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 IJCS / Year: 2002 / Volume 2 - Number 1 / Original Papers
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Nikolay P. Serdev, M.D., PH.D.
Pages: 1 - 10/


Head of Medical Center "Aesthetic Surgery and Aesthetic Medicine", 11 "20th April" St., 1606 Sofia, BULGARIA
President of the Bulgarian Society of Aesthetic Surgery and Aesthetic Medicine

The primary goal of facial aesthetic cosmetic surgery is beautification, achieving balance and harmony. The mental area must be addressed to the complete synthesis of the face. The concept of augmenting, correcting and adjusting the chin position has evolved so significantly that it is now an important procedure in face beautification. Various autogenous implants for chin augmentation have been in use for over 100 years. The advent of synthetic materials has given rise to various types of alloplastic implants with their advantages, disadvantages, and complications. The author's technique of chin soft tissue suspension, using a simple non-absorbable suture, is indicated to correct microgenia, to obtain the necessary projection, and to adjust chin symmetry. It is ideally suited for correction of most chin disproportions as: profile deficiencies, aging (Witch's) chin, asymmetries, disharmonies and is used for beautification and rejuvenation of the whole face as a single or combined operation with satisfying cosmetic results.

The importance of the chin in face beautification is determined by the fact that the chin is a part of the lower third of the face. Aesthetically it has to fit to the line of the straight profile, to the "beauty triangle" of the lower face, and the facial golden division in 3 proportionally equal parts (Fig. 1, 2, 3). Chin prominence gives the essence of visage character.

Profile deficiencies are due to congenital, traumatic and aging factors with different degrees of deformity. Loss of volume or a genetically small mandible affect the aesthetics and expression of the mouth, chin, and neck. Disharmony between the skeletal support and the soft tissue envelope is a common cause of aesthetic concerns.
Although standards of beauty evolve over time, classical facial features such as symmetry, straight profile, good chin projection and proportions remain as rules. A comprehensive beautification incl. rejuvenation of the chin depends on accurate analysis of the lower face with attention to the contours and deep-lying structures.
Many surgical options are available to restore the definition of the chin region. A large variety of materials are used by surgeons for augmentation purposes, although the search for the perfect implant continues.
The author's surgical suspensory procedure using a simple suture has the aim to return the chin's soft tissue to a more aesthetic and youthful position and to meet patients' demands for immediate result, fast recovery and beatification, without implanting foreign materials.

Although the process of facial aging is predictable, the rate of changes varies from person to person. With aging, laxity develops in the skin and subcutaneous tissues, the result of which is wrong projection and contour of the anterior mandible. The soft tissues are subject to gravity and undergo progressive atrophy. Aging (Witch's) chin is an unpleasant aesthetic defect, characterized by ptosis of the premental tissue and a deep submental fold. Bone resorption and soft tissue atrophy are the most important components. Loss of bone volume leads to loss of support for the soft tissues of the face.
Aesthetic cosmetic rejuvenation of the face and neck involves repositioning of poorly supported soft tissues. The effect of surgery in these cases, aiming to improve and restore a youthful appearance, depends on the bone structure, amount and distribution of subcutaneous fat, as well as the interconnectedness of the superficial muscles to the overlying skin.

THE AIM of the author's specific technique is to suspend the loose and hanging soft tissue of the chin, to give natural height of the chin projection and to forward the submental skin in order to obtain a youthful jaw line. Avoidance of common problems associated with implantation of foreign materials is an additional goal.

Suturing and suspending the loose chin soft tissue to obtain volume, projection and a straight profile.

Two skin punctures to insert the needle.

One or more sutures of the chin soft tissue are made to obtain roundness and projection of the chin where desired. The author uses only two skin punctures in the supra- and sub-mental folds to insert the needle. The suture may start from either one. The needle enters through the puncture, slips along the mandibular bone and exits through the other skin puncture. Now the needle reenters into the same puncture around the soft tissue and this time under the skin, and exits through the first puncture. The knot is tied and in this way the whole available chin soft tissue is tightened into the roundness of the suture circle. A blunt dissection and adjustment of eventual skin folding could be necessary. This ambulatory procedure takes only some minutes. No dermal closure and no bandages are used. Facial washing should be done on the following day. The skin puncture in the supra-mental fold may be visible for 2-3 days and patients may use make up. The early post op period swelling is almost invisible and patients can return to their social life as soon as they want [1, 2, 3].

Between 1993 and 2001, 295 patients underwent procedures for chin augmentation, 23 for chin form correction and 57 for beautification only, using the author's ambulatory suture technique. Patients operated between 1993 and 2001 have been followed up till now between 9 and 1 year with an excellent clinical success. No complications have been observed. There has been no aesthetic disappointment, no seromas, no haematomas, and no infection. The net soft tissue enhancement has been observed to be an average of 8.0 mm (range 4.1 to 11.8 mm) and the average increase in soft tissue projection - 76.8% (range 68.9% to 91.3%).
No asymmetry has been observed. On the contrary, this particular technique has been used to solve problems with asymmetry of the face (Fig.4, 5). Very often the dimple formed in the sub-mental fold enhances the Caucasian appearance and is very much loved by patients. Straight line of the profile has been obtained satisfactorily. Sometimes only 2 to 3 mm in the chin prominence have been insufficient to reach a straight profile line. Aesthetically, this difference is not visible for observers.

The obtained chin projection enhances the "beauty triangle" of the "chin and check bone complex". The neckline becomes slenderer and youthful. These visual criteria measure the degree of success in fashioning of chin aesthetics. Using our soft tissue suture technique, we believe, it is now possible to satisfy these criteria in most patients.
The longevity of this particular technique depends on the non absorbable material used and on the stage and progression in aging, i.e. atrophy of the soft tissue. In our patients we had a satisfactory longevity of results. Using serial photography during the follow up period we did not notice remarkable changes in the result.
The chin soft tissue suture technique for anterior adjustment and form correction provides a soft, natural facial appearance and it continues to be our method of choice for form correction, augmentation and beautification of the chin if patients reject implantation.

Fig.1 a,b. Before and after chin correction and enhancement, lower face ultrasonic liposculpture to obtain the beauty triangle of chin and cheekbones. The additional upper lip augmentation is a part of the face proportion adjustment and beautification.

Fig. 2 a,b. Before and after a rhinomentoplasty - chin enhancement and columella sliding to obtain nose tip projection, straight line of the profile, good proportions and 3 equal parts of the face.

Fig. 3 a, b, c.
A. Before, B. immediately after chin enhancement and tip rhinoplasty (columella sliding) to obtain a straight profile and aesthetic proportions of the face. (Intra op Betadine desinfection still not washed up.) A slender neckline obtained is recognized as an attractive feature of youth. C. 5 years later. It is difficult to find any change in the operated chin position during the 5 year follow up.

Fig. 4 a, b. Before (Betadine disinfected) and after correction of the chin position and nose deformity in one session. The chin is sutured to the left.

Fig. 5 a, b. Chin suturing to the left to treat the deformity of the face - before and after. Additional upper lip augmentation.

For the past several decades, various materials have been developed to improve the appearance of the chin as one of the various subunits of the face. Initially, autogenous tissue grafts, such as: removed nasal hump, described by Aufricht in 1934, autogenous skeletal and cartilage transplants, ear cartilage grafts, rib cartilage grafts, fat, fascia, tendon, and dermal fat grafts were used [4-8]. Additional options became available with the development of a variety of alloplastic materials for augmentation genioplasty. Polymers are used primarily for bone deficiency substitution. Mersilene mesh introduced in 1950, silicone and silicone bag-gel inplants, Gore-Tex, Medpor, Supramid, Silastic, injectable collagen, expanded polytetrafluoroethylene (e-PTFE), high-density polyethylene (HDPE), polydimethylsiloxane (PDMS), Proplast I (PI), Proplast II (PII), porous block hydroxyapatite (PBHA) are available for correction of microgenia [9-21]. Placed trough anterior oral sulcus incision or a submental incision with a screw fixation, a lot of these implants have good organotrophic characteristics, allowing tissue ingrowth. Available in a variety of block, sheet, and preformed shapes, they can be easily modeled and maintained. Antibiotics, irrigation, and closure of the incisions are performed [22-24]. A lot of injectable materials came to the market in the last decade [25]. The author has sufficient experience with injectable 5% polyacrylamide gel (Fig 6) too. Reviews of biomaterials used for mandibular implantation prove that although today's armamentarium of implant materials is vast, the search for the perfect implant continues [26-41].

Fig. 6 a, b. Before and after formation of the "beauty triangle" and the upper lip using injectable PAA-gel.

We address general considerations of toxicity relevant to all biomaterials [22]. Investigations and overviews present data from a large number of clinical series on incidence of complications for materials used in this specific application [22-24, 26-41]. Even few, there are results that show infection, displacement, temporary paresthesias, incidences of absorption, rejection, or extrusion, implant migration, etc. [22-24, 26, 27, 32]. Complications are manageable; these include implant displacement. Infection has been treated with irrigation, closed system suction, etc. Most often infection requires a reoperation to take the implant out. Other complications such as internal and external soft tissue erosion, indentation, slippage, asymmetry, and late bone resorption under the implant have been seen [5-8, 23]. Wound repair around implants is achieved through capsule formation. Fibrous capsule formation can be interrupted by infection, immune reaction, implant migration, or extrusion [24, 26-28].
No implant can be perfect for every face. Due to the search of simpler techniques, and based on our own experience, we propose an operation without implants, using only a suture of the chin soft tissue, suitable for chin enhancement, beautification and form correction. We have treated 375 patients with augmentation and form correction, of whom no one had a complication. 187 of them had combined face beautification operations done.

As a single procedure or simultaneously with other facial rejuvenation operations, chin soft tissue suturing is ideally suited for correcting most chin aesthetic disharmonies in patients with a congenitally small mandible, and patients requesting facial enhancement as well as correction of asymmetry. Simplicity and immediate return to social life are the major benefits of this procedure. It provides a natural, "non-operated" look that is largely sought by patients today.
When implants are not accepted by patients, our technique is a method of choice. It appears to be an attractive alternative to other chin augmentation techniques. It is suitable for different clinical pictures, without using implants, minimizing the tissue trauma.

As a single procedure or simultaneously with other facial rejuvenation operations, chin soft tissue suturing is ideally suited for correcting most chin aesthetic disharmonies in patients with a congenitally small mandible, and patients requesting facial enhancement as well as correction of asymmetry. Simplicity and immediate return to social life are the major benefits of this procedure. It provides a natural, "non-operated" look that is largely sought by patients today.
When implants are not accepted by patients, our technique is a method of choice. It appears to be an attractive alternative to other chin augmentation techniques. It is suitable for different clinical pictures, without using implants, minimizing the tissue trauma.

1. Serdev, N.P. Chin form correction and augmentation using simple suture. Int J Aesth Cosm Beauty Surg IJACBS 2001, 3 (1), 42-66
2. Serdev, N.P. Chin augmentation using simple suture - 1. IJACBS 2001, 2 (1)
3. Serdev, N.P. Chin augmentation using simple suture - 2. IJACBS 2001, 2 (1)
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Address correspondence:

Nikolay P. Serdev, MD, PhD
Medical Center "Aesthetic Surgery and Aesthetic Medicine"
11, "20th April" St., 1606 Sofia, Bulgaria
Phone (mobile) +359 888 802004
Fax +359 2 9515668
E-mail nserdev@infocom.bg

The Bulgarian Society of Aesthetic Surgery and Aesthetic Medicine

Send for publication: 11 04 2002

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 IJCS / Year: 2002 / Volume 2 - Number 1 / Original Papers
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