A balanced facial profile is desirable. In fact, it is difficult to look very attractive without jawline definition and adequate chin projection. Almost all popular movie stars or models, of any era, have a well-defined jawline, whether natural or enhanced. A few examples - Michelle Pfeiffer, Angelina Jolie, Rob Lowe, Cary Grant, any actor who's played James Bond and any actress who's played a Bond girl.

Unfairly, a strong chin is thought to be associated with strong character. The Chairman of the Board, the warrior-king, and the quarterback hero are all portrayed by men with strong chins in movies. Look at an ad for any branch of the U.S. military and you will see a strong chin. Idealized portraits of Napoleon in battle take almost cartoonish liberties in exaggerating his chin.

Cosmetic Augmentation: No Jaw-Breaking Required

Many people inherit a recessed chin. Sometimes a small chin may be associated with improper alignment of the teeth ("malocclusion"), in which case orthodontic treatment is needed to adjust the position of the teeth. If an overbite cannot be corrected with braces, orthognathic surgery is needed, which involves breaking the jaw bone and advancing it forward. However, patients with cosmetic concerns, who have a normal occlusion, do not need jaw-breaking surgery. A chin implant is used to augment the lower third of the face, balancing the lower third to the upper and middle thirds and improving facial proportions. It is a procedure that we can usually do well and reliably in plastic surgery, without a difficult recovery.

Facial Balance

I commonly point out any deficiency of the lower face in patients inquiring about other cosmetic procedures. I am not hesitant to do so because of the profound benefit that this procedure can give to facial balance. Frequently, I incorporate chin implants with facelifts or at the time of a submental lipectomy. Usually, chin augmentation is done at the same time as a submental lipectomy because the procedures complement each other so well in defining the jawline.

Chin Implants

Older implants were quite short, limited to the chin, and tended to produce a pointy chin. They also tended to move around. Modern implants wrap around the jawline, helping define the jawline along the sides, and do not move after healing. They are made of solid silicone, a material that is inert and is well known as a safe material to implant. The procedure is also reversible. If a patient decides later that he or she does not want the implant, it is easy to remove. This virtually never happens because patients prefer their appearance with the implant. It feels totally natural and is not fixed with screws. It is placed in a pocket made under the lining of the mandible, the "periosteum." Scar tissue forms and holds it securely in place. Because it is flexible, the incision does not need to be any longer than the incision used to perform the submental lipectomy.

Absorption of the bone under implants has been reported, but this does not seem to present a practical problem. I've followed patients with chin implants for over a decade with no noticeable changes on their profile views.

Achieving Facial Balance: Jawline ("Jowl") Augmentation

The jawline may be augmented with or without augmentation of the chin. When done on its own, these implants are called "jowl" implants - an unfortunate name because "jowls" commonly refer to the undesirable soft tissue hanging over the edge of the jaw (no one would want to augment this problem, which is treated with a facelift). Instead, in this context, "jowl" refers to the bony jawline itself on either side of the chin (anatomically, the "body" of the mandible). To reduce confusion, I prefer to call it "jawline" augmentation.

The aesthetic importance of an unbroken line along the jawline is increasingly being recognized. Commonly, there is a depression on either side of the chin which seems to become more pronounced with aging. If this depression is filled in, the chin tends to blend in with the jawline, which looks very attractive. This is why implants today are longer and wrap around the jaw, to help achieve this unbroken continuity. Jawline augmentation can also serve to camouflage the jowls. This can be a temporizing measure in patients who are not yet ready for a facelift.

Facial Profile Enhancement: Additional Procedures

Treating "Chubby Cheeks"

Buccal Fat Pad Resection

The buccal fat pads are cheek fat pads that are over-developed in some patients, giving the "chubby cheek" look, also called the "chipmunk look," neither of which are considered appealing. Fox, yes, chipmunk, no. By trimming this fat from the inside of the mouth, the chubbiness is reduced. This surgery may be done at the same time as jawline augmentation and a submental lipectomy (liposuction under the chin, direct fat excision and muscle repair) to reduce the negative synergy of a full cheek and a weak jawline. The "Calvin Klein model look" is characterized by a relatively shallow cheek and prominent jawline. Surgeons speak of an "ogee" which is an S-curve, bulging out at the cheekbone, concave at the lower cheek and then out again over the jawline.

How It Is Done

The buccal fat may be approached either through the mouth ("intraoral"), or using a facelift incision. The intraoral approach is commonly used in younger patients who are not having a facelift. This is done with the patient asleep. An incision is made along the mucosa inside the cheek. A few muscle fibers are spread apart and the fat pad pops into view. This fat pad resembles an egg yolk. It is trimmed and the incision in the mucosa is closed with an absorbable suture.

Intraoperative Photo :Buccal fat pad resection in a 39 year-old male. The fat pad resembles an egg yolk and is removed using an incision in the mucosa of the cheek. This patient desired more of a "Calvin Klein model" look.

What to Expect after Buccal Fat Pad Resection

This surgery is rarely done on its own. There is very little discomfort. The incisions are hidden on the inside of the mouth. Patients can feel the sutures on the inside above and behind the upper molars. These sutures dissolve on their own in about two weeks. Patients are instructed to use mouthwash and to be careful brushing their teeth to avoid these incisions. It is best to stick to a soft diet for about a week after surgery.

Buccal Fat Pad Reduction: Complications

In experienced hands, this procedure is very safe. Infection is unlikely. A hematoma is possible because there are some vessels which pass close to the fat pads. There is also a salivary duct in the area (Stenson's duct) which conceivably could be injured.

Underresection is possible, and I have had the opportunity to redo this procedure for a patient who had it done previously elsewhere and at surgery still had significant fat deposits. Overresection is also possible. Overresection might cause depressions of the cheeks which would be treated secondarily with fat injection, a problem best avoided. However, I have not seen this particular problem. The incisions are hidden inside the mouth and tend to heal quickly and very well. In experienced hands, this is a safe procedure with a low complication rate.

Care after Surgery

Facial Profile Enhancement: Additional Procedures

Repair of "Witch's Chin"

If ever there were an unflattering name for a deformity, this is it. I think that every patient in whom I have diagnosed a witch's chin elected for surgery at the first available opportunity! Patients are generally unaware of this label but they know they don't like the way their chin looks in profile. The soft tissue of the chin hangs off the bone.

How It Is Done

The excess tissue is removed by direct excision. The incision placement is identical to the incision used for a submental lipectomy, but it's longer to allow removal of excess fatty tissue and skin that are causing the problem. This creates the desired flat contour under the chin.

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What to Expect After Surgery

There is a linear scar under the chin, about five to six centimeters long (two inches). There is very little discomfort. Sutures are removed in three to seven days depending on whether a running suture or individual "interrupted" sutures are used.

Complications

This is a straightforward excision of extra tissue. The scar may require revision if it is conspicuous or if there is a persistent dog ear at one end or the other.