Discussion

Witch's Chin: A Progressive, Three-Step Technique

by Claudio Bernardi, M.D., Pier Luigi Amata, M.D. and Stefano Dura, M.D.

Discussion by Barry M. Zide, D.M.D., M.D.

Correction of chin ptosis is like lateral canthopexy. Some surgeons perform it routinely and others shy away. Although both procedures are anatomically uncomplicated, some mysterious forces stop the sur­geon, and these forces relate to the patient’s desire for perfection and the surgeon’s ability to deliver. This article deals with noniatrogenic ptosis and offers an appealing, although somewhat flawed, schematic for correction.

When the illustration does not equal the real anatomy, problems arise for the surgeon. Anatomically, the drawing is very incorrect and should have been changed. The mentalis arises immediately submucosal in the sulcus for a centime­ter or so; there is no space as drawn. The muscle never arises as it is drawn partly from pogonion, and the fibers go right into the dermis, which is also not depicted properly; the platysma comes to and often covers the menton; it does not insert into the genial tubercle.

First, let us consider some basic concepts regard­ing the ptosis examination; second, let me assess and analyze their process of correction; and third, let me provide some simple caveats.

The Basic Analysis

Side view of chin ptosis must be both static and dynamic. Static ptosis, i.e., the patient does not smile and there is soft tissue below the menton, can be caused by aging, denture resorption of the mandibular ridge, or zealous excessive submental liposuction (iatrogenic). I have not noted that these patients are usually hyperprojected, as the authors suggest. Often, there is a high labiomental fold, which makes the pad look big. Sometimes, it is just excessive chin pad thickness (normal value, 8 to 11 mm)., and that should be checked digitally.

Caveats

This procedure or some part of it can be done for the drooping soft tissue after chin implant removal as long as the lower lip position does not expose the lower incisors at rest. For patients who have a short vertical chin and ptosis, usually denture wearers, removal of ptotic soft tissue will make the chin even shorter. If the submental creases extend upward onto the face, the crease on the face requires undermining, not an extension of ellipse. Finally, regarding the postoperative dressing, I have found that those facial chin supports work well for a couple of days (not necessarily 5 days, as the authors suggest) and that the addition of enzymes such as Enzaid may help reduce the swelling.

Discussion from publication Plastic and Reconstructive Surgery, August 1999

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