Symposium on Cosmetic Surgery

Augmentation Mentoplasty

D. Ralph Millard, Jr., MD., F.A.C.s. *

Absence of the normal prominence of the chin is unconsciously

associated with weak character and from the view point of classical lines
is unattractive. Receding chins are often accentuated by protruding
upper teeth and a lax lower lip. The immediate effect of a chin implant
is quite dramatic, particularly from profile and three-quarter views.
The protrusion of the upper teeth is partially camouflaged, and the im-
plant beneath the chin skin takes up the slack of the lower lip. When a
receding chin is riding under the shadow of a large nose there is a rela-
tive exaggeration of both features. The solution does not lie in bolstering
the chin until it juts equal to the prominent nose or in trimming the nose
to insignificance to balance the diminutive chin. Rather it lies in a com-
promise-in building up the chin to fit the face, then reducing the nose
to match the new chin (Fig. 1).
One Out of Four
Among the last 100 patients requesting a reduction rhinoplasty, one
out of four deserved and received a chin implant. The lay public has
been educated thoroughly on the subject of nasal surgery, but few are
cognizant of the possibilities of mentoplasty. Consequently, when a chin
implant is suggested the patient often is astonished, grabs her chin and
looks to her parents for support. They in turn register shock at the
thought and then concern about the extra expense. Thirty minutes later
parents and patient have been pacified, but only when informed of the
permanent increase in chin contour, the simplicity of the procedure,
the absence of scars, speed of execution, lack of complications and
relative inexpensive cost when carried out in conjunction with nose
surgery.
For Sake of Harmony
There are chins that recede to such a degree that no matter how
much or how well the nose is reduced, there still can be no hope for
facial harmony. In such a case, rhinoplasty is refused by the surgeon

"Professor of Clinical Surgery, and Chief, Division of Plastic Surgery, University of Miami
School of Medicine, Florida

Surgical Clinics of North America- Vol. 51, No.2, April 1971 333
334 D. RALPH MILLARD, JR.

Figure 1. Above, The high humped bridge of the nose ard the slightly protuberant lower
lip both overpower the slightly receding chin. Below, After reduction rhinoplasty and augmen-
tation mentoplasty with a shaped silas tic sponge implant, the harmony of features has been
improved.

if mentoplasty is refused by the patient. The explanation given is, "Plas-

tic surgeons are not in the business of merely shaping noses but rather
the art of improving faces."
Choice of Implant
Of course, in severe malocclusion or marked microgenia, bilateral
osteotomy may be the procedure of choice; but in lesser degrees of
AUGMENTATION MENTOPLASTY 335
deformity, an implant is sufficient. A patient who is unwilling to go
through an extensive osteotomy may be greatly benefited by a mere chin
implant. Therefore, it is essential to keep the procedure uncomplicated,
and theoretically ideal autogenous implants of iliac bone or rib cartilage
are unnecessary.
For a number of years4 ,5 I used homologous cadaver rib cartilage
preserved in 1: 1000 aqueous merthiolate solution, as advised by Brown
and DeMere.2 It provided a material which was easy to obtain, transport,
and shape. The only objection was its gradual disappearance. After about
10 years, when my earlier implants were beginning to be only memories,
Silas tic plastics came on the market.
Although the medium Silastic block can be used for chin implants,
from my experience the fine sponge Silastic is better.3 It is easy to shape
with sharp scissors, easy to insert through a small incision, and produces
an increase in chin prominence without unnatural contour. It is un-
noticeable visibly or by palpation. It rests within the capsule with mini-
mal reaction, allows no fibrous infiltration and can be removed without
difficulty. There are standard Silas tic chin implants manufactured in
several sizes, but as each chin requires an individually shaped implant,
I prefer to "cut my own."
Insertion Route
As a resident I first tried the intraoral approach for the insertion of
chin implants. Reservations were expressed by the department chief
at such obvious flaunting of the long-established principle of not entering
the oral cavity, particularly when inserting a foreign body. That was
20 years ago, and over this period of time I have inserted hundreds of
implants with a remarkable lack of complications. In fact, those fearful
of infection should be encouraged, since only one implant has been
removed. This was homologous cartilage taken out by a colleague in
Boston 1 year after its insertion, and it was removed only because of
subacute irritation.
Detailed Technique
Certain precautions are taken to avoid infection while using the
intraoral approach, and these in great part explain the lack of this com-
plication.
1. Dental hygiene is important.
2. When the nose is to be reduced at the same time, the nose, chin,
and lower labial sulcus are carefully prepared.
3. The chin is marked to indicate the future position of the implant.
4. LOCAL ANESTHESIA. If indicated, the nose is blocked first.
Then 1 per cent lidocaine (Xylocaine) with epinephrine 1:100,000 is
introduced into the lower labial sulcus lateral to the chin markings on
each side to block the mental nerves, with a No. 30 needle. A small
amount of lidocaine is injected in the mucosa at the exact site of the fu-
ture small midline incision. From this vantage point, a longer No. 27
needle is inserted down to the periosteum and is directed in a radiating
arch over the anterior surface of the mandible to anesthetize the entire
area of the future implant pocket. To prevent distortion of contour, not
more than 3 ml. of lidocaine are used.
336 D. RALPH MILLARD, JR.

5. The pocket is developed by picking up the lower lip with the

left thumb and index finger to expose the lower labial sulcus. A 1 cm.
midline transverse stab through mucosa is made with a No. 15 Bard
Parker blade. The labial incision is not made in the depth of the sulcus,
where saliva could pool on the suture line, but rather up on the lip side
so that a 1 cm. mucosal flange flap is developed (Fig. 2A).
A No. 10 Bard Parker blade is used to extend the incision, leaving a
generous pad of subcutaneous tissue over the mandible until arriving
at the predetermined position for the implant. The dissection then is
carried to, but not beneath, the mandibular periosteum and the pocket
is cut to the exact size of the implant, care being exerted to keep the
scalpel close to bone to avoid the mandibular nerve, but not so close as
to cut the mental nerve (Fig. 2B). Hemostasis usually can be achieved
by packing and pressure, and only occasionally requires cautery.
6. While the pocket is being dissected, the assistant cuts the fine
sponge Silastic into the general shape for the specific patient. Then
while the assistant applies pressure to the chin area for hemostasis,
the surgeon tailors the implant to its final shape, thickest at the center
and tapered toward the ends to quite thin proportions. It is also beveled
along each side so that, rather than jut or bulge, it will bend and blend
with the mentum of the mandible (Fig. 2C).
These implants vary quite markedly, not only in thickness (0.75 to
1.5 cm.) but also in width (1 to 1.5 cm.) and especially in length (4 to
14 cm.). The mid-point of the upper edge of the implant is marked with
a stab of methylene blue and then the implant is soaked in a solution of
neomycin-bacitracin while the pack is removed from the pocket.
7. There is a trick to inserting this long, soft sponge through a 1 cm.
incision and yet prevent curling. The absolute tip of one end of the
sponge is picked up with a pair of long, smooth forceps and is introduced
to the far end of the pocket (Fig. 3A). Before the forceps is removed,
the implant is held in its middle by the assistant. Then the opposite
tip of the sponge is taken in a similar manner and guided into the oppo-
site far end of the pocket (Fig. 3B). If this manuever has been done cor-
rectly, the blue dot (Fig. 2C). marking the center of the sponge will be
seen peeking through the gaping 1 cm. incision. Observation and pal-
pation of the new chin contour will confirm the accuracy of the position
of the implant.
8. A saliva-tight closure is mandatory. A three-layer closure with
5-0 chromic catgut sutures is started, with the first stitch picking up
subcutaneous tissue anteriorly, then a small bit of the sponge at the
blue dot, and finally the subcutaneous tissue pad left over the mandible.
Several more sutures along this level, but without including the sponge,
are followed by a second layer of two sutures. The final mucosal closure
is made with a row of mattress sutures (Fig. 3C).
9. The postoperative pressure dressing is important. A small pad
is placed across the lower lip just superior to the implant, and the entire
chin area is strapped firmly with Elastoplast. This pressure is maintained
for 5 days to give the wound a chance to seal and heal.
10. Fluids by mouth the first day and soft diet for the next few days
is suggested. Oral antibiotics are used prophylactically during the first
5 postoperative days.
AUGMENTATION MENTOPLASTY 337

Figure 2. A, A 1 cm. incision is made in the lower labial sulcus 1 cm. rill on the lip from
the alveolar attachment. The scalpel leaves subcutaneous tissue on the mandible until arriv-
ing at future site of implant, then goes deep to periosteum. B, A No. 10 Bard Parker blade
hugging the periosteum dissects anterior mandibular pocket. C, The Silastic sponge is shaped
with scissors and the midpoint at the upper edge is marked with methylene blue.
338 D. RALPH MILLARD, JR.

c
Figure 3. A, Long smooth forceps introduces one extremity of the sponge to the absolute
end of the pocket. B, The sponge is fixed with a second forceps at its middle while the other
end is inserted in similar fashion. When in true position, the blue mark will be seen through
the 1 cm. incision C, 5-0 chromic catgut sutures in three layers will insure a saliva-tight
closure.
AUGMENTATION MENTOPLASTY 339
Submental Route
Alternative methods are used by other surgeons. Many still prefer
the submental approach. Aufricht' preferred this method of insertion
and used autogenous material, such as septal cartilage and the osseous
hump chopped into small pieces as a type of coarse "mush." The auto-
genous quality of such an implant has appeal, but there is seldom enough
material available, and the chances of maintaining a symmetrical and
adequate contour seem hazardous. Introduction of the implant is more
awkward from the submental position, and of course requires the forma-
tion of a skin scar.
Dimple
For those who desire a cleft or dimple on the chin, Pitanguy'l sug-
gests a wide intraoral incision and the dissection of a fibro-fatty flap left
adherent to the chin skin. He shapes his implant with a midline cleft
and pulls his little flap through the "intergluteal fold" of the implant,
and sutures it with some tension so that a dimple is formed. He offers
this approach as a method of insuring the position of the implant.
Complications
Infection. As explained previously, infection has not been a prob-
lem. No implant to date has been removed because of acute infection.
Only one was removed for chronic irritation, and the circumstances
with this patient seemed to be as much psychological as actual.
Hematoma. A large hematoma of course requires opening of the
wound and control of the bleeding.
Asymmetry. Occasionally the formation of a small hematoma will
present asymmetry of chin for several months, but in time this subsides.
Actual displacement or misplacement of the implant is rare but requires
correction.
Visual projections. Rarely, one end of the implant will show
through the skin. This occurs if the ends are too thick or the implant is
too long for the pocket. If the distal end of the pocket is not kept deep so
that the covering is thin, then the implant is more likely to project notice-
ably. This may require a tiny submental stab months later to allow re-
duction of the tip of the sponge.
Excess chin prominence. If the implant is too large, then it must
be reduced. If it is the correct size it still may present excess prominence
temporarily because of postoperative edema and hematoma. It may take
6 months for the swelling to subside. Most Silas tic sponge implants
shrink a minimal amount within the smooth-walled fibrous pocket.
Yet it is unwise to overcorrect by making the implant larger than desired.
The patient's anxiety, waiting for the shrinkage, overbalances any slight
gain in contour. One patient who needed only a slight increase in chin
contour insisted her implant was too large. She waited patiently the full
6 months and then insisted on its removal. The pocket and the associated
scar, even after removal of the implant, was responsible for a slight per-
manent but adequate improvement in chin projection.
340 D. RALPH MILLARD, JR.

Nerve injury. In one case in which excessive bleeding was finally

controlled with cautery, there was a partial, temporary, unilateral mandi-
bular nerve weakness which improved within a few weeks. Any numb-
ness to the lower lip has always been transient.

SUMMARY

A receding chin can be improved by the use of an implant which

not only increases chin prominence but camouflages protruding teeth
and softens the effect of a protuberant lower lip. When the nose is large,
it enhances the lack of chin. In fact, one out of four patients requesting
nasal reduction also deserves a chin implant. A fine Silas tic sponge,
individually tailored, is inserted through a 1 cm. lower labial sulcus in-
cision into an anterior mandibular pocket. Owing to the operative and
postoperative precautions described, this procedure has been almost
free of complications over the past 20 years and can be recommended
with little reservation.

REFERENCES
1. Aufricht, G.: Combined plastic surgery of nose and chin: Resume of twenty-seven years
experience. Amer. J. Surg., 95:23,1958.
2. Brown, J. B., and DeMere, M.: Establishing a preserved cartilage bank. Plast. Reconstr.
Surg., 3 :283, 1948.
3. Millard, D. R.: Adjuncts in augmentation mentoplasty and corrective rhinoplasty. Plast.
Reconstr. Surg., 36:48-61,1965.
4. Millard, D. R.: Buccal incision of chin implants. Southern Med. J., 52:1371-1374,1959.
5. Millard, D. R.: Chin implants. Plast. Reconstr. Surg., 13:70-74,1954.
6. Pitanguy,1. Augmentation mentoplasty. Plast. Reconstr. Surg., 42 :460-464,1968.

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