Importance of the Chin in Achieving a Feminine Lower Face: Narrowing the Chin by the “Mini V-line” Surgery

A Differential Analysis of Preferred Feminine Facial Contours for Transfeminine Individuals

BACKGROUND

Facial feminization surgeries are important gender-affirming procedures for transfeminine individuals. The literature provides guidance on classically feminine facial features but the aesthetic preferences of transgender patients have not been studied. This study aimed to define the preferred feminine facial proportions of transfeminine patients and compare them to a mixed population of US adults.

METHODS

An online survey was designed consisting of virtually modified images with progressive degrees of change in 6 facial features: forehead, nasal dorsum, chin projection, nasolabial angle, mandibular angle, and chin height. It was administered to transfeminine patients in a large-scale health system as well as the general population using an online market research instrument. Respondents ranked each image on a 7-point Likert scale from "very unattractive" to "very attractive" for a feminine face.

RESULTS

Both groups agreed that a moderately convex forehead without supraorbital ridge prominence, slightly sloped nasal dorsum, ∼105-degree nasolabial angle, and decreased chin height were considered most attractive. In addition, very concave nasal slope and ∼110-degree nasolabial angle were rated significantly higher by transfeminine respondents compared with controls. The most classically masculine versions of each feature were considered significantly more unattractive by transfeminine patients when compared with controls.

CONCLUSION

Transfeminine individuals share significant preferences in feminine facial features with control respondents. However, transfeminine patients were more averse to traditionally masculine features on a feminine face and more accepting of the most traditionally feminine versions of nasal contours. Understanding these differences can facilitate surgical planning between surgeons and patients and potentially improve patient satisfaction.

F-Chin/Feminizing the Chin: A Genioplasty Technique with Virtual Planning for Male-to-Female Transgender Patients

The chin is an essential structure in facial harmony and an important gender marker. Advancing a receding chin is fundamental to improve the facial appearance, particularly in male-to-female transgender patients. However, in patients with microgenia and/or retrognathia, desiring a more feminine appearance, a chin advancement can result in a wider, square shape; an undesirable effect. Genioplasty is a versatile procedure used in facial feminization surgery that allows modifying the natural anatomy of the chin in all three spatial dimensions. The technique herein described proposes a simple genioplasty procedure for feminizing the chin (F-chin genioplasty) in transgender patients where anteroposterior advance is required. Virtual planning was used to establish the landmarks for an anteroposterior advancement with transverse reduction in the chin. A perpendicular line to the Frankfurt plane passing through the incisal edge of the upper central incisor was used to plan the anteroposterior movement, and two vertical lines on the outer wall of the nasal cavity  for the chin transverse measurement. The authors present three case reports with the F-chin genioplasty transgender technique with satisfactory results, ensuring a more feminine facial appearance.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Aesthetic Genioplasty Based on Strategic Categorization

BACKGROUND

Genioplasty is a popular procedure used for lower facial contour correction. Various osteotomy techniques enable us to perform advancement, setback, reduction, or narrowing procedures. Computed tomographic images facilitate preoperative planning in detail. The authors used a novel planning method based on strategic categorization. The analytic results are described.

METHODS

This retrospective study reviewed 208 patients who underwent genioplasty procedures for facial contouring from October of 2015 to April of 2020. During preoperative evaluation of the mandible, the operative procedure selected was one of three types: (1) horizontal segment osteotomy, (2) vertical and horizontal segment osteotomy, and (3) bone graft after repositioning. Adequate osteotomies were followed by rigid fixation using a titanium plate and screws. The follow-up period ranged from 8 to 24 months (average, 17 months). The results were assessed based on medical records, photographs, and facial bone computed tomographic images.

RESULTS

Overall, the patients were satisfied with the outcomes and had responder-based improvement in lower facial contour and balance. Chin point deviations were noted in 176 cases; left-side deviation ( n = 135) was more frequent than right-side deviation ( n = 41). Strategic osteotomies based on precise measurements led to correction of asymmetries. Temporary partial sensory losses reported in 12 cases resolved within an average of 6 months after surgery.

CONCLUSIONS

Each patient's chief complaint and bony structures should be carefully evaluated before genioplasty procedures are performed. During the operation, meticulous osteotomy, precise movement, and rigid fixation are necessary. The strategic process used for genioplasty resulted in aesthetic balance and predictable outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

A Novel and Simplified Parameter for Mandible Angle Asymmetry Evaluation in Chinese Females

AIM

To develop a novel and simplified parameter for mandible angle asymmetry (MAA) evaluation for facial countering surgeries in Chinese females.

MATERIALS AND METHODS

A total of 250 craniofacial computer tomography of healthy Chinese individuals were collected in this retrospective study. Mimics 21.0 was applied for 3-dimensional anthropometry. The Frankfort and Green planes were set as referenced vertical and horizontal planes for measuring the distances to gonions. The differences in both orientations were analyzed to verify the symmetry. Mandible angle asymmetry (∠Go-N-ANS, MAA) which comprehensively represented horizontal and vertical placements was defined qas the novel parameter for asymmetric evaluation and quantitative analysis was conducted to generate referenced materials.

RESULTS

Mandible angle asymmetry was divided into horizontal and vertical asymmetry. No significant differences were found in either horizontal or vertical orientations. The horizontal difference was 3.09±2.52 mm, the reference range was (0.28, 7.54) mm, whereas the±ertical difference was 2.59±2.48 mm, the reference range was (0.12, 6.34) mm. The difference of MAA was 1.74±1.30 degrees, and the reference range was (0.10,4.32）degrees.

CONCLUSION

This study provided a novel parameter for asymmetric evaluation in the mandible angle region through quantitative 3-dimensional anthropometry, arousing plastic surgeons' attention to both aesthetics and symmetry in facial contouring surgery.

Correcting the Broad, Flat and Short Chin Using Modified M-genioplasty

BACKGROUND

Several genioplasty techniques can narrow the width of the chin. Nevertheless, patients with a broad and short chin who received these methods were unsatisfied with the outcomes. The goal of this study was to analyze the clinical outcomes of modified M-shaped genioplasty for broad, flat and short chin deformity.

METHODS

Thirty-eight patients with broad, flat and short chins were included in this study from January 2019 to December 2021. The preoperative design was performed individually according to the data of the chin and the patient's desire of final chin shape. Narrowing and vertical elongating genioplasty was performed for all the patients with modified M-shaped genioplasty under general anesthesia according to the preoperative designs. All patients have completed the FACE-Q preoperatively and 3 months postoperatively. The results were evaluated by clinical appearances and FACE-Q scores.

RESULTS

The vertical lengthening of the chin was 2-5 mm, with an average of 3.02 mm. The horizontal narrowing width was 3-6 mm, with an average of 5.6 mm. FACE-Q scores in satisfaction with the chin increased significantly from 35.34 ± 9.57 to 72.95 ± 6.81. There were no severe complications took place during the time frame of 3-24 months postoperatively.

CONCLUSIONS

The modified M-shaped genioplasty preserved the bone structure in the midsymphyseal area and suprahyoid muscular attachments as far as possible, and the bone segments may be repositioned quickly. This technique produced reliable and esthetically satisfying results in correcting a short, flat and broad chin, with altered vertical length, slope, width and protrusion three-dimensionally.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Hairline Correction by Hair Transplantation for Reducing Apparent Face Length in Long-Face Women

BACKGROUND

The long-face morphology is associated with aesthetic concerns, and surgery is often necessary to correct excess length in the frontal plane, in the upper, middle, and lower thirds of the face. However, correcting midline facial length in the frontal plane alone does not provide facial harmony. This study introduces a novel approach to correcting long-face morphology using measurements in the frontal, oblique, and lateral views, and reducing hairline measurements using hair transplants.

METHODS

Eighty-three patients were enrolled in the study. The authors measured the midline facial length in the frontal plane and the lengths of the upper, middle, and lower thirds of the face. The authors also measured four additional distances in the oblique and lateral views, including the distance from the infratemporal hairline to the chin and from the sideburn to the chin. The patients' midfrontal hairlines were lowered, and the distances from the infratemporal hairline to the chin and from the sideburn to the chin were also shortened. The results were evaluated by patients and the surgeon using a five-point Likert scale.

RESULTS

The mean patient Likert score was 4.5 (range, 3 to 5), and the mean surgeon Likert score was 4.9 (range, 3 to 5). No patients experienced adverse events. Three patients required touch-up surgery at the recipient sites to increase the hair density.

CONCLUSION

This novel approach to correcting long-face morphology using hair transplants to decrease hairline measurements provided excellent facial harmony and symmetry.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Surgical techniques used in chin feminization: Literature review and knowledge update

Genioplasty is commonly performed as part of facial feminization surgery. Commonly addressed areas in facial feminization surgery include the chin. According to some authors, 100% of patients request genioplasty surgery in order to feminize their faces. Specific genioplasty techniques (involving generally reduction surgery) applied to transgender patients have been rarely described in the literature. Objective: We aimed to carry out a review of the literature to update the current knowledge on this subject while achieving a comprehensive synthesis of the available surgical techniques for reduction genioplasty in trans Male to Female patients. Conclusion: Reduction genioplasty is frequently performed in facial feminization surgery. Multiple surgical techniques for chin feminization have been described in the existing literature. Reduction genioplasty requires combined work in the sagittal and transverse planes so as to obtain a harmonious result. However, no comparative study on the different surgical techniques has as yet been conducted. Patient satisfaction or surgical complications (which tend to be rare) cannot be related to any specific surgical technique.

3D Sliding Genioplasty and Its Role in Facial Feminization Surgery

The chin is a key element of the lower third of the face and plays the main role as a gender indicator. Since its introduction, genioplasty has become very popular and highly established for the treatment of various conditions. Additional procedures, such as mini V-line, V-line surgery, lateral cortex ostectomy, or mandible angle resection round out the result. (i) The 3D sliding genioplasty is a very effective feminizing procedure (ii) It enables the surgeon to modify the size, form, height, and position of the chin in all dimensions. (iii) We discuss our approach to sliding genioplasty.

Total inferior border ostectomy versus T-shape genioplasty for chin narrowing combined with mandibular contouring

The objective of this study was to compare the indications and outcomes of the total inferior border ostectomy and T-shape genioplasty. A retrospective study was conducted using the clinical notes and records of patients who underwent total inferior border ostectomy (group 1, n = 42) and T-shape genioplasty (group 2, n = 60). The outcomes were evaluated by assessment of computed tomography images combined with medical records and photographs. Lower facial height, chin width, chin symmetry, and facial proportions, as well as patient satisfaction and complications were investigated. The data were collected preoperatively and 6-24 months postoperatively. All 102 patients showed an improved lower facial contour. No severe complications were observed during the follow-up period. Although the postoperative lower to midfacial height ratios were similar in the two groups (P = 0.080), both the preoperative and postoperative chin width to lower facial height ratios were lower in group 1 (both P < 0.001). A larger amount of chin narrowing, as well as better chin symmetry were observed in group 1 (P < 0.001). In conclusion, compared to the T-shape genioplasty, the total inferior border ostectomy is well suited for a longer, wider, and more asymmetrical chin. The surgical options should be considered and chosen quantitatively to achieve aesthetically pleasing results.

Shaping the Lower Jaw Border with Customized Cutting Guides: Development, Validation, and Application in Facial Gender-Affirming Surgery

Importance: Three-dimensional planning software is not standardized in facial gender-affirming surgery. Objective: To develop and validate surgical planning software to create cutting guides to contour the lower jaw border. Design, Setting, and Participants: A 3-year prospective case series study done in three phases: software development, validation, and surgical guide application. Ethics committee approval was obtained to enroll the patients (Clinical Research Ethics Committee, Hospital Costa del Sol, Marbella, Spain). Main Outcomes and Measures: Validation phase: degree of agreement between the planned and obtained results, modification of cephalometric parameters, and surgical times. Application phase: surgical technique description, complications, and patient-reported outcome measures. Results: The degree of agreement between the planned and obtained results was inframillimetric (0.31 ± 0.70 mm). The guides reduced the mandible to within feminine parameters (p < 0.05). Surgical times decreased by 10.96% with chin ostectomies (p < 0.05) and 23.06% with lower jaw border (angle-to-angle) surgeries (p < 0.001). In the application phase, revision surgery was required for 11 patients out of 260 (4.23%). Conclusions and Relevance: The use of cutting guides on the lower jaw border is effective, helps reach standard feminine parameters, and decreases surgical times.

Evaluation and treatment of facial feminization surgery: part II. lips, midface, mandible, chin, and laryngeal prominence

Facial feminization surgery (FFS) refers to a set of procedures aimed at altering the features of a masculine face to achieve a more feminine appearance. In the second part of this twopart series, assessment and operations involving the midface, mandible, and chin, as well as soft tissue modification of the nasolabial complex and chondrolaryngoplasty, are discussed. Finally, we provide a review of the literature on patient-reported outcomes in this population following FFS and suggest a path forward to optimize care for FFS patients.

A New Concept of Narrowing Genioplasty: Home Plate-Shaped Sliding Osteotomy

BACKGROUND

Narrowing genioplasty is commonly performed among East Asian populations, as a broad and/or square chin can be aesthetically unappealing. This study was aimed to introduce the home plate-shaped sliding osteotomy technique for narrowing genioplasty and to evaluate the results of this technique.

METHODS

A retrospective chart review of 117 patients who underwent home plate-shaped sliding osteotomy alone between 2011 and 2019 was performed. The angles of oblique osteotomy lines and measurements of caudal repositioning, which significantly affect the postoperative chin shape, were evaluated.

RESULTS

The home plate-shaped sliding osteotomy technique was successfully accomplished for narrowing genioplasty as an isolated procedure. The mean distance of caudal repositioning was 3.9 ± 0.8 mm, and the mean angles of oblique osteotomy lines were 23.3 ± 4.8 degrees on the right and 21.8 ± 3.5 degrees on the left. This produced an aesthetically pleasing rounded and proportionately narrow chin. The incidence of minor complications was 6.0 percent. There were no major complications. In particular, the risk of inferior alveolar nerve injury was obviated, as an additional mandibular border osteotomy was not typically used with this technique.

CONCLUSIONS

This new surgical procedure for narrowing genioplasty provides improved aesthetic results by altering the chin shape, rather than reducing the transverse width of the chin. The versatility of this procedure allows the chin shape to be adjusted with respect to narrowing, vertical lengthening, anterior advancement, and asymmetric or cleft chin correction. The present study suggests that home plate-shaped sliding genioplasty may be an excellent alternative for correcting broad and/or square chins and more complex chin deformities.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Contouring the Mandible for Aesthetic Enhancement in Asian Patients

A prominent mandible that gives a squared face in Asians is considered unattractive as it imparts a coarse and masculine image. Mandibular contouring surgery allows slender oval faces. The purpose of conventional mandible reduction is to make the lower face appear slim in frontal view and to have a smooth contour in lateral view. As shaping the lateral contour of the mandible alone may result in minimal improvement in the frontal view, surgical techniques to reduce the width of the lower face through narrowing genioplasty (i.e., the "V-line" surgery) and sagittal resection of the lateral cortex should be combined. Examination of the shape and symmetry, the relationship between the maxilla and the mandible, understanding overlying soft tissue contribution, and understanding the overall balance of the face are mandatory. An important factor influencing ideal facial shape is patient's personal preference, which is often influenced by his/her ethnic and cultural background. Especially when consulting patients of different nationalities or ethnic backgrounds, careful attention should be paid to the patient's aesthetic sensibility regarding the ideal or desirable facial shape. Narrowing the chin and modification of chin shape can be accomplished by narrowing genioplasty with central strip resection. This midsymphyseal sectioning procedure yields safe and very satisfactory results. This procedure not only augments the narrowing effect by leaving soft tissues attached to the bone but also enables modification of chin shape by altering the shape of resection. The surgeon should customize the surgery based on a comprehensive assessment of the patient's preoperative chin and mandible morphology complemented by an assessment of their aesthetic goals.

[Secondary genioplasty]

Secondary genioplasty can be a real challenge for the practitioner. We will review the different types of genioplasty, the difficulties encountered and the possibilities of repair using concrete examples.

Three-Dimension-Printed Surgical Guide for Accurate and Safe Mandibuloplasty in Patients With Prominent Mandibular Angles

Performance of mandibuloplasty is highly dependent on each surgeon's experience, and reproducing the results of simulation surgery is often difficult. In order to obtain successful clinical outcomes, a fast and efficient surgery technique that minimizes operation time and risk to patients is needed. The authors designed a 3D-printed mandible fit surgical guide for use as a bridge between simulation and actual surgery.The authors enrolled 7 patients with prominent mandibular angle who visited the outpatient clinic of the Department of Plastic and Reconstructive Surgery at Asan Medical Center in Seoul, Korea between December 2013 and May 2017.The surgical guides were made with a 3D printer and simulated based on individual facial bone CT scans. The surgical guides were designed to fit the lower border of the mandible and to cover the portion planned for removal.The resulting personalized 3D-printed surgical guides were applied on both mandibular angles to the body and along the lower border of the mandible. Osteotomy of the mandibular angle and body were performed along the surgical guide. All patients recovered without any immediate postoperative complications. The use of 3D-printed surgical guide was effective in simplifying the process of mandibuloplasty.Our results demonstrate the value of 3D printing technology in mandibuloplasty.

Occlusion-Fit V-Line Guide and Gooseneck Saw for Safe and Accurate Mandibuloplasty in Asians

BACKGROUND

A slender or slim face with narrow facial features is considered esthetically appealing in Asian people. Plastic surgery to obtain an oval face, called a 'V-line,' is popular among young people.

MATERIALS AND METHODS

A total of 20 Korean patients were included in this study. The patients underwent mandibular anguloplasty with three-dimensional computer-aided design and manufacturing surgical guides that were accurately fitted to the upper and lower teeth, allowing for precise replication of a virtual surgery during a real surgical procedure.

RESULTS

There were no significant complications, including severe bleeding, facial nerve injury, or airway obstruction. All patients were satisfied with the esthetic and functional results, except for one who was neutral toward the result. The mean satisfaction score was 4.75, which was between 'satisfied' and 'very satisfied.'

CONCLUSION

The V-line guide and gooseneck saw allowed for safe and fast resection of bone in the mandibular angle area. This technique provides consistent results during surgery as well as minimizing surgical complications.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

The Mini-Zygoma Reduction Surgery: A Simple and Reliable Approach for Mid-Face Narrowing

Reduction of mid-face width is a major concern in Asian facial contouring surgery, and some patients want their mild or borderline problems to be improved in a minimally invasive manner. The authors' mini-zygoma reduction surgery technique is indicated for patients who seek both minimal invasiveness and reliability. Patients presenting with a wide mid-face and isolated zygomatic arch protrusion without severe zygomatic body prominence were included into the study. All surgeries are performed under local anesthesia and on an outpatient basis. Through temporal and sideburn incisions, complete osteotomy was performed on the temporal process of the zygomatic body and just in front of the anterior tubercle of the zygomatic arch. After transposition to a proper inward position, the osteotomized segment was rigidly fixed on the zygomatic arch with metal fixtures. All surgeries were successfully performed without excessive blood loss or any unpredicted events. Over the 6 to 18-month follow-up period, most patients were satisfied with the aesthetic results of the surgery, the rapid recovery, and the minimal postoperative swelling. Even with a 1-point fixation, the segment remained stable and did not show displacement of the bony segment. In patients showing a minimal zygomatic arch prominence and seeking minimally invasive surgery, the proposed technique can be a proper surgical option with reliable and predictable results. The surgery can be performed without general anesthesia and on an outpatient basis, thereby resulting in prompt postoperative recovery. Predictability and reliability is assured with rigid fixation with a metal fixture on the zygomatic arch.