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9. Salengros JC, El Founas W, Velghe-Lenelle CE, et al. Uvular and tonsillar pillar mucosal necrosis as a cause of severe sore throat after orotracheal intubation. Anaesth Intensive Care 2011;39:772Y773 10. Calikapan GT, Karakus F. Uvula necrosis after endotracheal intubation for rhinoplasty. Aesthetic Plast Surg 2008;32:710Y711 11. Tang SJ, Kanwal F, Gralnek IM. Uvular necrosis after upper endoscopy: a case report and review of the literature. Endoscopy 2002;34:585Y587 12. Seyfer AE, Prohazka D, Leahy E. The effectiveness of the superiorly based pharyngeal flap in relation to the type of palatal defect and timing of the operation. Plast Reconstr Surg 1988;82:760Y764 13. Schmelzeisen R, Hausamen JE, Loebell E, et al. Long-term results following velopharyngoplasty with a cranially based pharyngeal flap. Plast Reconstr Surg 1992;90:774Y778 14. Sloan GM. Posterior pharyngeal flap and sphincter pharyngoplasty: the state of the art. Cleft Palate Craniofac J 2000; 37:112Y122 15. Meek MF, Coert JH, Hofer SO, et al. Short-term and long-term results of speech improvement after surgery for velopharyngeal insufficiency with pharyngeal flaps in patients younger and older than 6 years old: 10-year experience. Ann Plast Surg 2003;50:13Y17 16. Dailey SA, Karnell MP, Karnell LH, et al. Comparison of resonance outcomes after pharyngeal flap and Furlow double-opposing z-plasty for surgical management of velopharyngeal incompetence. Cleft Palate Craniofac J 2006;43:38Y43 17. Deutsch HL, Millard DR Jr. A new cocaine abuse complex. Involvement of nose, septum, palate, and pharynx. Arch Otolaryngol Head Neck Surg 1989;115:235Y237 18. Greene D. Total necrosis of the intranasal structures and soft palate as a result of nasal inhalation of crushed OxyContin. Ear Nose Throat J 2005;84:512, 514, 516 19. Guss J, Cohen MA, Mirza N. Hard palate necrosis after bilateral internal maxillary artery embolization for epistaxis. Laryngoscope 2007;117:1683Y1684 20. Biro P, Seifert B, Pasch T. Complaints of sore throat after tracheal intubation: a prospective evaluation. Eur J Anaesthesiol 2005;22:307Y311 21. Hogan VM. A clarification of the surgical goals in cleft palate speech and the introduction of the lateral port control (l.p.c.) pharyngeal flap. Cleft Palate J 1973;10:331Y345 22. Jackson IT. Closure of secondary palatal fistulae with intra-oral tissue and bone grafting. Br J Plast Surg 1972;25:93Y105 23. Tezel E. Buccal mucosal flaps: a review. Plast Reconstr Surg 2002;109:735Y741 24. Turk AE, Chang J, Soroudi AE, et al. Free flap closure in complex congenital and acquired defects of the palate. Ann Plast Surg 2000;45:274Y279 25. Sinha UK, Young P, Hurvitz K, et al. Functional outcomes following palatal reconstruction with a folded radial forearm free flap. Ear Nose Throat J 2004;83:45Y48 26. McCombe D, Lyons B, Winkler R, et al. Speech and swallowing following radial forearm flap reconstruction of major soft palate defects. Br J Plast Surg 2005;58:306Y311 27. Roh TS, Lee WJ, Choi EC, et al. Radial forearm-palmaris longus tenocutaneous free flap; implication in the repair of the moderate-sized postoncologic soft palate defect. Head Neck 2009;31:1220Y1227 28. Kim JH, Chu HR, Kang JM, et al. Functional benefit after modification of radial forearm free flap for soft palate reconstruction. Clin Exp Otorhinolaryngol 2008;1:161Y165 29. Brown JS, Zuydam AC, Jones DC, et al. Functional outcome in soft palate reconstruction using a radial forearm free flap in conjunction with a superiorly based pharyngeal flap. Head Neck 1997;19:524Y534 30. Mari A, Arranz C, Gimeno X, et al. Nasal cocaine abuse and centrofacial destructive process: report of three cases including treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:435Y439

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Unusual Complication After Genioplasty Rafael Linard Avelar, MSc,*Þ Carlos Diego Lopes Sa´, DDS,þ Diego Felipe Silveira Esses, DDS,þ Ota´vio Emmel Becker, MSc,* Eduardo Costa Studart Soares, PhD,þ Rogerio Belle de Oliveira, PhD* Abstract: Facial beauty depends on shape, proportion, and harmony between the facial thirds. The chin is one of the most important components of the inferior third and has an important role on the definition of facial aesthetic and harmony in both frontal and lateral views. There are 2 principal therapeutic approaches that one can choose to treat mental deformities, alloplastic implants, and mental basilar ostectomy, also known as genioplasty. The latest is more commonly used because of great versatility in the correction of three-dimensional deformities of the chin and smaller taxes of postoperative complications. Possible transoperative and postoperative complications of genioplasty include mental nerve lesion, bleeding, damage to tooth roots, bone resorption of the mobilized segment, mandibular fracture, ptosis of the lower lip, and failure to stabilize the ostectomized segment. The study presents 2 cases of displacement of the osteotomized segment after genioplasty associated with facial trauma during postoperative orthognathic surgery followed by rare complications with no reports in the literature. Key Words: Genioplasty, chin, esthetics

F

acial beauty depends on the shape, proportion, position, and harmony of the facial thirds. The chin is one of the main anatomical structures of the lower third occupying a prominent position and influencing the definition of facial aesthetics and harmony, both in front and profile views.1 Chin surgery can be performed to refine orthognathic surgery, to provide an aesthetic gain of the technique or as an isolated aesthetic procedure in patients with satisfactory maxillomandibular relationship but who have a protruding or retropositioned chin.2 In mild to moderate cases of obstructive sleep apnea syndrome, chin advancement surgery is part of the treatment protocol, contributing to the high level of success.3 Aesthetic modifications to reposition the chin involve the lower lip, mentolabial sulcus, soft pogonion, and mentocervical distance.

From the *Oral and Maxillofacial Surgery Department, Pontifı´cia, Universidade Cato´lica do Rio Grande do Sul, Porto Alegre; †Department Faculdade Cato´lica Rainha do Serta˜o, Quixada´; and ‡Department Oral and Maxillofacial Surgery Service, Walter Cantı´dio University Hospital, Federal University of Ceara´, Fortaleza, Brazil. Received August 28, 2013. Accepted for publication November 26, 2013. Address correspondence and reprint requests to Rafael Linard Avelar, MSc, Pontifı´cia Universidade Cato´lica do Rio Grande do Sul, Av. Ipiranga, 6681, Porto Alegre/RS, Brazil CEP 90619-900; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000618

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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& Volume 25, Number 2, March 2014

Normally, these structures are closely related to the movement of bony segments.4,5 Two main therapeutic approaches can be used to address chin deformities, alloplastic implants, and basal osteotomy of the chin or genioplasty. The latter is the most widely used because of its great versatility to correct three-dimensional chin deformities through osteotomy angle variation with lower rates of postoperative complications.2 It was first described by Hofer in 1942, who called it ‘‘anterior horizontal osteotomy of the mandible’’ and later modified by Trauner and Obwegeser.3 Possible transoperative and postoperative complications of genioplasty include damage to the mental nerve, bleeding, damage to tooth roots, bone resorption of the mobilized segment, jaw fracture, ptosis of the lower lip, and failure to fixate the osteotomized segment. The study presents 2 cases of displacement of the osteotomized segment after genioplasty associated with facial trauma during postoperative orthognathic surgery followed by rare complications with no reports in the literature.

CLINICAL REPORT Patient 1 The 38-year-old patient suffered a fall from her own height on the fifth postoperative day after orthognathic surgery, which consisted of Le Fort I osteotomy, sagittal split osteotomy of the mandibular ramus, and genioplasty. The patient complained that it was ‘‘difficult to swallow, talk, and close the lips.’’ Ecchymosis on the left periorbital, mental, and cervical regions were found on physical examination. The profile view shows an inability to seal the lips and retropositioning of the lower third of the face causing a shortening of the cervical mental line and straightening of the labiomental angle (Fig. 1A). The profile teleradiography showed a considerable displacement of the osteotomized chin segment with a single screw fixated to it (Fig. 1B). On the 12th postoperative day, the patient underwent a new surgical procedure under general anesthesia during which the chin segment was repositioned and fixated with a 2.0-mm plate system. The patient has been receiving follow-up, and the chin position is correct (Fig. 2).

Patient 2 The second patient is a 19-year-old who sought attendance complaining of ‘‘breathing difficulty’’ on the third postoperative day after orthognathic surgery. During anamnesis, the patient reported to have suffered a trauma in the mental region while asleep. The patient presented class III occlusion and facial profile and was submitted to Le Fort I osteotomy with maxillary advancement and genioplasty. Physical examination showed inability to seal the lips and retropositioning of the chin (Fig. 3A). The profile teleradiography showed great displacement of the posterior osteotomized chin segment and shortening

FIGURE 1. Patient 1. A, Note inability to seal the lips and retropositioning of the chin. B, Teleradiography showed a considerable displacement of the osteotomized chin segment.

Brief Clinical Studies

FIGURE 2. Patient 1. After a year of follow-up, there is a profile harmony.

of the infrahyoid musculature (Fig. 3B). In this patient, the chin segment was fixated using two 2.0-mm screw system. The patient underwent a new surgical procedure under general anesthesia during which the chin segment was repositioned and fixated with two 2.0-mm plate systems and 2 screws. The patient has been receiving follow-up and presents a harmonious facial profile with good maxillary-mandibular relationship (Fig. 4).

DISCUSSION The chin is an essential structure in facial aesthetics, and it cannot be overlooked when planning treatment and performing orthognathic surgery.1 Genioplasty is widely performed to treat a number of abnormalities of the chin, cases of mandibular advancement or setback, correction of vertical height, and transverse asymmetries. Although some studies recognize that the use of alloplastic implants for chin augmentation is technically easy to perform and presents a low rate of complications, most literature reports insist that the basal osteotomy of the chin offers more advantages. This is due to its versatility, predictability of soft tissue contour, higher rate of patient satisfaction, and low incidence of postoperative complications.2,6 Guyuron and Raszewski7 reported a patient satisfaction rate of 85% to 90% for the alloplastic implant and 90% to 95% for genioplasty. Among 200 cases treated by genioplasty, Richard et al8 reported only 6 complications. The cases reported in the present study showed considerable displacement of the osteotomized segment after genioplasty caused by low-intensity blunt trauma to the face during the postoperative phase following orthognathic surgery with rare complications, and no similar reports were found in the literature. No biomechanical studies that show which type of osteosynthesis is the best for genioplasty were found in the literature. Fixation of the repositioned segment can be performed by using steel wires or rigid fixation systems. Both methods are considered effective, although the metal plates and screws are more popular because they are reliable, are easy to apply, and have reduced surgical time, and plates and screws of different lengths are available. The use of rigid metal fixation in the mental region presents a lower rate of postoperative problems compared with other sites of the facial skeleton. This is due to the thicker muscle skin coverage and excellent vascularization of the site.9 In a retrospective study, Defreitas et al10 showed that the use of the Paulus

FIGURE 3. Patient 2. A, Note inability to seal the lips and retropositioning of the chin. B, Teleradiography showed a considerable displacement of the osteotomized chin segment.

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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FIGURE 4. Patient 2. After a year of follow-up, there is a profile harmony.

plate is an extremely simple method, providing excellent stabilization of genioplasty. Two cases were discussed in the current study in which fixation failures of genioplasty occurred, although they were caused by trauma. In the first case, only 1 screw was used, and in the second, 2 screws were used to fixate the chin segment. Neurosensory deficit has been reported as the most common problem after orthognathic surgery.11 This complication may reduce the level of patient satisfaction.12 Genioplasty, when performed in isolation, has a relatively low incidence of sensory alteration.13 However, when performed in combination with the sagittal osteotomy of the mandibular ramus, it tends to aggravate inferior alveolar nerve injury. This condition has been attributed to the double injury to the nerve caused by the combination of osteotomies.12,13 Lindquist and Obeid6 showed in a study with 31 patients that only 10% of those who underwent isolated genioplasty had nerve alteration, whereas the incidence was of 28.5% in those who underwent genioplasty in combination with sagittal split osteotomy of the mandibular ramus. Previous studies showed that the recovery of the inferior alveolar nerve is much slower in patients undergoing mandibular osteotomy in combination with genioplasty.14,15 When surgery is performed in the mental region, careful planning and good surgical technique must be performed to avoid ‘‘degloving’’ injury of the chin. This condition associated with an inappropriate closing of the surgical wound without proper repositioning of the mentalis muscle can generate soft tissue ptosis with loss of lip support, which will be manifested by the flattening of the mentolabial sulcus, overexposure of the lower incisors, and lip incompetence.16,17 The nonunion after genioplasty advancement is a rare complication,18 with only 2 cases reported in the literature. In 1 of the reports, a panoramic radiography was taken 10 years after the completion of chin advancement, in which the healthy 25-year-old patient showed a defect in bone healing, requiring surgical intervention.19 Three factors must be observed to prevent this complication, bone contact, adequate fixation of the mobilized segment, and satisfactory postoperative care.18,19 Fracture of the mandible is a rare complication that can occur if the osteotomy of the 2 cortical bones is not performed completely before attempting to mobilize segments. If it occurs, the fracture line may extend into the body and ascending ramus, which may require an open reduction. Panoramic radiography will help discard pathological conditions of the mandible that might lead to the appearance of fractures.20,21 When high osteotomy is performed, it can damage the dental apices of mandibular incisors. Cephalometry in combination with the panoramic radiography of the mandible provides a good idea of the position of the tooth roots, which must be avoided during osteotomy and perforation to place the screws. If the dental apices are injured, endodontic treatment must be performed.6,8 Other reported complications are respiratory mucocele22,23 and periodontal disease.24

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1. Kim G-J, Jung Y-S, Park H-S, et al. Long-term results of vertical height augmentation genioplasty using autogenous iliac bone graft. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:51Y57 2. Strauss RA, Abubaker AO. Genioplasty: a case for advanced osteotomy. J Oral Maxillofac Surg 2000;58:783Y787 3. Farin˜a R, Valladares S, Rojas F. M-shaped genioplasty: a new surgical technique for sagittal and vertical chin augmentation: three case reports. J Oral Maxillofac Surg 2012;70:1177Y1182 4. Polido WD, Regis LC, Bell WH. Bone resorption, stability, soft-tissue changes following large chin advancements. J Oral Maxillofac Surg 1991;49:251Y256 5. Bell WH, Dann JJ. Correction of dentofacial deformities by surgery in the anterior part of the jaws. Am J Orthod 1989;64:162Y187 6. Lindquist CC, Obeid G. Complications of genioplasty done alone or in combination with sagittal split ramus osteotomy. Oral Surg Oral Med Oral Pathol 1988;66:13Y16 7. Guyuron B, Raszewski RL. A critical comparison of osteoplastic and alloplastic augmentation genioplasty. Aesthetic Plast Surg 1990;14:199Y206 8. Richard O, Ferrare JJ, Cheynet F, et al. Complications of genioplasty. Rev Stomatol Chir Maxillofac 2001;102:34Y39 9. Edwards C, Kiely KD, Eppley BL. Resorbable fixation techniques for genioplasty. J Oral Maxillofac Surg 2000;58:269Y272 10. Defreitas E, Ellis E, Sinn DP. A retrospective study of advancement genioplasty using a special bone plate. Bone. J Oral Maxillofac Surg 1992;50:340Y346 11. Kim SG, Park SS. Incidence of complications and problems related to orthognathic surgery. J Oral Maxillofac Surg 2007; 65:2438Y2444 12. Park JW, Choung P-H, Kho HS, et al. A comparison of neurosensory alteration and recovery pattern among different types of orthognathic surgeries using the current perception threshold. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:24Y33 13. Westermark A, Bystedt H, von Konow L. Inferior alveolar nerve function after mandibular osteotomies. Br J Oral Maxillofac Surg 1998;36:425Y428 14. Gianni AB, D’Orto O, Biglioli F, et al. Neurosensory alterations of the inferior alveolar and mental nerve after genioplasty alone or associated with sagittal osteotomy of the mandibular ramus. J Craniomaxillofac Surg 2002;30:295Y303 15. van Sickels JE, Hatch JP, Dolce C, et al. Effects of age, amount of advancement, and genioplasty on neurosensory disturbance after a bilateral sagittal split osteotomy. J Oral Maxillofac Surg 2002;60:1012Y1017 16. Zide BM, McCarthy J. The mentalis muscle. An essential component of chin and lower lip position. Plast Reconstr Surg 1989;83:413Y420 17. Rubens BC, West RA. Ptosis of the chin and lip incompetence: consequences of lost mentalis muscle support. J Oral Maxillofac Surg 1989;47:359Y366 18. Kim SG, Lee JG, Lee YC, et al. Unusual complication after genioplasty. Plast Reconstr Surg 2002;109:2612Y2613 19. Kim YH, Lee KM, Kim JT. Successful treatment of nonunion after sliding genioplasty. J Craniofac Surg 2011;22:2235Y2237 20. Goracy ES. Fracture of the mandible body and ramus during horizontal osteotomy for augmentation genioplasty. J Oral Surg 1978;36:893Y894 21. van Butsele B, Neyt L, Abeloos J. Mandibular fracture: an unusual complication following osteotomy of the chin. Acta Stomatol Belg 1993;90:189Y193 22. Anastassov GE, Lee H. Respiratory mucocele formation augmentation genioplasty with osteocartilaginous graft after nasal. J Oral Maxillofac Surg 1999;57:1263Y1265 23. Lazar F, ZurHausen M, Siessegger A, et al. Mucocele of the chin area. A rare complication after genioplasty with osteocartilagenous nasal bone transplant. Review of the literature and case report. Mund Kiefer Gesichtschir 2003;7:380Y385 24. Omnell ML, Tong DC, Thomas T. Periodontal complications following orthognathic surgery and genioplasty in 19 years old: a case report. Int J Adult Orthod Orthognath Surg 1994;9:133Y139

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Unusual complication after genioplasty.

Facial beauty depends on shape, proportion, and harmony between the facial thirds. The chin is one of the most important components of the inferior th...
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