present time computer imaging techniques, MRI and other diagnostic tools such as cephalometrics do not provide sufficient data to assist the surgeon to achieve a predictable outcome. The future, perhaps, will provide such necessary technology for individual customization of facial contour.

Preoperative planning must include evaluation of the patient’s zonal anatomy to ascertain the location and the extent of volume enhancement to be achieved. Multiple consultations may be necessary. The author spends a great deal of time on the morning of the surgery marking, measuring and discussing details with the patient. By directly drawing the premandibular anatomic zones on the patient’s facial skin, the patient and the surgeon can more accurately choose implants together that will accomplish the desired result.

It has been found that some men wish a straight jawline contour, and some desire a concave midlateral zone surrounded posteriorly by a strong, square contour that represents both the masseter muscle and the bony mandibular angle. In the front they desire a square jawline which extends variably into the midlateral zone depending on the look which they desire. In studying strong, masculine male square chin contours, the majority have a front prominent squareness that extends from a line drawn vertically from the corner of the mouth to the chin line. Some men desire this central squareness to be slightly narrower than the above dimensions and some desire a wider frontal squareness that is up to six centimeters in transverse anterior dimension. It is critically important for the surgeon to meticulously evaluate a patient’s desires with photographic images to determine exactly how to shape and place an extended anatomic implant in the central mentum zone.

IDEAL FACIAL IMPLANTS

Alloplastic implants for facial contour alterations should have several optimum ideal features. Primarily, their design must include a posterior surface which contours to the external surface of the mandible, as well as an external shape which imitates a desired natural anatomic configuration. When the margins of the implants are tapered to blend onto the bony surface, they will be nonpalpable, as well as nonvisible through the overlying soft tissue envelope. Facial implants should be readily exchangeable because as yet, there is no computer technology precise enough to give the surgeon and the patient the exact dimensions of implants necessary to achieve a desired contour. Facial contouring by alloplastic implant augmentation is still an art form which requires considerable experience. Facial implants should have no fixation patches, fenestrations or fabrics to immobilize them on the bony plane. Physiologic fibrotic encapsulation ensures their immobility. They should be malleable enough to insert through relatively small soft tissue apertures and conformable to the facial skeleton. There should be optimum host acceptability and a high resistance to infection so that the need for removal is rare. Implants should be easily modifiable by the surgeon before or during the procedure.

Silicone rubber implants fully meet the above ideal qualifications. They are readily exchangeable by open capsulotomy when desirable or necessary.

Any segment of the premandible region can be augmented individually and differentially to create chin/jawline contours according to the surgeon’s and the patient’s preference.

TECHNIQUE

The basic principles for augmenting the premandible are identical to those for contouring the malar/midface. These techniques result in successful procedures which have few serious or permanent complications.

It must be emphasized again that there are three critical parameters: shape, size and positioning. The degree to which these parameters are properly controlled determines the overall final facial contour and in most cases results in significant patient satisfaction

ANESTHESIA

It has been learned from a large experience of several thousands of facial implant procedures that anesthesia is a critical factor in determining the safety and precision with which they can be accomplished.

Two basic principles must be followed: First, the subperiosteal plane must be infiltrated generously. A solution of dilute lidocaine and epinephrine is used. Generous infiltration of up to 20 mls of dilute lidocaine/epinephrine solution appears to create an increased interstitial pressure at the capillary level which contributes to optimum hemostasis.

Secondly, all procedures are performed under general anesthesia making certain that the blood pressure is maintained at a systolic level of 90 to 110mms of Mercury. It can be consistently and predictably demonstrated that elevation of the blood pressure over this limit results in significant troublesome oozing and bleeding.

CHOOSING PREMANDIBLE IMPLANTS

Asymmetries in facial mass and volume are the “norm.” Over 80% of individuals have a unilateral facial deficiency with narrowing of the jawline and/or midfacial soft tissues, including bone. Correction for asymmetries, while difficult, and perhaps impossible, can frequently be improved by choosing differential implant thickness from side to side.

Augmentation of the submandibular zone is a separate aesthetic consideration. Traditional chin implants have never been able to lengthen facial contour. Craniofacial osteotomy bone grafting techniques have previously provided the only means to accomplish this contour change.

A new form of alloplastic implant, however, has been designed and successfully used by the author for 15 years and in over 50 patients. This implant augments and lengthens the face in both a vertical direction, as well as anterior posterior direction. It wraps around the inferior margin of the mandible and enhances the above facial dimensions by 3 to 5mms both centrally and in the midlateral zone. When indicated, use of this implant results in a profound and dramatic facial contour improvement. Implants which only augment the inferior border of the mandible in the midlateral zone can be used to correct the anterior mandibular sulcus of the aging face. Often additional release of the anterior mandibular ligament with jowl defatting and SMAS (Subcutaneous Muscular Aponeurotic System) plication techniques are necessary for optimum treatment of witch’s chin deformities.

Summary

Alloplastic facial augmentation for three dimensional aesthetic alterations have become state of the art in the new millennium. Infinite variations of facial contours can be achieved. Recent advances in the technology of implant designs and shapes, as well as understanding the principles of facial aesthetics which involve anatomic zones and regional volume deficiencies gives plastic surgeons for the first time tools to implement precise changes and with minimum morbidity. Cosmetic facial surgeons must learn and understand the zonal anatomy of the premandible region to be prepared for patient demands regarding their desires about changing their jawlines. Within a few years, computer technology will undoubtedly provide more precise implant architecture that will enable us to rapidly customize implants. Until that time, observing basic principles of technique will facilitate successful contouring of the premandible lower facial aesthetic segment.

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