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Chin Reduction, Advancement and Reshaping

Dr Zukowski and his staff at the Zukowski Center are renowned worldwide for being the best in FFS Facial Feminization Surgery. Based in Chicago America, Mark Zukowski is recognized within the transgender community as being the best.The chin in a male is typically much more square, less defined and vertically longer than that of a female.  Often there is an over projection of this area, and when one looks at the chin in relation to the neck, there are usually laxities that develop – even early in age – through the gravitational effects of heavier muscles combined with skin that loosens with age.  Specifically, there are a couple of different approaches to reshape the chin.  The “open approach” is to go through the inside of the mouth and to make a cut in the bone called a “genioplasty.”  This is a very simple and straightforward technique.  However, despite getting an x-ray, the nerve loops into the bone before coming out as the mental nerve.  When the cut is made, often the nerve is cut – a fact that the doctor may not be aware of.  This leads to permanent numbness to the chin and lip.  When one makes this cut, you have, in effect, separated the bone from its blood supply which is where its healing and nutrient base comes from.  Having detached the bone from its blood supply, you cannot further shape it because it would just simply melt away.  So you still have the problem of a square chin.  It’s a square chin that projects further forward, further back or, if you are make further cuts in the bone, you can decrease its vertical height.  The problem is it’s still a square chin, and you need rather significant fixation using plates and screws to get an adequate union of the bone fragments.  Where the cut bone slides on the sides, there is a residual and permanent notching felt in the bone.  Sometimes, depending upon the cuts and size of hardware used to affix the bone, there can be problems with infection, non-union, pain and change in bone shape due to reabsorption of bone that is not adequately vascularized.

Conceptually, if one hands you a piece of wood and says shorten it by an inch, there are those who will cut a piece of the bone out therefore requiring screws and nails to put it back together again. There are those who instead would, given the proper tools, be able to burr, shape and sand down the wood to the dimensions they wanted.  This, in effect, leaves a stable bone platform with a 3-dimensional shape.  Approaches through the inside of the mouth lead to the possibility of damage to the nerve branch that goes to the lower lip.  It is much more difficult to pull tissues upward against gravity and try to affix them to a very thin layer of tissue inside the mouth referred to as the buccal mucosa.  A patient requiring either a tracheal shave or central neck work as part of a lower facelift has those procedures done through an incision under the chin.  There is never a need to place an incision over the trachea unless it is specifically for voice purposes.  Tracheal prominences can readily be accessed by the savvy surgeon through an under the chin approach which is the same approach used for central neck work.  Through this same approach, one can very readily free up the tissues overlying the chin and can debulk those tissues through liposuction and direct trimming of the fibrous tissue layers.  I then use a high speed burr to 3-dimensionally shape not only the sides of the bone but more importantly underneath to be able to achieve a good projecting chin for the purposes of feminization.  The endoscope is used to assist the visualization of any nerve dissections and the interfaces between soft tissue as well as contour and shape of bone.  This allows the smallest incision necessary to achieve that particular procedure.

This approach is one that I have evolved to because it allows me a greater precision as well as avoids the complications that come with cutting bone and applying hardware which occurs to all surgeons equally with genioplasty.  It’s not a prediction with “open techniques” of who you are as the surgeon, the complications are there regardless.  With endoscopic techniques and assisted endoscopic techniques that contour bone and sculpt bone based upon the anatomy, one can achieve a better 3-dimensional shape and a stable bone platform.  At this point, any excess tissue is now drawn tight and downward into the neck in order to allow it shrink wrap to the new bone configuration.    It allows all the tissues to be pulled into the neck both centrally as well as sideways with the vector of skin pulling downward with gravity.  If you think about it, you are changing once again the foundation of the face, and it’s important to shrink wrap adequately the tissues around the new bone configuration.  If you don’t do it, you will get some sag and looseness to the tissues.  When one thinks about the two approaches one realizes that you cannot achieve a vertical reduction of the bone thru an inside the mouth approach unless you cut bone further in a horizontal direction causing the possibility of even greater damage to the nerves that loop down into the bone.  You certainly cannot reach the bottom border of the chin bone thru an intraoral incision in order to reduce its vertical height thru burring.  The wisdom of using an incision that has a proven track record for any surgery in the central neck as well as face lifting is well utilized in this approach.

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